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Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included an inventory of patient's strengths that could be used in formulating goals and active treatment interventions for seven (7) of eight (8) active sample patients (1, 2, 4, 5, 6, 7, and 8) and four (4) of four(4) non-sample patients included to review MTPs (9, 10, 11, and 12). The failure to identify patient strengths can adversely affect clinical decision-making in formulating MTPs. This deficiency also may impair the treatment team's ability to develop goals, and result in treatment plans that are not individualized to patients' unique presenting psychiatric needs.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): 1 (9/5/19); 2 (9/12/19); 3 (9/11/19); 4 (9/10/19); 5 (9/3/19); 6 (9/12/19); 7 (9/10/19), and 8 (9/11/19). The following non-sample active patients were also reviewed: 9 (5/16/19); 10 (8/22/19); 11 (9/11/19); and 12 (9/12/19). The MTPs contained the following identical or similarly worded inventory of strengths. Because the following inventory of strengths did not include a description of personal attributes such as accomplishments, skills, and interests, it was difficult to discern how these would be used in the treatment of patients or how they would help determine appropriate treatment goals.

"Spiritual beliefs" (Patients 2, 4, 5, 7, and 11); "Family involvement/responsibility" - (Patients 4, 5, 6, 7, 9, and 10); "Support system" - (Patients 6 and 7); "Demonstrates impulse control" - (Patient 6); "Ability to cooperate and identify personal goals" - (Patients 1, 6, 7, 8, 10,11, and 12); "High self-esteem" - (Patients 6 and 7); "Hopeful/optimistic" - (Patients 6, 7 and 8); "insight into problems" - (Patient 6, 10, and 11); "interpersonal skills and judgement" - (Patient 6); "Motivation for treatment" - (Patients 6 and 7); "Natural supports" - (Patients 5 and 6); "Optimism" - (Patients 1and 6); "Persistence" - (Patients 6 and 11); "Problem-solving skills" - (Patient 6); "Resiliency"- (Patients 1, 2, 6, 9, and 12); "Resourcefulness" - (Patients 6, 8, and 12); "Sense of humor" - Patients 6 and 10); "Socialization skills" - (Patients 2, 6, 9, and 10); "Social connectedness" - Patient 6 and 9); "Vocational skills" - (Patient 6); "Coping skills" - (Patient 1).

B. Interviews

1. In an interview on 9/11/19 at 2:30 p.m., RN#3 reviewed Patient 7's MTP. The RN agreed that the inventory of strengths did not include individualized personal attributes of the patient.

2. During the interview on 9/12/19 at approximately 11:00 a.m. with the Director of Nursing (DON), MTPs were reviewed. She did not dispute the findings that the inventory of strengths failed to include descriptive information unique to each patient's personal attributes.

3. During the interview on 9/13/19 at approximately 10:00 a.m., the Medical Director did not dispute the findings that the inventory of strengths in MTPs was not descriptive of each patient's personal attributes.

4. During an interview on 9/13/19 with RN#5 at 10:40 a.m. to discuss the overall treatment plan development process, the RN agreed that strengths identified on the treatment plan were often the same, such as "Spiritual belief," with no individualized descriptors for each patient.

Based on record review and interview, the facility failed to document treatment notes for weekend RN group interventions listed on Master Treatment Plans or on the Adult and Youth Units programming menu for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). Specifically, there was no or limited documented evidence to show detailed and comprehensive information that included the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments, if any. All patients were expected to attend these therapeutic weekend groups. However, there was inconsistent documentation of non-attendance in these groups. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs and documents regarding treatment notes were reviewed for the following patients were reviewed (MTP dates in parentheses): 1 (9/5/19); 2 (9/12/19); 3 (9/11/19); 4 (9/10/19); 5 (9/3/19); 6 (9/12/19); 7 (9/10/19), and 8 (9/11/19). This review revealed the following findings regarding treatment notes for the assigned treatment interventions by registered nurses in the MTPs. Weekend groups assigned to RNs were included in the "Adult Programming Menu" and "Youth Programming Menu." All patients were expected to attend these therapeutic weekend groups.


1. Patient 1 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Risk of Danger to Other; Discharge Planning - As Evidenced by ... is oppositional aggressive and can engage in behaviors that are self-harmful and sexually inappropriate."

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/28/19 through 9/1/19 revealed that the patient attended one (1) of a possible two group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. There was no documented evidence regarding the group that was not attended.

2. Patient 2 had the following treatment notes for the interventions for the problem of: "Forensic - As Evidenced by ... incompetent to stand trial for charges ..."

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/1/19 through 9/1/19 revealed that the patient attended five (5) of a possible 10 group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. Two were documented as the patient being excused from the group sessions. There was no other documented evidence regarding the patient non-attendance. The five recorded group treatment notes lacked detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/10/19 which documented: "Topic: Health Promotion" with no information regarding what was discussed during the group session. Documentation also included, "Participation: Actively engages/participates - Excellent" and "Behavior: Appropriate" without explaining precisely how these statements were determined.

3. Patient 3 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Risk of Danger to Others - As Evidenced by ... Aggressive behaviors are exhibited by [Patient] hitting peers, staff and family members ..."

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/1/19 through 9/1/19 revealed that there was no documented evidence that the patient participated in any of the possible 10 group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. There was one group conducted at 2:00 p.m., which was noted to be co-facilitated by the registered nurse. The documentation of this group session lacked detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/11/19 which documented: "Topic: Thought Process" with no information regarding what was discussed during the group session. Documentation, also, included, "Participation: Participated with prompt- Moderate" without explaining precisely how these statements were determined.

4. Patient 4 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Risk of Danger to Others; Discharge Planning - As Evidenced by ... behaviors unsafe toward others, inability to appropriately regulate [his/her] emotions, depression ..."

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/14/19 through 9/1/19 revealed that the patient attended one (1) of a possible 6 group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. There was no documented evidence regarding the patient non-attendance in the scheduled 10:00 a.m. group sessions. The one recorded group treatment note lacked detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/25/19, which documented: "Topic: Leisure Skill Development" had no information regarding what was discussed during the group session. Documentation also included "Participation: Intermittent participation-Adequate" and "Behavior: Calm" without explaining precisely how these findings were determined.

5. Patient 5 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Discharge Planning - As Evidenced by ... agitation, response to internal stimuli, and demonstration of disorganized speech ..."

MTP interventions: "Nursing will offer both BHRA [Behavioral Health Rehabilitation Aide] and RN group on both Saturday and Sunday. Staff will document [Patient] participation in those groups."

A review of treatment notes for registered nurse groups conducted on weekends from 8/12/19 through 9/1/19 revealed that the patient attended three (3) of a possible six (6) group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. One session on 8/24/19 was documented as being excused from the group session. There was no documented evidence regarding the patient non-attendance in the scheduled 10:00 a.m. group sessions. The three recorded group treatment notes lacked detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 9/1/19, which documented: "Topic: Behavioral Development" with no information regarding what was discussed during the group session. Documentation also included, "Participation: Actively engages/participates - Excellent" and "Behavior: Within Normal Limits" without explaining precisely how these findings were determined.

6. Patient 6 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Discharge Planning - As Evidenced by: ... history of polysubstance abuse ... struggles with the ability to recall events of the day prior to admission, however, disclosed that [s/he] had relapsed with cocaine prior to hospitalization ..."

MTP interventions: "[Patient 6] will be offered RN/BHRA groups on Saturday and Sunday."

A review of treatment notes for registered nurse groups conducted on weekends from 8/1/19 through 9/1/19 revealed that the patient attended seven (7) of a possible 10 group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. There was no documented evidence regarding the patient non-attendance in the scheduled 10:00 a.m. group sessions. The seven recorded group treatment notes did not consistently document detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/11/19, which documented: "Topic: Coping Skills" with no information regarding what was discussed during the group session. Documentation also included, "Participation: Actively engages/participates - Excellent" and "Behavior: Appropriate" without explaining precisely how these findings were determined.

7. Patient 7 had the following treatment notes for the interventions for the problem of: "Risk of Danger to self; Discharge Planning - As Evidenced by: ... extreme paramilitary delusions and paranoia ...

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/15/19 through 9/1/19 revealed that the patient attended four (4) of a possible six (6) group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. One session on 8/18/19 was documented as being excused from the group session. There was no other documented evidence regarding the patient non-attendance in the scheduled 10:00 a.m. group sessions. None of the five recorded group treatment notes contained detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/17/19, which documented: "Topic: Behavioral Modification" had no information regarding what was discussed during the group session. Documentation also included, "Participation: Actively engages/participates - Excellent" and "Behavior: Appropriate" without explaining precisely how these findings were determined.

8. Patient 8 had the following treatment notes for the interventions for the problem of: "Forensic - As Evidenced by: ... admitted ... for competency restoration ... At admission pt was disheveled, but clean, with outgrown beard and unkempt hair ... persistently responds to internal stimuli ..."

MTP interventions: The weekend groups to be conducted by registered nurses were not included in the treatment plan.

A review of treatment notes for registered nurse groups conducted on weekends from 8/14/19 through 9/1/19 revealed that the patient attended four (4) of a possible six (6) group sessions scheduled at 10:00 a.m. and facilitated by registered nurses. There was no documented evidence regarding the patient non-attendance in the scheduled 10:00 a.m. group sessions. There was inconsistent documentation including detailed information about the topic discussed and the patient's response to the group interventions such as the note dated 8/24/19, which documented: "Topic: Education" had no information regarding what was discussed during the group session. Documentation also included, "Participation: Actively engages/participates - Excellent" and "Behavior: Irritable" without explaining precisely how these findings were determined.

B. Interviews

1. In an interview with RN#3 on 9/11/19 at 2:15 p.m., the treatment notes for Patient 7 were discussed. MTP was reviewed. RN#3 agreed that the treatment notes did not contain detailed information about the topic discussed and the patient's response to the group session.

2. During the interview on 9/12/19 at 9:32 a.m., the Director of Nursing (DON), MTPs did not dispute the findings that treatment notes by registered nurses failed to consistently include detailed information about the topic discussed and how the patient responded to the group interventions.

3. During an interview on 9/13/19 with RN#5 at 10:40 a.m. to discuss the overall treatment plan development process, there was an agreement that RN treatment notes did not consistently include a description of what was discussed during each group session.