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Based on record review, observation and interview, the facility failed to:
I. Develop and document a multidisciplinary Master Treatment Plan (MTPs) based on the individualized needs of one of two sample patients (G1) on Unit 5 lower. The patient ' s treatment plan documented generic treatment interventions with little relationship to patient ' s reason for admission (inappropriate touching of females). In addition, neither the Master Treatment Plan nor the treatment plan updates addressed goals or interventions regarding the multiple episodes of seclusion which occurred over the course of this patient ' s hospital stay. Failure to address specific admitting problems and update treatment interventions can result in lack of the guidance to staff in providing treatment required for the patient ' s recovery and successful discharge. (Refer to B118)
I1. Ensure that when a patient is in an observation room and is prevented from leaving, it is identified as seclusion/restraint. For 2 of 2 non-sample patients observed in the Special Observation Rooms (S6 on Unit A; P5 on Unit B), seclusion was used without a physician ' s order and without documented justification. This failure results in a violation of the patient ' s right to receive treatment in the least restrictive environment. (Refer to B125 Part I)
III. Protect patients ' rights by ensuring that the use of chemical restraints was clearly identified as restraint and that all requirements for patient evaluation during the use of chemical restraints were followed for 4 of 12 sample patients (G1, G2, P3 and P4) and 3 of 3 patients added to the sample to evaluate the use of restraint (P5, P6 and P7). Failure to identify and complete required documentation for chemical restraint jeopardizes the patients ' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others. (Refer to B125 Part II)
IV. Protect patients ' rights to be treated with respect and dignity. Patients on Units A, B and C were required to wear scrubs instead of their own clothing during the first 3 days of admission. On Units A and B, 2 of 2 non-sample patients (S6 on Unit A and P5 on Unit B) were required to wear scrubs when on Special Observations (in Special Observation Room). Two of 2 non-sample patients (S7 on Unit A and P5 on Unit B) were also required to wear orange vests when on LOS (Line of Sight Observations). The practice of not allowing patients to wear their own clothes, but instead, requiring them to wear clothes that identify them as newly admitted or on special precautions is stigmatizing and violates patient rights. (Refer to B125, Part III)

Based on record review and interview, the facility failed to:
I. Develop and document multidisciplinary Master Treatment Plans based on the identified individual needs for one of two sample patients (G1) on Unit 5 lower. The patient ' s treatment plan documented generic treatment interventions with little relationship to patient ' s reason for admission (inappropriate sexual touching of females). In addition, neither the Master Treatment Plan nor the treatment plan updates addressed goals or interventions regarding the multiple episodes of seclusion which occurred over the course of this patient ' s hospital stay.
Findings include:
A. Record Review
1. Patient G1, admitted on 7/22/10, had a Master Treatment Plan dated 7/26/10 which listed diagnoses of " Phonological Disorder and Mild vs Moderate Mental Retardation. " However, the patient ' s admitting information stated " 20 yo [year old] AAM [African American Male] admitted on 314 order from Union Circuit Court, charge was Attempted Rape. " The patient had only one problem noted on the Master Treatment Plan which read " need for improved coping skills as manifested by a history of impulsive inappropriate behavior. " The patient ' s stated goal was " To keep my hands off females. " Inappropriate touching of females and verbally and physically threatening staff were the only diagnoses listed on the psychiatric evaluation.
2. The following short term goals on the MTP were not observable or measurable. The goals also did not relate to the patient ' s out of control behavior or inappropriate sexual behavior:
a. " pt will cooperate with eval. & any treatment for psychiatric condition daily while at ASH [Arkansas State Hospital] & will report any symptoms to staff. "
b. " Patient will meet with his social worker to complete the Psychosocial History, provide treatment, and make any appropriate discharge plans. "
c. " Patient will cooperate and comply with treatment regime, conduct self in a safe manner while at ASH. "
d. " Patient will be able to voice 3 negative effects of S/A [substance abuse] on MI [mental illness} 2 X ' s prior to discharge. " [This was a " generic " group the patient was to attend, although there was no data to support a substance abuse diagnosis.]
3. Further chart review revealed the patient to have major behavioral issues with multiple episodes of seclusion as indicated in the following physician orders and seclusion reports:
a. Physician order 8/1/10 at 11:42 p.m.: " Closed Door Seclusion for up to 2 hours for aggressive behavior toward staff. "
b. Physician order dated 8/2/10 at 5:50 a.m.: " renew closed door seclusion for up to 2 hours due to continued aggressive/assaultive behavior. "
c. Seclusion and Restraint report dated 8/8/2010 at 2:10 p.m. noted seclusion for threatening staff.
d. Seclusion and Restraint report dated 8/9/2010 at 7:10 p.m. noted seclusion for " patient grabbed the arm of a female staff member. "
e. Seclusion and Restraint report dated 8/27/2010 at 4:43 p.m. noted seclusion for " patient yelling, frustrated, not redirectable. "
4. Review of the patient ' s treatment plan updates dated 8/2/2010. 8/16/2010, 8/30/2010, 9/13/2010, 10/14/2010, and 10/26/2010 revealed no behavioral problem added to the patient ' s problem list, nor were there any goal changes on the MTP updates..
B. Interviews
1. In an interview on 11/8/10 at 2:00 p.m., MSW G1 stated that the treatment plan did not adequately address the needs of the patient. She stated " Our treatment plans are horrible. " When questioned about the treatment plan addressing the patient ' s behavioral issues, GI replied that neither the problem of inappropriate behavior or staff interventions for same were present in the plan. MSWG1 stated that the treatment plans on forensic unit, including patient G1 ' s plan, were problematic. 2. In an interview on 11/8/20 at 2:15 p.m., RN G1 reviewed the treatment plan of patient G1 to see whether the plan addressed the recurring usage of seclusion for control of the patient ' s behavior. After the review, GI stated that she was unable to find the information in the plan.
2. In an interview on 11/10/20 at 9:00 a.m., Patient G1 stated he did not remember his treatment plan or its content. He was able to state his goal as " to keep my hands in my pockets. "
II. Provide Master Treatment Plans that identified patient-related short-term and long-term goals stated in measurable terms, related to the problems which required hospitalization, for 11 of 12 sample patients (G1, G2, G3, D4, P1, P2, P3, P4, S1, S2, S3 and S4). This failure hinders the treatment team ' s ability to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs. It also can result in prolonged hospitalization. (Refer to B121)
III. Develop Master Treatment Plans that identified clearly delineated interventions to address specific patient problems for 8 of 12 active sample patients (G1, G2, G3, P1, P2, P4, S1 and S2 ). These patient ' s treatment plans included routine, generic discipline functions instead of individualized interventions. Failure to document specific treatment approaches can result in lack of consistency of approach and may hamper staff's ability to provide individualized care to each patient. (Refer to B122)

Based on record review and interview, the facility failed to provide Master Treatment Plans that identified patient-related short-term and long-term goals stated in measurable terms, related to the problems which required hospitalization for 11 of 12 sampled patients (G1, G2, G3, D4, P1, P2, P3, P4, S1, S2, S3 and S4). This failure hinders the treatment team ' s ability to measure change in the patient ' s behavior as a result of treatment interventions. It also may contribute to failure to modify plans in response to patient needs, resulting in prolonged hospitalizations. .
Findings include:
A. Record Review
1. Patient G1's Master Treatment Plan dated 7/26/10 had the following short term goals that were not observable or measurable. They also did not directly relate to the patient ' s behavior.
a. "Pt. will cooperate with eval [sic] and any treatment for psychiatric condition daily while at ASH and will report any symptoms to staff."
b. " Patient will meet with his social worker to complete the Psychosocial History, provide treatment, and make any appropriate discharge plans. "
c. " Patient will cooperate and comply with treatment regime, conduct self in a safe manner while at ASH. "
d. " Patient will be able to voice 3 negative effects of S/A [substance abuse] on MI [mental illness} 2 X ' s prior to discharge. "
2. Patient G2's Master Treatment Plan review dated 9/16/10 had the following non-measurable short term goal: "Pt. will cooperate with eval and tx for mental illness daily while at ASH and will report any symptoms to staff indicating sleep disturbance, hallucinations and disturbing thoughts and mood disturbance."
3. Patient G3's Master Treatment Plan dated 10/11/10 had the following non-measurable short term goal: "Pt. will interact in a safe manner while hospitalized."
4. Patient P1's Master Treatment Plan dated 11/01/01 had the following non-measurable short term goals: "Pt. will ...Work with his assigned social worker to complete the psychosocial history, provide tx, and d/c planning."
5. Patient P2's Master Treatment Plan dated 8/19/10 had the following non-measurable short term goal: "Pt. will exhibit 2 new coping skills for interaction with environment."
6. Patient P3's Master Treatment Plan dated 8/25/10 had the following non-measurable short term goal: "Pt. will present his full disclosure honestly and without thinking errors 2x weekly within 2 months."
7. Patient P4's Master Treatment Plan dated 10/06/10 had the following non-measurable short term goal: "Pt. will exhibit calm, safe behavior with stable mood and non-psychotic ... [illegible]."
8. Patient S1's Master Treatment Plan dated 10/07/10 had the following non-measurable short term goal: "Pt. will exhibit for 7 consecutive days in 2 weeks: [decrease] paranoia, no hallucinations, coherent and relevant speech."
9. Patient S2's Master Treatment Plan dated 10/14/10 had the following non-measurable short term goal: "Pt. will exhibit [decrease] AH, [decrease] VH, [increase] organization of speech, [increase] reality based thinking."
10. Patient S3's Master Treatment Plan dated 10/01/10 had the following non-measurable short term goal: " Will display good judgment aeb [as evidenced by] actively participating in various treatment modalities11. Patient S4's Master Treatment Plan dated 10/29/10 had the following non-measurable short term goal: "Pt. will interact with staff and peers in a socially appropriate manner without hitting or breaking personal boundaries 7 days in a 2 week period."
11. Review of "Treatment Planning Manual, Revised 1998, includes the following statements:
Section 2.13: "Goals should not be too vague ....should be related to the problem for which it addressed."
Section 2.14: "objectives need to be stated in specific, behavioral terms that can be measured and are easy to understand ....Don't confuse staff objectives with patient objectives ....Remember to include specific behaviors that can be easily observed by other staff."
B. Interview
1. In an interview on 11/09/10 at 3:00 p.m., MD R1 agreed that patient goals were not measurable.
2. In an interview on 11/10/10 at 9:00 a.m., SW1 agreed that patient goals were not measurable.
3. In an interview on 11/10/10 at 9:30 a.m., SW 3 agreed that patient goals were not measurable.

Based on record review and interview, the facility failed to develop Master Treatment Plans that clearly delineated interventions to address specific patient problems for 8 of 12 active sample patients (#G1, G2, G3, P1, P2, P4, S1 and S2). The treatment plans for these patients included interventions stated as routine, generic discipline functions. Failure to document specific treatment approaches results in lack of consistency of approach and impedes staff's ability to provide individualized care to each patient.
Findings include:
A. Record Review:
1. Patient G1's Master Treatment Plan dated 7/26/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn meds-Haldol, Ativan, Cogentin; assess for scheduled meds if indicated, therapeutic limit-setting."; "Will meet with his social worker to complete the Psychosocial history, provide treatment and make any appropriate discharge plans"; "Will cooperate and comply with tx [sic] regime, conduct self in a safe manner while at ASH."
2. Patient G2's Master Treatment Plan dated 9/16/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn and scheduled meds including lithium and olanzapine"; "Meeting 1:1 with SW"; "Nursing to encourage compliance with treatment, reality based bx, set limits, redirect."
3. Patient G3's Master Treatment Plan dated 10/11/10 had the following generic discipline interventions: " Nursing " : "encourage compliance to medical regime. Set limits. Provide support"; " Social Work " :"Meet 1:1 w/sw @least once a week for first 3 months and at least once a month from there after."
4. Patient P1's Master Treatment Plan dated 11/01/10 had the following generic discipline functions: "MD to manage medicines/monitor tx (treatment)/sx (symptoms)"; " SW: "Discharge planning"; "RN: Monitor tx/sx."
5. Patient P2's Master Treatment Plan dated 8/19/10 had the following generic discipline functions: "MD: To manage meds and monitor"; "SW: To develop dc [discharge] plans"; "RN: To administer meds and tx."
6. Patient P4's Master Treatment Plan dated 10/06/10 had the following generic discipline functions: "MD to manage treatment"; "SW to assist in discharge planning"; "RN to implement treatment."
7. Patient S1's Master Treatment Plan dated 10/07/10 had the following generic discipline functions: "MD to manage trt(treatment)"; "SW to assist with d/c plans"; "RN to implement nursing care plan."
8. Patient S2's Master Treatment Plan dated 10/14/10 had the following generic discipline functions: "MD to evaluate overall treatment"; "SW discharge planning/therapy"; "RN to provide overall care."
B. Interview
1. In an interview on 11/10/10, 9:00 a.m., SW1 agreed that that interventions on the sample patient ' s MTPs were generic staff functions instead of being based on individual patient needs.
2. In an interview on 11/10/10, 9:30 a.m., SW 3 agreed that interventions on the sample patient ' s MTPs were generic.
3. In an interview on 11/09/10 at 3:00 p.m., MD R1 agreed that interventions on the sample patients ' treatment plans were too generic.

Based on record review and interview, the facility failed to develop Master Treatment Plans that clearly delineated interventions to address specific patient problems for 8 of 12 active sample patients (#G1, G2, G3, P1, P2, P4, S1 and S2). The treatment plans for these patients included interventions stated as routine, generic discipline functions. Failure to document specific treatment approaches results in lack of consistency of approach and impedes staff's ability to provide individualized care to each patient.
Findings include:
A. Record Review:
1. Patient G1's Master Treatment Plan dated 7/26/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn meds-Haldol, Ativan, Cogentin; assess for scheduled meds if indicated, therapeutic limit-setting."; "Will meet with his social worker to complete the Psychosocial history, provide treatment and make any appropriate discharge plans"; "Will cooperate and comply with tx [sic] regime, conduct self in a safe manner while at ASH."
2. Patient G2's Master Treatment Plan dated 9/16/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn and scheduled meds including lithium and olanzapine"; "Meeting 1:1 with SW"; "Nursing to encourage compliance with treatment, reality based bx, set limits, redirect."
3. Patient G3's Master Treatment Plan dated 10/11/10 had the following generic discipline interventions: " Nursing " : "encourage compliance to medical regime. Set limits. Provide support"; " Social Work " :"Meet 1:1 w/sw @least once a week for first 3 months and at least once a month from there after."
4. Patient P1's Master Treatment Plan dated 11/01/10 had the following generic discipline functions: "MD to manage medicines/monitor tx (treatment)/sx (symptoms)"; " SW: "Discharge planning"; "RN: Monitor tx/sx."
5. Patient P2's Master Treatment Plan dated 8/19/10 had the following generic discipline functions: "MD: To manage meds and monitor"; "SW: To develop dc [discharge] plans"; "RN: To administer meds and tx."
6. Patient P4's Master Treatment Plan dated 10/06/10 had the following generic discipline functions: "MD to manage treatment"; "SW to assist in discharge planning"; "RN to implement treatment."
7. Patient S1's Master Treatment Plan dated 10/07/10 had the following generic discipline functions: "MD to manage trt(treatment)"; "SW to assist with d/c plans"; "RN to implement nursing care plan."
8. Patient S2's Master Treatment Plan dated 10/14/10 had the following generic discipline functions: "MD to evaluate overall treatment"; "SW discharge planning/therapy"; "RN to provide overall care."
B. Interview
1. In an interview on 11/10/10, 9:00 a.m., SW1 agreed that that interventions on the sample patient ' s MTPs were generic staff functions instead of being based on individual patient needs.
2. In an interview on 11/10/10, 9:30 a.m., SW 3 agreed that interventions on the sample patient ' s MTPs were generic.
3. In an interview on 11/09/10 at 3:00 p.m., MD R1 agreed that interventions on the sample patients ' treatment plans were too generic.

Based on record review and interview, the facility failed to develop Master Treatment Plans that clearly delineated interventions to address specific patient problems for 8 of 12 active sample patients (#G1, G2, G3, P1, P2, P4, S1 and S2). The treatment plans for these patients included interventions stated as routine, generic discipline functions. Failure to document specific treatment approaches results in lack of consistency of approach and impedes staff's ability to provide individualized care to each patient.
Findings include:
A. Record Review:
1. Patient G1's Master Treatment Plan dated 7/26/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn meds-Haldol, Ativan, Cogentin; assess for scheduled meds if indicated, therapeutic limit-setting."; "Will meet with his social worker to complete the Psychosocial history, provide treatment and make any appropriate discharge plans"; "Will cooperate and comply with tx [sic] regime, conduct self in a safe manner while at ASH."
2. Patient G2's Master Treatment Plan dated 9/16/10 had the following generic discipline interventions: "Meet with MD monthly and prn; prn and scheduled meds including lithium and olanzapine"; "Meeting 1:1 with SW"; "Nursing to encourage compliance with treatment, reality based bx, set limits, redirect."
3. Patient G3's Master Treatment Plan dated 10/11/10 had the following generic discipline interventions: " Nursing " : "encourage compliance to medical regime. Set limits. Provide support"; " Social Work " :"Meet 1:1 w/sw @least once a week for first 3 months and at least once a month from there after."
4. Patient P1's Master Treatment Plan dated 11/01/10 had the following generic discipline functions: "MD to manage medicines/monitor tx (treatment)/sx (symptoms)"; " SW: "Discharge planning"; "RN: Monitor tx/sx."
5. Patient P2's Master Treatment Plan dated 8/19/10 had the following generic discipline functions: "MD: To manage meds and monitor"; "SW: To develop dc [discharge] plans"; "RN: To administer meds and tx."
6. Patient P4's Master Treatment Plan dated 10/06/10 had the following generic discipline functions: "MD to manage treatment"; "SW to assist in discharge planning"; "RN to implement treatment."
7. Patient S1's Master Treatment Plan dated 10/07/10 had the following generic discipline functions: "MD to manage trt(treatment)"; "SW to assist with d/c plans"; "RN to implement nursing care plan."
8. Patient S2's Master Treatment Plan dated 10/14/10 had the following generic discipline functions: "MD to evaluate overall treatment"; "SW discharge planning/therapy"; "RN to provide overall care."
B. Interview
1. In an interview on 11/10/10, 9:00 a.m., SW1 agreed that that interventions on the sample patient ' s MTPs were generic staff functions instead of being based on individual patient needs.
2. In an interview on 11/10/10, 9:30 a.m., SW 3 agreed that interventions on the sample patient ' s MTPs were generic.
3. In an interview on 11/09/10 at 3:00 p.m., MD R1 agreed that interventions on the sample patients ' treatment plans were too generic.

Based on observations, record reviews and interviews, the Director of Nursing failed to monitor nursing practice to ensure that:
I. Master Treatment Plans contained patient-centered short-term nursing goals stated in measurable terms, related to the problems which required the current hospitalization for 7of 12 sampled patients. (G-3, P-2, P-4, S-1, S-2, S-3 and S-4) This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as contribute to patient stays beyond the resolution of the problems which led to hospitalization. (See B118)
Findings include:
A. Record Review:
1. Patient G3 ' s Master Treatment Plan dated 10/11/2010 had the following generic and non-measurable nursing goal: " Pt. will interact in a safe manner while hospitalized. "
2. Patient P2 ' s Master Treatment Plan dated 8/19/2010 had the following generic and non-measurable nursing goal: " Pt. will exhibit 2 new coping skills for interaction with environment. "
3. Patient P4 ' s Master Treatment Plan dated 10/06/2010 had the following generic and non-measurable short term nursing goal: " Pt. will exhibit calm, safe behavior with stable mood and non-psychotic [illegible]. "
4. Patient S1 ' s Master Treatment Plan dated 10/07/2010 had the following generic and non-measurable short term nursing goal: " Pt. will exhibit for 7 consecutive days in 2 weeks: (decreased) paranoia, no hallucinations, ... "
5. Patient S2 ' s Master Treatment Plan dated 10/14/2010 had the following generic and non-measurable short term nursing goal: " Pt. will exhibit (decrease) AH (auditory hallucinations), (decrease) VH (visual hallucinations), (increase) organization of speech, (increase) reality based thinking. "
6. Patient S3 ' s Master Treatment Plan dated 10/01/2010 had the following generic and non-measurable short term nursing goal: " Pt. will follow unit rules and instructions from staff with no more than one prompt daily for fourteen consecutive days within four weeks. "
7. Patient S4 ' s Master Treatment Plan dated 10/29/2010 had the following generic and non-measurable short term nursing goal: " Pt. will interact with staff and peers in a socially appropriate manner without hitting or breaking personal boundaries 7 days in a 2 week period. "
B. Interview:
In an interview on 11/09/2010 at 3:00 p.m., MDR1 agreed that patient goals were not measurable and interventions were generic.
II. Master Treatment Plans identified clearly delineated nursing interventions to address specific patient problems. Instead, treatment plans included nursing interventions for routine, generic discipline functions listed as individualized interventions for 8 of 12 sample patients (G1, G2, G3, P1, P2, P4, S1 and S2). This failure to document specific treatment approaches interferes with the assurance of consistency of approach to patient ' s problem(s) and impedes nursing staff ' s ability to provide individualized care to each patient.
Findings Include:
Record Review:
1. Patient G1 ' s Master Treatment Plan dated 7/26/2010 had the generic nursing intervention, " Will cooperate and comply with tx (treatment) regime, conduct self in a safe manner while at ASH. "
2. Patient G2 " s Master Treatment Plan dated 9/16/2010 had the generic nursing intervention, " Nursing to encourage compliance with treatment, reality based bx (behavior), set limits, redirect. "
3. Patients G3 ' s Master Treatment Plan dated 10/11/2010 had the generic nursing intervention, " Encourage compliance to medical regime. Set limits. Provide support. "
4. Patient P1 ' s Master Treatment Plan dated 11/01/2010 had the generic nursing intervention, " Monitor tx/sx (treatment/symptoms). "
5. Patient P2 ' s Master Treatment Plan dated 8/19/2010 had the generic nursing intervention, " To administer meds and tx. "
6. Patient P4 ' s Master Treatment Plan dated 10/06/2010 had the generic nursing intervention, " RN to implement treatment. "
7. Patient S1 ' s Master Treatment Plan dated 10/07/2010 had the generic nursing intervention, " RN to implement nursing care plan. "
8. Patient S2 ' s Master Treatment Plan dated 10/14/2010 had the generic nursing intervention, " RN to provide overall care. "
III. That when a patient is in an observation room but is prevented from leaving, it is considered seclusion and not observation. For 2 of 2 non-sample patients observed in the Special Observation Rooms (S6 on Unit A and P5 on Unit B), seclusion was applied without a physician ' s order to seclude and without documented justification. This failure results in a violation of the patient ' s right to receive treatment in the least restrictive environment. (Refer to B125 Part I).
IV. Protect patients ' rights to be treated with respect and dignity. Patients on Units A, B and C were required to wear scrubs instead of their own clothing during the first 3 days of admission. On Units A and B, 2 of 2 non-sample patients (S6 on Unit A and P5 on Unit B) were required to wear scrubs when on Special Observations (in Special Observation Room). Two of 2 non-sample patients (S7 on Unit A and P5 on Unit B) were also required to wear orange vests when on LOS (Line of Sight Observations). The practice of not allowing patients to wear their own clothes, but instead, requiring them to wear clothes that identify them as newly admitted or on special precautions is stigmatizing and violates patient rights. (Refer to B125, Part III)