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Based on record review and interview, the facility failed to provide complete psychosocial assessments for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The psychosocial evaluations did not include social work specific conclusions and recommendations; describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of social work input for treatment planning.

Findings include:

A. Record Review

1. Patient E1. There were no conclusions or recommendations noted in a psychosocial assessment dated 6/2/11.

2. Patient E2. There were no conclusions or recommendations noted in a psychosocial assessment dated 7/13/11.

3. Patient E10. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

4. Patient E16. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/14/11.

5. Patient W2. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/28/11.

6. Patient W3. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

7. Patient W13. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/9/11.

8. Patient W19. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/13/11.

B. Interview

In an interview on 10/25/11 at 2:15PM, the Director of Social Work was unable to find specific social work recommendations and conclusions in the sample patients' records and agreed that the psychosocial evaluations were missing the information. She stated, "We used to do it that way but then stopped when we combined the assessments into the present format."

Based on record review and interview, the facility failed to list patient assets in the Psychiatric Assessments in descriptive terms for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths.

Findings include:

A. Record Review

1. Patient E1 was admitted on 6/1/11. The Psychiatric Assessment dated 6/2/11, in the section titled "Patient Assets and Strengths," noted the following: "fair insight." No other descriptive information was noted.

2. Patient E2 was admitted on 7/12/11. In a Psychiatric Assessment dated 7/13/11, the section titled "Patient Assets and Strengths" noted the following: "good physical health." No other descriptive information was noted.

3. Patient E10 was admitted on 9/29/11. In a Psychiatric Assessment dated 9/30/11, the section titled "Patient Assets and Strengths" noted the following: "housing, family support." No other descriptive information was noted.

4. Patient E16 was admitted on 10/14/11. In a Psychiatric Assessment dated 10/15/11, the section titled "Patient Assets and Strengths" noted the following: "housing, family support." No other descriptive information was noted.

5. Patient W2 was admitted on 9/27/11. In a Psychiatric Assessment dated 9/28/11, the section titled "Patient Assets and Strengths" noted the following: "has housing at shelter." No other descriptive information was noted.

6. Patient W3 was admitted on 10/3/11. In a Psychiatric Assessment dated 10/4/11, the section titled "Patient Assets and Strengths" noted the following: "intelligence." No other descriptive information was noted.

7. Patient W13 was admitted on 9/8/11. In a Psychiatric Assessment dated 9/9/11, the section titled "Patient Assets and Strengths" noted the following: "accepts tx (treatment)." No other descriptive information was noted.

8. Patient W19 was admitted on 10/12/11. In a Psychiatric Assessment dated 10/13/11, the section titled "Patient Assets and Strengths" noted the following: "family." No other descriptive information was noted.

B. Interview

In an interview on 10/25/11 at 3:30PM, the Medical Director agreed that the assets noted in the above patients' Psychiatric Assessments were not descriptive in nature.

Based on record review and interview, the facility failed to develop Master Treatment Plans that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13, and W19). The Master Treatment Plans included checklists and written interventions which were routine, generic discipline functions that lacked focus for treatment. In addition 5 of 8 active sample patients had no written physician, nursing and social work interventions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

A review of medical records revealed that the pre-printed treatment plans only listed routine, generic discipline functions as interventions rather than individualized interventions to assist patients accomplish their treatment goals.

1. Patient E1 (Master Treatment Plan (MTP) dated 6/3/2011)

For the problem of "Mood disorder," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often as needed to: (hand written) assess illness & (and) meds." "Prescribe and adjust medication related to response to: (hand written) illness - (and) sympts- (symptoms)." "Supportive Therapy 5 x (times) week."
Nursing: "Administer medication to: (increase) mood stability monitor effect & (and) document." "Provide safe environment by observing (written in) (check) q (every) 15 min's and prn (as needed) - document." "Identify sleeping pattern q (every) nightly & (and) document, medicate teach relaxation tech (technique) as per orders."

2. Patient E2 (MTP dated 7/13/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to (hand written) assess symptoms & (and) resp (response) to meds." "Prescribe and adjust medication related to response to psychotic symptoms." "Supportive Therapy 5 x week." "Educate patient regarding (hand written) compliance illness."
Nursing: "Encourage attending at (hand written) nursing group 2x/week." "Assess and document patient's individual expression of delusion q (every) shift, prn," Activities Therapy: none.

For the problem of "Discharge Planning," the following generic interventions were checked:
Nursing: "Medication Education (hand written) review meds @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide support."

3. Patient E10 (MTP dated 10/4/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) address symptoms." "Prescribe and adjust medication related to response to: (hand written) stabilize symptoms." "Supportive Therapy 5 x week."
Nursing: "Encourage attendance at (written in) groups, unit activities, treatment planning." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (written in) dx (diagnoses) illness, relapse prevention, coping skills." "Use Behavior Agreement to assist patient in maintaining control by (hand written) Q (every) 15, Q (every) 30 min, time out in room to decrease stimuli."

For the problem: "Discharge Planning," the following intervention was entered:
Nursing: "Medication Education (hand written) review medication upon d/c (discharge)." "Encourage to verbalize feelings regarding discharge and provide support."

4. Patient E 16 (MTP dated 10/18/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) address his symptoms." "Prescribe and adjust medication related to response to: (hand written) stabilize his symptoms." "Supportive Therapy 2 x (times) week."
Nursing: "Encourage attendance at therapeutic group & (and) nurses groups 2x (times) wk (week)." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) signs and symptoms of disease." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talk to staff." "Other: obs (observe) Q (every) 15 min for safety or 1:1 if needed."

For the problem of "Substance Abuse," the following generic interventions were checked:
Physician: No intervention
Nursing: Patient goals were written in the section on interventions, in place of staff interventions: "Patient will be able to recognize triggers that lead to alcohol & (and) drug use for him." "Patient will gain insight & (and) set goal to attend therapeutic groups while here & (and) upon discharge."

For the problem of "Discharge Planning," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily and more often as indicated to: (hand written) address his symptoms." "Prescribe medication and adjust medication related to response and effects to: (hand written) stabilize his symptoms." "Supportive Therapy 7 x week."
Nursing: "Medication Education review @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide comfort."

5. Patient W2 (MTP dated (9/28/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) "assess sxs & (not legible) (signs and symptoms)." "Prescribe and adjust medication related to response to: (Hand written) "assess sxs & (not legible) (signs and symptoms)." "Supportive Therapy 5 x week." "Educate patient regarding (written in) diagnoses, tx (treatment), discharge plan."
Nursing: "Encourage [patient] to wear armband." "Encourage attendance at (hand written) Tx (treatment) team, nsg (nursing) psychologist group 2x/week." "Assess and document patient's individual expression of hallucinations/ (hand written) delusion." "Instruct patient on condition and management of schizophrenia/Rx ' d (ordered) medication." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talking (with) pt (patient), PRN (as needed) meds." "Ask staff to talk to me; take prn (as needed) meds if needed." "Observe q (every) 15 min for safety." "Assess sleep patterns, offer PRN (as needed) sleeper." "Speak quietly & directly, set behavioral limit." "Provide reality orientation."

For problem of "Discharge Planning" the following generic intervention was checked:
Nursing: "Medication Education - (hand written) stress benefit of adherence [sic]."

6. Patient W3 (MTP dated 10/4/11

For the problem of "Mood Disorder." the following generic interventions were checked:
Physician: "See the patient on individual basis at least daily or more often as needed to (hand written) assess sxs & (not legible), (assess signs and symptoms)." "Prescribe and adjust medication related to response to sxs & (not legible)." "Supportive therapy 5 x week." "Educate patient regarding: (hand written) dx (diagnoses), tx (treatment), d/c (discharge)."
Nursing: "Administer medication to: (hand written) stabilize mood." "Assess patient's behavior for (hand written) unpredictability." "Provide safe environment by observing (written in) Q (every) 15 minutes." "Monitor patient's patterns of food and fluid intake [blank] and weights weekly." "Others: "Assist pt (patient) to groups until able to motivate self to attend." "Assess for suicidal ideations 7-3 & 3-11." "Assist (with) ADL's (activities of daily livings) & encourage independence in self care."

For the problem of "Pain" the following generic interventions were checked:
Physician: "Medical consult date(s): (hand written) on admission." "Other: (hand written) physical therapy referral."
Nursing: "Assess pain daily, or if not controlled every shift." "Educate the patient to medications, schedule, medication and expected pain control." "Relaxation Breathing." "Diversional Activities - walking (to decrease) pain." "Other: (Hand written) Limit physical activity in group to pt's (patient's) tolerance."

For the problem of "Fall Prevention" the following generic interventions were checked:
Physician: "Refer to Physical Therapy"
Social Work: None
Nursing: "Maintain uncluttered environment." "Don't Fall; Ask for Help" Signs posted in room as a reminder." "Wears Non-skid socks at night." "Educate to use appropriate footwear." "Hydration." "Medications that may cause confusion, dizziness, weakness [sic]." "Orient to environment." "Observation every 15 minute checks."

For the problem of "Discharge Planning" the following generic intervention was checked:
Nursing: "Medication Education (hand written) Stress benefits of compliance [sic]."

7. Patient W 13 (MTP dated 9/12/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: (Identical interventions to the interventions identified for patient W2 for the problem of "Altered Thought").
Nursing: "Encourage attendance at (hand written) all scheduled groups." "Assess and document patient's individual expression of hallucinations." "Use Behavior Agreement to assist patient in maintain control by [blank]." "Others: (Hand written) Observe Q (every) 15 minutes for safety or 1:1 if needed. Encourage Computer use to assess organization of thoughts. Instruct patient on condition and management of (hand written) command hallucinations."

For the problem "Discharge Planning" the following generic intervention was checked:
Nursing: (Identical interventions to the interventions identified for patient W3).

8. Patient W19 (MTP dated 9/20/11)

For the problem of "Mood Disorder," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more as needed (hand written) depression and moodiness." "Prescribe and adjust medication related to response to: (hand written) symptoms." "Supportive Therapy 5x (times) week." "Educate patient regarding: meds & (and) symptoms."
Nursing: "Administer medication to: stabilize mood (decrease) depressed feelings, (decrease) suicidal ideations." "Assess patient's behavior for suicidal ideas with plan q (every) shift." "Provide safe environment by observing q (every) 30 mins & (and) q (every) 15 mins." "Educate patient on: (hand written) signs & symptoms of depression, schizoaffective D/O (disorder)." "Others: (hand written) Encourage to attend on unit activities AT, OT, NSO, Morning mtg (meeting) ...to (decrease) isolation."
Occupational Therapist: none
Activities Therapy: none.

For problem of "Discharge Planning", the following generic interventions were checked:
Physician: "See patient on individual basis at least daily and more often as indicated to: (hand written) compliance". Prescribe medication and adjust medication related to response and effects to: [sic]." "Supportive Therapy _____ x week [sic]." "Educate regarding condition and medication and discharge."
Nursing: "Medication Education (written in) stress benefit of compliance."

B. Staff Interviews

1. During an interview on 10/25/11 at 2:40p.m. with the two Assistant Directors of Nursing (ADON), the Master Treatment Plans for patients E1, E2, E10, E16, W2, W3, W13, and W19 were reviewed; both ADONs agreed that the interventions were generic discipline functions.

2. During an interview on 10/25/11 at 3:00p.m. with the Medical Director, the Master Treatment Plan for patients E1, E 2, E10, E16, W2, W3, W13, and W19 were reviewed. The Medical Director agreed that the interventions on the treatment plans were generic discipline functions.

3. During an interview on 10/26/11 at 10:45a.m. with the Social Work Director, patient W3 ' s Master Treatment Plan was reviewed; the Director agreed that there was no social work intervention for the problem of "fall."

I. Based on observation, interviews, policy and record review, the facility failed to implement a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors alerted the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures.

II. Based on record review and interviews, the facility failed to ensure that appropriate medication orders for the use of PRN [as necessary] medications were written and implemented. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for the medication use. For these patients, physician orders for PRN medication were written for poorly defined symptoms: "anxiety," "insomnia" and "agitation," and orders for different medications were written for the same symptoms or complaints. In addition, two orders were written that allowed nurses to choose to administer the medications IM [by intramuscular injection] or po [by mouth]. Ambiguous physician orders can result in serious complications in patients; in addition, such physician orders encourage nursing staff to function outside their scope of practice.

Findings include:

I. Failure to Recognize Seclusion

A. Observation

During an observation on 10/25/11 at 9:45AM on the Cornerstone East unit, active sample Patient E16 was lying on a bed in a single occupant room. IA #1 (Institutional Aide), assigned to provide one to one observation of the patient, was sitting in a chair directly under the door jamb leading into E16's room. IA#1 had to physically move the chair out of the way for the surveyor to enter the room to speak with Patient E16.

B. Interviews

1. In an interview on 10/25/11 at 9:40AM, Patient E16 was asked about being in a single bed room and whether or not s/he could leave the room at anytime. Patient E16 replied, "If I left the room now, they (nurses) would give a shot (IM injection of medication). I can't leave here."

2. In an interview on 10/25/11 at 9:41AM, IA#1 (institutional aide) stated that "[E16] can't leave the room until the treatment team meets and decides what happens."

3. In an interview on 10/25/11 at 9:50AM, the Associate Director of Nursing was informed of the situation. She stated that she did not feel that the situation constituted a seclusion event and stated that the surveyor must have "misunderstood how we do one-to-ones."

4. In an interview on 10/25/11 at 10AM, the situation was described to the Facility Administrator. She stated, "Of course that's seclusion, I'll take care of this problem at once."

5. In an interview on 10/25/11 at 3PM with both Associate Directors of Nursing (ADON), the situation that occurred that morning was again discussed. Both ADONs agreed that the episode should have been considered a seclusion event.

6. In an interview on 10/25/11 at 3:30PM, the Medical Director agreed that the event (described above) should have been treated as a seclusion episode.

C. Policy Review

Facility Policy # 213-014, titled "Restraint/Seclusion for Behavioral Management: Special Treatment Procedures, dated 3/30/82 and last updated 8/19/10, noted the following under the section titled "Definitions": "Seclusion: The involuntary confinement of a person in a room where the person is physically prevented from leaving."

D. Record Review

Review of Physician Orders for 10/25/11 failed to identify a physician order for patient E16 ' s seclusion. There was a physician order written on 10/25/11 at 9:30AM to "renew 1:1 observation for unpredictable behavior."

II. Ambiguous Medication Orders

A. Record Review

1. Patient E1: Physician's orders dated 6/1/11 noted two PRN (as needed) medications for the same indication (agitation): Lorazepam 1mg po (orally) q6hours (every 6 hours) as needed for anxiety/agitation and Zyprexa 10mg po every 6 hours as needed for agitation. Review of the MAR (Medication Administration Record) for the month of October 2011 showed that Patient E1 had not received either medication during that time span.

2. Patient E2: Physician's orders dated 9/28/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q4hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn "severe agitation" and Lorazepam 2mg IM q6hours prn "severe agitation." There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E2 had not received either medication during that time span.

3. Patient E10: Physician's orders dated 9/29/11 noted two PRN medications for the same indication (agitation): Zyprexa 10mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Zyprexa 10mg IM (intramuscularly) q6hours prn agitation and Lorazepam 2mg IM q6hours prn agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E10 had received oral PRN doses of Zyprexa 10mg on a daily basis from 10/1/11 through 10/18/11. Patient E10 also received an IM dosing of PRN Zyprexa on 10/6/11. Nursing notes for theses dates did not specify how or why these medications or routes of administration were chosen.

4. Patient E16: Physician's orders dated 10/14/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn (no indication noted) and Lorazepam 2mg IM q6hours prn (no indication noted). There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E10 had received Lorazepam 1mg po on 10/23/11. Nursing notes did not specify how or why this medication was chosen.

5. Patient W2: Physician's orders dated 9/27/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 1mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W2 had received Lorazepam 1mg po on two occasions, once in combination with Haldol 5mg po. Nursing notes did not specify how or why these medications or routes of administration were chosen.

6. Patient W3: Physician's orders dated 10/3/11 noted three PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation; Lorazepam 1mg po q6hours prn anxiety/agitation and Benadryl 25mg po q6hours prn mild to moderate agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W3 had not received any PRN dosing of these medications.

7. Patient W13: Physician's orders dated 9/8/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 2mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W13 had not received any PRN dosing of these medications.

8. Patient W19: Physician's orders dated 10/12/11 noted two PRN medications for the same indication (agitation): Zyprexa 10mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Zyprexa 10mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 2mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W19 had not received any PRN dosing during this time frame.

9. Patient S1: Physician's orders dated 9/27/11 noted three PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 2mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation; Lorazepam 2mg IM q6hours prn severe agitation and Zyprexa 10mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient S1 had received one dose of Lorazepam po on 10/4/11. Nursing notes did not specify how or why that medication was chosen.

Patient S1 also had two PRN medications for the same indication (insomnia): Benadryl 50 po qHS (hour of sleep) prn insomnia and Trazadone 50mg po prn insomnia. Review of the MAR noted that Patient S1 received single dosing of Trazadone on 10/13/11 and 10/17/11. Nursing notes did not specify how or why this medication was chosen.

10. Patient S2: Physician's orders dated 9/21/11 noted two PRN medications for the same indication (agitation): Benadryl 25mg po q4hours prn mild to moderate agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Lorazepam 1mg IM q6hours prn agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient S2 had received 5 doses of PRN Benadryl between 10/4/11 and 10/13/11. Nursing notes did not specify how or why this medication or route of administration was chosen.

B. Interviews

1. In an interview on 10/24/11 at 11:30AM with MD1, PRN medication orders were discussed. MD1 was shown the record for Patient E10 and stated, "The nurses should know that Lorazepam is for agitation because of anxiety and Zyprexa is for agitation from psychosis; they (nurses) just know that." MD1 was asked how the nursing staff would know that one drug is for anxiety and other is for psychosis unless it was specified in an order, MD1 responded "They just know that." RN1 then joined the interview and stated, "We make the choice based on our own skills, sometimes we let the patient choose." RN1 and MD1 were then asked if there had ever been a call from a nurse to a physician to clarify these orders; both stated "no." MD1 was asked if the facility pharmacist had ever called for clarification; MD1 stated "no."

2. In an interview on 10/25/11 at 10:40AM, RN2 was asked about Patient S1 and the PRN insomnia medication orders. RN2 stated, "I let the patient choose which drug they want; they know what works."

3. In an interview on 10/25/11 at 2:45PM with both Assistant Directors of Nursing, examples of PRN orders were shown to both of them. They both agreed that the orders were ambiguous and placed nursing staff in an inappropriate decision making role.

4. In an interview on 10/25/11 at 3:30PM, the Medical Director was shown examples of PRN medication orders; she agreed that the orders were ambiguous and did not give enough guidance to nursing staff for choosing PRN medications.

Based on record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 1 of 5 discharged patients whose records were reviewed (D2). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

Patient D2 was discharged from the facility on 8/18/11. In a Discharge Summary dated 9/15/11, the attending physician noted the "Hospital Course" as: "The patient remains depressed, preoccupied, anxious, did not sufficiently improve for safe discharge to the community and was therefore transferred to [state hospital] for further treatment and psychiatric stabilization." There was no information that described the patient's response to specific treatment modalities or strategies, thus limiting the information available to the accepting facility for the adequate transfer of care of a decompensated patient.

B. Interview

In an interview on 10/25/11 at 3:30PM, the Medical Director was shown the discharge summary for Patient D2. She agreed with the findings and stated, "There must be an addendum somewhere; this isn't a complete discharge summary." The Medical Director was unable to locate any addendum in the record. On 10/26/11 at 10AM, The Assistant Director of Nursing handed the surveyors Patient D2's record and stated that the physician had completed a handwritten addendum that morning (10/26/11). The addendum was dated 10/25/11 by the physician's handwriting. The Medical Director confirmed that the addendum had been written on the AM of 10/26/11.

Based on record review, policy review, interviews and observation, the Medical Director failed to:

I. Ensure that physicians listed patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths. (Refer to B117)

II. Ensure that clinical staff developed Master Treatment Plans that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs of 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The Master Treatment Plans included checklists and written interventions which were routine generic discipline functions that lacked focus for treatment. In addition, 5 of 8 active sample patients had no written physician, nursing and social work interventions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

III. Ensure that clinical staff implemented a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures (Refer to B125-I)

IV. Ensure that physicians wrote and implemented appropriate medication orders for the use of PRN [as necessary] medications. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for their use. For these patients, physician orders for PRN medication were written for poorly described conditions: "anxiety", "insomnia", and "agitation"; additionally, orders for two or three different medications were written for the same symptoms or complaints. Orders were also written which allowed nurses to choose to administer the medications by IM [intramuscular injection] or po [by mouth] without physician direction. Ambiguous physician orders can result in serious complications in patients as a result of improper PRN medications orders. In addition, such physician orders encourage nursing staff to function outside their scope of practice. (Refer to B125-II)

V. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 1 of 5 discharged patients whose records were reviewed (D2). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

I. Based on record review and interview, the Assistant Directors of Nursing failed to ensure that the Master Treatment Plan for 8 of 8 active sample patients (E1, E 2, E10, E16, W2, W3, W13, and W19) identified nursing interventions that were individualized and specific to the treatment needs of each patient. The Master Treatment Plans included lists of interventions with check marks and hand written additions, all of which were routine, generic nursing functions. Some of the checked interventions did not specify the frequency for care. These failures can result in fragmented nursing care and lack accountability.

Findings include:

A. Record review

1. Patient E1 (Master Treatment Plan (MTP) dated 6/3/2011)

For the problem of "Mood disorder," the following generic nursing interventions were checked: "Administer medication to: (increase) mood stability monitor effect & (and) document." "Provide safe environment by observing (written in) (check) q (every) 15 min's and prn (as needed) - document." "Identify sleeping pattern q (every) nightly & (and) document, medicate teach relaxation tech (technique) as per orders."

2, Patient E2 (MTP dated 7/13/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attending at (hand written) nursing group 2x/week." "Assess and document patient's individual expression of delusion q (every) shift, prn."

For the problem of "Discharge Planning," the following generic interventions were checked: "Medication Education review meds @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide support."

3. Patient E10 (MTP dated 10/4/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at (hand written) groups, unit activities, treatment planning." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) dx (diagnoses) illness, relapse prevention, coping skills." Use Behavior Agreement to assist patient in maintaining control by Q (every) 15, Q (every) 30 min, time out in room to (decrease) stimuli."

For the problem: "Discharge Planning," the following interventions were entered: "Medication Education (hand written) review medication upon d/c (discharge)." "Encourage to verbalize feelings regarding discharge and provide support."

4. Patient E 16 (MTP dated 10/18/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at therapeutic group & (and) nurses groups 2x (times) wk (week)." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) signs and symptoms of disease." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talk to staff." "Other: obs (observe) Q (every) 15 min for safety or 1:1 if needed."

For the problem of "Substance Abuse," there were no listed nursing interventions.

For the problem of "Discharge Planning," the following generic interventions were checked: "Medication Education review @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide comfort."

5. Patient W2 (MTP dated (9/28/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage Anne to wear armband." "Encourage attendance at Tx (treatment) team, nsg (nursing) psychologist group 2x/week." "Assess and document patient's individual expression of hallucinations/delusion." Instruct patient on condition and management of schizophrenia/Rx'd (ordered) medication." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talking (with) pt (patient), PRN (as needed) meds." "Ask staff to talk to me; take prn (as needed) meds if needed." "Observe q (every) 15 min for safety." Assess sleep patterns, offer PRN) as needed) sleeper." "Speak quietly & directly, set behavioral limit." "Provide reality orientation."

For problem of "Discharge Planning" the following generic nursing intervention was checked:
"Medication Education - (hand written) stress benefit of adherence [sic]."

6. Patient W3 (MTP dated 10/4/11

For the problem of "Mood Disorder." the following generic nursing interventions were checked: "Administer medication to: (hand written) stabilize mood." "Assess patient's behavior for (hand written) unpredictability." "Provide safe environment by observing (written in) Q (every) 15 minutes." "Monitor patient's patterns of food and fluid intake and weights weekly." "Others: "Assist pt (patient) to groups until able to motivate self to attend." "Assess for suicidal ideations 7-3 & 3-11." "Assist (with) ADL's (activities of daily livings) & encourage independence in self care."

For the problem of "Pain," the following generic nursing intervention were checked:
"Assess pain daily, or if not controlled every shift." "Educate the patient to medications, schedule, medication and expected pain control." "Relaxation Breathing." "Diversional Activities - walking (decreases) pain." "Other: (Hand written) Limit physical activity in group to pt's (patient's) tolerance."

For the problem of "Fall Prevention," the following generic nursing interventions were checked: "Maintain uncluttered environment." "Don't Fall; Ask for Help" [sic] Signs posted in room as a reminder." "Wears Non-skid socks at night." "Educate to use appropriate footwear," "Hydration," "Medications that may cause confusion, dizziness, weakness," "Orient to environment," "Observation every 15 minute checks."

For the problem of "Discharge Planning" the following generic nursing intervention was checked: "Medication Education (hand written) Stress benefits of compliance" [sic].

7. Patient W 13 (MTP dated 9/12/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at (hand written) all scheduled groups." Assess and document patient's individual expression of hallucinations." "Use Behavior Agreement to assist patient in maintain control by [blank]." "Others: (Hand written) "Observe Q (every) 15 minutes for safety or 1:1 if needed." "Encourage Computer use to assess organization of thoughts [sic]." "Instruct patient on condition and management of (hand written) command hallucination."

For the problem "Discharge Planning," the nursing interventions were identical to those for patient W3 above.

8. Patient W19 (MTP dated 9/20/11)

For the problem of "Mood Disorder," the following generic nursing interventions were checked:
"Administer medication to: stabilize mood (decrease) depressed feelings, (decrease) suicidal ideations." "Assess patient's behavior for suicidal ideas with plan q (every) shift." "Provide safe environment by observing q (every) 30 mins & (and) q (every) 15 mins." "Educate patient on: (hand written) signs & symptoms of depression, schizoaffective D/O (disorder)." "Others: (hand written) Encourage to attend on unit activities AT, OT, NSO, Morning mtg (meeting)...to (decrease) isolation."

For problem of "Discharge Planning", the following generic nursing intervention was checked:
"Medication Education (hand written) stress benefit of compliance."

B. Staff Interviews

In an interview on 10/25/11 at 2:40p.m. with the two Assistant Director of Nursing (ADON), the Master Treatment Plans for patients E1, E2, E10, E16, W2, W3, W13, and W19 were reviewed; both Assistant Directors agreed that the nursing interventions on the patients' treatment plans were generic nursing functions.

II. Based on observation, interviews, policy review and record review, the Director of Nursing failed to ensure that nursing staff implemented a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The nursing staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures. (Refer to B125-I)

III. Based on record review and interviews, the Director of Nursing failed to ensure that appropriate medication orders for the use of PRN [as necessary] medications were implemented by nursing staff. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for their use. For these patients, physician orders for PRN medication were written for poorly described conditions: "anxiety," "insomnia" and "agitation," and orders for different medications were written for the same symptoms or complaints. In addition, two orders were written which allowed nurses to choose to administer the medications IM [intramuscular injection] or po [by mouth]. Ambiguous physician orders can result in serious complications in patients as a result of improper PRN medications orders. In addition, such physician orders encourage nursing staff to function outside their scope of practice. (Refer to B125-II)

Based on record review and interview, the facility failed to provide complete psychosocial assessments for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The psychosocial evaluations did not include social work specific conclusions and recommendations; describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of social work input for treatment planning.

Findings include:

A. Record Review

1. Patient E1. There were no conclusions or recommendations noted in a psychosocial assessment dated 6/2/11.

2. Patient E2. There were no conclusions or recommendations noted in a psychosocial assessment dated 7/13/11.

3. Patient E10. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

4. Patient E16. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/14/11.

5. Patient W2. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/28/11.

6. Patient W3. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

7. Patient W13. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/9/11.

8. Patient W19. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/13/11.

B. Interview

In an interview on 10/25/11 at 2:15PM, the Director of Social Work was unable to find specific social work recommendations and conclusions in the sample patients' records and agreed that the psychosocial evaluations were missing this information. She stated, "We used to do it that way but then stopped when we combined the assessments into the present format."

Based on record review and interview, the facility failed to provide complete psychosocial assessments for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The psychosocial evaluations did not include social work specific conclusions and recommendations; describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of social work input for treatment planning.

Findings include:

A. Record Review

1. Patient E1. There were no conclusions or recommendations noted in a psychosocial assessment dated 6/2/11.

2. Patient E2. There were no conclusions or recommendations noted in a psychosocial assessment dated 7/13/11.

3. Patient E10. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

4. Patient E16. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/14/11.

5. Patient W2. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/28/11.

6. Patient W3. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

7. Patient W13. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/9/11.

8. Patient W19. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/13/11.

B. Interview

In an interview on 10/25/11 at 2:15PM, the Director of Social Work was unable to find specific social work recommendations and conclusions in the sample patients' records and agreed that the psychosocial evaluations were missing the information. She stated, "We used to do it that way but then stopped when we combined the assessments into the present format."

Based on record review and interview, the facility failed to list patient assets in the Psychiatric Assessments in descriptive terms for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths.

Findings include:

A. Record Review

1. Patient E1 was admitted on 6/1/11. The Psychiatric Assessment dated 6/2/11, in the section titled "Patient Assets and Strengths," noted the following: "fair insight." No other descriptive information was noted.

2. Patient E2 was admitted on 7/12/11. In a Psychiatric Assessment dated 7/13/11, the section titled "Patient Assets and Strengths" noted the following: "good physical health." No other descriptive information was noted.

3. Patient E10 was admitted on 9/29/11. In a Psychiatric Assessment dated 9/30/11, the section titled "Patient Assets and Strengths" noted the following: "housing, family support." No other descriptive information was noted.

4. Patient E16 was admitted on 10/14/11. In a Psychiatric Assessment dated 10/15/11, the section titled "Patient Assets and Strengths" noted the following: "housing, family support." No other descriptive information was noted.

5. Patient W2 was admitted on 9/27/11. In a Psychiatric Assessment dated 9/28/11, the section titled "Patient Assets and Strengths" noted the following: "has housing at shelter." No other descriptive information was noted.

6. Patient W3 was admitted on 10/3/11. In a Psychiatric Assessment dated 10/4/11, the section titled "Patient Assets and Strengths" noted the following: "intelligence." No other descriptive information was noted.

7. Patient W13 was admitted on 9/8/11. In a Psychiatric Assessment dated 9/9/11, the section titled "Patient Assets and Strengths" noted the following: "accepts tx (treatment)." No other descriptive information was noted.

8. Patient W19 was admitted on 10/12/11. In a Psychiatric Assessment dated 10/13/11, the section titled "Patient Assets and Strengths" noted the following: "family." No other descriptive information was noted.

B. Interview

In an interview on 10/25/11 at 3:30PM, the Medical Director agreed that the assets noted in the above patients' Psychiatric Assessments were not descriptive in nature.

Based on record review and interview, the facility failed to develop Master Treatment Plans that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13, and W19). The Master Treatment Plans included checklists and written interventions which were routine, generic discipline functions that lacked focus for treatment. In addition 5 of 8 active sample patients had no written physician, nursing and social work interventions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

A review of medical records revealed that the pre-printed treatment plans only listed routine, generic discipline functions as interventions rather than individualized interventions to assist patients accomplish their treatment goals.

1. Patient E1 (Master Treatment Plan (MTP) dated 6/3/2011)

For the problem of "Mood disorder," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often as needed to: (hand written) assess illness & (and) meds." "Prescribe and adjust medication related to response to: (hand written) illness - (and) sympts- (symptoms)." "Supportive Therapy 5 x (times) week."
Nursing: "Administer medication to: (increase) mood stability monitor effect & (and) document." "Provide safe environment by observing (written in) (check) q (every) 15 min's and prn (as needed) - document." "Identify sleeping pattern q (every) nightly & (and) document, medicate teach relaxation tech (technique) as per orders."

2. Patient E2 (MTP dated 7/13/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to (hand written) assess symptoms & (and) resp (response) to meds." "Prescribe and adjust medication related to response to psychotic symptoms." "Supportive Therapy 5 x week." "Educate patient regarding (hand written) compliance illness."
Nursing: "Encourage attending at (hand written) nursing group 2x/week." "Assess and document patient's individual expression of delusion q (every) shift, prn," Activities Therapy: none.

For the problem of "Discharge Planning," the following generic interventions were checked:
Nursing: "Medication Education (hand written) review meds @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide support."

3. Patient E10 (MTP dated 10/4/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) address symptoms." "Prescribe and adjust medication related to response to: (hand written) stabilize symptoms." "Supportive Therapy 5 x week."
Nursing: "Encourage attendance at (written in) groups, unit activities, treatment planning." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (written in) dx (diagnoses) illness, relapse prevention, coping skills." "Use Behavior Agreement to assist patient in maintaining control by (hand written) Q (every) 15, Q (every) 30 min, time out in room to decrease stimuli."

For the problem: "Discharge Planning," the following intervention was entered:
Nursing: "Medication Education (hand written) review medication upon d/c (discharge)." "Encourage to verbalize feelings regarding discharge and provide support."

4. Patient E 16 (MTP dated 10/18/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) address his symptoms." "Prescribe and adjust medication related to response to: (hand written) stabilize his symptoms." "Supportive Therapy 2 x (times) week."
Nursing: "Encourage attendance at therapeutic group & (and) nurses groups 2x (times) wk (week)." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) signs and symptoms of disease." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talk to staff." "Other: obs (observe) Q (every) 15 min for safety or 1:1 if needed."

For the problem of "Substance Abuse," the following generic interventions were checked:
Physician: No intervention
Nursing: Patient goals were written in the section on interventions, in place of staff interventions: "Patient will be able to recognize triggers that lead to alcohol & (and) drug use for him." "Patient will gain insight & (and) set goal to attend therapeutic groups while here & (and) upon discharge."

For the problem of "Discharge Planning," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily and more often as indicated to: (hand written) address his symptoms." "Prescribe medication and adjust medication related to response and effects to: (hand written) stabilize his symptoms." "Supportive Therapy 7 x week."
Nursing: "Medication Education review @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide comfort."

5. Patient W2 (MTP dated (9/28/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more often to: (hand written) "assess sxs & (not legible) (signs and symptoms)." "Prescribe and adjust medication related to response to: (Hand written) "assess sxs & (not legible) (signs and symptoms)." "Supportive Therapy 5 x week." "Educate patient regarding (written in) diagnoses, tx (treatment), discharge plan."
Nursing: "Encourage [patient] to wear armband." "Encourage attendance at (hand written) Tx (treatment) team, nsg (nursing) psychologist group 2x/week." "Assess and document patient's individual expression of hallucinations/ (hand written) delusion." "Instruct patient on condition and management of schizophrenia/Rx ' d (ordered) medication." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talking (with) pt (patient), PRN (as needed) meds." "Ask staff to talk to me; take prn (as needed) meds if needed." "Observe q (every) 15 min for safety." "Assess sleep patterns, offer PRN (as needed) sleeper." "Speak quietly & directly, set behavioral limit." "Provide reality orientation."

For problem of "Discharge Planning" the following generic intervention was checked:
Nursing: "Medication Education - (hand written) stress benefit of adherence [sic]."

6. Patient W3 (MTP dated 10/4/11

For the problem of "Mood Disorder." the following generic interventions were checked:
Physician: "See the patient on individual basis at least daily or more often as needed to (hand written) assess sxs & (not legible), (assess signs and symptoms)." "Prescribe and adjust medication related to response to sxs & (not legible)." "Supportive therapy 5 x week." "Educate patient regarding: (hand written) dx (diagnoses), tx (treatment), d/c (discharge)."
Nursing: "Administer medication to: (hand written) stabilize mood." "Assess patient's behavior for (hand written) unpredictability." "Provide safe environment by observing (written in) Q (every) 15 minutes." "Monitor patient's patterns of food and fluid intake [blank] and weights weekly." "Others: "Assist pt (patient) to groups until able to motivate self to attend." "Assess for suicidal ideations 7-3 & 3-11." "Assist (with) ADL's (activities of daily livings) & encourage independence in self care."

For the problem of "Pain" the following generic interventions were checked:
Physician: "Medical consult date(s): (hand written) on admission." "Other: (hand written) physical therapy referral."
Nursing: "Assess pain daily, or if not controlled every shift." "Educate the patient to medications, schedule, medication and expected pain control." "Relaxation Breathing." "Diversional Activities - walking (to decrease) pain." "Other: (Hand written) Limit physical activity in group to pt's (patient's) tolerance."

For the problem of "Fall Prevention" the following generic interventions were checked:
Physician: "Refer to Physical Therapy"
Social Work: None
Nursing: "Maintain uncluttered environment." "Don't Fall; Ask for Help" Signs posted in room as a reminder." "Wears Non-skid socks at night." "Educate to use appropriate footwear." "Hydration." "Medications that may cause confusion, dizziness, weakness [sic]." "Orient to environment." "Observation every 15 minute checks."

For the problem of "Discharge Planning" the following generic intervention was checked:
Nursing: "Medication Education (hand written) Stress benefits of compliance [sic]."

7. Patient W 13 (MTP dated 9/12/11)

For the problem of "Altered Thought," the following generic interventions were checked:
Physician: (Identical interventions to the interventions identified for patient W2 for the problem of "Altered Thought").
Nursing: "Encourage attendance at (hand written) all scheduled groups." "Assess and document patient's individual expression of hallucinations." "Use Behavior Agreement to assist patient in maintain control by [blank]." "Others: (Hand written) Observe Q (every) 15 minutes for safety or 1:1 if needed. Encourage Computer use to assess organization of thoughts. Instruct patient on condition and management of (hand written) command hallucinations."

For the problem "Discharge Planning" the following generic intervention was checked:
Nursing: (Identical interventions to the interventions identified for patient W3).

8. Patient W19 (MTP dated 9/20/11)

For the problem of "Mood Disorder," the following generic interventions were checked:
Physician: "See patient on individual basis at least daily or more as needed (hand written) depression and moodiness." "Prescribe and adjust medication related to response to: (hand written) symptoms." "Supportive Therapy 5x (times) week." "Educate patient regarding: meds & (and) symptoms."
Nursing: "Administer medication to: stabilize mood (decrease) depressed feelings, (decrease) suicidal ideations." "Assess patient's behavior for suicidal ideas with plan q (every) shift." "Provide safe environment by observing q (every) 30 mins & (and) q (every) 15 mins." "Educate patient on: (hand written) signs & symptoms of depression, schizoaffective D/O (disorder)." "Others: (hand written) Encourage to attend on unit activities AT, OT, NSO, Morning mtg (meeting) ...to (decrease) isolation."
Occupational Therapist: none
Activities Therapy: none.

For problem of "Discharge Planning", the following generic interventions were checked:
Physician: "See patient on individual basis at least daily and more often as indicated to: (hand written) compliance". Prescribe medication and adjust medication related to response and effects to: [sic]." "Supportive Therapy _____ x week [sic]." "Educate regarding condition and medication and discharge."
Nursing: "Medication Education (written in) stress benefit of compliance."

B. Staff Interviews

1. During an interview on 10/25/11 at 2:40p.m. with the two Assistant Directors of Nursing (ADON), the Master Treatment Plans for patients E1, E2, E10, E16, W2, W3, W13, and W19 were reviewed; both ADONs agreed that the interventions were generic discipline functions.

2. During an interview on 10/25/11 at 3:00p.m. with the Medical Director, the Master Treatment Plan for patients E1, E 2, E10, E16, W2, W3, W13, and W19 were reviewed. The Medical Director agreed that the interventions on the treatment plans were generic discipline functions.

3. During an interview on 10/26/11 at 10:45a.m. with the Social Work Director, patient W3 ' s Master Treatment Plan was reviewed; the Director agreed that there was no social work intervention for the problem of "fall."

I. Based on observation, interviews, policy and record review, the facility failed to implement a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors alerted the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures.

II. Based on record review and interviews, the facility failed to ensure that appropriate medication orders for the use of PRN [as necessary] medications were written and implemented. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for the medication use. For these patients, physician orders for PRN medication were written for poorly defined symptoms: "anxiety," "insomnia" and "agitation," and orders for different medications were written for the same symptoms or complaints. In addition, two orders were written that allowed nurses to choose to administer the medications IM [by intramuscular injection] or po [by mouth]. Ambiguous physician orders can result in serious complications in patients; in addition, such physician orders encourage nursing staff to function outside their scope of practice.

Findings include:

I. Failure to Recognize Seclusion

A. Observation

During an observation on 10/25/11 at 9:45AM on the Cornerstone East unit, active sample Patient E16 was lying on a bed in a single occupant room. IA #1 (Institutional Aide), assigned to provide one to one observation of the patient, was sitting in a chair directly under the door jamb leading into E16's room. IA#1 had to physically move the chair out of the way for the surveyor to enter the room to speak with Patient E16.

B. Interviews

1. In an interview on 10/25/11 at 9:40AM, Patient E16 was asked about being in a single bed room and whether or not s/he could leave the room at anytime. Patient E16 replied, "If I left the room now, they (nurses) would give a shot (IM injection of medication). I can't leave here."

2. In an interview on 10/25/11 at 9:41AM, IA#1 (institutional aide) stated that "[E16] can't leave the room until the treatment team meets and decides what happens."

3. In an interview on 10/25/11 at 9:50AM, the Associate Director of Nursing was informed of the situation. She stated that she did not feel that the situation constituted a seclusion event and stated that the surveyor must have "misunderstood how we do one-to-ones."

4. In an interview on 10/25/11 at 10AM, the situation was described to the Facility Administrator. She stated, "Of course that's seclusion, I'll take care of this problem at once."

5. In an interview on 10/25/11 at 3PM with both Associate Directors of Nursing (ADON), the situation that occurred that morning was again discussed. Both ADONs agreed that the episode should have been considered a seclusion event.

6. In an interview on 10/25/11 at 3:30PM, the Medical Director agreed that the event (described above) should have been treated as a seclusion episode.

C. Policy Review

Facility Policy # 213-014, titled "Restraint/Seclusion for Behavioral Management: Special Treatment Procedures, dated 3/30/82 and last updated 8/19/10, noted the following under the section titled "Definitions": "Seclusion: The involuntary confinement of a person in a room where the person is physically prevented from leaving."

D. Record Review

Review of Physician Orders for 10/25/11 failed to identify a physician order for patient E16 ' s seclusion. There was a physician order written on 10/25/11 at 9:30AM to "renew 1:1 observation for unpredictable behavior."

II. Ambiguous Medication Orders

A. Record Review

1. Patient E1: Physician's orders dated 6/1/11 noted two PRN (as needed) medications for the same indication (agitation): Lorazepam 1mg po (orally) q6hours (every 6 hours) as needed for anxiety/agitation and Zyprexa 10mg po every 6 hours as needed for agitation. Review of the MAR (Medication Administration Record) for the month of October 2011 showed that Patient E1 had not received either medication during that time span.

2. Patient E2: Physician's orders dated 9/28/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q4hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn "severe agitation" and Lorazepam 2mg IM q6hours prn "severe agitation." There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E2 had not received either medication during that time span.

3. Patient E10: Physician's orders dated 9/29/11 noted two PRN medications for the same indication (agitation): Zyprexa 10mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Zyprexa 10mg IM (intramuscularly) q6hours prn agitation and Lorazepam 2mg IM q6hours prn agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E10 had received oral PRN doses of Zyprexa 10mg on a daily basis from 10/1/11 through 10/18/11. Patient E10 also received an IM dosing of PRN Zyprexa on 10/6/11. Nursing notes for theses dates did not specify how or why these medications or routes of administration were chosen.

4. Patient E16: Physician's orders dated 10/14/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn (no indication noted) and Lorazepam 2mg IM q6hours prn (no indication noted). There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient E10 had received Lorazepam 1mg po on 10/23/11. Nursing notes did not specify how or why this medication was chosen.

5. Patient W2: Physician's orders dated 9/27/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 1mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W2 had received Lorazepam 1mg po on two occasions, once in combination with Haldol 5mg po. Nursing notes did not specify how or why these medications or routes of administration were chosen.

6. Patient W3: Physician's orders dated 10/3/11 noted three PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation; Lorazepam 1mg po q6hours prn anxiety/agitation and Benadryl 25mg po q6hours prn mild to moderate agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W3 had not received any PRN dosing of these medications.

7. Patient W13: Physician's orders dated 9/8/11 noted two PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 2mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W13 had not received any PRN dosing of these medications.

8. Patient W19: Physician's orders dated 10/12/11 noted two PRN medications for the same indication (agitation): Zyprexa 10mg po q6hours prn agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Zyprexa 10mg IM (intramuscularly) q6hours prn severe agitation and Lorazepam 2mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient W19 had not received any PRN dosing during this time frame.

9. Patient S1: Physician's orders dated 9/27/11 noted three PRN medications for the same indication (agitation): Haldol 5mg po q6hours prn agitation and Lorazepam 2mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Haldol 5mg IM (intramuscularly) q6hours prn severe agitation; Lorazepam 2mg IM q6hours prn severe agitation and Zyprexa 10mg IM q6hours prn severe agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient S1 had received one dose of Lorazepam po on 10/4/11. Nursing notes did not specify how or why that medication was chosen.

Patient S1 also had two PRN medications for the same indication (insomnia): Benadryl 50 po qHS (hour of sleep) prn insomnia and Trazadone 50mg po prn insomnia. Review of the MAR noted that Patient S1 received single dosing of Trazadone on 10/13/11 and 10/17/11. Nursing notes did not specify how or why this medication was chosen.

10. Patient S2: Physician's orders dated 9/21/11 noted two PRN medications for the same indication (agitation): Benadryl 25mg po q4hours prn mild to moderate agitation and Lorazepam 1mg po q6hours prn anxiety/agitation. Additionally, there were physician orders for Lorazepam 1mg IM q6hours prn agitation. There were no other parameters written for the use of the medications to help guide nursing with decision making. There was also no daily maximum dosing noted for either medication. Review of the MAR for the month of October 2011 showed that Patient S2 had received 5 doses of PRN Benadryl between 10/4/11 and 10/13/11. Nursing notes did not specify how or why this medication or route of administration was chosen.

B. Interviews

1. In an interview on 10/24/11 at 11:30AM with MD1, PRN medication orders were discussed. MD1 was shown the record for Patient E10 and stated, "The nurses should know that Lorazepam is for agitation because of anxiety and Zyprexa is for agitation from psychosis; they (nurses) just know that." MD1 was asked how the nursing staff would know that one drug is for anxiety and other is for psychosis unless it was specified in an order, MD1 responded "They just know that." RN1 then joined the interview and stated, "We make the choice based on our own skills, sometimes we let the patient choose." RN1 and MD1 were then asked if there had ever been a call from a nurse to a physician to clarify these orders; both stated "no." MD1 was asked if the facility pharmacist had ever called for clarification; MD1 stated "no."

2. In an interview on 10/25/11 at 10:40AM, RN2 was asked about Patient S1 and the PRN insomnia medication orders. RN2 stated, "I let the patient choose which drug they want; they know what works."

3. In an interview on 10/25/11 at 2:45PM with both Assistant Directors of Nursing, examples of PRN orders were shown to both of them. They both agreed that the orders were ambiguous and placed nursing staff in an inappropriate decision making role.

4. In an interview on 10/25/11 at 3:30PM, the Medical Director was shown examples of PRN medication orders; she agreed that the orders were ambiguous and did not give enough guidance to nursing staff for choosing PRN medications.

Based on record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 1 of 5 discharged patients whose records were reviewed (D2). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

Patient D2 was discharged from the facility on 8/18/11. In a Discharge Summary dated 9/15/11, the attending physician noted the "Hospital Course" as: "The patient remains depressed, preoccupied, anxious, did not sufficiently improve for safe discharge to the community and was therefore transferred to [state hospital] for further treatment and psychiatric stabilization." There was no information that described the patient's response to specific treatment modalities or strategies, thus limiting the information available to the accepting facility for the adequate transfer of care of a decompensated patient.

B. Interview

In an interview on 10/25/11 at 3:30PM, the Medical Director was shown the discharge summary for Patient D2. She agreed with the findings and stated, "There must be an addendum somewhere; this isn't a complete discharge summary." The Medical Director was unable to locate any addendum in the record. On 10/26/11 at 10AM, The Assistant Director of Nursing handed the surveyors Patient D2's record and stated that the physician had completed a handwritten addendum that morning (10/26/11). The addendum was dated 10/25/11 by the physician's handwriting. The Medical Director confirmed that the addendum had been written on the AM of 10/26/11.

Based on record review, policy review, interviews and observation, the Medical Director failed to:

I. Ensure that physicians listed patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths. (Refer to B117)

II. Ensure that clinical staff developed Master Treatment Plans that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs of 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The Master Treatment Plans included checklists and written interventions which were routine generic discipline functions that lacked focus for treatment. In addition, 5 of 8 active sample patients had no written physician, nursing and social work interventions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

III. Ensure that clinical staff implemented a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures (Refer to B125-I)

IV. Ensure that physicians wrote and implemented appropriate medication orders for the use of PRN [as necessary] medications. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for their use. For these patients, physician orders for PRN medication were written for poorly described conditions: "anxiety", "insomnia", and "agitation"; additionally, orders for two or three different medications were written for the same symptoms or complaints. Orders were also written which allowed nurses to choose to administer the medications by IM [intramuscular injection] or po [by mouth] without physician direction. Ambiguous physician orders can result in serious complications in patients as a result of improper PRN medications orders. In addition, such physician orders encourage nursing staff to function outside their scope of practice. (Refer to B125-II)

V. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 1 of 5 discharged patients whose records were reviewed (D2). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

I. Based on record review and interview, the Assistant Directors of Nursing failed to ensure that the Master Treatment Plan for 8 of 8 active sample patients (E1, E 2, E10, E16, W2, W3, W13, and W19) identified nursing interventions that were individualized and specific to the treatment needs of each patient. The Master Treatment Plans included lists of interventions with check marks and hand written additions, all of which were routine, generic nursing functions. Some of the checked interventions did not specify the frequency for care. These failures can result in fragmented nursing care and lack accountability.

Findings include:

A. Record review

1. Patient E1 (Master Treatment Plan (MTP) dated 6/3/2011)

For the problem of "Mood disorder," the following generic nursing interventions were checked: "Administer medication to: (increase) mood stability monitor effect & (and) document." "Provide safe environment by observing (written in) (check) q (every) 15 min's and prn (as needed) - document." "Identify sleeping pattern q (every) nightly & (and) document, medicate teach relaxation tech (technique) as per orders."

2, Patient E2 (MTP dated 7/13/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attending at (hand written) nursing group 2x/week." "Assess and document patient's individual expression of delusion q (every) shift, prn."

For the problem of "Discharge Planning," the following generic interventions were checked: "Medication Education review meds @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide support."

3. Patient E10 (MTP dated 10/4/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at (hand written) groups, unit activities, treatment planning." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) dx (diagnoses) illness, relapse prevention, coping skills." Use Behavior Agreement to assist patient in maintaining control by Q (every) 15, Q (every) 30 min, time out in room to (decrease) stimuli."

For the problem: "Discharge Planning," the following interventions were entered: "Medication Education (hand written) review medication upon d/c (discharge)." "Encourage to verbalize feelings regarding discharge and provide support."

4. Patient E 16 (MTP dated 10/18/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at therapeutic group & (and) nurses groups 2x (times) wk (week)." "Assess and document patient's individual expression of hallucinations." "Instruct patient on condition and management of (hand written) signs and symptoms of disease." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talk to staff." "Other: obs (observe) Q (every) 15 min for safety or 1:1 if needed."

For the problem of "Substance Abuse," there were no listed nursing interventions.

For the problem of "Discharge Planning," the following generic interventions were checked: "Medication Education review @ (at) time of discharge." "Encourage to verbalize feelings regarding discharge and provide comfort."

5. Patient W2 (MTP dated (9/28/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage Anne to wear armband." "Encourage attendance at Tx (treatment) team, nsg (nursing) psychologist group 2x/week." "Assess and document patient's individual expression of hallucinations/delusion." Instruct patient on condition and management of schizophrenia/Rx'd (ordered) medication." "Use Behavior Agreement to assist patient in maintaining control by (hand written) talking (with) pt (patient), PRN (as needed) meds." "Ask staff to talk to me; take prn (as needed) meds if needed." "Observe q (every) 15 min for safety." Assess sleep patterns, offer PRN) as needed) sleeper." "Speak quietly & directly, set behavioral limit." "Provide reality orientation."

For problem of "Discharge Planning" the following generic nursing intervention was checked:
"Medication Education - (hand written) stress benefit of adherence [sic]."

6. Patient W3 (MTP dated 10/4/11

For the problem of "Mood Disorder." the following generic nursing interventions were checked: "Administer medication to: (hand written) stabilize mood." "Assess patient's behavior for (hand written) unpredictability." "Provide safe environment by observing (written in) Q (every) 15 minutes." "Monitor patient's patterns of food and fluid intake and weights weekly." "Others: "Assist pt (patient) to groups until able to motivate self to attend." "Assess for suicidal ideations 7-3 & 3-11." "Assist (with) ADL's (activities of daily livings) & encourage independence in self care."

For the problem of "Pain," the following generic nursing intervention were checked:
"Assess pain daily, or if not controlled every shift." "Educate the patient to medications, schedule, medication and expected pain control." "Relaxation Breathing." "Diversional Activities - walking (decreases) pain." "Other: (Hand written) Limit physical activity in group to pt's (patient's) tolerance."

For the problem of "Fall Prevention," the following generic nursing interventions were checked: "Maintain uncluttered environment." "Don't Fall; Ask for Help" [sic] Signs posted in room as a reminder." "Wears Non-skid socks at night." "Educate to use appropriate footwear," "Hydration," "Medications that may cause confusion, dizziness, weakness," "Orient to environment," "Observation every 15 minute checks."

For the problem of "Discharge Planning" the following generic nursing intervention was checked: "Medication Education (hand written) Stress benefits of compliance" [sic].

7. Patient W 13 (MTP dated 9/12/11)

For the problem of "Altered Thought," the following generic nursing interventions were checked: "Encourage attendance at (hand written) all scheduled groups." Assess and document patient's individual expression of hallucinations." "Use Behavior Agreement to assist patient in maintain control by [blank]." "Others: (Hand written) "Observe Q (every) 15 minutes for safety or 1:1 if needed." "Encourage Computer use to assess organization of thoughts [sic]." "Instruct patient on condition and management of (hand written) command hallucination."

For the problem "Discharge Planning," the nursing interventions were identical to those for patient W3 above.

8. Patient W19 (MTP dated 9/20/11)

For the problem of "Mood Disorder," the following generic nursing interventions were checked:
"Administer medication to: stabilize mood (decrease) depressed feelings, (decrease) suicidal ideations." "Assess patient's behavior for suicidal ideas with plan q (every) shift." "Provide safe environment by observing q (every) 30 mins & (and) q (every) 15 mins." "Educate patient on: (hand written) signs & symptoms of depression, schizoaffective D/O (disorder)." "Others: (hand written) Encourage to attend on unit activities AT, OT, NSO, Morning mtg (meeting)...to (decrease) isolation."

For problem of "Discharge Planning", the following generic nursing intervention was checked:
"Medication Education (hand written) stress benefit of compliance."

B. Staff Interviews

In an interview on 10/25/11 at 2:40p.m. with the two Assistant Director of Nursing (ADON), the Master Treatment Plans for patients E1, E2, E10, E16, W2, W3, W13, and W19 were reviewed; both Assistant Directors agreed that the nursing interventions on the patients' treatment plans were generic nursing functions.

II. Based on observation, interviews, policy review and record review, the Director of Nursing failed to ensure that nursing staff implemented a seclusion protocol for 1 of 1 active sample patient (E16) who was placed in a single occupant room for "one to one observation" and was not permitted to leave the room; both the patient and the staff member providing the one to one observation believed that the patient [E16] was not allowed to leave the room. Patient E16 had been on a one to one observation since acting out on the unit at 3 PM the previous day. While Patient E16 was on the one to one observation status, an IA (Institutional Aide) sat in a chair in the doorway of the room, thus preventing the patient from leaving the room. The nursing staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. This deficient practice violates patients' rights to be free of restrictive measures. (Refer to B125-I)

III. Based on record review and interviews, the Director of Nursing failed to ensure that appropriate medication orders for the use of PRN [as necessary] medications were implemented by nursing staff. For 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19) and 2 of 2 active non-sample patients reviewed for seclusion and restraint episodes (S1 and S2), physician PRN orders failed to provide specific parameters for their use. For these patients, physician orders for PRN medication were written for poorly described conditions: "anxiety," "insomnia" and "agitation," and orders for different medications were written for the same symptoms or complaints. In addition, two orders were written which allowed nurses to choose to administer the medications IM [intramuscular injection] or po [by mouth]. Ambiguous physician orders can result in serious complications in patients as a result of improper PRN medications orders. In addition, such physician orders encourage nursing staff to function outside their scope of practice. (Refer to B125-II)

Based on record review and interview, the facility failed to provide complete psychosocial assessments for 8 of 8 active sample patients (E1, E2, E10, E16, W2, W3, W13 and W19). The psychosocial evaluations did not include social work specific conclusions and recommendations; describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of social work input for treatment planning.

Findings include:

A. Record Review

1. Patient E1. There were no conclusions or recommendations noted in a psychosocial assessment dated 6/2/11.

2. Patient E2. There were no conclusions or recommendations noted in a psychosocial assessment dated 7/13/11.

3. Patient E10. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

4. Patient E16. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/14/11.

5. Patient W2. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/28/11.

6. Patient W3. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/3/11.

7. Patient W13. There were no conclusions or recommendations noted in a psychosocial assessment dated 9/9/11.

8. Patient W19. There were no conclusions or recommendations noted in a psychosocial assessment dated 10/13/11.

B. Interview

In an interview on 10/25/11 at 2:15PM, the Director of Social Work was unable to find specific social work recommendations and conclusions in the sample patients' records and agreed that the psychosocial evaluations were missing this information. She stated, "We used to do it that way but then stopped when we combined the assessments into the present format."