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07813

Based on interview and record review it was determined that the facility failed to develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) sample patients (A1, A2, A3, A4, B11, C2, C7 and C18). The treatment plans were preprinted forms that included lists of problems with 5-7 goals and several interventions from which choices were to be identified for each patient. Many of the goals were generalized, based on compliance with treatment and attendance at activities rather than on the patient's specific problem. Some interventions were role functions without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient. This practice results in "sameness" from one plan to another and in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B121 and B122)

07813

Based on interview and record review the facility failed to ensure that treatment goals in the treatment plans were based on individual patient findings for eight (8) of eight (8) sample patients (dates of plans in parentheses) A1 (2/7/15); A2 (1/3/15 with last revision date of 2/5/15); A3 (2/12/15); A4 (2/1/15 with last review date of 2/15/15); B11 (1/31/15); C2 (2/10/15); C7 (2/109/15); C18 (1/16/15 with last review date of 2/10/15). All plans included lists of goals from a pre-printed form for the identified problems. Some goals were stated in non-measurable terms or as compliance or attendance at groups/activities, rather than evidence that the patient's problem had been reduced or resolved. This failure hinders the treatment team's ability to individualize treatment based on specific patient findings and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record review:

1. Patient A1:

a. For problem stated as "Violence risk directed at self as evidenced by Suicidal with plan...," treatment compliance was listed as goals: "Patient will attend 3-4 groups per day" and "Patient will attend individual and/or family therapy weekly." These goals were patient compliance rather than evidence that the patient's violent behavior had reduced/resolved.

b. For problem stated as "Hopelessness related to altered mood/depression," a non-measurable goal was listed as "Patient will maintain adequate appetite, sleep pattern, hygiene, and physical activity."

2. Patient A2:

For problem stated as "Alteration in thought process as evidenced by Hx (history) of psychosis," there were no identified goals when the plan was initiated on 1/31/15. A goal was added l on 2/5/15, "Pt (Patient) will attend abbreviated group time- 10-15 minutes per day." This goal was treatment compliance rather than behavioral evidence that the problem had been reduced or resolved.

In addition, a social work intervention was listed as a patient goal stated as "If Pt (patient continues to refuse group and abbreviated time, SW will offer 1:1 sessions weekly."

b. For problem identified as "Violence risk directed at others...," goals was listed as: "Patient will attend 2 groups per day," "Patient will attend individual and/or family therapy weekly, for alternate to group therapy" and "Patient will meet briefly w/ (with) AT (Activity Therapy staff when not attending groups." These were evidence of treatment compliance, rather than behavioral evidence that the violence had been reduced or resolved

3. Patient A3:

a. For problem stated as "Alteration in thought process as evidenced by delusional thinking a goal was listed as: "Patient will adhere to medication regimen as prescribed." This was evidence of patent treatment compliance rather than behavioral evidence that the problem was reduced or resolved.

b. For problem listed as "Ineffective individual coping related to loud outbursts," a non-measurable goal was listed as "Patient will be knowledgeable about meds (medications)."

4. Patient A4:

a. For problem stated as "Alteration in thought process as evidence by pt. (patient) having auditory hallucinations," goals were "Patient will adhere to medication regimen as prescribed" and "Patient will attend 2-3 group (sic) daily." These were evidence of treatment compliance, rather than behavioral evidence that the violence had been reduced or resolved.



b. For problem stated as "Violence risk directed at others..., a goal was listed as: "Patient will attend individual and/or family therapy weekly." This was evidence of treatment compliance, rather than behavioral evidence that the problem had been reduced or resolved.

5. Patient B11:

a. For problem listed as "Violence risk directed at self as evidenced by suicidal ideation," goals were listed as: "Patient will attend 3-4 groups per day" and "Patient will attend individual and/or family therapy weekly." These were evidence of treatment compliance, rather than behavioral evidence that the violence had been reduced or resolved



b. For problem stated as "Alteration in thought process as evidence by pt. (patient) having auditory hallucinations," there were no identified patient goals.

c. For problem stated as "Hopelessness related to altered mood/depression as evidenced by pt. (patient) suffers from depression," a general non-measurable goal was listed as "Patient will maintain adequate appetite, sleep pattern, hygiene, and physical activity." Another goal was listed as "Patient will comply with medication regimen." This goal was patient compliance rather than evidenced that patient's hopelessness had been reduced or resolved.

6. Patient C2:

a. For problem listed as "Alteration in thought process as evidenced by patient heard voices...," treatment compliance was listed as goals: "Patient will adhere to medication regimen as prescribed" and Patient will attend 2 groups per day till discharge." These goals were patient compliance rather than evidence that the patient's violent behavior had reduced/resolved

b. For problem listed as "Impulsivity..." a non-measurable goal was listed as "patient will maintain adequate appetite, sleep pattern, hygiene, and physical activity while in hospital and with direction of the doctor."

7. Patient C7:

a. For problem listed as "Violence risk directed at self..." a goal was listed as "Patient will attend 3-4 groups per day" and "Patient will attend individual and/or family therapy weekly." This goal was patient compliance rather than evidenced that the stated problem had been reduced or resolved.


b. For problem listed as "Violence risk directing at others..." a goal was listed as: "Patient will attend 2 groups per day during hospitalization." This goal was patient compliance rather than evidenced that patient's violence had been reduced or resolved.

c. For problem stated as "Alteration in thought process..." a goal was listed as: Patient will adhere to medication regimen as prescribed-Haldol and Ativan as prescribed during hospitalization." This goal was patient compliance rather than evidence that the patient's stated problem had been reduced or resolved.

8. Patient C18:

a. For problem listed as "Violence risk directed at self as evidenced by statements of wanting to kill (himself/herself)," goals were listed as "Patient will attend daily activities" and "Patient will take prescribed medications." These goals were patient compliance rather than evidence that the patient's violent behavior had been reduced/resolved



b. For problem listed as "Violence risk directed at others," a goal was listed as: "Patient will attend individual and/or family therapy weekly." This goal was patient compliance rather than evidence that patient's stated problem had been reduced or resolved.


c. For problem listed as "Alteration in thoughts evidenced by flight of ideas & delusional thoughts," non-measurable goals were: "Pt (Patient) will have less delusional thoughts," "Patient recognizes early exacerbation of illness...," and "Accept and understand 2 distressing symptoms are due to mental illness."

Another goal was listed as: "Accept medications as prescribed. (Haldol and PRN's)." This goal was patient compliance rather than evidence that patient's stated problem had been reduced or resolved.


B. Interviews:

1. During interview, with review of Patient B11's treatment plan, on 2/18/15 at 10:40 a.m., the DON, MD B3, SW B4 and RN B2 acknowledged that the goals on this patient's plan included compliance with treatment, rather than behavioral outcome based on problem statement.

2. During interview, with review of Patient C18's treatment plan, on 2/18/15 at 11:10 a.m., the DON, SW B7 and RN B6 acknowledged that the goals on this patient's plan included compliance with treatment, rather than measurable behavioral outcome.

07813

Based on interview and record review, the facility failed to adequately develop and document individualized treatment interventions with specific purpose and focus based on the needs of 8 of 8 active sample patients (dates of plans in parentheses) A1 (2/7/15); A2 (1/3/15 with last revision date of 2/5/15); A3 (2/12/15); A4 (2/1/15 with last review date of 2/15/15); B11 (1/31/15); C2 (2/10/15); C7 (2/109/15); C18 (1/16/15 with last review date of 2/10/15). Instead, treatment plans included interventions stated as role functions or lacked focus for treatment without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

1. Patient A1:

a. For problem stated as "Violence risk directed at self as evidenced by Suicidal with plan...," the only nursing interventions were listed as "Nursing staff will encourage patient to discuss urges to self-harm" and "If destructive behavior is exhibited, nursing staff will assist patient to recognize stressors leading to behavior thru 1:1 intervention." There were no nursing interventions based on specific patient findings to monitor and care for this safety risk in the clinical area in addition to education interventions.

b. For problem stated as "Hopelessness related to altered mood/depression," a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

A generalized nursing intervention was listed as "Nursing will promote adequate appetite, sleep, hygiene, and physical activity."

A generalized social work intervention was listed as "Social Work will encourage verbalization of thought or feelings regarding the depression via individual and/or group therapy. If patient unable to verbalize staff will list possible feelings associated with depression and ask patient to choose what best describes own feelings."

2. Patient A2:

a. For problem stated as "Alteration in thought process as evidenced by Hx (history) of psychosis," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to care for this patient in the clinical area.

A generalized social work intervention was listed as "Social Work will provide daily supportive therapy (individual or group) to help alleviate the client's fears and reduce feelings of alienation."

b. For problem identified as "Violence risk directed at others...," a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

There were no nursing interventions to guide staff in the monitoring of this patient in the clinical area based on presenting behaviors. A general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient.

3. Patient A3:

a. For problem stated as "Alteration in thought process as evidenced by delusional thinking," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects."


b. For problem listed as "Ineffective individual coping related to loud outbursts," a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

A general nursing intervention was listed as "nursing staff will assist pt. (patient) in identifying coping skills daily." Focus or coping skills examples were not identified.

4. Patient A4:

a. For problem stated as "Alteration in thought process as evidence by pt. (patient) having auditory hallucinations," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects."

b. For problem stated as "Violence risk directed at others...," a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

A general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient. Rather than listing nursing interventions to monitor and assist the patient in self-control of aggressive behavior, a nursing intervention was stated as "As a last resort pt. (patient) will be secluded &/or restrained."

5. Patient B11:

a. For problem listed as "Violence risk directed at self as evidenced by suicidal ideation," the only nursing intervention was listed as " Nursing staff will encourage patient to discuss urges to self-harm." There were no additional monitoring or prevention interventions to guide nursing personnel in the care of the patient.

b. For problem stated as "Alteration in thought process as evidenced by pt. (patient) having auditory hallucinations," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to care for this patient in the clinical area.

A generalized social work intervention was listed as "Social Work will provide daily supportive therapy (individual or group) to help alleviate the client's fears and reduce feelings of alienation."

c. For problem stated as "Hopelessness related to altered mood/depression as evidenced by pt. (patient) suffers from depression," a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

A role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no additional interventions to guide personnel in caring for the patient in the clinical area.

A generalized social work intervention was listed as "Social Work will encourage verbalization of thought or feelings regarding the depression via individual and/or group therapy. If patient unable to verbalize staff will list possible feelings associated with depression and ask patient to choose what best describes own feelings."

6. Patient C2:

a. For problem listed as "Alteration in thought process as evidenced by patient heard voices ...," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to guide nursing personnel to care for this patient if she presented hallucinatory behavior.

A generalized social work intervention was listed as "Social Work will provide daily supportive therapy (individual and/or group) to help alleviate the client's fears and reduce feeling of alienation."

b. For problem listed as "Impulsivity..." a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

An expected role function was listed as "Nursing will promote adequate nutrition, sleep, hygiene, and physical activity."

A generalized social work intervention was listed as "Social Work will encourage verbalization of thought or feelings regarding the depression via individual and/or group therapy. If patient unable to verbalize staff will list possible feelings associated with depression and ask patient to choose what best describes own feelings."

7. Patient C7:

a. For problem listed as "Violence risk directed at self..." the only nursing intervention to address presentation of violence to self in the clinical area was "If destructive behavior is exhibited, nursing staff will assist patient to recognize stressor leading to behavior thru 1:1 intervention."

b. For problem listed as "Violence risk directing at others..." a general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient. There were individualized interventions to guide nursing personnel to monitor and assist the patient in self-control of aggressive behavior.

c. For problem stated as "Alteration in thought process..." a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to guide nursing personnel to care for this patient if she presented hallucinatory behavior.

A generalized social work intervention was listed as "Social Work will provide daily supportive therapy (individual and/or group) to help alleviate the client's fears and reduce feeling of alienation."

8. Patient C18:

a. For problem listed as "Violence risk directed at self as evidenced by statements of wanting to kill (himself/herself)," the only physician intervention was listed as "MD will RX (prescribe) meds (medications)." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

b. For problem listed as "Violence risk directed at others..." a general role function was listed as a physician intervention: "Physician will assess symptoms..." There were no additional interventions to delineate the physician's role in treatment other than prescription of medications.

A general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." Rather than listing nursing interventions to monitor and assist the patient in self-control of aggressive behavior, a nursing intervention was stated as "Utilized restraint/seclusions as last resort for acting out."

c. For problem listed as "Alteration in thoughts evidenced by flight of ideas & delusional thoughts," a generalized social work intervention was listed as "Social Work will provide daily supportive therapy (individual and/or group) to help alleviate the client's fears and reduce feeling of alienation."
A role function for nursing was listed as "Administer medications as prescribed."

B. Interviews:

1. During interview, with review of Patient B11's treatment plan, on 2/18/15 at 10:40 a.m., the DON, MD B3, SW B4 and RN B2. MD B3 and RN B2 acknowledged that the interventions on this patient's treatment plan included role functions and were not specific based on this patient's needs.

2. During interview, with review of Patient C18's treatment plan, on 2/18/15 at 11:10 a.m., the DON, SW B7 and RN B6 reported that the current interventions on the treatment plan did not include the interventions that were being provided for this patient.

28209

Based record review and interview it was determined that the Medical Director failed to ensure:

I. That the facility developed and documented comprehensive treatment plans based on the individual needs of eight (8) of eight (8) sample patients (A1, A2, A3, A4, B11, C2, C7 and C18). The treatment plans were preprinted forms that included lists of problems with 5-7 goals and several interventions from which choices were to be identified for each patient. Many of the goals were generalized, based on compliance with treatment and attendance at activities rather than on the patient's specific problem. Some interventions were role functions without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient. This practice results in "sameness" from one plan to another and in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. That treatment goals in the treatment plans were based on individual patient findings for eight (8) of eight (8) sample patients (dates of plans in parentheses) A1 (2/7/15); A2 (1/3/15 with last revision date of 2/5/15); A3 (2/12/15); A4 (2/1/15 with last review date of 2/15/15); B11 (1/31/15); C2 (2/10/15); C7 (2/109/15); C18 (1/16/15 with last review date of 2/10/15). All plans included lists of goals from a pre-printed form for the identified problems. Some goals were stated in non-measurable terms or as compliance or attendance at groups/activities. This failure hinders the treatment team's ability to individualize treatment based on specific patient findings and to measure change in the patient consequent to treatment interventions. (Refer to B121)

III. That the facility adequately developed and documented individualized treatment interventions with specific purpose and focus based on the needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses) A1 (2/7/15); A2 (1/3/15 with last revision date of 2/5/15); A3 (2/12/15); A4 (2/1/15 with last review date of 2/15/15); B11 (1/31/15); C2 (2/10/15); C7 (2/109/15); C18 (1/16/15 with last review date of 2/10/15). Instead, treatment plans included interventions stated as role functions or lacked focus for treatment without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient This results in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

07813

Based on interview and document review, the Director of Nursing failed to ensure that Master Treatment Plans for eight (8) of eight (8) active sample patients (dates of plans in parentheses) A1 (2/7/15); A2 (1/3/15 with last revision date of 2/5/15); A3 (2/12/15); A4 (2/1/15 with last review date of 2/15/15); B11 (1/31/15); C2 (2/10/15); C7 (2/109/15); C18 (1/16/15 with last review date of 2/10/15) included individualized nursing interventions based on the patients' needs. Nursing interventions were listed as generic discipline functions/tasks and there was failure to identify safety and preventive interventions to care for patients presenting problems as violence to self or others and psychotic symptoms. The absence of individualized nursing interventions on patients' treatment plans hampers staff's ability to provide individualized nursing care to patients.

Findings include:

1. Patient A1:

a. For problem stated as "Violence risk directed at self as evidenced by Suicidal with plan...," the only nursing interventions were listed as "Nursing staff will encourage patient to discuss urges to self-harm" and "If destructive behavior is exhibited, nursing staff will assist patient to recognize stressors leading to behavior thru 1:1 intervention." There were no nursing interventions based on specific patient findings to monitor and care for this safety risk in the clinical area in addition to education interventions.

b. For problem stated as "Hopelessness related to altered mood/depression," a nursing intervention was listed as "Nursing will promote adequate appetite, sleep, hygiene, and physical activity." This intervention failed to include specific content based on patient's presenting needs regarding individual nutrition, sleep, hygiene and activity.


2. Patient A2:

a. For problem stated as "Alteration in thought process as evidenced by Hx (history) of psychosis," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to care for this patient in the clinical area.

b. For problem identified as "Violence risk directed at others...," there were no nursing interventions to guide staff in the monitoring of this patient in the clinical area based on presenting behaviors. A general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient.

3. Patient A3:

a. For problem stated as "Alteration in thought process as evidenced by delusional thinking," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." This intervention failed to include specific monitoring and observation based on specific medication(s).

b. For problem listed as "Ineffective individual coping related to loud outbursts," a general nursing intervention was listed as "nursing staff will assist pt. (patient) in identifying coping skills daily." Type or examples of coping skills needed by this patient were not specified.

4. Patient A4:

a. For problem stated as "Alteration in thought process as evidence by pt. (patient) having auditory hallucinations," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." Specific monitoring and observation based on presenting patient behaviors were not specified.

b. For problem stated as "Violence risk directed at others..., a general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient. Rather than listing nursing interventions to monitor and assist the patient in self-control of aggressive behavior, a nursing intervention was stated as "As a last resort pt. (patient) will be secluded &/or restrained."

5. Patient B11:

a. For problem listed as "Violence risk directed at self as evidenced by suicidal ideation," the only nursing intervention was listed as "Nursing staff will encourage patient to discuss urges to self-harm." There were no additional monitoring or prevention interventions to guide nursing personnel in the care of the patient.

b. For problem stated as "Alteration in thought process as evidenced by pt. (patient) having auditory hallucinations," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to care for this patient in the clinical area.

c. For problem stated as "Hopelessness related to altered mood/depression as evidenced by pt. (patient) suffers from depression," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no additional interventions to guide personnel in caring for the patient in the clinical area.

6. Patient C2:

a. For problem listed as "Alteration in thought process as evidenced by patient heard voices ...," a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to guide nursing personnel to care for this patient if she presented hallucinatory behavior.


b. For problem listed as "Impulsivity..." an expected role function was listed as "Nursing will promote adequate nutrition, sleep, hygiene, and physical activity." This intervention failed to include specific content based on patient's presenting needs regarding individual nutrition, sleep, hygiene and activity.


7. Patient C7:

a. For problem listed as "Violence risk directed at self..." the only nursing intervention to address presentation of violence to self in the clinical area was "If destructive behavior is exhibited, nursing staff will assist patient to recognize stressor leading to behavior thru 1:1 intervention." There were no interventions to guide staff in monitoring, prevention and responding to violence shown by the patient.

b. For problem listed as "Violence risk directing at others..." a general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." This intervention failed to include specific limits and expectations for this patient. There were individualized interventions to guide nursing personnel to monitor and assist the patient in self-control of aggressive behavior.

c. For problem stated as "Alteration in thought process..." a role function for nursing was listed as "Nursing will monitor medication regimen with observation of therapeutic effects and side effects." There were no specific nursing interventions to guide nursing personnel to care for this patient if she presented hallucinatory behavior.

8. Patient C18:

a. For problem listed as "Violence risk directed at others..." a general nursing intervention was listed as "Nursing will provide clear limits and expectations to the patient." Rather than listing nursing interventions to monitor and assist the patient in self-control of aggressive behavior, a nursing intervention was stated as "Utilize restraint/seclusions as last resort for acting out..."

b. For problem listed as "Alteration in thoughts evidenced by flight of ideas & delusional thoughts," a role function for nursing was listed as "Administer medications as prescribed." This intervention did not include specifics based on patient's medications.

B. Interviews:

1.During interview, with review of Patient B11's treatment plan, on 2/18/15 at 10:40 a.m., the DON and RN B2 acknowledged that the interventions on this patient's treatment plan included role functions and were not specific based on this patient's needs.

2. During interview, with review of Patient C18's treatment plan, on 2/18/15 at 11:10 a.m., the DON and RN B6 reported that the current interventions on the treatment plan did not include the interventions that were being provided for this patient.