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Based on record review, interviews and policy review, the facility failed to develop and document master treatment plans (MTPs) that included treatment interventions by psychiatrists for 6 of 8 active sample patients (A1, A2, A3, B1, C1 and C2) and group therapy interventions for 4 of 8 active sample patients(A1, A4, B1 and C1). These failures result in lack of guidance for staff in providing psychiatric care and a lack of coordination between different treatment modalities.

Findings include:

A. Record Review:

1. Patient A1 was diagnosed with schizoaffective disorder and treated with Abilify and Geodon according to his psychiatric evaluation (PE) dated 4/12/11, psychiatrist progress notes (PPNs) 4/13/11-4/24/11 and medication administration record (MAR) dated 4/24/10. His MTP dated 4/12/11 did not include any psychiatric interventions. According to group participation flow sheets, dated 4/13-4-16/11, patient A1 was expected to be in various group therapies daily. However, no group therapy interventions were listed on his MTP.

2. Patient A2 was diagnosed with major depressive disorder and treated with Paxil according to her PE dated 4/18/11, PPNs 4/19/11-4/24/11 and MAR dated 4/20/11. Her MTP dated 4/19/11 did not include any psychiatric interventions.

3. Patient A3 was diagnosed with major depressive disorder with psychotic features and panic disorder. He was treated with Remeron and Klonopin according to his PE dated 4/20/11, PPNs 4/21/11-4/24/11 and MAR dated 4/24/11. His MTP dated 4/20/11 did not include any psychiatric interventions.

4. Patient A4 was diagnosed with bipolar disorder. According to group participation flow sheets, dated 4/7/-4/9/11, patient A4 was expected to be in various group therapies daily. Her MTP dated 4/7/11 did not include any group therapy interventions.

5. Patient B1 was diagnosed with bipolar disorder and treated with Geodon and Celexa according to his PE dated 4/22/11, PPNs dated 4/24/11 and MAR dated 4/24/11. His MTP dated 4/23/11 did not include any psychiatric interventions. According to group participation flow sheets dated 4/24/11, he was expected to be in various group therapies daily. His MTP did not include any group therapy interventions.

6. Patient C1 was diagnosed with chronic paranoid schizophrenia and treated with Seroquel and Abilify according to his PE dated 4/18/11. PPNs 4/20/11-4/24/11 and MAR dated 4/24/11. His MTP dated 4/18/11 did not include any psychiatric interventions. According to group participation flow sheets dated 4/19/11 - 4/21/11, he was expected to be in various group therapies daily. His MTP did not include any group therapy interventions.

7. Patient C2 was diagnosed with psychotic disorder, NOS and depressive disorder. She was treated with Prozac and Olanzapine according to her PE dated 4/5/11, PPNs 4/6/11-4/24/11 and MAR dated 4/24/11. Her MTP dated 4/4/11 did not include any psychiatric interventions.

B. Interviews:

1. In an interview on 4/26/11 at 9:00a.m., the Medical Director acknowledged that the treatment plans did not include psychiatric interventions.

2. In an interview on 4/26/11 at 10:00a.m., the Director of Nursing Services and the Program Manager acknowledged that treatment plans did not include psychiatric interventions and group therapy interventions.

3. In an interview with the Activity Manager on 4/26/11 at 1:15PM, she stated that activity staff "provide two groups daily but we do not participate in treatment planning."

Based on observation, record review, policy review and interviews, the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the medical staff.

Specifically the Medical Director failed to:

I. Ensure that psychiatric interventions were identified in the master treatment plans for 6 of 8 active sample patients (A1, A2, A3, B1, C1 and C2). These failures result in lack of guidance for staff in providing psychiatric care and a lack of coordination between different treatment modalities.

Findings include:

A. Record Review:

1. Patient A1 was diagnosed with schizoaffective disorder and treated with Abilify and Geodon according to his psychiatric evaluation (PE) dated 4/12/11, psychiatrist progress notes (PPNs) 4/13/11-4/24/11 and medication administration record (MAR) dated 4/24/10. His MTP dated 4/12/11 did not include any psychiatric interventions.

2. Patient A2 was diagnosed with major depressive disorder and treated with Paxil according to her PE dated 4/18/11, PPNs 4/19/11-4/24/11 and MAR dated 4/20/11. Her MTP dated 4/19/11 did not include any psychiatric interventions.

3. Patient A3 was diagnosed with major depressive disorder with psychotic features and panic disorder. He was treated with Remeron and Klonopin according to his PE dated 4/20/11, PPNs 4/21/11-4/24/11 and MAR dated 4/24/11. His MTP dated 4/20/11 did not include any psychiatric interventions.

4. Patient B1 was diagnosed with bipolar disorder and treated with Geodon and Celexa according to his PE dated 4/22/11, PPNs dated 4/24/11 and MAR dated 4/24/11. His MTP dated 4/23/11 did not include any psychiatric interventions.

5. Patient C1 was diagnosed with chronic paranoid schizophrenia and treated with Seroquel and Abilify according to his PE dated 4/18/11. PPNs 4/20/11-4/24/11 and MAR dated 4/24/11. His MTP dated 4/18/11 did not include any psychiatric interventions.

6. Patient C2 was diagnosed with psychotic disorder, NOS and depressive disorder. She was treated with Prozac and Olanzapine according to her PE dated 4/5/11, PPNs 4/6/11-4/24/11 and MAR dated 4/24/11. Her MTP dated 4/4/11 did not include any psychiatric interventions.

B. Interviews:

1. In an interview on 4/26/11 at 9:00a.m., the Medical Director acknowledged that the treatment plans did not include psychiatric interventions.

2. In an interview on 4/26/11 at 10:00a.m., the Director of Nursing Services and the Program Manager acknowledged that treatment plans did not include psychiatric interventions.

II. Ensure that group therapy interventions were identified in the master treatment plans for 4 of 8 active sample patients (A1, A4, B1 and C1).This failure may delay treatment effectiveness with a lack of input into interdisciplinary treatment planning by activity therapy staff and deprive patients of important, individualized physical and mental activities to help alleviate symptoms of mental illness.

Findings include:


A. Record Review:

1. According to group participation flow sheets, dated 4/13-4-16/11, patient A1 was expected to be in various in group therapies daily. However, no group therapy interventions were listed on his MTP.

2. According to group participation flow sheets, dated 4/7/-4/9/11, patient A4 was expected to be in various group therapies daily. Her MTP dated 4/7/11 did not include any group therapy interventions.

3. According to group participation flow sheets dated 4/24, patient B1 was expected to be in various group therapies daily. His MTP did not include any group therapy interventions.

4. According to group participation flow sheets dated 4/19-21/11, patient C1 was expected to be in various group therapies daily. His MTP did not include any group therapy interventions.

B. Interviews:

1. In an interview on 4/26/11 at 10:00a.m., the Director of Nursing Services and the Program Manager acknowledged that treatment plans did not include group therapy interventions.

2. In an interview with the Activity Manager on 4/26/11 at 1:15PM, she stated that activity staff "provide two groups daily but we do not participate in treatment planning."

III. Ensure that activity therapy staff were included in the treatment planning process. There were no activity therapy assessments found in 8 of 8 active medical records reviewed (A1, A2, A3, A4, B1, B2, C1, and C2). Activity therapy staff did not attend treatment planning meetings. This failure may delay treatment effectiveness with a lack of input into interdisciplinary treatment planning by activity therapy staff and deprive patients of important, individualized physical and mental activities to help alleviate symptoms of mental illness.

Findings include:

A. Observation

During an observation on 4/25/11 at 2:05PM, a treatment team meeting was observed on the Adult Unit II in a group/interview room. There was no activity therapy staff member present in the meeting.

B. Record Review

1. For Patient A1, admitted 4/12/11, there was no therapeutic activity assessment on the chart.

2. For Patient A2, admitted 4/18/11, there was no therapeutic activity assessment on the chart.

3. For Patient A3, admitted 4/20/11, there was no therapeutic activity assessment on the chart.

4. For Patient A4, admitted 4/6/11, there was no therapeutic activity assessment on the chart.

5. For Patient B1, admitted 4/22/11, there was no therapeutic activity assessment on the chart.

6. For Patient B2, admitted 4/23/11, there was no therapeutic activity assessment on the chart.

7. For Patient C1, admitted 4/18/11, there was no therapeutic activity assessment on the chart.

8. For Patient C2, admitted 4/4/11, there was no therapeutic activity assessment on the chart.

C. Policy Review


In the "Nursing Policy and Procedure Manual," "Treatment Plan Protocol" (last reviewed 03/10), the "Policy" is "...Hospital shall provide for high quality treatment throughout the entire continuum of care. This is accomplished through the treatment planning process." In the section "Responsible Party," the "Admitting RN" is responsible for "Individualization of the treatment plan includes using cultural, spiritual, age-specific, biological, psychological, and social evaluation by all [italics added] members of the treatment team within seventy-two (72) hours."

D. Interview

In an interview on 4/26/11 at 1:15PM, the Activity Manager stated that no activity therapy assessments are done and that "we provide two activity groups a day but do not do assessments." "We have not been invited to attend treatment planning meetings."

Based on observation, record review, and interview the facility failed to assure that activity therapy staff provided individual therapeutic activity assessments or attended treatment team planning meetings for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, C1, and C2). There were no activity therapy interventions on 4 of 8 master treatment plans (MTPs) reviewed (A1, A4, B1, and C1). This failure may delay treatment effectiveness with a lack of input into interdisciplinary treatment planning by activity therapy staff and deprive patients of important, individualized physical and mental activities to help alleviate symptoms of mental illness.

Findings include:

A. Observation
During an observation on 4/25/11 at 2:05PM, a treatment team meeting was observed on the Adult Unit II in a group/interview room. There was no activity therapy staff member present in the meeting.

B. Record Review

The following information was found in the medical records on 4/25/11.

1. For Patient A1, admitted 4/12/11, there was no therapeutic activity assessment on the chart. There was no activity therapy intervention listed on the MTP dated 4/12/11.

2. For Patient A2, admitted 4/18/11, there was no therapeutic activity assessment on the chart.

3. For Patient A3, admitted 4/20/11, there was no therapeutic activity assessment on the chart.

4. For Patient A4, admitted 4/6/11, there was no therapeutic activity assessment on the chart.
There was no activity therapy intervention listed on the MTP dated 4/7/11.

5. For Patient B1, admitted 4/22/11, there was no therapeutic activity assessment on the chart.
There was no activity therapy intervention listed on the MTP dated 4/23/11.

6. For Patient B2, admitted 4/23/11, there was no therapeutic activity assessment on the chart.

7. For Patient C1, admitted 4/18/11, there was no therapeutic activity assessment on the chart.
There was no activity therapy intervention listed on the MTP dated 4/18/11.

8. For Patient C2, admitted 4/4/11, there was no therapeutic activity assessment on the chart.

C. Interview

In an interview on 4/26/11 at 1:15PM, the Activity Manager stated that no activity therapy assessments are done and that "we provide two activity groups a day but do not do assessments." "We have not been invited to attend treatment planning meetings."