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Based on observation, interview and document review, the hospital failed to provide necessary treatment interventions, including CPR and calling 911 for an emergency response team for non sample patient Y, who was found unresponsive in bed. Nursing notes indicated the patient was alive at 5a.m., but at 6a.m. was found unresponsive in bed, with no vital signs present. Chart review revealed that no effort was made to resuscitate the patient, who was pronounced dead by a nurse around 6:20a.m. Interview of staff revealed that although there was no physician order in the chart at the time of the patient's death, staff believed that a "Do Not Resuscitate (DNR)/Do Not Intubate (DNI)" form, signed by the patient's daughter and witnesses by a nurse was sufficient justification to withhold care. Further investigation revealed that at the time of the survey, 4 of the 17 patients in the facility also had DNR forms in the chart but did not have physician orders. Thus, those four patients were in danger of having essential care withheld without justification should they require emergency resuscitation. This situation was identified as an IMMEDIATE JEOPARDY to patient safety, and the facility was notified on 3/15/2011 at 2:20p.m.
The facility presented a Plan of Correction on 3/15/2011 at 5p.m. After review of the implementation of the plan, the IMMEDIATE JEOPARDY was removed at 3p.m. on 3/16/2011

Findings related to the IMMEDIATE JEOPARDY include:

A. Patient Y

1. Patient Y was admitted to Oceans Behavioral Hospital on 3/1/2011 at 4:30p.m. According to a "nursing psychiatric note" written by RN #2 on 3/2/2011, patient Y was assisted to go to the bathroom at 5a.m. Later that morning, at 6 a.m., according to an entry in the same nursing psychiatric note, patient Y was found to be unresponsive. The note stated "called to patient's room per MHT (mental health technician), pt. lying unresponsive in bed. on (right) side with back to door. Assessed, 0 respirations, 0 pulse felt or heard, 0 B/P (blood pressure). (Name of the doctor) notified, updated, pt. pronounced dead." According to this patient's medical record, no efforts were made to revive this patient. RN #2 called the coroner sometime between 6:00A.M. and 6:20A.M. At 6:20AM, according to the same "nursing psychiatric note," RN2 wrote "DeRidder police Dept. notified of death, no action required."


In an interview on 3/14/2011 at 3p.m., the Director of Nursing (DON) stated that when Patient Y became unresponsive, 911 was not called and CPR was not started because there was a DNR order in the patient's medical record. The DON produced the "Do not Resuscitate (DNR)/Do Not Intubate (DNI)" document from the record and stated that she believed that the "DNR/DNI form" was the DNR order. During the interview, the DON acknowledged that there was no DNR order by a physician.

Further record review showed that on 3/1/2011, there was a "Do Not Resuscitate (DNR)/Do Not Intubate (DNI) form filled out and signed by the patient's daughter and witnessed by an RN. The bottom of the form was not signed by the treating psychiatrist until 3/7/11 and by the treating medical doctor until 3/8/11, days after the patient died at the facility.

There was no DNR (Do not Resuscitate) order written by a physician either on the "Physician Admission Order" form or on "Oceans Inpatient Program Physicians Orders" form.

According to the staff, no attempt to revive the patient was made because the record of the patient contained a "Do Not Resuscitate (DNR) Form." However that form, as noted above, was not signed by physicians prior to the patient's death, and the chart did not contain a DNR physician's order, which would be required to authorize the withholding of care.

B. Observations

In an observation on 3/15/2011at 9:45AM, active sample patient 2 and 3 non-sample patients (A, B and C) were noted to be wearing green bracelets (Oceans Behavior Hospital's color code for a DNR patient). Review of the medical records for each of these 4 patients revealed that all 4 records had a similar DNR/DNI document [i.e. "Do Not Resuscitate (DNR)/Do not Intubate (DNI)", but did not have physician's orders to authorize the withholding of treatment.

C. Additional Record Review

1. Non-sample patient A was admitted on 2/21/11. This patient's medical record had a DNR/DNI document signed by the patient's two sisters and witnessed by an RN on 2/21/11. The bottom part of the form was signed by only one physician on 2/21/11. There was no DNR order written by a physician either on the "Physician Admission Order" form, on the "Oceans Inpatient Program Physicians Orders" form, or any other place in the patient's medical record.

2. Non sample patient B was admitted on 3/4/11. A DNR/DNI form was signed by the patient's sister and witnessed by an RN on the same day. The bottom part of the form was signed by two MDs, on 3/5/11 and 3/8/11 respectively. There was no DNR order by a physician in the chart.

3. Non sample patient C had a DNR form signed by "NCA", no name or relationship noted on the form, witnessed by an RN on 3/10/11, and signed by two MDs on 3/14/11. No DNR physician order was found anywhere in the chart.

D. Interviews

1. In an interview on 3/15/2011, at 9:45a.m., RN#1 was asked "How do you know which patients are 'DNR'?" RN#1 answered, "Charts are flagged with DNR stickers. RN#1 also stated that she looked for "an Advanced Directive for DNR, a DNR consent form with two physician signatures, and a DNR bracelet placed on a patient." RN #1 agreed that a physician's order was lacking in the medical record of all 4 patients (sample pt. #2 and non-sample patients A, B and C).

2. In an interview on 3/15/2011 at 9:50a.m., RN # 2 stated, "The DNR consent form is not really a physician order, but in Oceans Hospital, this is what they use." RN #2 said, "Legally, we are supposed to code (call for emergency help) without a physician's order for DNR." RN#2 agreed that physician's orders for DNR were lacking in the medical record of all 4 patients (sample pt. #2 and non-sample patients A, B and C).

3. In an interview on 3/16/2011 at 1:15p.m., MD1, who is also the coroner, said that he had not examined patient Y upon admission or before pronouncing the patient dead. He acknowledged that the nurse pronounced Patient Y dead.

D. Policy Review

Hospital Policy, titled "Tx-Spec.04 'Do not Resuscitate' DNR guidelines" and dated March 2008 stated:

"PURPOSE: to provide guidelines to physicians regarding writing of a "Do Not Resuscitate order."

The policy outlined the following procedure the physician needed to use prior to writing a DNR order:

"Discusses DNR request with patient and informs the attending physician" "Assesses the patient's capacity to make a DNR decision.....If the patient is judged to lack capacity, the DNR decision is to be reached jointly by the appropriate family members and the physician....If the attending physician feels that the patient's best interests are not being sought, he can ask that a court appointed guardian be named." "If there is a disagreement by the patient or his surrogate with the decision not to resuscitate, DNR will not be written."

"If the DNR is determined to be appropriate, the physician will write a DNR order. A verbal order cannot be accepted"

After review of the implementation of the plan, the IMMEDIATE JEOPARDY was removed at 3p.m. on 3/16/2011

II. Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included long term goals (LTG) and short term goals (STG) that were stated in measurable behavioral terms for 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15). This failure hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in patient behaviors. (Refer to B121)

III. Based on record review and interview, the facility failed to develop Master Treatment Plans that delineated physician, nursing and social work interventions to address the specific treatment needs of 8 of 8 sample patients (2, 3, 7, 9, 10, 11, 13 and 15). This failure results in a lack of guidance to staff in providing individualized, coordinated treatment, and can result in prolonged hospitalization for patients. (Refer to B122)

IV. Based on observation, interview and record review the facility failed to provide active treatment measures for 4 of 8 cognitively impaired active sample patients (2, 3, 7 and 11). The scheduled treatment groups failed to relate to the special needs and problems of these patients. The patients were expected to attend the scheduled groups held on the unit. Alternative interventions were not provided when the patients did not attend the scheduled groups or when they attended the groups without but were unable to participate due to cognitive impairment. Failure to provide alternative activities potentially impairs the patients' attainment of treatment goals and may prolong hospitalization. (Refer to B125-I)

V. Based on interview and record review the facility failed to ensure that all patients on the unit, including 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15), received sufficient hours of therapeutic activities, particularly during evening hours and on weekends, which focused on restoring and/or developing higher levels of physical and psychosocial functioning. This failure results in long periods of inactivity and prevents patients from moving toward an optimal level of functioning. (Refer to B125-II)

Based on record review and interview, the facility failed to develop Master Treatment Plans that included measurable short term and long term goals for 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15). The treatment plans consisted of a face sheet that had a space to handwrite a patient's long term goals [LTGs], and a pre-printed form consisting of a list of short term goals [STGs] for listed problem(s). Staff checked off their selections for a patient from the available choices. The goals were not stated as measurable behaviors for the patients to achieve. The goals for all patients were also identical or very similar. This failure hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in patient behaviors.

Findings include:

A. Record Review

1. The facility's Master Treatment plan (MTP) consisted of a face sheet that contained a space to handwrite a patient's long term goals, and a pre-printed MTP form consisting of a list of problems, short term goals, and interventions. Staff checked off their selections for a patient from choices under each heading (problems, goals, and interventions).

2. Active sample patient #2.

Non-measurable patient goals on the MTP, dated 3/7/11, were as follows: For the problem "Gravely disabled R/T [related to] mood disturbance," LTGs were: "Pt [patient] will have overall improvement in mood/behaviors prior to d/c [discharge]." "Pt will have improved affect prior to d/c." STGs were "Pt will display overall improvement in mood within 21 days." "Pt will display an overall stabilizing of energy level within 7 days."

3. Active sample patient #3.

Non-measurable goals on the MTP, dated 3/10/11, were as follows: For the problem "Gravely disabled R.T. (return to) mood disturbance," LTGs were "Pt will exhibit decreased signs and symptoms of depression prior to d/c." "Pt will exhibit improved affect prior to d/c." STGs were "Pt will exhibit [decreased] behaviors prior to d/c." "Pt will display an overall improvement in mood within 14 days." "Pt will appropriately interact with peers and staff within 7 days."

4. Active sample patient #7.

Non-measurable goals on the MTP, dated 3/2/11, were as follows: For the problem "Gravely disabled R/T mood disturbance," LTGs were "Pt will exhibit decreased signs and symptoms of depression prior to d/c." "Pt will exhibit improved affect prior to d/c." STGs were "Pt will exhibit an overall improvement in mood within 7 days." "Pt will appropriately interact with peers and staff within 2 days."

5. Active sample patient #9.

Non-measurable goals on the MTP, dated 3/4/11, were as follows: For the problem "Gravely disabled R/T mood disturbance," LTGs were "Pt will exhibit decreased signs and symptoms of depression prior to d/c." "Pt will exhibit improved affect prior to d/c." STGs were "Pt will exhibit an overall improvement in mood within 10 days." "Pt will appropriately interact with peers and staff within 3 days."

6. Active sample patient #10.

Non-measurable goals on the MTP, dated 2/2/11, were as follows: For the problem "Gravely disabled R/T mood disturbance," LTGs were "Pt will exhibit improvement in mood/behaviors prior to d/c." "Pt will exhibit decreased bizarre behavior prior to d/c." STGs were "Pt will display an overall improvement in mood within 21 days." "Pt will display an overall stabilizing of energy level within 7 days."

7. Active sample patient #11.

Non-measurable goals on the MTP, dated 3/8/11, were as follows: For the problem of "Gravely disabled R/T thought/mood disturbance," LTGs were "Pt will exhibit [decreased] signs and symptoms of depression prior to d/c." "Pt will exhibit improved affect prior to d/c." STGs were "Pt will display an overall improvement in mood within 7 days." "Pt will appropriately interact with peers and staff within 4 days."

8. Active sample patient #13.

Non-measurable goals on the MTP, dated 3/9/11, were as follows: For the problem "Gravely disabled RT delusions, hallucinations," LTGs were "Pt will have an overall improvement in mood by d/c." "Pt will exhibit [decreased] A/V [audio/visual] hallucinations and delusional thinking prior to d/c." STGs were "Pt will display an overall improvement in mood within 14 days." "Pt will display an overall stabilizing of energy level within 7 days."

9. Active sample patient #15.

Non-measurable goals on the MTP, dated 3/5/11, were as follows: For the problem "Gravely disabled R/T mood disturbance," LTGs were "Pt will have overall improvement in mood." "Pt will exhibit improved affect prior to d/c." STGs were "Pt will display an overall improvement in mood within 21 day." "Pt will appropriately interact with peers and staff within 5 days."

B. Interviews

1. In an interview on 3/15/11 at 1:40p.m. with SW #1., the non-measurable goals on the Master Treatment plans were discussed. SW #1 replied, "I see what you mean."

2. During an interview on 3/16/11 at 9:20a.m. with the Nursing Director, the non-measurable goals on the treatment plans were discussed. The Nursing Director stated, "I agree."

Based on record review and interview, the facility failed to provide Master Treatment Plans for 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15) that included treatment interventions with a specific focus, based on the individual needs and abilities of each patient. Interventions on the MTPs were generic monitoring and discipline functions to be performed by physicians, nurses, social workers, and activity therapy staff. This failure results in a lack of guidance to staff in providing individualized, coordinated treatment, and can result in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. The facility used a pre-printed Master Treatment Plan (MTP) that contained a list of potential interventions for problem(s).Staff put a check mark next to the interventions that they chose for each patient. The same pre-printed form was used for all 8 active sample patients. In addition, all sample patients had the exact same interventions for the problem, "Gravely disabled R/T (related to) mood disturbance."

2. Active sample patient #2 (MTP dated 3/7/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plans & [and] team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval [Psychiatric Evaluation] within 60 hrs [hours]."
Nursing: "Educate on disease process/symptom management with nursing group x [times] 30 minutes x 2 per week, provide safe structural environment daily for the duration of treatment." "Educate in medication regimen daily and prn [as needed]." Social Services: "Gather history & assess level of function, develop Multidisciplinary Treatment Integration [MTI}." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

3. Active sample patient #3 (MTP dated 3/10/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x [times] 60 minutes x 3 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services:
"Gather history & assess level of function, develop multidisciplinary treatment integration [MTI]." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

4. Active sample patient #7 (MTP dated 3/2/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x 60 minutes x 2 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services: "Gather history & assess level of function, develop multidisciplinary treatment integration [MTI]." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

5. Active sample patient #9 (MTP dated 3/4/11).

For the problem "Gravely disabled R/T mood disturbances," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x 60 minutes x 2 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services: "Gather history & assess level of function, develop multidisciplinary treatment integration [MTP]." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

6. Active sample patient #10 (MTP dated 2/21/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x 30 minutes x 2 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services: "Gather history & assess level of function, develop multidisciplinary treatment integration [MTI]." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

7. Active sample patient #11 (MTP dated 3/8/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x 60 minutes x 2 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services: "Gather history & assess level of function, develop multidisciplinary treatment integration [MTI]." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

8. Active sample patient #13 (MTP dated 3/9/11).

For the problem of "Gravely disabled R/T delusions, hallucinations," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptom management with nursing group x 6, minutes x 2 - 3 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services:
"Gather history & assess level of function." "Develop multidisciplinary treatment integration plan in 72 hrs [hours]."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

9. Active sample patient #15 (MTP dated 3/15/11).

For the problem "Gravely disabled R/T mood disturbance," the generic interventions were:
Physician: "Direct treatment plan & team on admit and weekly, prescribe and evaluate effectiveness of medication as needed, complete Psych eval within 60 hrs."
Nursing: "Educate on disease process/symptoms management with nursing group x 60 minutes x 2- 3 per week." "Provide safe structural environment daily for the duration of treatment." "Educate on medication regimen daily and prn."
Social Services: "Gather history & assess level of function." "Develop multidisciplinary treatment integration plan in 72 hrs." "Engage patient's family/significant others in continued support and participation of treatment."
Therapeutic Recreation: "Provide leisure activities to increase coping strategies and reality orientation, provide redirection to task."

B. Interviews

1. In an interview on 3/15/11 at 1:40p.m. with SW #1, the generic social work interventions on the Master Treatment Plans were discussed. SW #1 agreed with the findings.

2. In an interview on 3/16/11 at 9:20a.m. with the Nursing Director (DON), the generic interventions on the Master Treatment Plans were discussed. The DON agreed with the findings and stated, "The plans don't tell me anything."

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

I. Provide active treatment measures for 4 of 8 cognitively impaired active sample patients (2, 3, 7 and 11). The scheduled treatment groups failed to relate to the special needs and problems of these patients. The patients were expected to attend the scheduled groups held on the unit. Alternative interventions were not provided when they failed to attend the groups, or when they attended the groups without the cognitive ability to participate, and thus could not benefit from the treatment. Failure to assure patients' meaningful participation in assigned treatment or provide alternative treatment activities potentially impairs patients' attainment of treatment goals and may prolong their hospitalization.

II. Ensure that all patients on the unit, including 8 of 8 active patients (2, 3, 7, 9, 10, 11, 13 and 15), received sufficient hours of therapeutic activities, particularly during evening hours and on weekends, which focused on restoring and/or developing higher levels of physical and psychosocial functioning. This failure results in long periods of inactivity and prevents patients from moving toward an optimal level of functioning.

Findings include:

I. Lack of active treatment measures for 4 of 8 active sample patients

A. Patient 2

1. The admission Psychiatric Evaluation, dated 3/9/11, stated that patient 2 was admitted on 3/7/11. The patient was described as "orientation impaired," "insight gravely impaired," and "judgment gravely impaired." S/he was admitted due to "aggressive, combative behavior toward staff, peers; refusing personal care." The admission diagnoses included "Dementia, NOS [not otherwise specified], and impulse control D/O [disorder], and poss. [possible] bipolar d/o."

2. The Master Treatment Plan dated 3/10/11 stated that patient 2 would be "educated on disease process, symptom management with nursing group x [times] 30 minutes x 2 per week," "educate in medications regimen daily and prn [as needed]," and "provide leisure activities to increase coping strategies and reality orientation." No other interventions were listed for this cognitively impaired patient, who could not benefit from these groups.

3. In an interview on 3/14/11 around 10:00a.m., RN #1stated that there was only one unit schedule of activities for all patients and that all groups were held on the unit. Specific groups were not listed in the Master Treatment Plan, or on the unit schedule. Review of the "Daily Schedule" of groups revealed it listed categories of groups: "Social Service Groups," "Nursing Group" or "Activities" (groups held by recreation therapy staff). Nursing groups were held Monday, Friday and Saturday at 9a.m. Social work groups were held Tuesday, Wednesday and Thursday at 9a.m. and 1:00p.m. Activity therapy groups were held at 10:15a.m. and 2:15p.m. Monday and Friday.

4. Patient 2 was observed on 3/14/11 at 10:20a.m., attending an "Activities" group on the unit for 2 to 3 minutes. Then Patient 2 was observed wandering around in the hallway. S/he was observed lying in his/her own bed during the "Social Services" group at 1:00p.m. on 3/14/11, lying in another patient's bed on 3/14/11 at 4:35p.m., and lying in his/her own bed on 3/15/11 during the 9:00a.m. "Social Services group." A staff member was observed in the patient's room, attempting to converse with the patient on 3/14/11 around 10:45a.m. Patient #2 was talking incoherently.

5. A review of group notes (Activity, Social Services, and Nursing), for the week of 3/7/11 - 3/11/11 revealed that patient 2 was did not attend the Social Services group on 3/8/11 in the "a.m." [morning], but did attend the "p.m." [afternoon] Social Work group. A description of his/her behavior during the group was: "expressive aphasia...Tried to talk...One group member sensitive to speech disability. Group time turned to subject of kindness and caring." Patient #2 was not documented as attending any nursing groups during the week of 3/7/11 - 3/11/11.S/he did not attend the activity therapy groups on 3/9/11 but did attend a 2:00 p.m. activity group on 3/10/11 with "minimal participation."

6. During an interview on 3/14/11 at 1:10p.m. MHT #1was asked why patient 2 was in bed and not in group. MHT #1 stated, "[Patient 2] doesn't sleep well during the night."

7. During a telephone interview on 3/16/11 at 1:30p.m. with the Medical Director, the lack of active treatment measures for patient 2 was discussed. The Medical Director stated, "We do as much as we can. Providing alternative treatment for those who need it is something we need to work on."

B. Patient 3

1. The admission Psychiatric Evaluation, dated 3/10/2011, described patient 3's mental status as "anxious, agitated and uncooperative ... orientation 'impaired'; recent memory 'impaired'...remote memory 'impaired'." Patient 3's insight and judgment were described as "gravely impaired." Attention and Concentration were "impaired" as well. This patient's admitting diagnoses included Dementia, Alzheimer's type, moderate with agitation.

2. Review of the Master Treatment Plan, dated 3/11/11, revealed that patient 3 was to be "educated on disease process/symptom management with nursing group x 60 min.x3 per week" and that staff was to "educate (patient) on medications regimen daily and prn." The patient was too cognitively impaired to benefit from the education activities.

3. Patient 3 was observed attending the 10:30 AM and 1:00PM groups on 3/15/2011, and the 10:30AM group on 3/16/2011. He was in attendance but did not participate in group activities and did not contribute to the process.

4. In an interview on 3/16/2011 at 4p.m., SW#1 agreed that the social work interventions and group activities were generic and not individualized for patient 3.

5. In an interview on 3/16/2011 at 4:30p.m., the Social Work Director agreed that the treatment interventions by the social workers needed to be more individualized for patients.

6. In an interview on 3/14/11 around 10:00a.m., RN #1stated that there was only one unit schedule of activities for all patients, and that all groups were held on the unit. Specific groups were not listed on patient 3's Master Treatment plan, or on the unit schedule.

C. Patient 7

1. The admission Psychiatric Evaluation, dated 3/5/11, described patient7 as follows: "remote memory intact...insight and judgment gravely impaired...attention, concentration, and abstract thinking impaired." The patient was admitted for "depressed mood [with] suicidal ideation." The admission diagnoses included "Dementia NOS."

2. Patient 7's Master Treatment Plan, dated 3/2/11, stated that the patient would be "educated on disease process/symptom management with nursing group x 60 minutes x 2 per week" and "educated on medications regimen daily and prn." The patient was too cognitively impaired to benefit from the education activities.

3. Patient 7 was observed attending an "Activities" group on the unit on 3/14/11 at 10:30a.m. for about 5 minutes. He then left the group, returned to his room, and got in his bed. Staff did not attempt to stop the patient from leaving the group or inquired where he was going. Patient 7 was observed in a "Social Services Group" conducted on the unit on 3/14/11 from 1:00p.m. to 1:50p.m. During the group, he sat quietly, looking down towards the floor, and did not speak unless addressed by the group leader. His remarks were all 2-3 words and he was not responding to his surroundings.

4. The "Daily Schedule" showed that a total of 4one hour-long groups were scheduled daily, Monday through Friday from 9:00a.m. to 9:00p.m. - Nursing or Social Work group at 9a.m., "Activity" groups at 10:15a.m. and 3p.m., and a "Social Services Group" at 1:00p.m. The staff expected patient 7 to attend these activities.

A review of group notes (Activity, Social Services, and Nursing) for the week of 3/7/11 - 3/11/11 revealed that patient 7 attended the "a.m." Social Work group on 3/7/11, but did not attend the "p.m." group. He attended both Social Work groups on 3/8/11. His behavior was documented as "pt [patient] dysphoric-responded when prompted." He did not attend any Nursing or Recreation Therapy groups on 3/7/11 or 3/8/11. The patient was documented as not attending any groups on 3/9/11 or 3/11/11. He attended a Recreation group on 3/10/11. The group notes documented the patient as "pt appears depressed" He attended a Nursing group on 3/10/11 [no time listed], and was documented as "remains confused."

5. During an interview on 3/16/11 at 10:00a.m. with MHT #1, the lack of alternative therapeutic activities for patients like patient 7 who are cognitively impaired and/or do not attend the scheduled groups was discussed. MHT#1 stated, "We do our best to encourage the patients to attend, but can't force them. Some of them don't have the mind to attend. I mean they just don't understand what's going on."

D. Patient 11

1. The admission Psychiatric Evaluation, dated 3/9/2011, stated that patient 11 was "agitated, anxious and depressed" The patient was described as being oriented to "person" but not to time and place. His/her recent memory and remote memory were described as "impaired." His/her insight and judgment were stated as "poor." His/her attention was "impaired" and his/her concentration was "impaired." Patient's Axis I diagnosis was "Alzheimer's dementia with behavioral disturbances and depression."

2. Review of patient 11's Master Treatment Plan, dated 3/8/11, revealed that the patient was to be "educated on disease process, symptom management with nursing group x [times] 30 minutes x 2 per week," and that staff was to "educate (patient) in medications regimen daily and prn [as needed]", and "provide leisure activities to increase coping strategies and reality orientation." The patient was too cognitively impaired to benefit from the assigned education activities. No alternative activities were listed for this cognitively impaired patient.

3. On 3/14/2011 at 10:30a.m., patient11 was observed attending social worker's group, and at 1p.m., he was observed attending an Activity Therapy group. During the social work group, the patient sat in a chair by the door and did self stimulating activities such as folding and unfolding his/her jacket for the entire time the group met. There was no evidence of the patient's participation in the group activities.

4. In an interview on 3/16/2011 at 4p.m., SW #1agreed that the social work interventions and group activities were generic and not individualized for patient 11.

5. In an interview on 3/16/2011 at 4:30p.m., the Social Work Director agreed with the surveyor's findings that the treatment interventions by the social workers were not individualized for patient 11.

6. In an interview on 3/14/11 around 10:00a.m., RN #1stated that there was only one unit schedule of activities for all patients, and that all groups were held on the unit. Specific groups were not listed in the Master Treatment plans. All patients were expected to attend these groups.

II. Lack of therapeutic activities, especially on evenings and weekends

A. Document Review

1. Review of the facility's treatment schedule revealed one unit schedule for all the patients that included hour-long groups between the hours of 9:00a.m. and 3:00p.m. daily. A nursing group was held Monday and Friday at 9:00a.m.; a Social Work group was held Tuesday, Wednesday and Friday at the same time. Another Social Work group was held daily at 1:00p.m. An activity Therapy group was held twice a day during the week - one group at 10:15 a.m. and the other group at 2:15p.m. No groups were scheduled from 3:00p.m. through 9:30p.m. Only 1 group (a Nursing Group) was scheduled for the weekend. This group was at 9:30a.m. on Saturday only, and focused on a topic chosen by the nurse who ran the group. No groups were offered on Sundays.

B. Interviews

1. During an interview on 3/16/11 at 9:00a.m., the Activities Director stated that she only works the day shift, Monday through Friday. The Activities Director stated, "I don't know what happens on the weekends."

2. In an interview on 3/16/11 at 9:45a.m., active sample patient #9 stated that there was no group therapy on weekends. S/he complained about the inability to go outside, stating that s/he had requested to go outside to get fresh air, but could only do so during smoke break. The patient did not smoke and did not want to mingle with smokers.

3. In an interview on 3/16/11 at 10:15a.m., active sample patient 13 was asked what s/he did on the weekends. S/he replied, "Nothing. I can read only so much or watch TV. I just sit around."

Based on record review, hospital policy review and interview, the facility failed to ensure that patient discharge summaries were completed in a timely fashion for 1 of 5 patients whose records were reviewed (D1). Failure to complete summaries for patients being discharged compromises communication with future clinicians, and can result in inadequate provision of follow-up care for patients.

Findings include:

A. Record Review

Patient D1 was admitted on 1/28/11 and was discharged on 2/2/11. When the medical record for patient D1 was reviewed on 3/14/11 at 11AM, no discharge summary was present in the record.

B. Policy Review

Facility Policy, HIM-05 titled "Documentation Guidelines," dated March 2007 and revised January 2008, stated. "All medical records must be completed 30 days following a discharge."

C. Staff Interview

In an interview on 3/14/11 at 1:30p.m. the Director of Health Information Management stated that she was unable to locate this discharge summary within the medical record system.

Based on record review, staff interview and policy review, the Medical Director failed to:

I. Ensure that the facility developed Master Treatment plans (MTPs) that included long term goals (LTG) and short term goals (STG) that were stated in measurable behavioral terms for 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15). This failure hampers the ability of the treatment team to provide goal directed treatment and determine the effectiveness of interventions, based on changes in patient behaviors.
(Refer to B121)

II. Ensure that the Master Treatment Plans for 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15) included individualized treatment modalities (interventions). The treatment plans listed generic discipline tasks instead of individualized interventions. In addition, all of the patients had the same or very similar interventions. This failure results in lack of clarity and specificity as to how the staff will address patient issues and problems. (Refer to B122)

III. Ensure that active treatment measures were provided for 4 of 8 cognitively impaired active sample patients (2, 3, 7 and 11). The scheduled treatment groups did not address the special needs and problems of these patients. The patients were expected to attend the scheduled groups held on the unit. Alternative interventions were not provided when the patients did not attend the groups, or when they attended the groups without participation, thus could not benefit. The failure to provide meaningful treatment activities for patients with cognitive impairment hampers the patients' attainment of treatment goals and can prolong their hospitalization. (Refer to B125-I)

IV. Ensure that all patients on the unit, including 8 of 8 active patients (2, 3, 7, 9, 10, 11, 13 and 15), received sufficient hours of therapeutic activities, particularly during evening hours and on weekends, which focused on restoring and/or developing higher levels of physical and psychosocial functioning. This failure results in long periods of inactivity, and can prevent patients from moving toward an optimal level of functioning. (Refer to B125-II)

VI. Ensure that patient deaths in the facility were pronounced by an MD after examination of patient. Patient Y was admitted to the facility on 3/1/2011at 4:30p.m. S/he was found unresponsive on 3/2/2011 at 6a.m. Nursing notes state that an RN called the coroner who also happened to be MD#1. MD #1 asked the RN to have the patient's body removed to a funeral home.

MD#1 was interviewed on 3/16/2011 at 2pm. He stated that he did not see the patient and agreed with the surveyor's finding that the RN made the death pronouncement.
(Refer to B103 Part I)

VII. Ensure that patient discharge summaries were completed in a timely fashion for 1 of 5 discharged patients whose records were reviewed (D3). Failure to complete medical summaries for patients being discharged compromises communication with future clinicians, potentially resulting in inadequate provision of follow-up care. (Refer to B133)

Based on record review and interview, the Nursing Director failed to monitor and evaluate the quality and appropriateness of nursing care provided to patients. Specifically the Nursing Director failed to:

I. Ensure that nursing interventions on the Master Treatment Plans of 8 of 8 active sample patients (2, 3, 7, 9, 10, 11, 13 and 15) were based on the individual needs and abilities of each patient. Nursing interventions on the MTPs were nursing education tasks that were not focused or individualized for patients. This failure results in a lack of guidance to staff in providing individualized, coordinated treatment, and can result in prolonged hospitalization for patients.

Findings include:

A. Record Review (MTP dates in parentheses)

1. The facility used a pre-printed Master Treatment Plan (MTP) that contained a list of potential interventions for problem(s). Staff put a check mark next to the interventions that they chose for each patient. The same pre-printed form was used for all sample patients.

2. Review of the MTPs for sample patients 2 (3/7/11), 3 (3/10/11), 7 (3/2/11), 9 (3/4/11),10 (2/21/11), 11 (3/8/11), 13 (3/9/11) and 15 (3/15/11) revealed that all of the patients had the exact same generic nursing interventions for the same listed problem, "Gravely disabled R/T (related to) mood disturbance." The interventions were: "Educate on disease process/symptom management with nursing group x [times] 30 minutes x 2 per week, provide safe structural environment daily for the duration of treatment." "Educate in medication regimen daily and prn [as needed]."

B. Interview

In an interview on 3/16/11 at 9:20a.m. with the Nursing Director (DON), the generic interventions on the Master Treatment Plans were discussed. The DON agreed with the findings and stated, "The plans don't tell me anything."

II. Ensure safety for 3 of 15 non-sample patients (21, 22 and 23) whose incident reports for falls were reviewed for facility policy and procedure compliance. Non-sample patient 21 was on 1:1 observation when the patient sustained an unwitnessed fall. Non-sample patient 22 and 23 had falls that were not reported to their physicians per facility policy. These failures result in physical harm to patients.

Findings include:

A. Record Review/Interview

1. Non-sample patient 21

a. A nursing psychiatric assessment dated 1/3/11 at 8:00p.m. stated that the patient was on a 1:1 observation. An incident report dated 1/4/11 at 4:05a.m. (about 12 hours after the incident) stated "pt on floor beside bed, agitated, reddened area to (r) [right] shoulder blade [with] small area with thin abrasion to top layer of skin, no bleeding." The note mentioned finding the patient on floor beside the bed on 1/3/11 at 8:00p.m., but it did not describe the location of the staff member who was supposed to be watching the patient.

b. In an interview on 3/16/11 around 3:30p.m. with the Nursing Director (who was also the Performance Improvement Coordinator), the incident report for non-sample patient 21 was reviewed. The Nursing Director stated that when she reviewed the incident report, she had not noticed that patient 21 was on 1 to 1 observations at the time of the fall. When asked how this incident could have happened, the Nursing Director stated, "I'm guessing, but I suspect the mental health technician had been asked to do something else on the unit at the time of the patient's fall. The patient was on 1 to 1 due to fall issues only."

c. Facility policy (revised January 2010) and titled "Patient Incident & Occurrences the use of Reporting" stated under "Procedure": "Facility staff will report all patient occurrences through the use of the facility incident reporting form....Notify patient's family and physician."

2. Non-sample Patient22

a. An Incident Report dated 1/5/11 at "a.m." (no specific time documented) stated "patient on floor lying on side with toilet tipped over." The incident report included no documentation that a physician had been notified of the fall. The nursing psychiatric notes dated 1/5/11 (7:30a.m. and 8:00a.m.) did not mention the incident.

3. Non-sample patient 23

a. An Incident Report dated 2/20/11 at 8:30p.m. stated "(patient) was found lying in doorway of bathroom, stated had to go to the bathroom. Abrasion to rt [right] elbow, left forearm, and over left eye." The incident report included no documentation that a physician was notified. The reports of nursing psychiatric assessments dated 2/20/11 (7:30a.m.) and 2/20/11 (7:30p.m.) contained no documentation of a physician being notified of the patient's fall.

B. Additional Staff Interviews

In an interview on 3/16/11 around 3:30p.m. with the Nursing Director, the issue of the falls for non-sample patients 22 and 23 was discussed. The Nursing Director stated, "As Performance Improvement Coordinator, I read all the incident reports. I didn't notice that the physicians were not notified in these two cases, but they should have been."

III. Monitor and supervise the nursing practice of 1 of 1 registered nurse (RN #2) who pronounced a patient dead without the physical presence of a physician. This nursing action was outside the scope of professional nursing practice.

A. Record Review

A Nursing Progress Note, for Patient Y, written by RN #2 and dated 1/2/11 at 6:00a.m. stated, "Called to patient's room by MHT [mental health technician] Pt [patient] lying unresponsive in bed on (r) side with back to door. Assessed 0 respirations, 0 pulse felt or heard, 0 B/P [blood pressure], [name of doctor] notified updated. Pt pronounced dead...."

B. Interview

In an interview on 3/17/11 around 10:30a.m. with the Nursing Director, the action of the RN2 (pronouncing a patient Y dead), was discussed. The Nursing Director's initial reply was, "She didn't pronounce him dead." When it was pointed out that there was no documentation that a physician had seen the patient in person, the Nursing Director nodded in affirmative, but said nothing.