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Based on medical record review, interview, and document review, the hospital failed to ensure that the medical records maintained by the hospital permitted determination of the degree and intensity of the treatment provided to individuals who were furnished services in the hospital as evidenced by: failed to ensure that a individual comprehensive treatment plan was developed for each patient ( B-0118), failed to ensure that individual treatment plans [ITP] were based on an inventory of identified strengths and weakness, (B-0119), failed to ensure that individual treatment plans included short term and long range goals (B-0121), failed to ensure that written treatment plans included specific treatment modalities utilized (B-0122), failed to ensure that the individual treatment plans included the responsibilities of treatment team members (B-0123), and failed to ensure that treatment provided to patients were documented in such a way to assure that all active therapeutic effects were included (B-0125).

Based on medical record review and interview, the hospital failed to ensure that an individual treatment plan that was comprehensive in scope was developed for each patient in 8 of 8 active sampled patients ( Patient #1, #2, #3, #4, #5, #6 #7, and #16). Findings include:

(1) Patient #1, a 10 year old Hispanic female was admitted to the hospital on 9/13/2010.

The 9/15/2010 review of patient #1's ITP contained generic activities which are not coordinated and not individualized.

The review of the patient #1's ITP revealed that for identified problem # 1 (suicidal) and problem #2 (homicidal): Treatment goal #1 [to reduce suicidal ideation and increase coping skills], and treatment goal #2 [to reduce thoughts of harming others and find ways to express feelings of anger towards others] were not measurable. Additionally,
a)Physician interventions were not recorded,
b)Nursing interventions were limited to "patient will ID positive coping skills and patient will attend goals, groups, class, and activities.",
c)the ITP did not specify which coping skills to be taught nor the frequency, duration, or the focus of the groups to be provided,
d)case management interventions were limited to "therapeutic dialogue and group therapy",
e) there was no notation of frequency or duration of the group therapy or therapeutic dialogue or what the focus of these interventions were going to be,
f) activity therapy interventions were limited to "increase self-esteem, anger management, and improve communication skills and learn positive coping skills" [these stated interventions are not interventions but objectives/goals] and
g) types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.

(2) Patient #2, a 16 year old female was admitted to the hospital on 8/25/2010. The patient presents as a 16 year old female with autism, behavioral concerns and an estimated IQ of 70. The psychiatrist assessment identifies needs in the areas of mood stabilization, social skills, and impulse control. The mood stabilization and social skills needs were not addressed in the patient's ITP.

The 9/15/2010 review of the patient ITP revealed that the ITP is non-specific and generic. The patient's Behavior Treatment Plan dated 9/7/2010 states that "pt. can attend programming if she chooses."

For patient #2's identified problem # 1 (aggression) and problem #2 (self-harm), the ITP for revealed that:
a) the treatment goal#1 was "increase coping and less or no aggression" and treatment goal #2 was "patient will use coping skills to cope with self harm thoughts" which are not measurable,
b) the Physician intervention consisted of a single word that was not legible,
c) Nursing interventions were limited to "patient will attend classes and learn positive coping skills in a safe environment". The ITP did not specify which coping skills were to be taught nor the frequency, durations, or group focus to be provided,
d) case management interventions were limited to "therapeutic discussion, individualized behavior treatment plan, 1:1 constant observation for safety". There was no notation of frequency, duration, or focus of the therapeutic discussions to be provided, nor was it made clear how case management services was going to provide 1:1 constant observation of the patient,

As previously noted, the patient's behavior treatment plan dated dated 9/7/2010 stated that "pt can attend programming if she chooses". Activity therapy interventions were limited to "develops positive coping skills, stress management, emotions management, and improve communications skills, and anger management". These are not interventions but objectives/goals.

The types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.

The above findings regarding patients #1 and #2 were verified with the Child and Adolescent Manager on 9/15/2010 at 1215 hours.

(3) Patient #16, a 75 year old African American male was admitted to the hospital on 7/22/2010. The 9/15/2010 review of patient #16's ITP revealed that the ITP identifies generic activities which are not coordinated and not individualized. There is no identifiable link to assessment information or to goals or objectives.

For patient #16's identified problem # 1 (hears voices, thinks the walls transfer sound), problem #2 (fall risk), problem #3 (discharge planning) and problem #4 (refusing meds by history) the ITP revealed that:
a) Physician interventions were not stated,
b) Nursing interventions regarding fall risk were limited to "assess gait as medications are adjusted" [no specific fall precautions other than this notation recorded in the patient's ITP],
c) case management interventions were "provide individual therapy to address issues and coordination of services". There was no notation of frequency,duration, or focus of the therapeutic discussions to be provided, nor which services required co-ordination, and
d) activity therapy interventions were limited to "educate patient on positive coping skills for stress management and encourage positive interactions with peers". The types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.



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(4) Patient #3, a 61 year old Caucasian male was admitted to the hospital on 7/27/2010.

The ITP for patient #3 was reviewed 9/15/2010, and revealed that for identified problem #1 (agitation) and problem #2 (fall risk):
a) there were no specified goals,
b) there were no specified measurable outcomes,
c) Physician interventions were illegible,
d) the nursing intervention section of the ITP was left blank,
e) case management services interventions did not specify frequency or duration of individual supportive contacts that were to be provided to the patient or education and support to be provided to unspecified family members,
f) activity therapy interventions only stated that patient will participate in structured groups. The types of groups, frequency of groups, or duration of groups were not specified, and
g) the frequency and number of planned electroconvulsive treatments were not specified.

(5) Patient #4 a 67 year old female was admitted to the hospital on 8/20/2010.

The ITP for patient # 4 was reviewed on 9/16/2010 and revealed that for the identified problem #1 (auditory hallucinations and agitation):
a) the treatment goals were to "stabilize mood and psychosis, increase in ADL's, compliance with care and prescribe management", which were not measurable,
b) Physician interventions were illegible,
c) Nursing interventions were limited to assessing the patient's ability to participate in ADL classes, clarity of thoughts, and ability to engage in classes and social groups;
d) case management services interventions did not specify frequency or duration of contacts with the patient, family, and DPOA and included "to (illegible) with appropriate supports/supervision to increase patient's ability to maintain in the community",
e) activity therapy interventions only stated "patient to attend all groups, focus on task, increase leisure education, and increase coping skills". Types of groups, frequency of groups, or duration of groups were not specified.

(6) Patient #5, a 76 year old female, was admitted to the hospital on 9/11/2010.

For patient #5, the ITP was reviewed on 9/15/2010 and revealed for problem #1 (anxiety, depression, paranoia, noncompliance with medications):
a) the treatment goals are "patient will have mood stabilization, decrease in anxiety, depression, clear thought process, demonstrate safe behavior by taking meds as prescribed", which are not measurable,
b) Physician interventions were not specified,
c) Nursing interventions did not specify the structure or support that was to be provided, and did not specify the group activities that the patient was to be encouraged to participate in, nor specify which coping skills the patient was to be able to identify,
d) case management services interventions did not specify the duration of the daily supportive 1:1 daily frequency or duration of supportive 1:1 contact to be provided nor specify what type of "safe discharge plan" was going to be collaborative with family and external resources,
e) activity therapy interventions only stated that the patient will actively participate in intensive group focusing on coping skills. Frequency, duration, and type of groups to be provided activity therapy services were not specified.


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(7) Patient #6, a 14 year old Caucasian girl, was admitted to the hospital on 9/9/2010.

The 9/15/2010 review of patient #6's ITP dated 9/10/2010 revealed that for identified problem #1 (Depression/Self harm):
a) the treatment goal to "improve coping" was not not measurable and also was not a measure of whether the patient was still harming herself or was still depressed,
b) Physician interventions were not recorded,
c) Nursing interventions were limited to "do close observation checks and teach positive coping skills". The ITP did not specify skills to be taught nor the methodology (i.e. group or individual) to be used in teaching the skills to be acquired,
d) case management interventions were limited to "therapeutic dialogue and group therapy". There was no notation of frequency or duration of the group therapy or therapeutic dialogue or what the focus of these interventions were going to be
e) activity therapy interventions only stated that the patient "develops coping skills, stress management, emotion management, communications skills, and improve self esteem". Types of groups, frequency of groups, or duration of groups were not specified.


(8) Patient #7, a 89 year old female, was admitted to the hospital on 9/9/2010.


The ITP for patient #7 was reviewed on 9/15/2010 and revealed that for the identified problem #1(decrease anger and aggression) and problem #2 (activated by not specified):
a) treatment goal #1 that "patient will verbalize when anger is increasing" and treatment goal #2 that "patient will utilize proper techniques for anger management" were not measurable,
b) Physician interventions were not legible
c) Nursing interventions were not specified
d) Case management interventions were limited to "individual contacts to address (illegible) and agitation" and family education and support." There was no notation of frequency or duration of the individual contacts nor any any specific information regarding the type of education to be provided or the focus of the support to be provided,
e) activity therapy interventions only stated that "educate patient on positive coping skills for anger and depression in the intensive group setting. Types of groups, frequency of groups, or duration of groups were not specified.

(9) The ITP for patients #1, #2, #3, #4, #5, #6, #7 and #16 did not specify a target date by which identified problems would be resolved or a target date for the achievement of specified treatment goals.

Based on medical record review, the hospital failed to ensure that developed Individualized Treatment Plans (ITP) included an inventory of the patient's strengths and assets that were identified and incorporate into an Individual Treatment Plan in 8 of 8 sampled active cases (patient #1, #2, #3, #4, #5, #6, #7, and #16). Findings include:

The format of the hospital's Multidisciplinary Team Master Treatment Plan provides a place to document (a) Patient Strengths, (b) Patient Supports/Resources, and (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge.

Medical record reviews conducted 9/15/2010 and 9/16/2010 revealed that:

1) Patient #1 ITP sections (a) Patient Strengths, and (b) Patient Supports/Resources were left blank. ITP section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge only noted "therapeutic dialogue".

2) Patient #2 ITP section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge did not address inpatient treatment issues.

3) Patient #16 ITP sections (b) Patient Supports/Resources and (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge were left blank.




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4) Patient #3 sections (b) Patient Supports/Resources and (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge were left blank.

5) Patient #4 section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge did not address inpatient treatment issues.

6) Patient #5 section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge did not address inpatient treatment issues.





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7) Patient #6 section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge only stated "therapeutic dialog".

8) Patient #7 section (c) How Patient Strengths, Supports, and Resources Will Be Used In Treatment and Discharge was left blank.

Based on medical record review, the hospital failed to ensure that Individualized Treatment Plans (ITP) included short term and long term goals in 8 of 8 sampled active cases (patient #1, #2, #3, #4, #5, #6, #7, and #16). Findings include:

1) The 9/15/2010 and 9/16/2010 review of patient #1, #2, #3, #4, #5, #6, #7, and #16 Individualized Treatment Plans (ITP) revealed that the format of the hospital's Multidisciplinary Team Master Treatment Plan provides a place to document Target Symptom/Issue for Treatment and an associated Treatment goal. The format of the hospital's Multidisciplinary Team Master Treatment Plan makes not provision for distinguishing between short term and long term goals.

2) The 9/15/2010 review of the patient #1's ITP revealed that for identified problem # 1 (suicidal) and problem #2 (homicidal), stated treatment goal #1 (reduce suicidal ideation and increase coping skills), and treatment goal #2 (reduce thoughts of harming others and find ways to express feelings of anger towards others) did not include short-term and long term goals, nor include dates of projected achievement.

3) The 9/15/2010 review of the patient #2's ITP revealed that for identified problem # 1 (aggression) and problem #2 (self-harm), stated treatment goal#1 (increase coping and less or no aggression) and treatment goal #2 (patient will use coping skills to cope with self harm thoughts) did not include short-term and long-term goals, nor include dates of projected achievement.

The above findings regarding patients #1 and #2 were verified with the Child and Adolescent Manager on 9/15/2010 at 1215 hours.

4) The 9/15/2010 review of the patient #16's ITP revealed that for identified problem # 1 (hears voices, thinks the walls transfer sound), problem #2 (fall risk), problem #3 (discharge planning) and problem #4 (refusing meds by history), stated treatment goal #1 (displays no evidence of delusion thinking or hallucinations), treatment goal #2 (no falls), treatment goal #3 (medication -illegible-in place at discharge and patient and agitation is minimal with no striking out impulsively with effective redirection of behaviors), treatment goal #4 (takes meds consistently) did not include short-term and long-term goals, nor include dates of projected achievement.

5) The 9/15/2010 review of patient #3's ITP revealed that for identified problem #1 (agitation) and problem #2 (fall risk) there were no specified goals. (5) Patient #4 a 67 year old female was admitted to the hospital on 8/20/2010.

6) The 9/16/2010 review of patient # 4's ITP revealed that for the identified problem #1 (auditory hallucinations and agitation), treatment goal #1 (stabilize mood and psychosis, increase in ADL's, compliance with care and prescribe management) did not include short-term and long-term goals, nor include dates of projected achievement.

7) The 9/15/2010 review of patient #5's ITP revealed that for problem #1 (anxiety, depression, paranoia, noncompliance with medications), treatment goals (patient will have mood stabilization, decrease in anxiety, depression, clear thought process, demonstrate safe behavior by taking meds as prescribed) did not include short-term and long-term goals, nor include dates of projected achievement.

8) The 9/15/2010 review of patient #6's ITP dated 9/10/2010 revealed that for identified problem #1 (depression/self harm), treatment goal #1 (improve coping) did not include short-term and long-term goals, nor include dates of projected achievement.

9) The 9/15/2010 review of patient #7's ITP revealed that for identified problem #1 (decrease anger and aggression) and problem #2 (activated by not specified), treatment goal #1 (patient will verbalize when anger is increasing) and treatment goal #2 (patient will utilize proper techniques for anger management) did not include short-term and long-term goals, nor include dates of projected achievement.

10) The treatment goals for patients #1, #2, #3, #4, #5, #6, #7 and #16 were not measurable. Lack of measurability prevents an objective assessment of the patient's progress towards goal attainment.

Based on medical record review, the hospital failed to ensure that Individualized Treatment Plans (ITP) included specific treatment modalities to be utilized in 8 of 8 sampled active cases (patient #1, #2, #3, #4, #5, #6, #7, and #16). Findings include:

The 9/15/2010 and 9/16/2010 review of patient #1, #2, #3, #4, #5, #6, #7, and #16 Individualized Treatment Plan (ITP) revealed that the treatment modalities specified in the patient's Multidisciplinary Team Master Treatment Plan were general in nature and not specific as evidenced by:

1) Patient #1's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; none were recorded,
b) Nursing interventions; these were limited to "patient will ID positive coping skills and patient will attend goals, groups, class, and activities". The ITP did not specify coping skills to be taught nor the frequency, duration, or the focus of the groups to be provided,
c) Case management interventions; these were limited to therapeutic dialogue and group therapy. There was no notation of frequency or duration of the group therapy or therapeutic dialogue or what the focus of these interventions were going to be,
d) activity therapy interventions; these were limited to increase self-esteem, anger management, and improve communication skills and learn positive coping skills. These are not interventions but objectives/goals. Types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.

(2) Patient #2's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician intervention; this consisted of a single word that was not legible,
b) Nursing interventions; these were limited to "patient will attend classes and learn positive coping skills in a safe environment". The ITP did not specify coping skills to be taught nor the frequency and duration of groups, or group focus to be provided,
c) case management interventions; these were limited to therapeutic discussion, individualized behavior treatment plan, 1:1 constant observation for safety. There was no notation of frequency,duration, or focus of the therapeutic discussions to be provided, nor was it made clear how case management services was going to provide 1:1 constant observation of the patient.

The patient's behavior management treatment plan dated dated 9/7/2010 stated that "pt can attend programming if she chooses"; Activity therapy interventions were limited to develops positive coping skills, stress management, emotions management, and improve communications skills, and anger management. These are not interventions but objectives/goals. Types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.

(3) Patient #16's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; there were none stated,
b) Nursing interventions regarding fall risk noted that patient should be assessed as medications are adjusted. No specific fall precautions other than this notation recorded in the patient's ITP,
c) case management interventions; these were "to provide individual therapy to address issues and coordination of services". There was no notation of frequency,duration, or focus of the therapeutic discussions to be provided, nor which services required co-ordination,
d) activity therapy interventions; these were limited to "educate patient on positive coping skills for stress management and encourage positive interactions with peers". Types of activity therapy groups to be provided, frequency of groups, or duration of groups were not specified.


(4) Patient #3's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; the entry was illegible,
b) the nursing intervention section of the ITP was left blank,
c) case management services interventions; these did not specify frequency or duration of individual supportive contacts that were to be provided to the patient or education and support to be provided to unspecified family members,
d) activity therapy interventions; these only stated that patient will "participate in structured groups". Types of groups, frequency of groups, or duration of groups were not specified, and
e) the frequency of planned electroconvulsive therapy was not specified.

(5) Patient #4's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; these were illegible,
b) Nursing interventions were limited to "assessing the patient's ability to participate in ADL classes, clarity of thoughts, and ability to engage in classes and social groups",
c) case management services interventions; these did not specify frequency or duration of contacts with the patient, family, and DPOA,
d) activity therapy interventions; these only stated that "patient to attend all groups, focus on task, increase leisure education, and increase coping skills". Types of groups, frequency of groups, or duration of groups were not specified.

(6) Patient #5's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; none were specified,
b) Nursing interventions; these did not specify the structure or support that was to be provided, and did not specify the group activities that the patient was to be encouraged to participate in, nor specify which coping skills the patient was to be able to identify,
c) case management services interventions; these did not specify the duration of the daily supportive 1:1 daily frequency or duration of supportive 1:1 contact to be provided nor specify what type of "safe discharge plan" was going to be collaborative with family and external resources,
d) activity therapy interventions only stated that patient will actively participate in intensive group focusing on coping skills. Frequency, duration, and type of groups to be provided activity therapy services were not specified.

(7) Patient #6's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; none were recorded,
b) Nursing interventions; these were limited to "do close observation checks and teach positive coping skills". The ITP did not specify skills to be taught nor the methodology (i.e. group or individual) to be used in teaching the skills to be acquired,
c) case management interventions were limited to "therapeutic dialogue and group therapy". There was no notation of frequency or duration of the group therapy or therapeutic dialogue or what the focus of these interventions were going to be,
d) activity therapy interventions only stated "develops coping skills, stress management, emotion management, communications skills, and improve self esteem". Types of groups, frequency of groups, or duration of groups were not specified.


(8) Patient #7's ITP specified the following treatment (intervention) modalities to be utilized:
a) Physician interventions; these were not legible,
b) Nursing interventions; none were specified,
c) case management interventions; these were limited to "individual contacts to address (illegible) and agitation" and family education and support." There was no notation of frequency or duration of the individual contacts nor any any specific information regarding the type of education to be provided or the focus of the support to be provided.
d) activity therapy interventions; these only stated that "educate patient on positive coping skills for anger and depression in the intensive group setting. Types of groups, frequency of groups, or duration of groups were not specified.

Based on medical record review and interview, the hospital failed to ensure that a patient's Individual Treatment Plan (ITP) included the responsibilities of each member of the treatment team in 8 of 8 sampled active patients (patient #1, #2, #3, #4, #5, #6, #7, #16). Findings include:

The 9/15/2010 and 9/16/2010 review of patient #1, #2, #3, #4, #5, #6, #7, and #16 Individualized Treatment Plan (ITP) revealed that:

1) The format of the hospital's Multidisciplinary Team Master Treatment Plan (i.e. Individualize Treatment Plan) provides a section entitled Responsible Team Member's Signatures (RTMS). In the RTMS section, signature lines are provided for the psychiatrist, nursing, chaplain, pharmacy, PA/APN, internal case manager, activity therapist, patient care provider, social work, and other.

Staff #1 (a registered nurse), interviewed 9/16/2010 at approximately 1100 hours on the geriatric unit, explained that staff who participate in the development of the patient's ITP sign their respective signature lines in the RTMS section of the patient's ITP.

2) Signatures of team members were generally unreadable or only consisted of initials.

3) Specific staff responsibilities were not noted or assigned as to to who will promulgate the interventions recorded in the intervention sections of a patient's ITP.

4) A psychiatrist did not sign patient #5, and #6 ITP. Psychiatric interventions were not specified in patient #1, #6 #16 ITP. Psychiatric interventions in patient # 2 ITP consisted of a single word that was not legible.

Based on medical record review, the hospital failed to ensure active treatment for 2 of 9 patients (#2 and #17) Findings include:



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1) Patient #2, a 16 year old female was admitted to the hospital on 8/25/2010 for assaultive and self-abuse behaviors. The 9/16/2010 review of the patient's medical record revealed that the patient presents as a 16 year old female with autism (Asperger Syndrome), behavioral concerns and an estimated IQ of 70. The psychiatric assessment identified needs in the areas of mood stabilization, social skills, and impulse control.

The patient's 9/7/2010 Behavior Treatment Plan states that "Patient can attend programing if she chooses." The clinical rational for this treatment approach is not specified. Given the patient's diagnosis and functioning level, consistent programing is generally needed to achieve the patient needs specified in the psychiatric admission assessment.


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2) Patient #17, a 73 year old female was admitted to the hospital on 10/04/2009 for increased symptoms of confusion, restlessness, and wandering outside her house. Medical record and document review reveals that on 10/10/2009 at approximately 1545 hours the patient had an unwitnessed fall in the unit hallway by the nursing station. Staff responded to the patient and placed her in a geri-chair and took vitals. Initially the patient was unresponsive to questions for a few seconds. A "bump" (1.25" X 1.5 inches) was noted on the back of the right side of the patient's head and a rug burn to the right of center on her forehead. The initial neuro check found that her grips were not equal but subsequent checks showed they were equal. All checks were noted to have a left facial droop (which was present at the time of admission and prior to the fall). Physician Assistant (PA#1) was called and neuro checks were ordered every 2 hours. Following her fall, the patient was not assessed by the Physician Assistant or a physician while hospitalized at Pine Rest. Nursing note dated/timed 10/10/09 at 2218 hours stated that the "patient has been hyperverbal, and talking nonsensically...The hematoma on the back of her head was measured to 2 X 2 inch from 1.25 X 1.5 inch. PA#1 notified of patient's condition. PA#1 ordered the patient to be sent to St. Mary's ER for head CT and assessment of hip and pelvis."

Patient was sent to St. Mary's ER on 10/10/09 at 2300 hours for evaluation and CT scan. Patient was subsequently admitted to St. Mary's neuro unit for skull fracture and multiple cerebral hemorrhages. As patient was found to have an inoperable bleed, a palliative care consult was requested. On 10/12/2009 at 1203 hours the patient was transferred to Trillium Woods Hospice. The patient expired on 10/16/2009 at Trillium Woods Hospice.