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Based on document review and interview, the facility failed to inform patients, and their representatives that no Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) was onsite 24 hours a day, seven days a week.

Findings include:
1. Review of facility policies, postings, and patient forms indicated no information was provided to inform patients, and their representatives that no Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) was onsite 24 hours a day, seven days a week.

2. In interview on 12-4-2019 at 1730 hours, employee #S2, Chief Operating Officer, was unable to provide a policy, posting, or patient form to validate this requirement being met.

Based on tour and interview, the facility failed to provide for a ligature free environment of care for patients in secured psychiatric units.

Findings include:
1. While touring on 12-2-2019, at 1500 hours, it was observed that:: 10 of 10 patient rooms had main doors with door knobs that would constitute potential ligature risk points, 6 of 10 internal bathroom doors had knobs constituting potential ligature risk points, and 7 of 9 shower knobs constituting potential ligature risk points.

2. In interview on 12-4-2019 at 1730 hours, employee #S2, Chief Operating Officer, confirmed the above noted areas as ligature risk concerns.

Based on document review and interview, the facility failed to include a monitor and standard for two (2) contract services: Organ and tissue donation, and dietetic services as part of the hospital QAPI program.

Findings include:
1. Review of quarterly QAPI reports did not include a monitor and standard for two (2) contract services: Organ and tissue procurement/donation, and dietetic services as part of the hospital QAPI program.

2. In interview on 12-4-2019 at 1730 hours, employee #S2, Chief Operating Officer, confirmed that the 2 contract services listed above were not included in the facility QAPI program.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6, failed to protect 1 of 1 linen closets in accordance with LSC Section 19.3.5.3.,failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters, failed to ensure 1 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters, and failed to ensure annual inspection and testing of 1 of 1 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

During record review with the Facilities Manager on 12/03/19 at 12:49 p.m., no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The most recent annual test and inspection was completed on 05/19/19. Based on interview at the time of record review, the Facilities Manager agreed that visual semi-annually inspections of the fire-alarm system were not completed.

Based on observation and interview, the facility failed to protect 1 of 1 linen closets in accordance with LSC Section 19.3.5.3. Section 19.3.5.3 require healthcare facilities to be protected throughout by an approved, supervised automatic sprinkler system. This deficient practice could affect up to 12 patients and staff.

Findings include:

During a tour of the facility with the Facilites Manager on 12/03/19 at 2:31 p.m. the linen closet near the nurses station was found to not contain a sprinkler. The closet measured approximately 24 inches by 72 inches. Based on interview at the time of observation, the Facilities Manager agreed that the closet did not have a sprinkler and additionally stated that he thought the closet did contain a sprinkler.

2) Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

During a tour of the facility with the Facilities Manager on 12/03/19 at 2:40 p.m. 1 of 4 lay-in ceiling tiles was missing in the document closet. This was confirmed by the Facilities Manager at the time of observation.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the quarterly sprinkler system inspection records on 12/03/19 at 12:24 p.m. with the Facilities Manager present, there was no quarterly sprinkler system inspection report available for the second quarter (April, May, June) of 2019. During an interview at the time of record review, the Facilities Manager acknowledged there was no written documentation available to show the sprinkler system had been inspected during the second quarter of 2019. Additionally, he stated that the sprinkler inspection vendor was delayed, and did not arrive until 07/12/19.

Based on record review and interview, the facility failed to ensure 1 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

During record review of titled "Oaklawn Fire Drill Observation Checklist" with the Facilities Manager on 12/03/19 at 12:13 p.m., the fire drill for 08/21/19 did not record the transmission of the alarm. This was confirmed by the Facilities Manager at the time of record review.

Based on observation, records review, and interview, the facility failed to ensure annual inspection and testing of 1 of 1 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.

Findings include:

During record review with the Facilities Manager on 12/03/19 at 12:51 p.m. the facility was unable to provide an annual fire door inspection. During a subsequent tour of the facility on the same day from 2:25 p.m. to 3:00 p.m. a fire door was located in the Fire Wall that separates the Inpatient facility from the remaining building. Based on interview at the time of record review, the Facilities Manager agreed that the door was not inspected according to NFPA 80.

Based on document review, observation and interview, the facility failed to ensure kitchenettes were clean for 2 of 2 observed (general diet kitchenette and diabetic/special diet kitchenette), and a ready to use patient microwave was clean for 1 of 2 observed (diabetic/special diet kitchenette). The facility failed to ensure a portable sharps container had a lid on it for 1 of 1 portable sharps containers observed in the lab.

Findings include:

1. Facility policy titled "Exposure Control Plan: Prevention of Occupational Exposure to Bloodborne Pathogens" last reviewed/revised on 4/30/19 indicated the following: "...5. Engineering Controls: Use of available technology/devices to control or eliminate exposure. a) Available technology and devices such as puncture resistant sharps containers...will be used by employees to control and/or eliminate the risk of exposure...12) Facilities Practices...a)The Facilities Department will assure that buildings are maintained in a clean and sanitary condition for the safety of all clients and employees. All employees have responsibility in this process..."

2. During a tour of the Cedars Inpatient Unit with S12 (Infection Control Preventionist) on 12/4/19 beginning at 10:13 a.m. the following was observed:

(A) An uncovered, one quart, portable sharps container was located in a white supply caddy on a desk in the lab. The uncovered sharps container was observed to contain needles and blood collecting tubing. One needle was observed to be sticking straight up in the container. The blood collecting tubing was observed to have blood located in the tubing.

(B) An accumulation of dried food debris/splatter yellow in color was observed on the inside top, sides, bottom, glass tray and on the inside of the door of a microwave. An accumulation of dried food debris/spills were observed on the bottom of the refrigerator. The top glass shelf of the refrigerator was sticky to touch where individual juices were stored. Four pantry cabinet drawers had dried food debris/splatter on the outside and inside of the drawers that hold individual food items of peanut butter, jelly, crackers and granola. Four of seven pantry cabinet doors had dried food debris on the outside of the cabinet doors. (Diabetic/Special Diets Kitchenette)

(C) A heavy accumulation of gray dust/debris was observed on top of a wooden supply cabinet located in the nurse's station.

(D) An accumulation of dried food debris/spills and a strain of dark hair were observed in the freezer where ice cream and bread were stored. An accumulation of dried spills pink in color and dried food debris were observed in the bottom of the refrigerator. An accumulation of dried spills light orange in color and dried food debris were observed in the top shelf of the refrigerator door. (General Diet Kitchenette)

3. During an interview with S12 on 12/4/19 at approximately 12:05 p.m., he/she verified the observations of the Diabetic/Special Diets Kitchenette, General Diet Kitchenette, heavy accumulation of dust/debris on top of the wooden supply cabinet located in the nurse's station and the uncovered portable sharps container located in the lab. S2 verified that the uncovered portable sharps container is to have a lid on it covering the items inside.

Based on document review and interview the hospital failed to provide and document ongoing active treatment in a manner that assured appropriateness, correctness and completeness of therapeutic efforts.

Specifically, the facility failed to:

I. Develop individualized Master Treatment Plans (MTPs) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). Many MTPs contained similarly worded short-term goals for patients, which were not measurable outcome behaviors. Some of the listed goals were stated as staff expectations for the patient's participation in treatment rather than behavioral outcomes for the patient to achieve. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the MTP in response to patient need. (Refer to B121)

II. Develop MTPs that evidenced individualized treatment interventions with specific focus based on individual needs of eight (8) of eight (8) active sample patient (A1, A2, A4, A5, A6, A7, A8 and A13). Specifically, interventions were identical or similarly worded and were statements of routine generic discipline functions. Nursing interventions failed to identify specific monitoring and preventive interventions for safety risks (suicide, self-harm, psychotic behaviors) based on individual patient behaviors presented in the clinical area. These deficiencies result in a sameness of treatment plans and result in staff being unable to provide consistent and focused active treatment. (Refer to B122)

III. Provide a sufficient number of active therapy groups/activities conducted by professional health professionals to meet the needs of the patient population. The majority of groups/activities were conducted by non-professional nursing assistants (technicians); these groups/ activities were more leisure-oriented or psycho-educational groups, rather than active treatment activities based on the individualized needs of the patient population. This deficient practice results in fragmented treatment for all patients in the facility and potentially delays their improvement. (Refer to B125)

Based on record review and interview, patient assessment information did not include detailed psychosocial assessments with the recommendations for the role of social work in the treatment of patients during hospitalization for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). This failure hindered treatment planning and continuity of treatment for the patient by social work staff.

Findings include:

A. Record Review

The Psychosocial Assessments for the following active sample patients were reviewed (assessment dates in parentheses): A1 (11/5/19); A2 (11/19/19); A4 (11/26/19); A5 (11/26/19); A6 (11/28/19); A7 (8/28/19); A8 (11/26/19) and A13 (7/6/19). This review revealed the following findings:

1. The psychosocial assessments for Patients A1, A2, A4, A5, A6 and A7 included the following identical generic statement: "During the course of inpatient hospitalization, [s/he] will receive psychiatric and nursing care, recreational therapy groups, group psychotherapy and individual support."

This information failed to include what part of this treatment was to be provided by social work and the focus for the modality.

2. The psychosocial assessments failed to address the specific treatment role of social work during hospitalization for Patients A8 and A13.

B. Interview

During interview, with review of the psychosocial assessments, on 12/3/19 at 12:50 p.m., the Director of Social Work verified the above documented findings.

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs), called "Inpatient Treatment Plan," that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). Many MTPs contained similarly worded short-term goals (called objectives) for patients, which were not measurable outcome behaviors. Some of the listed goals were stated as staff expectations for the patient's participation in treatment rather than behavioral outcomes for the patient to achieve. The goal statement on the MTP lacked individualized symptoms, specific descriptors, and observable behaviors. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the MTPs in response to patient need.

Findings include:

A. Record Review:

1. Patient A1: MTP dated 11/23/19 listed the "Treatment Focus" as "Suicidal ideation [patient] states [s/he] is highly suicidal right now and has suicidal thoughts to strangle or slit wrists."

a. Short-term goal: "[Patient] will have less depression AEB [as evidenced by] talking with staff each shift in one-to-one (1:1) about my anger and how to deal with it effectively, participate in three-five (3-5) scheduled activities each day for three (3) days, and expressing anticipation of at least two (2) events in [his/her] future, as monitored by unit staff [sic]." Goal was stated as a staff expectation or treatment compliance issue rather than behavior outcomes to evaluate whether the patient's stated problem had been reduced/resolved. The scheduled activities were not identified nor the focus. "Expressing anticipation of at least two (2) events in the future" was ambiguous, thus not a measurable goal.

b. Short-term goal: "[Patient] will take initiative to notify staff, accept diversion activities, and use learned coping skills before injuring self, as monitored by inpatient staff." Goal was a staff expectation statement, not a specific, observable, measurable goal statement written in behavioral terms. The statement also failed to identify what "coping skills" the patient would be identifying to utilize. There was no objective method of verifying whether the patient would self-report ("notify staff"). Goal was a treatment compliance statement rather than a measurable goal.

2. Patient A2: MTP dated 11/23/19 listed the "Treatment Focus" as "lacerations to right wrist/forearm made with a knife, in an attempted suicide. Pt [Patent] has a hx [history] of cutting ..." A staff treatment goal written as a patient goal was stated as "In order for [Patient] to obtain stability in [his/her] depression, goal of this hospitalization is to address [his/her] imminent level of dangerousness, to increase [his/her] ability to cope with grief issues, and to stabilize [his/her] depression."

3. Patient A4: MTP dated 12/2/19 listed the "Treatment Focus" as "[Patient] admits to having felt suicidal with a plan to overdose on pills or walking into traffic. [S/he] has a history of six (6) OD [overdose] attempts in past. [S/he] has been feeling increasingly depressed in past few weeks.... states self-care has been poor, sleep is approx. [approximately] two-three (2-3) hours per night. [S/he] feels anxious and depressed and easily tearful."

a. Short-term goal: "[Patient] will have less depression AEB [as evidenced by] participating in three-five (3-5) scheduled activities each day for three (3) days, sleeping six-eight (6-8) hours for two (2) nights in a row, and expressing anticipation of at least two (2) events in [his/her] future, as monitored by staff." Goal was staff expectation statement. Not a measurable goal.

4. Patient A5: MTP dated 11/27/19 listed the "Treatment focus as symptoms related to a delusion about "man" who "tells me to do bad things." A non-measurable goal was stated as "During the course of inpatient hospitalization, [Patient's] psychotic symptoms will subside in nature, [his/her] suicidal thoughts will decrease [his/her] sleep will improve, and [s/he] will learn skills to cope more effectively with [his/her] illness."

5. Patient A6: MTP dated 12/2/19 listed the "Treatment Focus" as "Client became angry and used a plastic fork to scratch [his/her] right arm. Multiple superficial cuts three-five (3-5) inches in length...has had auditory hallucinations in the past."

a. Short-term goal: "[Patient] will attend and participate in three-five (3-5) scheduled activities each day for three (3) days, as monitored by unit staff." Goal was staff expectation statement not measurable.

b. Short-term goal: "[Patient] will take initiative to notify staff, accept diversion activities, and use learned coping skills before injuring self, as monitored by inpatient staff." Goal was staff expectation statement rather than a measurable goal. No objective method of verifying whether the patient would self-report "notify" staff. The "coping skills" to be utilized were not identified.

6. Patient A7: MTP dated 11/27/19 listed the "Treatment Focus" as " [Patient] states reason [s/he] is here is because 'I've been talking to people through telepathy. I met this [boy/girl] I seen at the hospital; [he/she] supposed to be my soul mate. People from church that I hear talk to me [sic]. They are basically watching over me.'"

a. Short-term goal: "[Patient] will be able to eat at least 75% of [his/her] meals, take [his/her] medications, and complete ADLs [activities of daily living] without continual monitoring/prompting for three (3) days in a row, as observed by unit staff." Goal was not written in behaviors to be achieved, but rather staff expectation statement.

b. Short-term goal: "[Patient] will follow simple directions or instructions from staff during any one-on-on (1:1) interactions with [him/her] with three (3) or fewer prompts, as observed by staff." Goal described routine staff function and expectation, which does not define patient improvement or lack thereof, not a measurable goal.

c. Short-term goal: "[Patient] will talk with staff and peers with reality-based, coherent conversation that is appreciated by them for three (3) days in a row, as observed by staff [sic]." Goal was stated as staff expectation.

7. Patient A8: MTP dated 12/2/19 listed the "Treatment Focus" as "severely psychotic." A staff treatment goal written as a patient goal was stated as "During the course of inpatient hospitalization, the primary goal of inpatient treatment is to reduce [Patient's] psychotic symptoms, to provide options for residential addiction treatment, and to help [him/her] to learn coping skills to function more effectively in the community."

8. Patient A13: MTP dated 11/27/19 listed the "Treatment Focus" as "driving and acting erratically. Also, report of a delusion that [s/he] is an Arabic [royalty]."

a. A non-measurable goal was stated as "During the course of inpatient hospitalization, [his/her] psychotic symptoms will stabilize, [his/her] delusional symptoms will subside, and there will be no evidence of dangerousness or grave disability."

b. Treatment compliance written as a patient goal was stated as "Will have less paranoia AEB [As Evidenced By] participation in three-five (3-5) scheduled activities each day for three (3) days, as monitored by unit staff."

B. Interview:
During interview, with review of treatment plans, on 12/3/19 at 9:50 a.m., the Director of Nursing and the Nurse Manager verified the findings related to treatment plan goals.

Based on interview and record review, the facility failed to develop Master Treatment Plans (called Inpatient Treatment Plan), that evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). Specifically, interventions were identical or similarly worded and were statements of routine generic discipline functions.

Nursing interventions failed to identify specific monitoring and preventive interventions for safety risks (suicide, self-harm, psychotic behaviors) based on individual patient behaviors presented in the clinical area. These deficiencies result in a sameness of treatment plans and result in staff being unable to provide consistent and focused active treatment.

Findings include:

A. Record Review:

The MTP for the following active sample patients were reviewed (treatment plan dates in parentheses): A1 (11/23/19); A2 (11/23/19); A4 (12/2/19); A5 (11/27/19); A6 (12/2/19); A7 (11/27/19); A8 (12/2/19) and A13 (11/27/19). This review revealed the following deficiencies related to physician, social work, nursing and recreational therapy interventions on the Master Treatment Plans.

All discipline interventions on the MTPs were identical or similarly worded despite different presenting symptoms and needs of each patient. Most interventions were statements of generic staff role functions instead of individualized interventions to assist patient to accomplish identified treatment goals. Nursing interventions failed to identify specific monitoring and preventive interventions for safety risks (suicide, self-harm, psychotic behaviors) based on individual patient behaviors presented in the clinical area. All interventions failed to include a specific and scheduled frequency of contact.

B. Interviews:

1. During interview, with review of treatment plans, on 12/3/19 at 12:00 p.m., the Director of Nursing and the Nurse Manager acknowledged that interventions were generic and verified that nursing interventions to guide staff in monitoring and preventing risk behaviors were absent.

2. During interview on 12/3/19 at 12:50 p.m., the Director of Social Work acknowledged that the interventions on all master treatment plans were generic and non-specific based on individual patient findings.

Based on document review and interview, the facility failed to provide a sufficient number of active therapy groups/activities conducted by professional health professionals (physicians, social workers, nurses and rehabilitation therapists) to meet the needs of the patient population. The majority of groups/activities were conducted by non-professional nursing assistants (technicians); these groups/ activities were more leisure-oriented or psycho-educational groups, rather than active treatment activities based on the individualized needs of the patient population. This deficient practice results in fragmented treatment for all patients in the facility and potentially delays their improvement.

Findings include:

A. Review of the weekly schedule for the certified acute adult unit provided by Administration revealed the follow information:

1. There are no scheduled therapeutic active treatment groups/activities to be conducted by professionals after 2:00 p.m. on Mondays through Fridays with the exception of one (1) RN psycho-educational group on Tuesdays, Thursdays and Saturdays.

2. There is only one (1) scheduled therapeutic active treatment group/activity group on Saturdays to be conducted by a health care professional (a RN psycho-educational group).

3. There is only one (1) scheduled therapeutic active treatment group/activity group on Sundays to be conducted by a health care professional (a Chaplain group).

All other groups/activities on the program schedule are assigned to non-professional nursing assistants (technicians).

B. Forms completed by staff that had conducted groups/activities from 11/25/19 through the first day of the survey (12/2/19) were reviewed on 12/3/19 at 11:30 a.m. with the Director of Nursing and the Nurse Manager of the certified adult patient unit. These forms revealed that for this eight (8) day period of time nine (9) of 20 or 45% of scheduled groups with professional staff assigned as leaders were canceled.

C. Interviews:

1. A group scheduled for 12/2/19 from 12:30 - 1:30 p.m. titled "Coping Skills" to be conducted by a rehabilitation therapist was canceled. At 12:50 p.m. on this date Mental Health Technician 1 (MHT 1) was interviewed about the group cancelation. MHT 1 reported that s/he understood that the assigned rehabilitation therapist was on maternity leave. S/he reported that during the past two weeks some of the groups assigned to this staff member had been cancelled.

2. During interview on 12/2/19 at 1:05 p.m., when asked about group cancellations, the Director of Social Work reported that sometimes there is "chaos" on the patient unit and "things go by the wayside."

3. During a meeting on 12/3/19 at 11:30 a.m., the findings as documented in Sections A and B above were verified by the Director of Nursing and the Nurse Manager.

Based on interview and document review, it was determined that monitoring and evaluation by the Medical Director failed to include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. Specifically the Medical Director failed to:

I. Assure that individualized Master Treatment Plans (MTPs) were developed that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). Many MTP contained similarly worded short-term goals for patients, which were not measurable outcome behaviors. Some of the listed goals were stated as staff expectations for the patient's participation in treatment rather than behavioral outcomes for the patient to achieve. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the MTPs in response to patient need. (Refer to B121)

II. Assure that Master Treatment Plans were developed that evidenced individualized treatment interventions with specific focus based on individual needs of eight (8) of (8) active sample patient (A1, A2, A4, A5, A6, A7, A8 and A13). Instead, interventions were identical or similarly worded and were statements of routine generic discipline functions. Nursing interventions failed to identify specific monitoring and preventive interventions for safety risks (suicide, self-harm, psychotic behaviors) based on individual patient behaviors presented in the clinical area. These deficiencies result in a sameness of treatment plans and result in staff being unable to provide consistent and focused active treatment. (Refer to B122)

III. Assure that a sufficient number of active therapy groups/activities were provided by professional health professionals to meet the needs of the patient population. The majority of groups/activities were conducted by non-professional nursing assistants (technicians); these groups/ activities were more leisure-oriented or psycho-educational groups, rather than active treatment activities based on the individualized needs of the patient population. In addition, many of the active treatment offerings were cancelled. This deficient practice results in fragmented treatment for all patients in the facility and potentially delays their improvement. (Refer to B125)

Based on document review and interview, the facility failed to have a Director of Nursing (DON) with a Master's Degree in Psychiatric or Mental Health Nursing, and/or documented evidence of consultation from a nurse with a Master's Degree in Psychiatric/Mental Health Nursing. This failure resulted in the facility not having a qualified nursing director to manage psychiatric/mental health nursing care for the patients.

Findings include:

A Record Review

On 12/3/19 at 2:30 p.m., the nurse surveyor reviewed the personnel record issued from the facility's Human Resources office. It was noted there was no continuing education in psychiatric nursing or any consultation with a nurse with a Master's Degree in Psychiatric/Mental Health Nursing for the entire year 2019. A computer learning class list showed one (1) class for four and a half (4.5) hours on 2/26/19 on the topic of Ethics of Supervision and two (2.0) hours on 3/19/19 on Trauma. No other education information was available for year 2019.

B. Interview

1. During an interview on 12/3/19 at 12:00 p.m., the Director of Nursing (DON) reported that she is an Associate Degree Nursing Graduate with experience in the DON position since 11/1/15. She stated she has no consultation currently with a Master's Degree nurse in Psychiatric/Mental Health Nursing.

2. During an interview on 12/3/19 at 2:50 p.m., the facility's Human Resources Director verified the above documented findings and on 12/4/19 at 9:30 a.m. provided written information supporting these findings.

Based on record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. Active treatment interventions implemented by Registered Nurses for eight (8) of (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A13) listed nursing interventions that were not routine, generic discipline functions expected to be regularly provided by nursing staff for all patients (such as, "monitoring," "assist," "encourage," "provide," written as active treatment interventions), or staff expectations/compliance statements. These failures to develop focused, individualized nursing interventions could result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122)

II. Nursing staff identified medication teaching frequency and method of delivery (group or individual session).

III. Nursing Interventions identified the specific goals being addressed.

Based on interview and document review, it was determined that monitoring and evaluation by the Director of Social Work failed to include sufficient review and corrective measures to assure compliance with necessary practices and documentation of treatment in the facility. Specifically the Director of Social Work failed to:

I. Ensure that patient assessment information included detailed psychosocial assessments with recommendations for the role of social work in the treatment of patients during hospitalization for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). This failure hindered treatment planning and continuity of treatment for the patient by social work staff. (Refer to B108)

II. Ensure that MTPs evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of (8) active sample patients (A1, A2, A4, A5, A6, A7, A8 and A13). Specifically, interventions were identical or similarly worded and were statements of routine generic discipline functions. These deficiencies result in a sameness of treatment plans and result in staff being unable to provide consistent and focused active treatment.