HospitalInspections.org

Based on interview and record review, the facility's governing body failed to demonstrate oversight of the facility's contracted services. This has the potential to affect all patients at the facility. The facility census was 23.

Findings include:

Review of the facility's governing body meeting minutes from 01/24/18 to 09/26/19 revealed no discussion of the quality of the services provided under contract or the approval of any contracts.

During interivew on 09/26/19 at 11:15 A.M., Staff G confirmed the contracts have not been discussed at the governing body meetings.

Based on observation, record review and interview, the faciltiy failed to ensure patients received care in a safe setting (A144); and failed to ensure physician orders were obtained when physical restraint was used (A154). The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility census was 23.

Based on observation, staff interview and record review, the facility failed to ensure patients received care in a safe setting. This has the potential to affect all patients receiving psychiatric services at the facility. The facility inpatient census was 23.

Findings include:

1. Tour of the main facility on 09/23/19 at 1:30 P.M. revealed hand sanitizer dispenser located in the center of the milieu which contained foaming hand sanitizer.

Rectangular call light boxes were in each of the patient rooms with the approximate measurements of eight inches wide, four inches high and two and a half inches deep.

Bed cords were on the back of the bed covered with a thin plastic container secured with non-tamper resistant screws.

A television was mounted in the wall with no cover on the television. The mount and cables could be accessed behind the television.

The top of the patient room doors were 90 degrees at the corners with no pressure alarms at the top of the doors.

All findings were verified by Staff G and Staff H at the time of the observations.

Review of the Material Safety Data Sheet (MSDS) for the foaming instant hand sanitizer located in the milieu revealed it contained 62% Ethyl Alcohol. The MSDS also stated if ingested, may cause abdominal discomfort, nausea, vomiting and diarrhea. Under the first-aid measures it stated that if swallowed, get medical help or contact poison control center right away.

2. Review of the risk assessment for the main hospital revealed the facility identified the shower room's ligature risks as both shower heads. The mitigation plan for this was to recaulk and no patient was to be in the shower room unsupervised.

In patient rooms 101, 102, 103, 113, and 114 the shower heads were identified and the mitigation was to recaulk.

All the bed rails were on the risk assessment for all rooms. The mitigation plan was 15 minute checks and bed alarms on when occupied for high sensitivities.

The alarm boxes in all the patient rooms were identified with the mitigation being room doors left open; if a patient is in the room its either with a staff member or patient is in bed with alarm on; 15 minute checks and 10 minute checks in the evening. It stated the call boxes are not screwed in to the wall, so they will fall off when weight is applied. No manufacturer's evidence was provided that this would happen.

TV wall spaces were identified with the mitigation plan to apply Plexiglas across the openings.

The hand sanitizer in the milieu was identified as a poisonous hazard. The mitigation plan was 15 minute checks and patients in line of site of staff.

3. Tour of the satellite facility on 09/24/19 at 9:00 A.M. revealed call boxes measured approximately three inches wide by five inches high by three inches deep.

In the two private rooms, doors were located on the outside of the cabinets around the sink. Non-tamper resistant screws were securing the doors in a shut location.

Cords were on the back of the beds, rolled up and secured with one quarter inch zip ties, covered with a thin plastic container that was secured with non-tamper resistant screws.

There were gaps between the hand rails in the bathrooms with an eighth inch to a quarter inch gap between the rail and the wall.

Lighting units were mounted on the ceiling and were approximately six inches thick; caulking was noted between the ceiling and light fixture. Staff C and Staff H were unable to verify the caulking was tamper resistant at the time of the observation.

In room 105, a half inch depth was at the corner of the light between the corner and the caulking, making space for a ligature attachment location.

Paper towel holders and soap dispensers were by the sinks in the patient rooms, which could be used as ligature points.

The plastic faucet covers had an approximate quarter inch gap between it and the wall.

At 9:35 A.M., maintenance staff removed the plastic cover for the sprinkler head located in a patient restroom. The sprinkler heads were not ligature resistant and could be reached easily without standing on any item. These findings were verified by Staff C and Staff H at the time of the observation.

4. Review of the risk assessment for the satellite location revealed in the patient rooms, the shower knobs, mirrors, thermostat, door stopper, call box, hinges, outlets, bed cords, and bed rails were identified as a ligature risk. The mitigation plan was 15 minute checks.

In the day room, the refrigerator handle, paper towel holder, hand sanitizer, window blind knobs, chairs, tables, outlets, shelves, and equipment were identified as a ligature risk. The mitigation plan was to always have a staff member present in the day room with patients.

The sprinkler heads and paper towel dispensers in the patient rooms were not identified in the risk assessment.

During interview on 069/24/19 at 2:30 P.M. with Staff C and Staff F revealed the facility does not currently have a plan developed to correct all the identified ligature and other risks, they only have the mitigation of the risks.

Based on record review and interview, the facility failed to ensure physician orders were received for the use of physical restraints. This affected one (Patient #1) of 30 patient medical records reviewed. This had the potential to affect all patients receiving psychiatric services at the facility. The facility census was 23.

Findings include:

Review of Patient #1's medical record revealed an admission date of 09/07/19 with a diagnoses including dementia with behavioral disturbances.

Review of nursing documentation dated 09/08/19 revealed Patient #1 was administered two "as needed" medications including Benadryl 50 milligrams (mg) intramuscularly (IM), an antihistamine used for allergies and tremors from psychiatric medications, and Geodon 10 mg IM, an anti-psychotic medication. No documentation of the patient being physically restrained or an order for physical restraint was in the medical record.

Review a incident report dated 09/08/19 revealed staff used a physical restraint to move and administer intramuscular (IM) psychiatric medications to Patient #1. The incident report documented Staff I physical picked up Patient #1 under his/her arms and carried him/her to their room. Staff I placed Patient #1 on his/her bed so the Registered Nurse could administer IM medications.

Interview with Staff C on 09/25/19 at 3:10 P.M. revealed Patient #1 was physically restrained during the medication administration and there was no physician order.

Review of the facility policy titled "Behavioral PRN IM injection policy (NU.89)", revealed "if the patient's behavior and situation pose risk to the patient and staff member, the staff may provide a 30-second therapeutic hold when administering IM injection. If more than 30-second therapeutic hold is required, an order must be obtained from the provider."

Based on record review, observation and interview, the facility failed to ensure physician orders were completed as ordered, wounds were assessed and care planned interventions were implemented. This affected two (Patients #1 and #3) of 30 medical records reviewed. The census was 23.

Findings include:

1. Review of Patient #1's medical record revealed an admission date of 08/22/19 with a diagnosis of dementia with behavioral disturbances.

Review of physician orders revealed and order dated 08/27/19 to obtain a basic metabolic profile (BMP) on 08/30/19.

Review of the treatment log for August of 2019 revealed the lab work was not obtained. This was verified during interview on 09/24/19 at 11:40 A.M. by Staff B, who verified the lab was not refused, obtained nor was the physician notified.

Patient #1's care plan for fall prevention, dated 09/21/19, contained an intervention dated 09/21/19 for hipsters to be applied as tolerated.

Observation on 09/24/19 at 2:10 P.M. revealed Patient #1 up walking around as if he/she was cleaning in the main area. Staff B was asked if the patient had on hipsters as care planned for falls. Staff B verified the patient did not have on hipsters. Staff B stated nurses inform the patient care technicians on what interventions each patient needs and stated there is no documentation showing if hipsters are applied as care planned.


2. Review of Patient #3's medical record revealed an admission date of 09/20/19 and a diagnosis of dementia with behavioral disturbances. The patient was admitted with a venous ulcer of the left lower extremity.

Review of the admission skin assessment revealed the patient had a venous wound to the left great toe, left second toe and a skin tear to the top of the left hand. The physician ordered Bacitracin ointment and a bandage to be applied to the left hand skin tear twice a day on 09/20/19. The physician ordered Mupirocin 2% Ointment to be applied the left toe wounds, wrapped and secured on 09/20/19. There was no order or assessment for the right great toe wound.

Review of the physician orders and treatment records revealed there was no assessment or order for the treatment for the right great toe. Review of the treatment records revealed no documented treatment had been done since 09/20/19 for the left toe wounds. There was no mention of the right great toe wounds on the treatment record. These findings were verified during interview with STaff B on 09/25/19 at 2:20 P.M.

Observation on 09/25/19 at 1:50 P.M. of Patient #3's dressing change revealed Staff D gathered the needed supplies to complete the dressing changes and washed his/her hands prior to entering the patient's room. Staff D removed the dressing from the left toes, then removed the dressing, dated 09/23/19, from the right great toe. Without changing gloves, Staff D cleansed the wounds with normal saline and patted them dry. Staff D then changed gloves without handwashing and applied the Mupirocin 2% Ointment to the left toe wounds and wrapped them. Again, without changing gloves or hand washing, Staff D applied Mupirocin 2% Ointment to the right great toe wound and wrapped it. Staff D dated the dressings. Staff D changed his/her gloves, no handwashing, and removed the bandage to the left hand skin tear, cleansed with normal saline, pat dry and then changed his/her gloves. Staff D applied the ointment as ordered and then the bandage. At no time during the dressing changes did the nurse wash his/her hands. Staff D verified that she/did not wash her hands at any time during the dressing changes immediately after exiting the patients room.

Based on observation, interview and record review, the facility failed to administer medications as ordered. This affected two (Patients #13 and #17) of 30 patient medical records reviewed. The facility census was 23.

Findings include:

1. Review of Patient #13's clinical record revealed the patient was admitted to the hospital on 09/13/19 for threatening violence against his family. There was a physician order dated 09/17/19 to administer Marinol 2.5 milligrams twice a day at 8:00 A.M. and 12:00 P.M.

A review of the medication administration record revealed the medication had not been first administered until 09/19/19 at 8:00 A.M..

On 09/24/19 at 10:45 A.M. in an interview, Staff J explained the medication was not given because it had not been delivered from pharmacy. She confirmed it was an error.

2. Review of Patient #17's clinical record revealed the patient was admitted to the facility on 09/04/19 with a diagnosis of dementia with behavioral disturbance.

A review of the physician order revealed dated 09/07/19 revealed Dilantin was to be administered three times a day. The medication administration record revealed the administration times were set at 9:00 A.M., 3:00 P.M., and 9:00 P.M.

A review of the automated medication dispenser revealed the administration times were set at 9:00 A.M., 1:00 P.M., and 9:00 P.M.

On 09/24/19 at 3:15 P.M. Staff K was observed to administer Dilantin, an anti-seizure medication.

On 09/24/19 at 3:15 P.M. in an interview, Staff K explained when there is a conflict between administration times in the automated medication dispenser and administration times on the medication administration record, the medication administration record prevails.

A review of the facility's standardized medication administration policy, last reviewed on July 2019, stated three times a day meant 9:00 A.M., 1:00 P.M., and 9:00 P.M. The policy did not address a conflict between the automated medication dispenser and the medication administration record.

Based on observation, interview, and record review, the facility failed to ensure failed to ensure hazardous areas were maintained (K321); failed to ensure testing of emergency and exit lights (K291); failed to ensure dryers were maintained (K500); failed to ensure outlets in wet locations were protected (K511); failed to ensure annual testing of electrical outlets (K914); failed to ensure fire and smoke dampers were tested and maintained (K521); and failed to develop a complete fire safety plan (K711). The accumulative effect of these deficiencies resulted in the facility's failure to provide a safe environment for all patients, staff and visitors.

Based on observation, record review and staff interview, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 22.


See K-321 - facility failed to maintain hazardous areas
See K-500 - facility failed to ensure dryers were maintained
See K-511 - facility failed to ensure outlets in wet locations were protected
See K-914 - facility failed to ensure annual testing of electrical outlets

Based on observation, record review and staff interview, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 22.

See K-291 - failed to ensure monthly test of emergency and exit lights

Based on observation, record review and staff interview, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 22.

See K-521 - facility failed to ensure fire and smoke dampers were tested and maintained

Based on observation, record review and staff interview, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 22.

See K-711 - facility failed to develop a complete fire safety plan

Based on observation, record review and interview, the facility failed to develop a system for controlling infections and communicable diseases that included cleaning point of care devices, specifically glucometers, in accordance with their manufacturer instructions; cleaning the patient ice and water dispenser to ensure no build up of residue; and failed to ensure nurses washed their hands during dressing changes (A749). The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility census was 23.

Based on observation, interview and record review, the facility failed to develop a system for controlling infections and communicable diseases that included cleaning point of care devices, specifically glucometers, in accordance with their manufacturer instructions; cleaning the patient ice and water dispenser to ensure no build up of residue: and failed to ensure nurses washed their hands during dressing changes. These have the potential to affect all patients in the facility. The facility census was 23.

Findings:

1. On 09/23/19 at 3:00 P.M. in an interview, Staff C explained glucometers are used on more than one patient and are cleaned between each with a disposable germicidal surface wipe.

A review of that surface wipe's container revealed it had Environmental Protection Agency (EPA) registration number 70144-2-80366.

On 09/24/19 at 12:06 P.M. Staff K was observed cleaning the glucometer with said surface wipe. During interview at this time, STaff K confirmed that was the wipe she and the staff use to clean the glucometer after use with a patient.

A review of the glucometer's manufacturer instructions revealed the manufacturer's directions to clean the device with a product of EPA registration number 9480-4. The instructions state, "Other disinfectants have not been tested. The effect of other disinfectants used interchangeably has not been tested with the meter. Use of disinfectants other than [EPA registration number 9480-4] may damage the meter."


31007

2. During tour of the main hospital on 09/23/19 at 1:30 P.M., a brownish residue was observed in the outlet ports of the water and ice dispenser.

These findings were verified by Staff G at the time of the observation.

3. During tour of the satellite location on 09/24/19 at 9:00 A.M., a brownish residue was observed in the outlets of the water and ice dispensers.

These findings were verified by Staff C at the time of the observations.


32088

3. Review of Patient #3's medical record revealed an admission date of 09/20/19 for dementia with behavioral disturbances. The patient was admitted with a venous ulcer of the left lower extremity. Review of the admission skin assessment revealed the patient had a venous wound to the left great toe, left second toe and a skin tear to the top of the left hand.

Observation on 09/25/19 at 1:50 PM of Patient #3's dressing change revealed Staff D gathered the needed supplies to complete the dressing changes and washed his/her hands prior to entering the patients room. Staff D identified removed dressings to the left toes and then removed the dressing to the right great toe. Without changing gloves or washing hands, the wounds were cleansed and patted dry. Staff D changed gloves and applied ointment to both the left tow and right toe wounds without changing gloves or washing hands between wound sites. Gloves were changed, then the left hand skin tear dressing was removed, cleansed and a new dressing applied. STaff D changed gloves, then applied ointment. Staff D was not observed to wash hands at any time during the dressing change. STaff D verified she/did not wash her hands at any time during the dressing changes immediately after exiting the patient's room.

Based on staff interview and record review, the hospital failed to ensure they had a policy on reevaluating patients who were readmitted within 24 hours of discharge. This had the potential to affect all patients. The census was 23.

Findings include:

Interview on 09/26/19 at 3:52 P.M. with Staff E revealed the facility does not have a policy for evaluating patients that have been readmitted within 24 hours of discharge. Staff E stated the hospital has not been reviewing patients who have been re-admitted within 24 hours to ensure proper treatment was provided.

Review of the faciltiy policy titled "Discharge Planning", revised May 2019, revealed patients will be discharged to the least restrictive environment, taking the patient's or their legal representatives choices into consideration. The patient/ legal representative will be advised of recommendations for services in the community and with consent, appropriate referrals will be made by the discharge planner. Discharge planning begins at admission and based off of input from the patient and multidisciplinary team, a discharge plan is developed.

Based on record review, document review, observation, and interview, the facility failed to:

I. Ensure that active treatment measures, such as group or individual treatment, were provided for two (2) of ten sample patients (A1 and A4). Specifically, both patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed in their Master Treatment Plans (MTPs). In addition, the majority of patients on the Treatment Unit Cincinnati were either in their bed, watching television, or walking around the dayroom. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-l)

II. Provide evening and weekend therapeutic and leisure groups to address the needs of all patients. The Activity Director, the only activity person assigned to the Treatment Unit Cincinnati and one Activity Director on the Treatment Unit Wilmington, did not provide groups after 2:30 p.m. on Monday-Friday and not at all on the weekends. On Monday-Friday, all the groups provided to the patients were conducted by the Activity Director and consisted of only leisure groups. There were no therapeutic groups provided by professional staff during the week or on weekends. Failure to provide therapeutic treatment activities that address individual patients' needs prevents patients from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

Based on record review and interview, the facility failed to provide social work assessments that met professional social work standards, including conclusions and individualized treatment recommendations that described individualized anticipated social work roles in treatment and discharge planning for eight (8) of ten active sample patients (A1, A2 , A3, A4, A5, A6, A7, and A8). At the time of the survey, social workers on the Treatment Unit Cincinnati did not conduct groups and determined interventions for other disciplines on the Master Treatment Plan (MTP). This deficiency has the potential to result in a lack of professional social work treatment services for those patients and a lack of input to the treatment team.

Findings include:

A. Medical Records

1. Patient A1's Psychosocial Assessment was dated 08/16/19. This assessment did not list conclusions and listed the treatment recommendation, "[Patient] is encouraged to participate in groups while at Assurance. [S/he] would benefit from medication management."

2. Patient A2's Psychosocial Assessment was dated 9/30/19. This assessment did not list conclusions and listed the recommendations of, "[S/he] will gain mood and medication management while at Assurance and be encouraged to participate in group activities as well."

3. Patient A3's Psychosocial Assessment was dated 09/05/19. This assessment did not list conclusions and listed the treatment recommendations, "[Patient] will receive mood and medication management. [Patient] will be encouraged to participate in groups."

4. Patient A4's Psychosocial Assessment was dated 09/23/19. This assessment did not list conclusions and listed the treatment recommendation, "S/he will receive mood and medication management to address his/her agitation/aggression."

5. Patient A5's Psychosocial Assessment was dated 09/03/19. This assessment did not list conclusions and listed no treatment recommendations.

6. Patient A6's Psychosocial Assessment was dated 09/13/19. This assessment did not list conclusions and listed the treatment recommendations, "[Patient] will receive mood and medication management at Assurance Health. [S/he] will be encouraged to attend groups."

7. Patient A7's Psychosocial Assessment was dated 09/13/19. This assessment did not list conclusions and listed the treatment recommendation, "[S/he] will be encouraged to take medications and participate in groups."

8. Patent A8's Psychosocial Assessment was dated 09/13/19. This assessment did not list conclusions and listed the treatment recommendation, "[S/he] will receive mood and medication management while at Assurance Health. [S/he] will be encouraged to attend group activities."

B. Interviews

1. In an interview on 09/25/19 at 1:30 p.m., the Director of Social Work concurred that Psychosocial Assessments did not include conclusions based on the data in the assessment and failed to list the treatment recommendations provided by social workers consistently.

2. In an interview on 09/27/19 at 9:45 a.m., the Corporate Quality Assurance Director, the Chief Executive Officer, and the Corporate Director of Operations concurred with the findings of the lack of Social Work conclusions and recommendations in the Psychosocial Assessments.

Based on record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for nine (9) of ten patients in the sample (A1, A2, A3, A4, A5, A6, A7, A8, and A9). Treatment interventions listed only routine discipline functions rather than individualized treatment interventions. This practice has the potential to lead to the failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A. Medical Records

1. Patient A1's Master Treatment Plan (MTP), dated 08/16/19, listed for the Problem,
"Aggression," the generic job description interventions of, "Physician will prescribe medication to lessen agitation," and Registered Nurse (RN) will, "Administer medication as ordered and
monitor for effectiveness and side effects."

2. Patient A2's MTP, dated 09/03/19, listed for the Problem, "Aggression," the generic
job description interventions of, "Physician will prescribe medications to lessen aggression," and RN will, "Administer medications as ordered and monitor for effectiveness and side effects."

3. Patient A3's MTP dated, 09/05/19, listed for the Problem, "Aggression," the generic
job description intervention of, "Physician will prescribe medications to lessen aggression."

4. Patient A4's MTP dated, 08/23/19, listed for the Problem, "Aggressive/Assaultive," the
generic job description interventions of, "Physician will prescribe the mood stabilizing
medication to lessen aggression impulses," and RN will "Administration medications as ordered
and monitor for effective and side effects."

5. Patient A5's MTP, dated 09/03/19," listed for the Problem, "Aggression," the generic job description intervention of, "Physician will prescribe medication to lessen aggression."

6. Patients A6's MTP, dated 09/13/19, listed for the Problem "Aggression," the generic job description interventions of, "Physician will assess mood, mental status, effectiveness of medication," and "Nursing to assess mood, behavioral status, orientation, appetite, sleep patterns, interactions on unit, and perception of medication effectiveness."

7. Patient A7's MTP, dated 09/13/19, listed for the Problem, "Aggression," the generic job
description interventions of, RN will "Administer medication as ordered and monitor for
effectiveness and side effects," and RN will "Document behavior as to type duration, and
presenting factors."

8. Patient A8's MTP, dated 09/12/19, listed for the Problem, "Aggression," the job description interventions of, "Physician will prescribe mood stabilizing medications to lessen aggressive impulses," and "Nursing to assess mood, mental status, effectiveness of medication."

9. Patients A9's MTP, dated 9/06/19, listed for the Problem, "Delusions; Paranoid type,"
the generic job description interventions of, "Physician to prescribe medication to reduce
delusional thinking, and "Nursing to assess Mood, Behavioral status, Hygiene status,
Orientation, Appetite, sleep pattern, and interaction on unit."

B. Interview

1. In an interview on 09/27/19 at 9:45 a.m., the Corporate Quality Assurance Director, the Chief Executive Officer, and the Corporate Director of Operations concurred with the lack of
individualized treatment interventions.

Based on record review, document review, observation, and interview, the facility failed to:

I. Ensure that active treatment measures, such as group or individual treatment, were provided for two of ten sample patients (A1 and A4). Specifically, both patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed in their Master Treatment Plans (MTPs). In addition, the majority of patients on Treatment Unit Cincinnati were either in their bed, watching television, or walking around the dayroom. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

II. Provide evening and weekend therapeutic and leisure groups to address the needs of all patients. The Activity Director, the only activity person assigned to the Treatment Unit Cincinnati and one Activity Director on the Treatment Unit Wilmington, did not provide groups after 2:30 p.m. on Monday-Friday and not at all on the weekends. There were no therapeutic groups provided by professional staff (Social Work and Nursing) during the week or on weekends. Failure to provide therapeutic treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process.

Findings include:

I. Group Attendance

A. Specific Patient Findings

1. Patient A1 was admitted on 8/15/19. The Psychiatric Evaluation, dated 8/16/19, documented the reason for hospitalization as " ...agitation, irritability, wandering, and verbal and physical aggression." The patient was in a nursing home prior to admission.

a. A review of the MTP, dated 8/16/19, showed that there were no groups listed as interventions and no mention of Patient A1's refusal to attend the scheduled groups. In addition, the MTP did not list alternatives that would be provided to Patient A1 when s/he refused the group.

b. An observation on the Treatment Unit Cincinnati on 9/25/19 at 11:10 a.m. revealed that Patient A1 was standing near the table where a Music Group was being held. Patient A1 was in and out of the group as s/he walked around the dayroom.

c. An observation on the Treatment Unit Cincinnati on 9/25/19 at 1:40 p.m. revealed that Patient A1 was standing near the table where an Arts and Relaxation Group was being held. Patient A1 left the group shortly after it started.

d. A review of the Activity Therapy Participation Notes from 9/10/19-9/23/19 revealed that 71 groups were scheduled. Patient A1's participation was documented during this time as: In bed (23 of 71-32% groups); Walking (17 of 71-24% groups); Passive Observer (24 of 71-34% groups) and Actively Participated (7 of 71-10% groups). In an interview on 9/26/19 at 3:30 p.m., the Activity Director defined Passive Observer as when the patient is in the vicinity of the group but does not engage and requires prompting. Review of the Participation Note form revealed that under the "Alternative" section of the form, the alternatives offered to Patient A1 (and all other patients) were, "Walking, Rest [in bed], TV, Visitor, Socialization [or] PT [Physical Therapy]."

e. In an interview on 9/25/19 at 3:00 p.m., Social Worker 1 (SW1) described Patient A1 as difficult to get to participate in groups. She further stated that s/he likes to walk around the dayroom instead of going to group.

2. Patient A4 was admitted on 8/22/19. The Psychiatric Evaluation, dated 8/23/19, documented the reason for admission as "[S/he] has been physically aggressive toward staff and family ...slapped a nurse in the face."

a. A review of the Master Treatment Plan, dated 8/23/19, revealed no mention of Patient A4's refusal to attend the scheduled groups or alternatives that could be provided to Patient A4 when s/he refused groups.

b. An Observation on the Treatment Unit Cincinnati on 9/25/19 at 11:10 a.m. revealed that Patient A4 was asleep in bed. A Music Group was being held during this time.

c. The Observation on the Treatment Unit Cincinnati on 9/25/19 at 1:40 p.m. revealed that Patient A4 was asleep in bed.

d. The review of the Activity Therapy Participation Notes from 9/3/19-9/24/19 revealed that 92 groups were scheduled. Patient A4's participation was documented during this time as: "In bed/sleeping in the milieu" - 14 of 92 groups (15%); "Walking" - 33 of 92 group (36%); "Passive Observer" - 27 of 92 groups (29%); and "Actively Participated" - 18 of 92 groups (20%).

e. The review of the Participation Note form also revealed that under the "Alternative" section of the form, the alternatives offered to Patient A4 (and all other patients) were, "Walking, Rest [in bed], TV, Visitor, Socialization [or] PT [Physical Therapy]."
In an interview on 9/25/19 at 3:00 p.m., Social Worker 1 (SW1) described the participation of Patient A4 in groups as "It depends on [his/her] mood."

B. General Observations

1. Observation on the Treatment Unit Cincinnati on 9/25/19 at 11:00 a.m. revealed that the census was 16 patients. A Music Group was being held during this time. Ten patients were in bed (including sample Patients A2, A3, A4 A7, and A8), one patient was dancing, Patient A1 was standing in the group, and four patients were sitting at a table listening to music and minimally interacting with the group leader.

2. Another observation on the Treatment Unit Cincinnati on 9/25/19 at 1:40 p.m. revealed that an Arts and Relaxation Group was being held. Five patients, including A1, were in attendance. One patient was walking in the dayroom (A7), one patient was standing in the dayroom, seven patients were in bed (including sample patients A2, A3, A5, A6, and A8), and two patients were watching television.

C. Interviews

1. In an interview on 9/25/19 at 11:15 a.m., Mental Health Technician 1 (MHT1) was seen sitting in Patient A2's room. MHT1 stated that she was doing a 1:1 observation with Patient A2 because "[s/he] [Patient A] was kind of violent." When asked how long Patient A2 had been in bed, MHT1 stated that Patient A2 ate breakfast and went back to sleep.

2. In an interview on 9/26 /19 at 2:30 p.m., LPN1 (Licensed Practical Nurse 1) acknowledged that many of the patients did not attend the group.

3. In an interview on 9/27/19 at 9:00 a.m., the Chief Executive Officer (CEO), the Corporate Quality Assurance Director, and the Corporate Director of Operations all agreed that active treatment was not being provided to the majority of patients.

II. Lack of treatment evenings and weekends

A. Document review
Review of the September 2019 Schedule revealed that five leisure groups were offered daily from 9:30 a.m. - 3:00 p.m. There were no groups on the schedule after 3:00 p.m.

B. Interviews

1. In an interview on 9/26 /19 at 2:30 p.m., Licensed Practical Nurse (LPN1) acknowledged that after 3:00 p.m., the patients, " ...watch television, socialize or stay in their rooms."

2. In an interview on 9/26/19 at 3:30 p.m., the Director of Activity Therapy stated that he conducted all the groups offered on Monday-Friday from 9:30 a.m.-3:00 p.m. The Director said that he prepared the schedule for the weekend, but the nursing staff provided the groups. He further stated that he left activity "buckets" that contained coloring books, art supplies, and puzzles for the nursing staff to use when doing groups. When asked if the nursing staff followed his schedule on weekends, the Director of Activity Therapy stated, "Probably not as often as I would like them to." Attendance was not tracked for the weekend groups at the Cincinnati location, so it was unknown how many groups were conducted and how many patients attended.

3. In an interview on 9/27/19 at 9:00 a.m., the Chief Executive Officer (CEO), the Corporate Quality Assurance Director, and the Corporate Director of Operations all agreed that groups were not offered in the evenings and irregularly on the weekends.

Based on medical record review and interview, the facility failed to ensure that the date and
time for follow-up appointments were included in the discharge summaries of seven (7) of seven (7)
discharge records (B1, B2, B3, B4, B5, B6, and B7). The lack of definite follow-up
appointments has the potential to force patients, who may still be compromised in their ability to act for themselves, to negotiate with agencies or offices which they might find difficult to do, and therefore, may fail to do. Nursing homes or other residential facilities may not have the ability to obtain appointments within the facility time frame of seven days.

Findings include:

A. Medical Records

Patient B1's discharge summary dated, 8/12/19, Patient B2's discharge summary dated,
08/15/19, Patient B3's discharge summary dated, 7/29/19, Patient B4's discharge summary,
dated 07/31/19, Patient B5's discharge summary, dated 7/25/19, Patient B6's discharge
summary, dated 8/22/18, Patient B7's discharge summary dated, 8/29/19, all failed to
document the time and date of a follow-up appointment.

B. Interviews

1. In an interview on 9/27/19 at 9:45 a.m., The Corporate Quality Assurance Director, the Chief
Executive Officer, and the Corporate Director of Operations concurred with the lack of
documentation of specific follow-up appointments on the discharge summaries.

2. In an interview on 9/27/19 at 10:15 a.m., the Chief Medical Officer concurred with the lack
of specific follow-up appointments on discharge summaries.

Based on record review, document review, observation, and interview, the Chief Medical Officer failed to ensure that:

I. Active treatment measures, such as group or individual treatment, were provided for two of ten sample patients (A1 and A4). Specifically, both patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). In addition, the majority of patients on Treatment Unit Cincinnati were either in their bed, watching television, or walking around the dayroom. Failure to provide active treatment results in the affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-l)

II. Evening and weekend therapeutic and leisure groups to address the needs of all patients were provided. The Activity Director, (the only activity person assigned to the Treatment Unit Cincinnati), did not provide groups after 2:30 p.m. Monday-Friday and not at all on the weekends. On Monday-Friday, all the groups provided to the patients were conducted by the Activity Director and consisted of only leisure groups. There were no therapeutic groups provided by professional staff during the week or on weekends. Failure to provide therapeutic treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

III. The date and time for follow-up appointments were included in the discharge summaries of
seven of seven discharge records (B1, B2, B3, B4, B5, B6, and B7). The lack of
definite follow-up appointments has the potential to force patients, who may still be
compromised in their ability to act for themselves, to negotiate with agencies or offices which
they might find difficult to do, and therefore may fail to do. Nursing homes or other residential
facilities may not have the ability to obtain appointments within the facility time frame of seven
days. (Refer to B134)

Interviews

1. In an interview on 9/27/19 at 9:00 a.m., the Chief Executive Officer (CEO), the Corporate Quality Assurance Director, and the Corporate Director of Operations all agreed that active treatment was not being provided to the majority of patients and that groups were not offered during the evening and not consistently offered on the weekend.

2. In an interview on 9/27/19 at 10:15 a.m., the Chief Medical Officer concurred with the lack
of specific follow-up appointments on discharge summaries

Based on record review and interview, the Director of Nursing failed to ensure that the nursing interventions were individualized and specific to patient needs and were instead routine generic discipline functions for six of nine patients (A1, A2, A4, A6, A7, and A8). This practice has the potential to lead to the failure of individualized treatment interventions and to result in the nursing staff's inability to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A. Record review

1. Patient A1's Master Treatment Plan (MTP), dated 8/16/19, listed for the Problem,
"Aggression," the generic job description intervention, Registered Nurse (RN) will, "Administer
medication as ordered and monitor for effectiveness and side effects."

2. Patient A2's MTP dated 9/03/19, listed for the Problem, "Aggression," the generic
job description intervention, RN will, "Administer medications as ordered and monitor for
effectiveness and side effects."

3. Patient A4's MTP dated, 8/23/19, listed for the Problem, "Aggressive/Assaultive," the
generic job description intervention, RN will "Administration medications as ordered
and monitor for effective and side effects."

4. Patients A6's MTP, dated 9/13/19, listed for the Problem "Aggression," the generic nursing
Intervention, "Nursing to assess mood, behavioral status, orientation, appetite, sleep patterns,
interactions on unit, and perception of medication effectiveness."

5. Patient A7's MTP, dated 9/13/19, listed for the Problem, "Aggression," the generic job
description interventions, RN will "Administer medication as ordered and monitor for
effectiveness and side effects," and RN will "Document behavior as to type duration, and
presenting factors."

6. Patient A8's MTP, dated 9/12/19, listed for the Problem, "Aggression," the
job description intervention, "Nursing to assess mood, mental status, effectiveness of
medication."

7. Patients A9's MTP, dated 9/06/19, listed for the Problem, "Delusions; Paranoid type,"
the generic job description intervention, "Nursing to assess Mood, Behavioral status, Hygiene status, Orientation, Appetite, sleep pattern, and interaction on unit."

B. Interviews

1. In an interview on 9/26/19 at 10:00 a.m., the Assistant Director of Nursing agreed that the nursing interventions were generic nursing functions that were offered to all patients.

2. In an interview on 09/27/19 at 9:45 a.m., The Corporate Quality Assurance Director, the Chief
Executive Officer, and the Corporate Director of Operations concurred with the lack of
individualized nursing interventions.

Based on document review and interview, the facility failed to provide qualified therapists and support personnel to ensure that patients were provided with ongoing treatment. Specifically, the facility at both the Cincinnati and Wilmington location had only one Activity Therapist who provided all the groups offered (five groups per day). There were no additional therapists to offer groups in the evenings and on weekends. A failure to provide therapeutic activities to meet individualized patient needs has the potential to delay the patients' recovery.

Findings include:

A. Document Review

1. Review of the September Schedule revealed that the activity therapists (only one therapist employed at the Cincinnati location and one therapist employed at the Wilmington location) offered all the scheduled groups (leisure groups only which included "Table Volleyball," "Family Feud," and "Movie."). These activity therapists were unavailable to provide evening and weekend activities at both locations and relied on the nursing staff to conduct the groups. In addition, the September Schedule contained the disclaimer, "Activities are subject to change depending on patient needs."

2. Review of the hospital policy, "Therapeutic Recreation Services," revised 5/2019, stated, "One-to-one activities will be offered to those patients who are not physically or emotionally able to tolerate group activities."

B. Interviews

1. In an interview on 9/25/19 at 3:30 p.m., the Activity Director at the Cincinnati location, acknowledged that he conducted all the scheduled groups because there was no other therapist to conduct them. When asked if social workers or nurses did groups during the week or on weekends, he stated, "No." When the surveyor asked about the disclaimer on the schedule, the Activity Therapist responded that although there were groups on the schedule, he would do what the patients in attendance wanted or would tailor the content according to the needs of the group. He acknowledged that most of the patients did not attend the groups. He noted that at the end of the day (appeared as "One to One" on the schedule at 3:00 p.m.), he touched base with those patients who isolated in their rooms and did not attend the groups. He explained that he had little time to interact with these patients since he had to document the groups before going home. When asked what he did when he conducted the one-to-ones, the Activity Director noted a variety of things like massage, card games, or if the patient was asleep, he might leave a magazine in their room. He volunteered that he had done three one-to-ones that day, although there were 11 to 12 patients who did not attend any groups. He stated, "Those [patients] who come in and out of the milieu, I don't go to them only to the ones who isolate." The Director of Activity Therapy volunteered that his last day on the job was the following day and that the Director of Activity at the Wilmington location would be coming over (to Cincinnati) a few days a week.

2. In an interview on 9/27/19 at 9:00 a.m., the Chief Executive Officer (CEO), the Corporate Quality Assurance Director, and the Corporate Director of Operations all agreed that one activity therapist should not be doing all the scheduled groups. They also agreed that all the groups should not be leisure groups and that more professional groups should be added.