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Based on record review and staff interview the facility failed to ensure that the psychiatric evaluations for three (3) (A4,A5 and A7) of the eight (8) active sample patients included the patient's assets in descriptive, non-interpretive fashion. The failure to identify patient strengths impairs the treatment team's ability to choose treatment modalities which best utilize the patient's attributes in therapy.

Findings include:

Record review;

1. The psychiatric evaluation completed on 6/21/16 for patient A4, stated patient strength as "General craftiness in manipulation".

2. The psychiatric evaluation completed on7/13/16 for patient A5, stated patient strength as "Determined".

3. The psychiatric evaluation completed on 7/15/16 for patient A7, stated patient strength as "He is a sociable young boy, considerate and polite".

Staff Interview:

In a meeting and review with the medical director on 7/20/16 at 10am, the director concurred with the above identified patients assets as inadequate and further stated "we need to continue to search for strengths that are useful to treatment".

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified physician, nursing and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. Additionally some identified interventions were actually worded as if they were short-term goals. These deficiencies resulted in a lack of guidance for staff in providing individualized treatment that was purposeful, problem specific and goal directed.

Findings

A. Record Review:

Review of the sample patients' Master Treatment plans revealed the plans included generic nursing and social work interventions for the listed problems of "Depression-Grief Unresolved-Rule Out Suicidal Ideation", "Depression with Suicidal Ideations and Posttraumatic Stress Disorder (PTSD)", "Depression/Anxiety with Aggressive Behavior and Suicidal/Homicidal Ideation", "Psychosis Unspecified", "Psychosis NOS-Anxiety", "Depression with Suicidal Ideation and Aggression", and "Homicidal Ideation and Suicidal Ideations with aggression". The interventions were the same for each patient having one or more of these identified problems.

1. For problem "Depression-Grief Unresolved-Rule-out Suicidal Ideation" Patient A1 MTP dated 7/11/16 interventions stated:

Nursing: "Pt [patient] given opportunity to express grief as it manifests."

2. For problem "Depression with Suicidal Ideations and Posttraumatic Stress Disorder (PTSD)" Patient A2 MTP dated 7/14/16 interventions stated:

Physician: "To assist pt [patient] with [sic] medication and changes in mood be monitored."

Nursing: "Pt [patient] will express 3 coping skills that s/he finds effective in managing his/her moods/behaviors."

3. For problem "Depression with Suicidal Ideations and Posttraumatic Stress Disorder (PTSD)"
Patient A3 MTP dated 7/14/16 interventions stated:

Physician: "Monitor vital signs and mood changes and behavior."

Nursing: "Pt [patient] will express 3 coping skills such as meditation and deep breathing."

4. For problem "Depression/Anxiety with Aggressive Behavior and Suicidal/Homicidal Ideation" Patient A4 MTP dated 7/5/16 interventions stated:

Physician: "Adjust meds and monitor signs and symptoms and prevent seizures."

Nursing: "Check vitals, regulate and assess sleeping patterns."

5. For problem "Psychosis Unspecified" Patient A5 MTP dated 7/14/16 interventions stated:

Social Work: "Demonstrate acceptance to the client through calm, nurturing manner, good eye contact and active listening."

Nursing: "Reorient as needed. Administer medications"

6. For problem "Psychosis NOS-Anxiety" Patient A6 MTP dated 7/15/16 interventions stated:

Social Work: "Demonstrate acceptance to the client through calm, nurturing manner, good eye contact and active listening."

Nursing: "Educate patient about medication."

7. For problem "Depression with Suicidal Ideation and Aggression" Patient A7 MTP dated 7/15/16 interventions stated:

Nursing: "Monitor sleep monitor."

8. For problem "Homicidal Ideation and Suicidal Ideations with aggression" patient A8 MTP dated 7/14/16 interventions stated:

Nursing: "Monitor patient sleep pattern each night."

B. Interviews:

1. In the interview on 7/20/16 at 10:45 a.m. with the Director of Nursing, nursing interventions on the sample patients MTP's were discussed. The Director of Nursing agreed that the interventions are routine nursing staff duties and that some of the nursing interventions listed are actually short-term goals.

2. In the interview on 7/20/16 at 10:00 a.m. with the Medical Director, the physician interventions on the sample patients MTP's were discussed. The Medical Director agreed with the findings that the interventions were generic and stated, "They are not good enough. They need to focus on diagnosis and demonstrate clear goals and interventions."

3. In the interview on 7/19/16 at 2:30 p.m. with the Director of Social Work was asked about the social work interventions on the sample patients MTP's being generic and/or routine functions. The Director of Social Work agreed with the findings and stated, "There is work to be done with interventions."

Based on record review and interview this standard is not met, specifically the medical director failed to ensure that the 1) psychiatric evaluations included inventory of patient's assets that are useful in therapy for three (3) of eight (8) active sample patients [A4,A5 and A7] (Refer to B117), and 2) treatment interventions for eight (8) of eight (8) active sample patients (A1,A2,A3,A4,A5,A6,A7, and A8) identified in interdisciplinary treatment plans that are specific to identified patient problems. (Refer to B122)

In a meeting and review with the medical director on 7/20/16 at 10 a.m. the medical director concurred with the above deficiencies.

Based on interview and document review, the Nursing Director failed to ensure Master Treatment Plans (MTP) identified nursing interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. Additionally some identified interventions were actually worded as if they were short-term goals. This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation, and revision of care to reflect progress/lack towards recovery. (Refer to B122)