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Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient centered Short-Term Goals (STG) stated in observable, measurable behavioral terms for 8 of 12 active sample patients. (P1, P2, P3, B2, B3, B4, G1and G4) This lack of patient specific goals hampers the treatment team's ability to assess changes in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

Findings include:

A. Record Review

1. Patient P1 (MTP dated 2/9/17) had for the problem, "Suicidal Ideation", the STG, "[Patient] will notify staff daily if [he/she] is having thoughts or impulses to self-harm."
For the problem, "Paranoia with Psychotic Features", the MTP listed the STG, "[Patient] will be able to have a reality based conversation for 3 minutes with staff daily."

2. Patient P2 (MTP dated 2/3/17) had for the problem, "Psychosis", the STG, "[Patient] will report the presence of AH (auditory hallucinations) to staff while on the unit when they are present."

3. Patient P3 (MTP dated 1/31/17) had for the problem, "Psychosis", the STG, "[Patient] will demonstrate understanding of what is real and not real when speaking with staff daily."
For the problem, "Aggression", the MTP listed the STG, "[Patient] will seek out staff [she/he] trusts when feelings of aggression are present."

4. Patient B2 (MTP dated 2/12/17) had for the problem, "Psychosis", the STG, "[Patient] will have a (positive) social interaction with staff or peer for 5 minutes."

5. Patient B3 (MTP dated 2/10/17) had for the problem, "Suicidal Ideations", the STG, "[Patient] will report to staff when [he/she] is experiencing thoughts of self harm."

6. Patient B4 (MTP dated 2/5/17) had for the problem, "Mood Instability", the STG, "[Patient] will report to staff if [he/she] feels depressed."

7. Patient G1 (MTP dated 2/3/17) had for the problem, "Psychosis", the STG, "[Patient] will express increased feelings of safety and decreased paranoia."

8. Patient G4 (MTP dated 2/6/17) had for the problem, "Psychosis", the STG, "[Patient] will display increased attention to things and people around [him/her]."

B. Policy Review

The facility policy titled "Treatment Planning" with the last revision date of 1/17, stated that " ...long term goals are then broken down into shorter term individual objectives, describing the measurable, logical progression of appropriate steps the individual agrees to take toward achievement of the long-term goal(s)."

C. Interview

In interview on 2/14/17 at 10:00 AM, RN3 and the Director of Nursing agreed that the Short-Term Goals identified by the surveyors were not written as observable, measurable goals.