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Based on document review, observation and interview, the facility failed to ensure appropriate appraisal of an emergency in one instance.

Findings include:

1. Review of facility policy, Walk-In Emergency Services Policy, last approved 01/2019, indicated the following. If a patient arrives at the NeuroDiagnostic Institute requesting emergency medical or psychiatric assistance, security will call the RN (Registered Nurse) who is serving as house supervisor.

2. On 5/22/2019, at approximately 9:02 am, with staff N9 (Security Officer) at the entrance lobby desk the following was observed. A car pulls up to the entrance doors. An individual ask for the emergency room. N9 directs the individual to another facility's emergency department. The individual does not understand the directions. N9 walks outside and directs the individual to another facility's emergency department.

3. Interview on 5/22/2019, at approximately 9:46 am, N9 confirmed that he/she directed individual to another facility's emergency department. N9 confirmed he/she had no official training in assessing emergency patients.

4. Interview on 5/22/2019, at approximately 10:03 am, with staff N11 (Security Manager) confirmed he was not aware of policy to call a RN supervisor to assess emergency patients when they arrive. He/she indicated that upon first opening they received approximately 200 cases a month of people pulling up to entrance doors looking for emergency room.

Based on document review and interview, the facility failed to ensure documentation related to behavior that warrented restraint in 1 of 22 medical records (MR) (patient 7's) reviewed.

Findings include:

1. Review of facility policy, Seclusion and Restraint Policy, Last Approved, 04/2019, indicated the following. When restraint or seclusion is used, there must be documentation in the patient's medical record of the following... The patient's condition or symptom(s) that warranted the use of the restraint or seclusion...

2. Review of patient 7's MR lacked documentation of the patient's condition or symptom(s) that warranted the use of the restraint or seclusion.

3. Interview on 5/22/2019, at approximately 12:45 pm, with staff N1 (Director of Nursing) confirmed the above.

Based on document review and interview, the facility failed to ensure orders were carried out for 1 of 22 medical records (MR) (patient 5's) reviewed.

Findings include:

1. Review of facility policy, Chart Check for New Physician Orders, Last Revised 05/2019, indicated the following. New orders that have not been initiated and addressed are to be initiated and addressed immediately by the nurse.

2. Review of patient 5's MR indicated CMP Routine Blood (Comprehensive metabolic panel), CBC w/ Diff Routine Blood (Complete Blood Count with differential) and a Lipid Pnl Routine Blood (Lipid Panel) were ordered on 04/17/19. The orders were still pending on 5/22/2019.

3. Interview on 5/22/2019, at 13:19, staff N1 (Director of Nursing) confirmed the above.

Based on document review and interview, the facility failed to ensure appropriate documentation of history and physical (H&P) in 6 of 22 medical records (MR) (patients 4, 6, 9, 11, 12 and 19's) reviewed.

Findings include:

1. Review of facility policy, Medical Records Documentation, Last Approved 05/2019, indicated the following. Physical Examination... Examination elements must include... Temperature... Pulse... Respiration... Blood Pressure...

2. Review of patients 4, 6, 9, 11, 12 and 19's MR H&Ps lacked vital signs.

3. Interview on 5/22/2019, with staff N6 at approximately 11:52 am, confirmed patient 4's MR H&Ps lacked vital signs.

4. Interview on 5/22/2019, with N6 at approximately 13:27 am, confirmed patient 6's MR H&Ps lacked vital signs.

5. Interview on 5/22/2019, with N6 at approximately 13:43 am, confirmed patient 9's MR H&Ps lacked vital signs.

6. Interview on 5/22/2019, with staff N5 at approximately 14:07 am, confirmed patient 11's MR H&Ps lacked vital signs.

7. Interview on 5/22/2019, with staff N6 at approximately 14:09 am, confirmed patient 12's MR H&Ps lacked vital signs.

8. Interview on 5/22/2019, with N5 at approximately 15:14 am, confirmed patient 19's MR H&Ps lacked vital signs.

Neurodiagnostic Institute was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies.

This seven story facility with a basement and a penthouse was determined to be of Type I (332) construction and was partially sprinklered. The facility has a fire alarm system with hard wired smoke detectors in the corridor and in spaces open to the corridor. The facility has a capacity of 159 and had a census of 45 at the time of this survey.

All areas where patients have customary access were sprinklered except for the alcoves for drinking water dispensers on the third floor near the southwest dining area, the west alcove on the third floor, the alcove by Room E651 on the sixth floor and the alcove on the seventh floor in the northeast wing. All areas providing facility services were fully sprinklered.

Based on document review, observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy (see tag K131), to ensure 1 of 3 exit passageways serving as a discharge from a stair enclosure was in accordance with LSC 18.2.2.7 (see tag K227), to maintain protection of 2 of 3 interior stairwells. LSC 18.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier (see tag K311), to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. Interface equipment such as elevator recall and elevator shutdown shall be installed, tested and maintained in accordance with NFPA 72 (see tag K345), to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected (see tag K345), to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.5 (see tag K347), to ensure closets in 4 of over 5 alcoves for drinking water dispensers were provided with an automatic sprinkler to ensure sprinkler coverage in all portions of the building (see tag K351), to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.1(1) (see tag K361), to ensure openings through 2 of 8 ceiling smoke barriers were protected to maintain the fire resistance rating of the smoke barrier (see tag K372), to ensure 5 of over 22 smoke barrier doors were provided with an astragal, rabbet or bevel (see tag K374), to ensure fire-rated vision panels were installed in 1 of over 22 smoke barrier doors in the facility (see tag K379), the facility failed to maintain testing of 5 of 5 elevator firefighter recall in accordance with 9.4.6, Elevator Testing (see tag K531), and to ensure annual inspection and testing of 33 of 33 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 tag K761).

The cumulative effect of these systemic problems resulted in the hospital'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.

1. Based on document review, observation and interview, the facility failed to ensure a safe environment in one seclusion room's entrance area (Unit 7 East).

2. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. Interface equipment such as elevator recall and elevator shutdown shall be installed, tested and maintained in accordance with NFPA 72. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect over three patients, staff and visitors.

3. Based on record review, observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants.

4. Based on record review, interview and observation, the facility failed to maintain testing of 5 of 5 elevator firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with firefighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice could affect all patients, staff and visitors in the facility.

5. Based on observation, records review, and interview, the facility failed to ensure annual inspection and testing of 33 of 33 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:
(a) No open holes or breaks exist in surfaces of either the door or frame.
(b) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(c) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(d) No parts are missing or broken.
(e) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(f) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(g) If a coordinator is installed, the inactive leaf closes before the active leaf.
(h) Latching hardware operates and secures the door when it is in the closed position.
(i) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(j) No field modifications to the door assembly have been performed that void the label.
(k) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.



Findings include:

1. a. Review of facility policy, Environmental Safety Survey, last revised 12/2018, indicated to establish procedures for monitoring patient care units for general safety, infection prevention, hazardous materials & waste, and fire safety issues... The Unit Director will be responsible for completing one of the monthly Environmental Safety Surveys each month... Electrical cords, covers, and receptacles in good condition.

b. On 5/20/2019, at approximately 3:56 pm, on Unit 7 East with staff N5 (Associate Director of Nursing) the following was observed. The seclusion room's entrance area had multiple wires hanging out of an electrical outlet.

c. Interview on 5/20/2019, at approximately 3:56 pm, with N5 confirmed the above. N5 stated this was an ongoing issue.

2. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, electronic shunt trip fire alarm system interface equipment monitoring devices for Elevator 2 was listed as "out" on control panels in the first floor emergency command center for this high-rise building. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the fire alarm system interface equipment for Elevator 2 was not working properly and is scheduled for repair.

3. Based on record review with the Executive Physical Plant Director on 05/20/19 at 11:15 a.m., the initial fire alarm system testing report was dated 03/11/19 by SafeCare. The report indicated "all tested devices are working properly. Based on observations during a tour of the facility, the following was noticed:
a) Room W 534 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
b) Room W 551 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
c) Room W 552 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
d) Room E 534 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
e) Room E 562 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
f) The west stairwell smoke detector mounted on the ceiling of the landing had the initial orange dust cover still installed on the detector.

Based on interview at the time of each observation, the Maintenance Supervisor acknowledged each above mentioned smoke detector as having the orange dust cover as being in place on the smoke detector, and stated that she would have the dust cover removed by her staff as soon as she could have them get the necessary items to have them remove the dust covers.

4. Based on record review with the Executive Physical Plant Director on 05/21/19 at 9:00 a.m., documentation for the monthly firefighter recall testing was not available for review for all five of the facility elevators. Based on observations with the Executive Physical Plant Director and the Maintenance Supervisor during a tour of the facility from 11:00 a.m. to 3:04 p.m. on 05/20/19 and again on 05/21/19 from 9:02 a.m. to 12:18 p.m., the facility had a total of five elevators, all with the firefighter recall ability. Based on interview at the time of record review, the Executive Physical Plant Director acknowledged the lack of documentation for monthly firefighter emergency operations recall testing on all facility elevators.

5. Based on record review with the Executive Physical Plant Director on 05/21/19 at 9:00 a.m., no annual inspection of the fire door assembly documentation was available for review. Based on observations with the Executive Physical Plant Director and the Maintenance Supervisor during a tour of the facility from 11:00 a.m. to 3:04 p.m. on 05/20/19 and again on 05/21/19 from 9:02 a.m. to 12:18 p.m., there were at least 21 sets of fire door assemblies throughout the facility that needed to have a documented annual fire door assemble inspection. Based on interview at the time of records review, the Executive Physical Plant Director stated an annual inspection was not conducted for the fire door assemblies and confirmed the aforementioned doors were all in a one or two hour fire barrier.

1. Based on observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect 10 patients, staff, and visitors on the second floor.

2. Based on document review, observation and interview; the facility failed to ensure 1 of 3 exit passageways serving as a discharge from a stair enclosure was in accordance with LSC 18.2.2.7. LSC 18.2.2.7 states exit passageways complying with 7.2.6 shall be permitted. LSC 7.2.6.3 states an exit passageway that serves as a discharge from a stair enclosure shall have not less than the same fire resistance an opening protection rating as those required for the stair enclosure. This deficient practice could affect over 20 patients and staff if utilizing the center stairwell exit passageway on the first floor.

3. Based on observation and interview, the facility failed to maintain protection of 2 of 3 interior stairwells. LSC 18.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.6.5 states see 7.1.3.2.1 for enclosures of exits. LSC 7.1.3.2.1 states the separation shall have a minimum 2-hr fire resistance rating where the exit connects four or more stories. Existing penetrations shall be protected in accordance with 8.3.5. This deficient practice could affect over 20 patients, staff and visitors.

4. Based on observation and interview, the facility failed to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.5. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5 (see also 18.2.5.4), unless otherwise permitted by one of the following:
(A) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.
(B) Waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
(C)*This requirement shall not apply to spaces for nurses' stations.
(D) Gift shops not exceeding 500 ft2 (46.4 m2) shall be permitted to be open to the corridor or lobby.
(E) In a limited care facility, group meeting or multipurpose therapeutic spaces shall be permitted to open to the corridor, provided that all of the following criteria are met:
(a) The space is not a hazardous area.
(b) The space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the space is arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.
(c) The space does not obstruct access to required exits.
(F) Cooking facilities in accordance with 18.3.2.5.3.
This deficient practice could affect over 20 patients and staff.

5. Based on observation and interview, the facility failed to ensure closets in 4 of over 5 alcoves for drinking water dispensers were provided with an automatic sprinkler to ensure sprinkler coverage in all portions of the building. This deficient practice could affect over 20 patients, staff and visitors.

6. Based on observation and interview, the facility failed to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.1(1). LSC 18.3.6.1(1) states that spaces shall be permitted to be unlimited in area and open to the corridor provided that all of the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, and hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurse's station or a similar space.
(d) The space does not obstruct access to required exits.
This deficient practice could affect over 20 patients and staff.

7. Based on observation and interview, the facility failed to ensure openings through 2 of 8 ceiling smoke barriers were protected to maintain the fire resistance rating of the smoke barrier. LSC 18.3.7.3 states smoke barriers shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating unless, otherwise permitted. This deficient practice could affect patients and staff.

8. Based on record review, observation and interview; the facility failed to ensure 5 of over 22 smoke barrier doors were provided with an astragal, rabbet or bevel. This deficient practice could affect over 30 residents, staff and visitors in the vicinity of the fire barrier door set by the new administrative office wing.

9. Based on record review, observation and interview; the facility failed to ensure fire-rated vision panels were installed in 1 of over 22 smoke barrier doors in the facility. LSC Section 18.3.7.10 states vision panels in doors in smoke barriers shall be of fire-rated glazing in approved frames. This deficient practice could affect over 10 patients, staff and visitors.

Findings include:

1. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, the minimum two-hour fire rated construction for the occupancy separation wall between the adjoining Community Hospital and the first floor of the facility was not maintained. At the southwest fire barrier door set on the first floor, drywall only extended for one foot above the suspended ceiling and left exposed metal studs which extended another six inches above the drywall. Exposed concrete block which had been the exterior wall for Community Hospital extended another six feet above the metal studs. In addition, the west door in the southwest fire barrier door set on the first floor failed to self close and latch into the door frame when tested to close multiple times. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the occupancy separation wall did not extend to the deck of the floor above leaving exposed metal studs and concrete which failed to maintain a minimum two-hour fire rated construction for the southwest tenant separation wall on the first floor.

2. Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, the center stairwell exit discharge on the first floor does not exit directly to the public way but into an internal passageway which is not protected with the same fire resistance rating of the center stairwell vertical opening. Based on the facility blueprints, the north wall and the west wall which forms an 'L' shaped wall directly west of the stairwell exit door on the first floor were not rated at a minimum 2-hour fire resistance rating. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, "Smoke Barrier" was printed above the suspended ceiling on the north wall and the west wall which forms an 'L' shaped wall directly west of the center stairwell exit door on the first floor. In addition, exposed metal studs were noted above the suspended ceiling in the south wall of the center stairwell exit passageway west of the center stairwell exit door on the first floor. The south wall of the passageway is an exterior wall of the facility. Based on interview at the time of record review and of the observations, the Executive Physical Plant Director stated he was not certain if the exit passageway was constructed per the blueprints and all walls in the exit passageway were constructed with not less than the same fire resistance required for the center stairwell enclosure.

3. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the west stairwell on the first floor was not firestopped.
b. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the center stairwell on the sixth floor was not firestopped.
c. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the west stairwell on the sixth floor was not firestopped.
d. The annular space surrounding a structural support in the center stairwell in the penthouse was not firestopped.
Based on interview at the time of the observations, the Executive Physical Plant Director agreed it could not be assured the two interior stairwells were enclosed with a minimum 2-hr fire resistance rating.

4. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. A non fire rated rolling door was noted in the corridor wall to the Nourishment Room identified as Room E353 on the third floor. The Nourishment Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
b. A non fire rated rolling door was noted in the corridor wall to the Med Room on the third floor. The Med Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
c. A non fire rated rolling door was noted in the corridor wall to the Nutrition Room on the seventh floor. The Nutrition Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
Based on interview at the time of observations, the Executive Physical Plant Director agreed the aforementioned rooms were open to the corridor and not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.

5. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the alcoves for drinking water dispensers on the third floor near the southwest dining area, the west alcove on the third floor, the alcove by Room E651 on the sixth floor and the alcove on the seventh floor in the northeast wing were not sprinklered. Based on interview at the time of the observations, the Physical Plant Director agreed the aforementioned locations did not have sprinkler coverage.

6. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. A non fire rated rolling door was noted in the corridor wall to the Nourishment Room identified as Room E353 on the third floor. The Nourishment Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
b. A non fire rated rolling door was noted in the corridor wall to the Med Room on the third floor. The Med Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
c. A non fire rated rolling door was noted in the corridor wall to the Nutrition Room on the seventh floor. The Nutrition Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
Based on interview at the time of observation, the Executive Physical Plant Director agreed the aforementioned rooms were open to the corridor and not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.

7. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the alcoves for drinking water dispensers on the third floor near the west dining area and on sixth floor by Room E651 did not have a ceiling smoke barrier which exposed the unprotected decking of the floor above. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the aforementioned locations did not have a ceiling smoke barrier which exposed the unprotected decking of the floor above and did not maintain the 1-hour fire resistance rating of the ceiling smoke barrier.

8. Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, each story is divided into at least two smoke compartments from outside wall to outside wall with smoke barrier walls and doors. Floor plans were provided by the facility indicating the location of smoke barrier walls and doors on each floor. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following sets of swinging smoke barrier doors in smoke barrier walls were not equipped with an astragal, rabbet or bevel at the meeting edges of the steel doors which caused a gap in between the meeting edges of the doors when in the fully closed position:
a. In the first floor lobby by the center elevator lobby.
b. In the south corridor on the first floor by the locker room.
c. On the third floor by the center stairwell.
d. On the sixth floor near the center stairwell.
e. On the seventh floor near the center stairwell and by Room W732.
Based on interview at the time of the observations, the Executive Physical Plant Director agreed the aforementioned smoke barrier door sets were not provided with an astragal, rabbet or bevel.

9. Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, each story is divided into at least two smoke compartments from outside wall to outside wall with smoke barrier walls and doors. Floor plans were provided by the facility indicating the location of smoke barrier walls and doors on each floor. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, a fire-rated vision panel was not installed in the single leaf smoke barrier door for Room C300 in the smoke barrier wall near the center elevator lobby on the third floor. The door was identified as being in the smoke barrier wall based on the review of facility blueprint documentation and the provided floor plans. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the door to Room C300 was in the third floor smoke barrier wall and was not provided with a fire-rated vision panel.

Based on document review, observation and interview, the facility failed to ensure implementation of infection control procedures in one facility.

Findings include:

1. Review of facility policy, Environmental Safety Survey, last revised 12/2018, indicated to establish procedures for monitoring patient care units for general safety, infection prevention, hazardous materials & waste, and fire safety issues... The Unit Director will be responsible for completing one of the monthly Environmental Safety Surveys each month... ...Emergency Life Support equipment available and in good repair (CPR Mask [Cardiopulmonary Resuscitation], Ambu-bag (parent ventilator), 02 Tubing[oxygen tubing], Oxygen > 500 psi [greater than 500 pounds per square inch)... Clean linens are stored in: covered carts, closed cabinets or curtain (s) drawn.

2. On 5/20/2019, at approximately 1:52 pm, on unit 3 West, with staff N5 (Associate Director of Nursing) the following was observed. Clean uncovered linen stored in the same room as dirty linen.

3. Interview on 5/20/2019, at approximately 1:52 pm, with N5 (Associate Director of Nursing) confirmed the above.

4. On 5/20/2019, at approximately 3:17 pm, on the unit 4 East, with staff N6 (Associate Director of Nursing) the following was observed.
Emergency response box contained Purple Nitrile Sterile gloves 1 size 6-6 1//2 lot number Sm51613XX and 1 size 8-8 1/2 SM51635XX, in yellowed packaging.

5. Interview on 5/20/2019, at approximately 3:17 pm, on the unit 4 East, with N6 confirmed the above.

6. On 5/20/2019, at approximately 3:33 pm, on the 6th floor, with N6 the following was observed. The stair landing exiting the gym was covered in dust balls.

7. Interview on 5/20/2019, at approximately 3:33 pm, on the 6th floor, with N6 confirmed the above.

Based on record review, observation and staff interview it was determined that the facility failed to ensure that:

1. Master Treatment Plans were dated correctly, that Problems were identified in behavioral fashion, that goals that were behaviorally measurable, that modalities that were more than generic discipline functions, and that responsible staff were identified correctly for the modalities selected. (See B118, B121, B122 and B123 for details)

2. Active treatment was conducted and documented by Recreational staff on evenings and weekends. (See B125 for details)

3. Psychosocial Assessments contained a description of the role of the social work staff in discharge planning. (See B108 for details)

4. Physical examinations contained vital sign data that supported the diagnoses given. (See B120 for details)

5 .Discharge Summaries contained a description of the patient at the time of discharge. (See B135 for details)

Based on record review and staff interview, it was determined that Psychosocial Assessments for six (6) of eight (8) patients (Patients B, C, D, F, G and H) failed to contain a description of the anticipated efforts social work staff would pursue in discharge planning. This failure resulted in no information being made available to the other members of the multidisciplinary treatment team about the social service staff's anticipated efforts. The findings include:

A. Record Review:

1. Patient B: The Psychosocial Assessment dated 4/26/19 had no information concerning what anticipated efforts, contacts, possible placement sites, etc. were going to be pursued by the social service staff.

2. Patient C: The Psychosocial Assessment dated 4/17/19 stated "Mental health education will be provided to patient and [his/her] family" as the sole description of the anticipated efforts of the social service staff.

3. Patient D: The Psychosocial Assessment dated 5/15/19 stated "SW (Social Worker) will provide assistance with helping (Patient D) reach [his/her] treatment goals while [he/she] is at NDI (Neurodiagnostic Institute) and provide family support and education."

4. Patient F: The Psychosocial Assessment dated 4/22/19 had no information concerning what anticipated efforts, contacts, possible placement sites etc. were going to be pursued by the social service staff.

5. Patient G: : The Psychosocial Assessment dated 3/01/19 had no information concerning what anticipated efforts, contacts, possible placement sites, etc. were going to be pursued by the social service staff.

6. Patient H: The Psychosocial Assessment dated 2/28/19 had no information concerning what anticipated efforts, contacts, possible placement sites, etc. were going to be pursued by the social service staff.

B. Staff Interview:

On 5/21/19 at 11:10 a.m. the Director of Social Work was interviewed. After examining the Psychosocial Assessments of Patients B, C, G and H, the Director agreed that they failed to include the anticipated efforts of the social service staff in discharge planning.

Based on record review and staff interview it was determined that the Psychiatric Evaluations for three (3) of eight (8) patients (Patients A, B and H) failed to include a description of patient assets in descriptive rather than interpretive fashion. This failure resulted in no information being available to the other members of the multidisciplinary treatment team about what interests, accomplishments, or other personal assets might be utilized in the selection of treatment modalities.

The findings include:

A. Record Review:

1. Patient A: The Psychiatric Evaluation dated 11/26/19 had no description of patient assets.

2. Patient B: The Psychiatric Evaluation dated 4/25/19 stated as the patient's assets "Family involvement, Optimism, Support system."

3. Patient H: The Psychiatric Evaluation dated 2/14/19 had no description of patient assets.

B. Staff Interview:

On 5/22/19 at 9:00 a.m. the psychiatrist/Clinical Director was interviewed. The absence of an assessment of patient assets was a partial focus of the interview. The clinical director agreed with the findings and the need for Psychiatric Evaluations to contain the information.

Based on record review and staff interview it was determined that the Master Treatment Plans for eight (8) of eight (8) patients (A, B, C, D, E, F, G and H) failed to include:

1. The date of the establishment of the Master Treatment Plan.
On 5/20/19 at approx. 4:00 p.m. Line Service Manager#1 was asked to identify the precise date of the 8 MTPs. The difficulty arose from the multiple computer generated inputs by various treatment team members on different occasions from the date stated on the MTPs.

2. Identification of a Problem stated in an "as evidenced by" manner that described what exactly the patient's behaviors were that the treatment team was setting up goals and treatment interventions to address.

3. Substantiated diagnoses (For details, See B120)

4. Goals defined in a behaviorally measurable manner. (For details, See B121)

5. Selected treatment modalities that were more than generic disciplinary tasks and that were patient specific. For details, See B122)

6. Identification of responsible staff for the treatment modalities selected and ensure the staff held responsible belonged to the appropriate discipline. (For details, See B123)

Based on record review and staff interview it was determined that for seven (7) of eight (8) patients (Patients B, C, D, E, F, G and H) the Physical Examination failed to include a description of the patient's Vital Signs. This absent information makes it impossible to substantiate diagnoses.

The findings include:

A. Record Review:

1.The following patient History and Physical Examinations (date of performance in parenthesis) all lacked Vital Sign information on the electronic document for physical findings. Patient B(4/25/19), C(4/16/19), D(5/14/19), E(4/29/19), F(4/22/19), G(3/5/19) and H(5/15/19).

2. Patient F, a 16 year old, was diagnosed as "Morbidly Obese," yet the Physical Exam did not record the weight, the height, etc. upon which the diagnosis was based. Unit staff reported Patient F weighed under 400 lbs. In the Treatment Review of Patient F on 5/21/19 at 10:00 a.m. it was reported that there was currently an approximate 2 lb. loss per week.

B. Staff Interview:

On 5/22/19 at 9:00 a.m. the Clinical Director was interviewed. A partial focus was the lack of Vital Signs in the Physical Exam. The clinical director agreed this information was basic to substantiating a diagnosis.

Based on record review and interview, the facility failed to provide Treatment Plans that identified patient-related short-term goals. The long-term-goals (LTG) that were identified were not stated in observable, measurable and behavioral terms for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). This failure hindered the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to the failure of the team to modify plans in response to patient needs and lead to prolonged hospitalization.

Findings include:

A. Record Review

1. Patient A was admitted to the facility on 10/6/2003. The Psychiatric annual Evaluation dated 11/28/2018 identified the psychiatric diagnosis "paranoid schizophrenia." The Master Treatment Plan (MTP) dated 5/2/2019 identified Long Term Goals (LTG) as: "[Patient's] psychiatric symptoms, overall social functioning and self-care will improve to the point that [s/he] is able to work with [her/his] gatekeeper to develop a realistic discharge plan to a less restrictive setting." This goal was not written in observable, measureable patient behaviors.

2. Patient B was admitted to the facility on 4/25/2019. The Psychiatric Evaluation dated 4/26/2019 identified the psychiatric diagnosis "Schizoaffective disorder bipolar type." The Master Treatment Plan (MTP) dated 4/30/2019 identified the Long-Term Goal (LTG) as: "[Patient] psychiatric symptoms and functioning will be stabilized to the point that [s/he] can live in a less restrictive environment." This goal was not written in observable, measureable patient behaviors.

3. Patient C was admitted to the facility on 4/16/2019. The Psychiatric Evaluation dated 4/16/2019 identified the psychiatric diagnosis "Schizophrenia, unspecified." The Master Treatment Plan (MTP) dated 4/23/2019 identified the Long-Term Goal (LTG) as: "[Patient's] psychiatric symptoms and functioning will be stabilized to the point that [s/he] can live in a less restrictive environment." This goal was not written in observable, measureable patient behaviors.

4. Patient D was admitted to the facility on 5/14/2019. The Psychiatric Evaluation dated 5/15/2019 identified psychiatric diagnoses "Major Depression disorder, recurrent, severe with psychotic features; borderline personality disorder; PTSD [post-traumatic stress disorder], unspecified, anxiety disorder." The Master Treatment Plan (MTP) dated 5/20/2019 identified Long Term Goals (LTG) as: "[Patient] will be able to manage self-harm and suicidal ideations by using effective coping mechanisms while in the mist [sic] of conflict and tension." This goal was not written in observable, measureable patient behaviors.

5. Patient E was admitted to the facility on 4/29/2019. The Psychiatric Evaluation dated 4/29/2019 identified psychiatric diagnoses of "DMDD [disruptive mood dysregulation disorder], ADHD [attention deficit hyperactivity disorder], PTSD [post-traumatic stress disorder]." The Master Treatment Plan (MTP) dated 5/6/2019 identified the Long-Term Goal (LTG) as: "[Patient] will eliminate [his/her] violent behavior so that [he/she] can return to [his/her] parents successfully." This goal was not written in observable, measureable patient behaviors.


6. Patient F was admitted to the facility on 4/22/2019. The Psychiatric Evaluation dated 4/22/2019 identified the psychiatric diagnoses "Schizophrenia; history of cannabis abuse." The Master Treatment Plan (MTP) dated 4/26/2019 identified Long Term Goal (LTG) as: "[Patient] will comply with treatment and improve [his/her] overall health so that [he/she] can be discharged to a less restrictive facility." This goal was not written in observable, measureable patient behaviors.


7. Patient G was admitted to the facility on 3/1/2019. The Psychiatric Evaluation dated 3/1/2019 identified psychiatric diagnoses of "PTSD [post-traumatic stress disorder]; DMDD [disruptive mood dysregulation disorder]." The Master Treatment Plan (MTP) dated 3/7/2019 identified the Long Term Goal (LTG) as: "[Patient] will not threaten or actively attempt to hurt [himself/herself] or others such that [he/she] will be able to successfully live in the community without being a danger to [himself/herself] and/or others." This goal was not written in observable, measureable patient behaviors.


8. Patient H was admitted to the facility on 2/20/2018. The Psychiatric
Annual Evaluation dated 2/14/2019 identified psychiatric diagnoses of "Schizophrenia, unspecified; Dementia in other diseases classified elsewhere with behavioral disturbance; opioid dependence, in remission." The Master Treatment Plan (MTP) dated 4/25/2019 identified the Long-Term Goal (LTG) as: "[Patient] will improve [his/her] self-care and social skills to a level where [he/she] can live in a less restrictive environment. Once attaining these goals, [he/she] will be referred for discharge." This goal was not written in observable, measureable patient behaviors.


B. Interviews

1. In an interview on 5/21/2019 at 10:30 a.m., RN2 stated "The goal is generic and not integrated well in the Treatment Plan."

2. In an interview on 5/21/2019 at 3 p.m. the Director of Clinical Services was asked about the LTGs on the MTPs and agreed the goals were not measurable or patient specific.

3. In an interview on 5/21/2019 at 1:45 p.m. the Director of Nursing Services, was asked about the LTGs on the MTPs. The Director agreed the goals were not measureable or patient specific.

Based on record review, document review, and interviews, the facility failed to ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H) included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. These deficiencies resulted in Treatment Plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and therefore potentially leads to inconsistent and ineffective treatment.

Findings include:

A. Record Review

Review of the sample patients' Master Treatment Plans (MTPs) revealed that the plans included lists of routine generic discipline functions inappropriately listed as individualized interventions for 8 out of 8 sample patients. The facility failed to develop Treatment Plans that identified clearly delineated interventions to address specific patient problems. Instead, interventions on plans included the following:

1. Patient A---MTP dated 5/2/2019

a. Did not identify a Problem for the following nursing intervention: "Assess mood/behavior at least 1x/day for 5 min [minutes]."

b. Did not identify a Problem for the following physician intervention: "Meet 1x/wk [week] to eval [evaluate] response/side effects of medications."

2. Patient B---MTP dated 4/30/2019

a. For the Problem "Psychological Impairment-Thought" the following physician intervention was listed: "Eval [evaluation] med [medication] response & [and] side effects x 1/wk [week]."

b. For the Problem "Psychological Impairment-Thought" the following nursing intervention was listed: "Provide medication when scheduled; Assess orientation at least 5 min [minutes]/day."

3. Patient C---MTP dated 4/23/2019
a. For the Problem "Psychological Impairment-Thought" the following physician intervention was listed: "Eval [evaluation] med [medication] response & [and] side effects x 1/wk [week]."

b. There were no nursing interventions listed.

4. Patient D---MTP dated 5/20/2019
a. For the Problem "Psychological Impairment-Mood" the following physician intervention was listed: Evaluate responses & [and] SEs [side effects] to med [medications] weekly."

b. For the Problem "Psychological Impairment-Mood" the following nursing intervention was listed: "Provide medications as scheduled."

5. Patient E---MTP dated 5/6/2019
a. For the Problem "Violence Risk" the following physician intervention was listed: "Evaluate symptoms/side effects 2x weekly."

b. For the Problem "Violence Risk" the following nursing intervention was listed: "RN [registered nurse] will provide prescribed meds[medications]/daily."

6. Patient F---MTP dated 4/26/2019
a. For the Problem "Psychological Impairment-Thought" the following physician intervention was listed: "Evaluate response and side effects 2x a week."

b. For the Problem "Psychological Impairment-Thought" the following nursing intervention was listed: "Provide medication as prescribed daily."

7. Patient G---MTP dated 3/7/2019
a. For the Problem "Self-Harm" the following physician intervention was listed: "Evaluate response and side effects 2x a week."

b. For the Problem "Self-Harm" the following nursing intervention was listed: "Assess points daily to monitor changes in behavior/mood."

8. Patient H---MTP dated 4/25/2019
For the Problem "Psychological Impairment-Mood" the following physician intervention was listed: "Will meet 1x/wk [week] to eval [evaluate] medications and side effects."


B. Interviews

1. In an interview on 5/21/2019 at 11:00 a.m., RN4 acknowledged that RN interventions were not individualized and contained routine job duties such as passing medications.

2. In an interview on 5/21/2019 at 10:30 a.m, RN2 confirmed there were no nursing interventions for Patient C.

Based on record review and interview, the facility failed to ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the MTPs for five (5) of eight (8) active sample patients (B, D, E, F and H). This practice resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Patient B (MTP dated 4/30/19) had a psychologist listed as being responsible for rehab intervention and did not have a rehab therapy staff member identified.

2. Patient D (MTP dated 5/20/19) had:
a. a psychologist listed as being responsible for social work interventions and did not have a social work staff identified.

b. a psychologist listed as being responsible for nursing interventions and did not have a registered nurse identified.

c. a psychologist listed as being responsible for rehab intervention and did not have a rehab therapy staff identified.

3. Patient E (MTP dated 5/6/19) had the Service Line Manager, who is not a registered nurse, listed as being responsible for nursing interventions and did not have a registered nurse identified.

4. Patient F (MTP dated 4/26/19) had a psychologist listed as being responsible for social work interventions and did not have a social work staff member identified.

5. Patient H (MTP dated 4/25/19) had:

a. the Service Line Manager, who is not a registered nurse, listed as being responsible for nursing interventions and did not have a registered nurse identified.

b. the Service Line Manager as being responsible for rehab therapy interventions and did not have a rehab staff member identified.

B. Interview:

1. On 5/21/2019 at 11:30 a.m.in an interview with the Recreational Therapy Director, the Director reviewed the Treatment Plans and stated the names of responsible persons for the rehab interventions were not rehab staff members.

2. On 5/21/2019 at 1:45 p.m. in an interview the Director of Nursing, the Director reviewed the Treatment Plans described is Section A, above. The Director stated being unable to states why a nurse was not listed as the responsible person for nursing interventions.

3. On 5/21/2019 at 3:30 p.m. in an interview with the Clinical Services Director, the Director reviewed the Treatment Plans described in Section A, above and was unable to explain why a psychologist was assigned as the responsible staff for rehab interventions.

Based on record review and interview the facility failed to:

I. Provide therapeutic programming on Saturdays and Sundays for all the patients on the Adult Units (2 West, 4 East, 6 East and 7 East). The groups offered to patients were recreational or leisure in focus and did not address the identified psychiatric needs of the patients. Failure to offer groups that focus on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization.

II. Provide active treatment for four (4) of four (4) patients (A, B, C and D) on the Adult Units (2 West, 4 East, 6 East and 7 East) on Saturdays and Sundays. In addition, the groups that were provided were non-therapeutic groups consisting of recreational or leisure activities such as watching a movie. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

Findings include:

A. Record Review

l. The Director of Clinical Services (Psychologist) provided the monthly Adult Programing Menu (scheduled programing) for April 2019 and May 2019. The groups are scheduled Monday thru Friday from 8:30 AM until 7:00 PM. There was no active treatment provided Saturdays and Sundays.

2. The Rehabilitation Director provided the monthly activity schedule for the month of May.

a. Saturday there are: "Social Break from 9:00 AM until 11:00 AM; 11:00 AM -11:45 PM 7 East on unit activity; 12:30 PM - 1:15 PM 2 West on unit activity1:15 PM - 2:00 PM 4 East on unit activity; 2:00 PM - 2:30 PM 6 East on unit activity2:30 PM- 3:30 PM Open Gym"

b. Sunday there is: "Chapel Service from 1: 00 PM until 1: 45 PM."

3. There were no progress notes provided to review if these activities occurred, were offered to the patients, or which patients participated in the activity.

B. Interview

1. In a meeting with the Director of Clinical Services on 5/21/2019 at 3:30 p.m., the Director of Clinical Services agreed there was no active treatment provided on Saturday or Sundays or active treatment documentation on the weekends.

2. In a meeting with the Recreational Therapy Director on 5/21/2019 at 11:30 a.m., the Recreational Therapy Director reported there is only (1) one Recreational Therapist for all (4) four Adult Units for Saturdays and that the therapist can only provide one activity per unit due to short staffing. The Recreational Therapy Director reported that there are "activity boxes" on the unit that have movies and other leisure/diversional activities for nursing staff to use with patients. No activities were provided on Sundays except Chapel. The Recreational Therapy Director reported there is no documentation of the activities provided on Saturday or Sunday or a record of patients who attended.

Based on record review and staff interview it was determined that for one (1) of five (5) discharged patients (Patient I1) the Discharge Summary did not have a description of the patient at the time of discharge. Instead, the Discharge Summary had been written 2 days before discharge.

The findings include:

A. Record Review:

The Discharge Summary dated 4/01/19 for Patient I1described "Condition of Patient-Chronic responding to internal stimuli and inappropriate affect. Otherwise, relatively stable." The Discharge Summary further documents "Discharge on 4/03/19 ....

B. On 5/22/19 at 9:00 a.m. the clinical director after examining the Discharge Summary agreed that as documented the patient's assessment did not disclose the status of the patient on the day of discharge.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H) and for 1of 5 discharged patients (I1) the clinical director failed to ensure:

1. Psychiatric Evaluations contained an assessment of patient assets in descriptive not interpretive fashion. (For details, See B117)

2. Physical examinations contained vital sign data that supported the diagnoses. (For details, See B120)

3. Master Treatment Plans contained all necessary information, (For details, See B118, B120, B121, B122 and B123)

4. Discharge Summaries reflected the clinical status of the patient on the day of discharge. (For details, See B135)

These failures resulted in questionable diagnoses, Master Treatment Plans that were not patient specific and reflected interventions particular to each patient as well as the goals set by the team were behaviorally measurable to ascertain if progress or lack of progress had occurred.

Based on record review and interview, the Director of Nursing failed to ensure that Master Treatment Plans (MTPs) for six (6) of eight (8) active sample patients (B, C, D, E, F and G) included individualized and patient specific active treatment nursing interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. These deficiencies resulted in Treatment Plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment.

Findings include:

A. Record Review

1. Patient B---MTP dated 4/30/2019

For the problem "Psychological Impairment-Thought" the following nursing intervention listed: "Provide medication when scheduled; Assess orientation at least 5 min [minutes]/day."

2. Patient C---MTP dated 4/23/2019

There were no nursing interventions

3. Patient D---MTP dated 5/20/2019

For the problem "Psychological Impairment-Mood" the following nursing intervention listed: "Provide medications as scheduled."

4. Patient E---MTP dated 5/6/2019

For the problem "Violence Risk" the following nursing intervention listed: "RN [registered nurse] will provide prescribed meds[medications]/daily."

5. Patient F---MTP dated 4/26/2019

For the problem "Psychological Impairment-Thought" the following nursing intervention listed: "Provide medication as prescribed daily."

6. Patient G---MTP dated 3/7/2019

For the problem "Self-Harm" the following nursing intervention listed: Assess points daily to monitor changes in behavior/mood."


B. Interview

On 5/21/2019 at 1:45 p.m. in an interview, the Director of Nursing (DON) was asked about interventions on the Master Treatment Plans. The DON agreed with the findings that the interventions were routine job duties.

Based on record review and staff interview it was determined that for six (6) of eight (8) patients (B, C, D, F, G and H) the Psychosocial Assessments contained a description of the anticipated efforts of the social service staff in discharge planning. (For details, See B108)

Based on record review and staff interview, the facility failed to provide therapeutic activities and rehabilitative services based on patients' needs and interests. Specifically, the facility did not deploy activity therapy staff to provide therapeutic activities on Saturdays and Sundays. These failures resulted in patients not receiving a full complement of therapies, and patients not receiving individualized and goal-directed activity therapies.

A. Record Review

The Rehabilitation Director provided the monthly activity schedule for the month of May:

a. Saturday there are: "Social Break from 9:00 AM until 11:00 AM; 11:00 AM -11:45 PM 7 East on unit activity; 12:30 PM - 1:15 PM 2 West on unit activity1:15 PM - 2:00 PM 4 East on unit activity; 2:00 PM - 2:30 PM 6 East on unit activity2:30 PM- 3:30 PM Open Gym"

b. Sunday there is: "Chapel Service from 1: 00 PM until 1: 45 PM."

B. Staff Interview:

The Recreational Therapy Director was interviewed on 5/21/2019 at 11:30 a.m. The Recreational Therapy Director reported there is only (1) one Recreational Therapist for all Adult Units for Saturdays and, therefore, can only provide one activity per unit due to their short staffing. The Recreational Therapy Director reported that there are "activity boxes" on the unit that have movies and other leisure/diversional activities for nursing staff to use with patients. No activities are provided on Sundays except Chapel. The Recreational Therapy Director reported there is no documentation of the activities provided on Saturday or Sunday or record of patients who attended.