HospitalInspections.org

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

I. Ensure that the severe medical problems of 2 of 2 discharged patients (D1 and E1) reviewed for medical care were evaluated and treated. Patient D1 had a history of multiple serious medical conditions, eating problems, and medication non-compliance; Patient E1 developed acute cellulitis while hospitalized. Neither patient received adequate medical attention for these problems. Failure to address these problems compromised the patients' medical status, requiring transfer to a medical hospital. Failure to address medical problems is a risk to patients' health, and it prevents them from achieving an optimal level of functioning. (Refer to B125-I)

II. Ensure that staff adequately follow restraint procedures, including needed documentation, for the use of physical holds for 1 of 5 discharged patients (E6) whose record was initially reviewed for the occurrence of a fall. The nursing staff utilized physical holds to administer medications to this patient without physician orders for restraint or documentation of appropriate nursing and physician assessments. The use of physical restraint without appropriate physician orders and documentation of required assessments is a potential danger to patients and is a violation of patient rights. (Refer to B125-II)

III. Ensure that the psychiatric symptoms of 1 of 8 active sample patients (A9) were stabilized prior to discharge. This patient was discharged without full stabilization of his delusions, impaired insight and judgment. The discharge plan required him/her to live alone and manage his/her own medications and psychiatric follow-up appoints. There was lack of evidence that the patient had the ability to utilize the discharge services that were offered. This resulted in the patient having inappropriate aftercare plans. This deficient practice is a health risk for the discharged patient, and potentially puts the community at risk due to the patient's psychiatric symptoms. (Refer to B125-III)

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A3, A5, A9, A10, A11 and A13) that included focused interventions based on the individual needs and abilities of each patient. None of the 8 sample patients MTPs included physician interventions. In addition, the interventions to be performed by nurses, social workers, and activity therapy staff were generic discipline functions instead of individualized interventions. These failures result 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. Patient A1 (MTP dated 6/15/11)

For the identified problem of "Disturbed sensory perception AEB (as evidenced by) hallucinations, mania, delusions, constant singing, insomnia, poor intake food & hydration RT (related to) dx (diagnosis) of Dementia," the generic interventions were as follows:

Nursing: "1. Provide quiet environment. 2. Administer meds (medications) and assess effectiveness. 3. Reorient, redirect pt (patient) as needed. 4. Monitor sleep rest pattern.5. Use calm face to face approach. 6. Provide simple activities that the patient can accomplish." Another set of nursing interventions for the same problem (written by another nurse) were: "1. Observe & monitor for any hallucinations, delusions & mania. 2. Monitor hrs (hours) of sleep. 3. Monitor meal & hydration intake. 4. Nutritional Consult if po (oral) intake does not improve. 5. Monitor pt. wt. (weight). 6. Provide safe environment. 7. Provide plenty of time for meals. Assist pt. as needed. 8. Reorient as needed."

Social Work: "Social service will: Gather history & assess level of function; (CIA [initial psychosocial assessment] during 1st 72 hrs). Develop multidisciplinary treatment Integration (MTI Plan in 72 hrs). Engage Pt's (patient's) family/significant other in continued support and participation of tx (treatment). Provide Psychotherapy Group session daily. Provide Indiv. (individual) therapy PRN (as needed). Complete D/C (discharge) planning. Contact family weekly to provide status report of progress or lack thereof."

Activity Therapy: "Activities Director will: Provide an environment for pt. to experience & practice positive social behaviors. Keep an accurate & updated account of pt. moods & behavior. Initiate activities within a group setting to role model socially acceptable behaviors."

2. Patient A2 (MTP dated 6/7/11)

a. For the identified problem of "Disturbed thought process R/T (related to) Dementia, Alzheimer's," the generic interventions were as follows:

Nursing: "1. Monitor compliance (with) med (medication) regimen, meals, & care. 2. Give simple instructions & allow Pt. to process instructions. 3. Use calm approach. 4. Reorient daily & PRN. 5. Allow Pt to verbalize thoughts. 6. Give choices."

b. For the identified problem of "Altered mood R/T (related to) Dementia AEB (as evidenced by) (increased) aggression, agitation and physically abusive toward staff," the generic interventions were as follows:

Social Work: The listed interventions were identical to those for Patient A1 except the following: "Provide Psychotherapy group daily" and "Contact family to provide a status report or lack thereof." The following interventions were added: "Provide Psychotherapy daily" and "Contact family weekly to provide a status report."

c. For the identified problem of "Disturbed thought process AEB verbal/physical aggression to peers & staff, yelling @ staff/peers, refusing meals R/T wanting to die," the generic interventions were as follows:

Activities Therapy: "Activities Director will: Provide leisure activities to help pt. cope (with) disturbed thought process & (decrease) all verbal, physical, and yelling @ staff/peers to promote functional ability."

d. For the identified problem "Self care deficit AEB: refusing self care," the generic interventions were as follows:

Nursing: "1. Explain care prior to rendering it. 2. Allow Pt time for personal care. 3. Assist (with) care as needed. 4. Provide comfortable environment for personal care. 5. Encourage Pt to participate in personal care."

e. For the identified problem "Violence, risk for directed @ others. R/T aggression," the generic interventions were as follows:

Nursing: "1. Limit negative stimuli. 2. Provide safe environment. 3. Re-direct violent behaviors with physical exercise. 4. Use calm approach. 5. Give meds as ordered. 6. Allow Pt to verbalize by giving choices."

3. Patient A3 (MTP dated 6/16/11)

a. For the identified problem of "Confusion, chronic R/T Alz's (Alzheimer's) Dementia Dx (diagnosis) AEB: Increased Agitation Wandering Elopement from NH (nursing home) deterioration in self care abilities," the generic interventions were as follows:

Nursing: "1. Provide a safe environment. 2. Avoid excessive activity or stimulation. 3. Use a calm, face to face approach. 4. Praise desired behaviors. 5. Assess for effectiveness, SE's (side effects) of medications. 6. Provide Nursing Groups 3-4 times per week. 7. Encourage group participation. 8. Reorient, redirect pt. as needed. 9. Evaluate sleep/rest pattern. 10. Provide plenty of time to answer in groups."

b. For the identified problem of "Altered mood R/T Dementia Alz (Alzheimer's), AEB (increased) agitation, wandering, impulsive behavior, i.e. (that is), wandering," the generic interventions were as follows:

Social Work: The interventions were identical to those for Patient A1 except that "Provide Indiv. (individual) therapy PRN (as needed)" was listed instead of "Provide Psychotherapy daily."

c. For the identified problem of "Agitation, Wandering from NH, and Altered Mood R/T Alz/Dementia AEB: Chronic confusion, increased agitation, wandering, elopement from NH, and deterioration in self care abilities," the generic interventions were as follows:

Activities Therapy: "Activity Director - Will provide leisure activities that pt. can participate in to practice + socialization and learn effective ways to stay active 2 x a day, 5 days a week. - Will provide encouragement and reassurance to pt when necessary to assist in gaining a positive view of self and over all life. - Will maintain accurate and timely records on a daily basis to provide information to medical staff and treatment teams when assessing the overall progress pt. is making towards goals and objectives. - Will provide an educational and relaxing environment for pt to participate and learn during group activities daily. - Will maintain confidentiality as deemed by HIPPA [sic] (Health Insurance Portability and Accountability Act) at all times. - Will encourage and assist pt. in reaching and stabilizing + progress throughout the pts. Stay at OBH (the facility)."

4. Patient A5 (MTP dated 6/28/11)

For the identified problem of "Altered thought processes R/T (related to) MDD (Major Depressive Disorder) and GAD (generalized anxiety disorder) AEB (as evidenced by): uncontrollable crying, worrying, expression of grief, increased anxiety, fatigue, trembling," the generic interventions were as follows:

Nursing: "Provide a safe environment"; "avoid excessive activity or stimulation"; "praise desired behaviors" and "Individual therapy."

Social Work: "gather history and assess level of function"; "develop Multidisciplinary Treatment Integration plan within 72 hours"; "provide psychotherapy group daily" and "provide individual therapy PRN (as needed)."

Activity Therapy: "Provide activities to increase patient's self- esteem and quality of life 2 X per day, 5 days per week throughout pt's stay @OBH (the facility)."

5. Patient A9 (MTP dated 6/15/11)

For the problem, "Disturbed thought process R/T diagnosis Schizophrenia AEB: inappropriate affect, delusions of grandeur, sleep disturbance, impaired insight, impaired judgment, impaired impulse," the generic interventions were as follows:

Nursing: "Provide a safe environment, avoid excessive activity or stimulation, praise desired behaviors, assess for effectiveness, SEs (side- effects) of medications, encourage group participation." "Provide nursing groups 3 - 4 times per week."

Social Work: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

Activity Therapy: No interventions were listed.

6. Patient A10 (MTP dated 6/22/11)

a. For the identified problem of "Alterations in Thought Processes R/T Dementia, agitation, aggression," the generic interventions were as follows:

Nursing: "Nurse to: 1. Provide freq. (frequent) orientation to facility, date, time & situation. 2. Give positive feedback for appro. (appropriate) thinking & behaviors. 3. Use simple explanations with face to face interactions. 4. Re-direct false ideas."

Social Work Interventions: Identical to those for Patient A1.

Activities Therapy: Identical to those for Patient A3.

b. For the identified problem of "Self care deficit R/T Recent falls, Disability, Confusion," the generic interventions were as follows:

Nursing: "Nursing will: 1. Provide safe environment. 2. Provide assistance for identified self care deficits. 3. Allow plenty of time to perform tasks. 4. Provide structured schedule for ADL's (activities of daily living). 5. Allow Pt to provide all self care within physical limits."

7. Patient A11 (MTP dated 6/13/11)

For the identified problem of "disturbed thought processes AEB pt's increased anxiety regarding colostomy bag, and obsessed with cutting his catheter," the generic interventions were as follows:

Nursing: "Use simple direct questions"; "give positive feedback"; "listen to pt's concern regarding his care" and "Provide nursing groups 3 - 4 times per week."

Social Work: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

Activity Therapy: "Provide group activities focused on the importance of medication compliance, physical fitness, hygiene care, and implementing activities in pt's life that are enjoyable to decrease anxiety and depression and improve pt's quality of life."

8. Patient A13 (MTP dated 6/21/11)

For the identified problem of "altered thought processes R/T (related to) dementia AEB increased confusion, agitation, and hallucinations," the generic interventions were as follows:

Nursing: "Provide frequent orientation, to facility, date, time, situation" and "give positive feedback for appropriate thinking and behaviors."

Social Work: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN, complete d/c planning."

Activity Therapy: "provide encouragement and reassurance to pt when necessary to assist in gaining a positive view of self and over all life" and "Provide an educational and relaxing environment for pt to participate and learn during group activities daily."

9. None of the Master Treatment Plans for these patients included physician interventions.

B. Staff Interviews

1. IN an interview on 6/28/11 at 1:15p.m., the Director of Social Work acknowledged that social work interventions on the above sample patients' treatment plans were generic social work functions and identical or very similar for the patients.

2. In an interview on 6/28/11 at 4:30p.m., the Director of Nursing (DON) acknowledged that nursing interventions on the above treatment plans were generic nursing tasks.

3. During a telephone interview on 6/29/11 at 10:50a.m., the Medical Director acknowledged that there were no physician interventions on the reviewed treatment plans and stated "Yes, you are right...I agree there needs to be (physician interventions on the Master Treatment Plans)...for sure."

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

I. Ensure that the severe medical problems of 2 of 2 discharged patients (D1 and E1) reviewed for medical care, were appropriately evaluated and treated. Patient D1 had a history of multiple serious medical conditions, eating problems, and medication non-compliance; Patient E1 developed acute cellulitis while hospitalized. Neither patient received adequate medical attention for these problems. Failure to address these problems compromised the patients' medical status, requiring transfer to a medical hospital. Failure to address patients' medical problems is a risk to the patients' health, and it prevents them from achieving an optimal level of functioning.

II. Ensure that staff adequately follow restraint procedures, including needed documentation, for the use of physical holds for 1 of 5 discharged patients (E6) whose records were initially reviewed for the occurrence of a fall. Staff used physical holds (restraint) to administer medications to this patient without a physician order for the restraint. There also was no documentation of the nursing and physician assessments required for restraint use. The use of physical restraint without physician orders and documentation of required assessments can be dangerous for the patient. It also is a violation of patient rights.

III. Ensure that the psychiatric symptoms of 1 of 8 active sample patients (A9) were stabilized prior to discharge. This patient was discharged without full stabilization of his delusions, impaired insight and judgment. The discharge plan required him/her to live alone and manage his/her own medications and psychiatric follow-up appoints. There was lack of evidence that the patient had the ability to utilize the discharge services that were offered. This resulted in the patient having inappropriate aftercare plans. This deficient practice is a health risk for the discharged patient, and potentially puts the community at risk due to the patient's psychiatric symptoms.

Findings include:

I. Failure to ensure that severe medical problems were evaluated and treated.

Findings include:

A. Patient D1

1. Record review

a. Patient D1 was a 65 year old admitted 5/6/11 with the diagnoses of "Dementia, moderate with agitation" and "Depressive D/O (disorder) NOS (not otherwise specified) R/O (rule out) MDD (major depressive disorder)." The patient also had a history of multiple medical disorders, including "CHF (congestive heart failure)," "CAD (coronary artery disease)," "DM (diabetes mellitus)," "thrombocytopenia (a blood disorder)," "A-fib (atrial fibrillation)," "DDD (degenerative disc disease)," and "hyperlipidemia (high cholesterol)." The History and Physical Examination dated 5/6/11 noted no findings other than "ischemic discoloration bilaterally legs." However, the initial Social Work, Activity Therapy, and Nursing assessments documented that the patient had been refusing food and medications prior to admission.

b. Despite Patient D1's known medical disorders and presentation with poor oral intake, blood was not collected for laboratory testing until 5/9/11 at 3:49p.m. The results were abnormal for BUN (blood urea nitrogen), Hemoglobin, Hematocrit, Ammonia, TSH (thyroid stimulating hormone), and serum creatinine level. However, there was no documentation that the test results were reviewed by a physician until 5/11/11 at 4:35p.m.

c. An electrocardiogram (ECG) was not performed until 5/11/11 at 1:31p.m. (5 days after admission). The report showed "abnormal ECG" results. There was no evidence that the EKG findings were reviewed by a physician during the patient's hospitalization.

d. A review of Patient D1's medication record (MARS) revealed that the patient refused the majority of his medical and psychiatric medications, including prescribed insulin, Glucophage, Coreg, Aspirin, potassium, Mobic, Zocor, Flomax, Bactrim DS, Wellbutrin, Exelon Patch, Megace, and Synthroid. The medical record contained no documentation that the medical staff had addressed the medication non-compliance or had evaluated its impact on the patient's deteriorating medical status.

e. During the course of the hospitalization, nursing and psychiatrist progress notes documented that Patient D1 had poor oral intake, clinical signs of deterioration, and the onset of nausea and vomiting. The documentations were as follows:

A nursing progress note dated 5/8/11 at 7:20a.m. stated: "Skin (with) ashen hue."

A nursing progress note dated 5/8/11 at 9:00p.m. stated: "Refuses to eat...Ate only small amt. (amount) of ice cream...color ashen."

A psychiatrist note on 5/9/11 at 4:50p.m. stated, "poor po (oral) intake."

A nursing progress note dated 5/9/11 at 8:00p.m. stated, "(oxygen) sat (saturation) remains 80-83%, (MD3) notified, orders rec'd (received), (oxygen) started @ 2L (liters)/NC (nasal canulla)."

A nursing progress note dated 5/10/11 at 8:00p.m. stated "vomiting phlegm." A physician's telephone order, obtained on 5/11/11 at 11:15a.m. read, "Phenergan 25 mg (milligrams) IM/PO (intramuscular/by mouth) Q4hr PRN N/V (every 4 hours as needed for nausea/vomiting)."

A nursing progress note dated 5/11/11 at 11:30a.m. stated, "Spoke with...dietician regarding consult R/T (related to) very poor appetite/intake: 14 meals, refused 12, ate 25% of 2, wt. (weight) loss. Please advise ASAP (as soon as possible), concerned."

A psychiatrist note on 5/11/11 at 4:35p.m. stated: "(no) appetite + nausea & vomiting...multiple medical issues - abn (abnormal labs) (elevated)...ammonia...undernourished." The medical record contained no documentation of assessment, treatment, or communication of these issues at that time.

A nursing progress note dated 5/12/11 at 7:00a.m. stated, "Poor appetite continues. Staff reports repeated N/V (nausea/vomiting) - within seconds of swallowing - food or drink. (decreased) BP (elevated) P (pulse)...Order rec'd to send [patient] to (medical hospital) ER (emergency room)." The nursing assessment stated that at 10:50a.m., Patient D1 "left (with) (facility) staff for transport to (medical hospital) ER."

f. The medical record had no documentation that a face to face evaluation of the patient was completed by a medical physician from the time of admission (5/6/11) until 5/11/11. A medical physician note written on 5/11/11 at 12:30p.m., stated: "No ENT (ears nose throat)"; "Drink WNL (within normal limits)"; "Maybe gave up"; "Admit lab not done"; "Skin Pulmonary Cardiac Abdominal WNL." There was no documentation that the medical physician further assessed Patient D1's inadequate oral intake or nausea and vomiting, nor that the medical physician was aware of the abnormal laboratory results at that time. However, orders were written on 5/11/11 at 12:30p.m. to "(increase) fluid" and for "BMP (basic metabolic panel) in AM (morning)."

g. The discharge summary from the local medical hospital dated 5/19/11 stated that Patient D1 was transferred for admission to the medical hospital on 5/12/11. At the time of admission, the patient was noted to be "dehydrated." Diagnostic studies revealed a moderate amount of aspiration into the lungs. Patient D1 was noted to have atrial fibrillation which was treated with cardioversion as well as medication adjustment. His heart returned to a normal sinus rhythm during the hospitalization. Patient D1 was noted to be eating "very well" and "drinking well" after two days of treatment in the medical hospital. Discharge diagnoses from the medical hospital were "Paroxysmal atrial fibrillation, pneumonia, and cholelithiasis (gall bladder disease)." He was discharged from the medical hospital to return to his previous nursing home.

2. Staff Interviews

a. During a telephone interview on 6/29/11 at 9:30a.m., the medical physician for Patient D1 stated that he "probably should have seen him (Patient D1) when his physical status worsened" but that he "probably did not" do so. He stated that he does not come to the facility on a daily basis, but that he usually comes every other day if he has physical examinations to complete on newly admitted patients. He stated that he did not believe that laboratory blood studies were obtained on weekends because "they only do labs on Monday through Friday." He also stated that there had been a problem with obtaining "timely electrocardiograms."

b. During a telephone interview on 6/29/11 at 10:50a.m., the Medical Director (who was also the attending psychiatrist for Patient D1) stated that Patient D1 should have been medically cleared prior to admission to the facility. He stated that the facility did not always obtain laboratory blood studies in a timely manner "especially on Friday." He stated that laboratory blood studies should have been obtained and reviewed earlier for Patient D1, based on the history of the patient, and "not waiting three days (to obtain the laboratory blood studies)."

B. Patient E1

1. Record Review

a. Patient E1 was a 62 year-old admitted 4/16/11 with the diagnoses of "Dementia, NOS," "Depressive D/O NOS," and "Impulse Control D/O NOS." At the time of admission, there were no acute medical issues noted on physical examination or other assessments.

b. The following nursing progress notes documented the patient's condition during the hospitalization:

4/23/11: (7:30a.m.): "L (left) foot (with) swelling & redness to 1st joint - great toe. Tender to touch foot elevated [sic]." 9:40a.m.: "foot remains swollen & tender (with) redness. Phoned (medical physician) message left. Awaiting return call." (4:53p.m.): "no change in assessment of foot. Phoned (medical physician) as he has not returned call." (5:32p.m.): "spoke (with) (the medical physician). Order rec'd (received) for Rocephin IM." (5:40p.m.) [physician telephone order]: "Get uric acid level in AM. Start Allopurinol 300mg daily after lab work."

4/24/11: (7:20a.m.): "L foot redness & warm to touch." (12:14p.m.): "rec'd fax (received fax)." The faxed report showed abnormal CBC (complete blood count) and WBC (white blood cell count) findings. 8:00p.m.: "L (left) foot reddened across top & around outer side, warm to touch, swollen."

4/25/11, (7:30a.m.): "L foot top, side & up leg - red, swollen & warm to touch. Decreased urine output...Dr.'s (doctor's) appt. (appointment) made @ 815 - (patient) - sent to (medical physician's) office @ 9:00."

c. The medical record for Patient E1 contained no documentation that Patient E1 had been seen and evaluated by a physician from the time of development of his symptoms (4/23/11) until 4/25/11. There were only physician telephone orders for medication and laboratory tests.

d. Patient E1's discharge summary from the facility dated 5/7/11 stated, "On 4/25/11 patient was sent to (MD3's) office related to not eating, not drinking, decreased urine output, swelling to L (left) foot and R (right) thumb and increased WBC's (white blood cell count). Patient was then sent to (medical hospital) as a direct admit." In spite of the medical problem which developed during hospitalization and resulted in a transfer to the medical hospital, the discharge diagnoses were the same as the admission diagnoses.

e. The discharge summary from the local medical hospital dated 4/28/11 stated that Patient E1 was hospitalized from 4/25/11 to 4/28/11 with "cellulitis." The "Present Illness" section of the discharge summary from the local hospital summarized the medical condition of Patient E1 while at the psychiatric facility as follows: (Patient E1) "developed a red right [sic] leg over the weekend. He was started on Rocephin and has gotten worse. He is not eating or drinking. He has decreased urine output." The "Physical Examination" section of the discharge summary stated that Patient E1 was "very poorly responsive. He was dehydrated." The "Hospital Course" section of the discharge summary stated that Patient E1 was treated with intravenous antibiotics.

2. Staff Interviews

a. In a telephone interview on 6/29/11 at 9:30a.m., the medical physician for Patient E1 acknowledged that he relied on the assessments by nursing staff to determine the medical condition of Patient E1 without examining the patient him/herself.

b. In a telephone interview on 6/29/11 at 10:50a.m., the Medical Director, who was also the attending psychiatrist for Patient E1, said "no question" that a physician should have assessed Patient E1's foot and leg immediately, rather than relying on nursing evaluations or waiting several days to do the evaluation.

C. Additional Staff Interview

In an interview on 6/28/11 at 4:30p.m., the DON agreed that Patients D1 and E1 required direct assessments by a physician earlier in their hospitalizations. She stated that she felt nursing staff were "picking up" for the physicians by assessing the patients and communicating the findings to the physicians on the telephone.

II. Failure to adequately follow restraint procedures for physical holds

Findings include:

1. Review Patient E6's medication record (MARS) revealed that the patient was given Ativan 1 mg (milligrams) intramuscular on the following dates: 4/16/11 at 3:50p.m. for "severe agitation," 4/18/11 at 9:45p.m. for "yelling, cursing staff," and 4/19/11 at 7:00p.m. for "cont. (continuing) to yell, curse staff. "

2. In an interview on 6/29/11 at 9:00a.m., Licensed Practical Nurse, LPN2 stated that s/he administered these medications (referring to #1 above) to Patient E6 on the documented dates. S/he stated that Patient E6 was given intramuscular medication for agitation and intrusive behaviors as ordered by the physician. S/he also stated that Patient E6 was physically held by facility staff during "some" of these injections due to the patient's agitation and resistance. LPN2 acknowledged that there was no documentation of physician orders or assessments for use of the physical holds (restraints).

3. A review of the medical record for Patient E6 revealed no physician order or other documentation for the physical hold utilized by staff on the dates the medications were administered.

4. During an interview on 6/28/11 at 10:55a.m., LPN 1 stated that if a patient refuses an injection, staff would have to "hold the patient" so that s/he can give the injection.

5. In an interview on 6/28/11 at 11:00a.m., RN1, the unit charge nurse, stated that physical holds were mostly used to give patients injections of medications. S/he was not able to recall where a policy about physical holds was located or if she had seen one.

6. In an interview on 6/28/11 at 4:30p.m., the Director of Nursing stated that patients were sometimes held by facility staff in order to administer medications or for "out of control" patient behaviors. She said that the facility did not have a definition for physical holds as restraints in current policies.

7. During a telephone interview with the Medical Director on 6/29/11 at 10:50a.m., when asked about the use of physical holds in the hospital, he stated "no question" that there needed to be orders and assessments when physical holds were used by staff to give injections or physically intervene with patients.

8. Facility policy "TX-Spec-07: Seclusion and Restraints," adopted August 2006 and revised September 2009, was reviewed for guidelines on the use of restraints. The policy did not contain definitions or procedures that identified physical holds as restraints.

III. Adequately stabilize Patient A9's symptoms before discharge

Patient A9 was a 60 year who was admitted on 6/15/11 with a psychiatric diagnosis of Paranoid Schizophrenia. The medical diagnoses included diabetes mellitus, hypertension, peripheral vascular disease, and anemia. The patient was discharged on 6/28/11 without full stabilization of his delusions, impaired insight and judgment. Patient A9 was discharged to live alone and manage his/her own medications and psychiatric/medical appointments.

A. Observations

1. On 6/27/11 at approximately 10:00a.m., Patient A9 was observed to be disruptive in TR (Therapeutic Recreation) group. The patient interrupted other patients, required redirection multiple redirections, was unable to stay on task, and made statements that he/she was a staff member.

2. On 6/27/11 at approximately 3:00p.m., Patient A9 was observed pacing in the hallway and talking to self (verbalizing fear that staff or someone was going to "shoot me in my head", and the need to protect self).

3. During an observation of a RT (recreational therapy) group on 6/28/11 at 11:00a.m., Patient A9 knelt down and began singing a song that had nothing to do with the group task.

B. Record Review and Staff Interview

1. While reviewing Patient A9's medical record on 6/28/11 at approximately 1:30p.m., the surveyor saw (on the physicians order sheet) that the patient had been discharged. Both surveyors then reviewed the patient's medical record and behavior over the prior three days and conducted additional interviews.

2. On 6/28/11 at approximately 1:35p.m., the surveyors interviewed SW1, the social worker in charge of Patient A9's case. When asked about the discharge plans for the patient and clarification of some of the SW1's progress notes, SW1 stated that it had been decided by the treatment team that the patient was "resourceful and manipulative" and could be treated as an outpatient. When the surveyors reviewed the severity of the patient's psychosis, (e.g. paranoid and grandiose delusions), SW 1 stated that the patient was pretending and was no longer delusional.

C. Additional Record Review/Interview

1. Nursing Progress Notes

a. 6/26/11 (7:30p.m.): In a note [form completed by nurse] for Patient A9, the following boxes were checked for "Thought Content": "confused," "bizarre," "rambling," "delusion," "hallucinating," "demanding," "guarded." The notations for the BIRP (B- behavior, I- intervention, R- response, P-plan) were recorded as: "B- Standing in dayroom next to a confused patient. Touched by patient. Yelling 'don't touch me,' asked by writer to move from patient to chair and eat his snack. I - Redirect, encourage, assist as needed, R- Sitting quietly at table eating snack, no agitation or irritable behavior noted, P - follow plan of care."

b. 6/27/11 (7:30a.m.): In a note [form completed by nurse], the "Thought Content" boxes were checked for "bizarre," "rambling," "delusion," "hallucinating," "demanding," and "guarded." The BIRP notes were recorded as, "B- Bizarre , stares incessantly @ staff, accusing staff of abusing another patient, C/O 'mutiny on bounty' to RN, rambles under his breath, I - Redirect, reorient and encourage PRN, R - no change, P - continue POC (plan of care)."

c. On 6/28/11 at approximately 4:30p.m., the surveyors asked the Director of Nursing about nursing progress notes for Patient A9 for that day. The DON stated that the nurses had not written them yet.

2. Social Work Progress Notes

The following progress notes were written by Social Worker SW1:

6/27/11 (8:15a.m.): "Pt signed release for Ocean Behavioral in Kentwood, La. Pt reported he wanted to continue his inpt (in-patient) services there if agreeable with doctor." In another entry with the exact same date and time, SW1 stated, "D/C planning - LRSW (license registered social worker) met with pt concerning D/C (discharge) plans. Patient stated he would like to d/c (be discharged to) home with services."

6/27/11 (8:30a.m.): "LRSW spoke with (a staff member at the Veterans Administration) in reference to D/C planning for the pt. The VA (Veterans Administration) will not pay for services as in-patient at another hospital/ facility. Outpatient services will have to be coordinated through (name of clinic) mental health services."

6/27/11 (8:45a.m.): "LRSW spoke with (person's name) concerning patient being admitted to another facility utilizing his Medicaid. Patient is allowed to use Medicaid to transfer to another facility but the VA (Veteran's Administration) will not authorize further in-patient care."

6/27/11 (8:55a.m.): "(person's name) stated that she and (other person's name) were not (unclear word) Friday and didn't return call to complete D/C planning Thurs (Thursday) or Fri (Friday)..."

6/27/11 (no time noted): "LRSW spoke with Administrator on the patient's change of mind options. Administrator stated to let the Clinical Director decide pt d/c option at the treatment team meeting today."

6/28/11 (no time noted): "Spoke with (person's name) at VA in Alexandria to confirm housing situation."

3. Physician Progress Notes

a. A progress note written by MD2 and dated 6/24/11 read. "Psy, seen, eval, __ (psychiatrist seen, evaluated; other illegible word).... D/W (discussed with) staff - still delusional, claims staff is [his/her] wife, threatened to kill staff, extremely unpredictable, on meds, no S/E (side-effects), will (increase) Zyprexa, will pursue other options, e.g. VA, will continue options until placement." There were no physician progress notes between this note and the note documented in "b." below.

b. A progress note dated 6/27/11 and written by MD1 read, "Seen and staffed with treatment team. Calmer, easier to redirect in group, no problem with meds, denied S/H (suicidal or homicidal) ideations, decreased paranoid ideations, lots of behavioral problems related to personality traits, add personality d/o nos (not otherwise specified) to Axis II, potential d/c tomorrow, follow plan as (illegible word)."

4. The discharge order for the patient, dated 6/28/11 was "D/C to home, continue current meds & diet, F/u (follow-up) (with) primary MD (physician), F/u (follow up with) mental health clinic, VA in Alexandria, F/u c us PRN (follow up with us as needed)- V/O (verbal order)." The verbal discharge order was from the Clinical Director.

Based on observation, interview and document review, the Clinical Director failed to:

I. Ensure adequate availability of medical physicians and services to evaluate and treat the acute medical problems of 2 of 2 discharged patients (D1 and E1) whose records were reviewed for medical care. Patient D1 had a history of serious medical disorders, eating problems, and medication non-compliance, and his condition worsened during the hospitalization. Patient E1 developed acute cellulitis while hospitalized. The medical staff failed to do timely face-to-face evaluations for these patients; instead, they relied on nursing staff assessments. Laboratory tests also were not completed in a timely manner. Both patients were transferred to a medical hospital for treatment of their medical problems. Inadequate availability of medical staff and services results in patients not receiving timely medical attention, potentially leading to serious outcomes for patients.

Findings include:

A. Patient D1

1. Patient D1 was a 65 year old admitted 5/6/11 with the diagnoses of "Dementia, moderate with agitation" and "Depressive D/O (disorder) NOS (not otherwise specified) R/O (rule out) MDD (major depressive disorder)." The patient also had a history of multiple medical disorders, including "CHF (congestive heart failure)," "CAD (coronary artery disease)," "DM (diabetes mellitus)," "thrombocytopenia (a blood disorder)," "A-fib (atrial fibrillation)," "DDD (degenerative disc disease)," and "hyperlipidemia (high cholesterol)." The History and Physical Examination dated 5/6/11 noted no findings other than "ischemic discoloration bilaterally legs." However, the initial Social Work, Activity Therapy, and Nursing assessments documented that the patient had been refusing food and medications prior to admission.

2. Despite Patient D1's known medical disorders and poor oral intake, blood was not collected for laboratory testing until 5/9/11 at 3:49p.m. (3 days after admission). The results were abnormal for several tests. There was no documentation that the test results were reviewed by a physician until 5/11/11 at 4:35p.m. An electrocardiogram (ECG) was performed on 5/11/11 at 1:31p.m. (5 days after admission). The report showed "abnormal ECG" results. There was no documentation that the EKG findings were reviewed by a physician.

3. The Patient D1's medication record (MARS) showed that the patient refused the majority of his medical and psychiatric medications. The medical record contained no documentation that the medical staff addressed the patient's medication non-compliance.

4. During the course of the hospitalization, the following nursing progress notes were recorded regarding Patient D1's medical condition:

5/8/11: (7:20a.m.) "Skin (with) ashen hue"; (9:00p.m.) "Refuses to eat... Ate only small amt. (amount) of ice cream...color ashen."
5/9/11 (8:00p.m.): "(oxygen) sat (saturation) remains 80-83%, (MD3) notified, orders rec'd (received), (oxygen) started @ 2L (liters)/NC (nasal canulla)."
5/10/11 (8:00p.m.): "vomiting phlegm." 5/11/11 (11:15 a.m.) [MD order]: "Phenergan 25 mg (milligrams) IM/PO (intramuscular/by mouth) Q4hr PRN N/V (every 4 hours as needed for nausea/vomiting)."
5/11/11 (11:30a.m.): "Spoke with...dietician regarding consult R/T (related to) very poor appetite/intake: 14 meals, refused 12, ate 25% of 2, wt. (weight) loss. Please advise ASAP (as soon as possible), concerned."
5/12/11 (7:00a.m.): "Poor appetite continues. Staff reports repeated N/V (nausea/vomiting) - within seconds of swallowing - food or drink. (decreased) BP (elevated) P (pulse)...Order rec'd to send [patient] to (medical hospital) ER (emergency room)." The nursing assessment stated that at 10:50a.m., Patient D1 "left (with) (facility) staff for transport to (medical hospital) ER."

5. The following psychiatrist notes were recorded:

5/9/11 (4:50p.m.): "poor po (oral) intake."
5/11/11 (4:35p.m.) "(no) appetite + nausea & vomiting...multiple medical issues - abn (abnormal labs) (elevated)...ammonia...undernourished."

6. The medical record had no documentation that a face to face evaluation of the patient was completed by a medical physician from the time of admission (5/6/11) until 5/11/11. A medical physician note written on 5/11/11 at 12:30p.m., stated: " No ENT (ears nose throat)"; "Drink WNL (within normal limits)"; "Maybe gave up"; "Admit lab not done"; "Skin Pulmonary Cardiac Abdominal WNL." There was no documentation that the medical physician further assessed Patient D1's inadequate oral intake or nausea and vomiting, nor that the medical physician was aware of the abnormal laboratory results at that time. However, orders were written on 5/11/11 at 12:30p.m. to "(increase) fluid" and for "BMP (basic metabolic panel) in AM (morning)."

7. The discharge summary from the local medical hospital dated 5/19/11 stated that Patient D1 was transferred for admission to the medical hospital on 5/12/11. At the time of admission, the patient was noted to be "dehydrated." Diagnostic studies revealed a moderate amount of aspiration into the lungs. Patient D1 was noted to have atrial fibrillation which was treated with cardioversion as well as medication adjustment. His heart returned to a normal sinus rhythm during the hospitalization. Patient D1 was noted to be eating "very well" and "drinking well" after two days of treatment in the medical hospital. Discharge diagnoses from the medical hospital were "Paroxysmal atrial fibrillation, pneumonia, and cholelithiasis (gall bladder disease)." He was discharged from the medical hospital to return to his previous nursing home.

8. In a telephone interview on 6/29/11 at 9:30a.m., the medical physician for Patient D1 stated that he "probably should have seen him (Patient D1) when his physical status worsened" but that he "probably did not" do so. He stated that he does not come to the facility on a daily basis, but that he usually comes every other day if he has physical examinations to complete on newly admitted patients. He stated that he did not believe that laboratory blood studies were obtained on weekends because "they only do labs on Monday through Friday." He also stated that there had been a problem with obtaining "timely electrocardiograms."

9. In a telephone interview on 6/29/11 at 10:50a.m., the Medical Director (who was also the attending psychiatrist for Patient D1) stated that Patient D1 should have been medically cleared prior to admission to the facility. He stated that the facility did not always obtain laboratory blood studies in a timely manner "especially on Friday." He stated that laboratory blood studies should have been obtained and reviewed earlier for Patient D1, based on the history of the patient, and "not waiting three days (to obtain the laboratory blood studies)."

B. Patient E1

1. Patient E1 was a 62 year-old admitted 4/16/11 with the diagnoses of "Dementia, NOS," "Depressive D/O NOS," and "Impulse Control D/O NOS." At the time of admission, there were no acute medical issues noted on physical examination or other assessments.

2. The following nursing progress notes documented the patient's condition during the hospitalization:

4/23/11: (7:30a.m.): "L (left) foot (with) swelling & redness to 1st joint - great toe. Tender to touch foot elevated [sic]." 9:40a.m.: "foot remains swollen & tender (with) redness. Phoned (medical physician) message left. Awaiting return call." (4:53p.m.): "no change in assessment of foot. Phoned (medical physician) as he has not returned call." (5:32p.m.): "spoke (with) (the medical physician). Order rec'd (received) for Rocephin IM." (5:40p.m.): [physician telephone order]: "Get uric acid level in AM. Start Allopurinol 300mg daily after lab work."

4/24/11: (7:20a.m.): "L foot redness & warm to touch." (12:14p.m.): "rec'd fax (received fax)." The faxed report showed abnormal CBC (complete blood count) and WBC (white blood cell count) findings. 8:00p.m.: "L (left) foot reddened across top & around outer side, warm to touch, swollen."

4/25/11, (7:30a.m.): "L foot top, side & up leg - red, swollen & warm to touch. Decreased urine output...Dr.'s (doctor's) appt. (appointment) made @ 815 - (patient) - sent to (medical physician's) office @ 9:00."

c. The medical record for Patient E1 contained no documentation that Patient E1 had been seen and evaluated by a physician from the time of development of his symptoms (4/23/11) until 4/25/11. There were only physician telephone orders for medication and laboratory tests.

3. Patient E1's discharge summary from the facility dated 5/7/11 stated, "On 4/25/11 patient was sent to (MD3's) office related to not eating, not drinking, decreased urine output, swelling to L (left) foot and R (right) thumb and increased WBC's (white blood cell count). Patient was then sent to (medical hospital) as a direct admit." In spite of the medical problem which developed during hospitalization and resulted in a transfer to the medical hospital, the discharge diagnoses were the same as the admission diagnoses.

4. The discharge summary from the local medical hospital dated 4/28/11 stated that Patient E1 was hospitalized from 4/25/11 to 4/28/11 with "cellulitis." The "Present Illness" section of the discharge summary from the local hospital summarized the medical condition of Patient E1 while at the psychiatric facility as follows: (Patient E1) "developed a red right [sic] leg over the weekend. He was started on Rocephin and has gotten worse. He is not eating or drinking. He has decreased urine output." The "Physical Examination" section of the discharge summary stated that Patient E1 was "very poorly responsive. He was dehydrated." The "Hospital Course" section of the discharge summary stated that Patient E1 was treated with intravenous antibiotics.

5. In a telephone interview on 6/29/11 at 9:30a.m., the medical physician for Patient E1 acknowledged that he relied on the assessments by nursing staff to determine the medical condition of Patient E1 without examining the patient him/herself.

6. In a telephone interview on 6/29/11 at 10:50a.m., the Medical Director, who was also the attending psychiatrist for Patient E1, said "no question" that a physician should have assessed Patient E1's foot and leg immediately, rather than relying on nursing evaluations or waiting several days to do the evaluation.

7. Additional Staff Interview

In an interview on 6/28/11 at 4:30p.m., the DON agreed that Patients D1 and E1 required direct assessments by a physician earlier in their hospitalizations. She stated that she felt nursing staff were "picking up" for the physicians by assessing the patients and communicating the findings to the physicians on the telephone.

II. Ensure that the treatment team provided Master Treatment Plans (MTP) for 8 of 8 active sample patients (A1, A2, A3, A5, A9, A10, A11 and A13) included individualized interventions by all disciplines. None of the 8 sample patients MTPs included physician interventions. In addition, the interventions to be performed by nurses, social workers, and activity therapy staff were generic discipline functions instead of individualized interventions. These failures result in a lack of guidance to staff in providing individualized, coordinated treatment, and can result in prolonged hospitalization for patients. (Refer to B122)

III. Ensure that staff followed restraint procedures, including needed documentation, for the use of physical holds for 1 of 5 discharged patients (E6) whose record was initially reviewed for the occurrence of a fall. Staff utilized physical holds (restraint) to administer medications to this patient without physician orders for restraint. There also was no documentation of appropriate nursing and physician assessments required for use of restraint. The use of physical restraints without appropriate physician orders and documentation of required assessments is a potential danger for patients and is a violation of patient rights. (Refer to B125-II)

IV. Ensure that the psychiatric symptoms of 1 of 8 active sample patients (A9) were adequately stabilized prior to discharge. The patient was discharged without full stabilization of his delusions, impaired insight and judgment. The discharge plan required him/her to live alone and manage his/her own medications and psychiatric follow-up appoints. There was lack of evidence that the patient had the ability to utilize the discharge services that were offered. This resulted in the patient having inappropriate aftercare plans. This deficient practice is a health risk for the discharged patient, and potentially puts the community at risk due to the patient's psychiatric symptoms. (B125-III)

Based on record review and interview, it was determined that the Director of Nursing failed to provide adequate monitoring of the quality of nursing care. Specifically, the DON failed to:

I. Ensure that the Master Treatment Plans of 8of 8 active sample patients (A1, A2, A3, A5, A9, A10, A11 and A13) included nursing interventions that were individualized for the patients, based on the patients' assessed needs. Instead, the nursing interventions were routine nursing/milieu functions. This failure hampers staff's ability to provide individualized patient care.

Findings include:

A. Record Review

1. Patient A1 (MTP dated 6/15/11)

For the identified problem "Disturbed sensory perception AEB (as evidenced by) hallucinations, mania, delusions, constant singing, insomnia, poor intake food & hydration RT (related to) Dx (diagnosis) of dementia," the generic nursing interventions were: Nursing: "Provide quiet environment"; "Administer meds (medications) and assess effectiveness"; "Reorient, redirect pt (patient) as needed"; "Monitor sleep rest pattern"; "Use calm face to face approach" and "Provide simple activities that the patient can accomplish."

2. Patient A2 (MTP dated 6/7/11)

For the identified problem "Disturbed thought process R/T (related to) Dementia, Alzheimer's," the generic nursing interventions were: "Monitor compliance (with) med regimen, meals, & care"; "Give simple instructions & allow Pt. to process instructions" "Use calm approach"; "Reorient daily & PRN"; "Allow Pt to verbalize thoughts" and "Give choices."

For the identified problem "Altered mood R/T (related to) dementia AEB (as evidenced by) (increased) aggression, agitation and physically abusive toward staff," the generic nursing interventions were: "Explain care prior to rendering it"; "Allow Pt time for personal care"; "Assist (with) care as needed"; "Provide comfortable environment for personal care" and "Encourage Pt to participate in personal care."

For the identified problem "Violence, risk for directed @ others. R/T aggression," the generic nursing interventions were: "Limit negative stimuli"; "Provide safe environment"; "Re-direct violent behaviors with physical exercise"; "Use calm approach"; "Give meds as ordered" and "Allow Pt to verbalize by giving choices."

3. Patient A3 (MTP dated 6/16/11)

For the identified problem "Confusion, chronic R/T Alz's (Alzheimer's) Dementia Dx (diagnosis) AEB: Increased Agitation Wandering Elopement from NH (nursing home) deterioration in self-care abilities," the generic nursing interventions were "Provide a safe environment"; "Avoid excessive activity or stimulation"; "Use a calm, face to face approach"; "Praise desired behaviors"; "Assess for effectiveness, SE's (side effects) of medications"; "Provide Nursing Groups 3-4 times per week"; "Encourage group participation"; "Reorient, redirect pt. as needed"; "Evaluate sleep/rest pattern" and "Provide plenty of time to answer in groups."

4. Patient A5 (MTP dated 6/28/11)

For the problem, "Altered thought processes R/T (related to) MDD (Major Depressive Disorder) and GAD (generalized anxiety disorder) AEB (as evidenced by): uncontrollable crying, worrying, expression of grief, increased anxiety, fatigue, trembling," the generic nursing interventions were: "Provide a safe environment"; "avoid excessive activity or stimulation," and "praise desired behaviors."

5. Patient A9 (MTP dated 6/15/11)

For the problem, "Disturbed thought process R/T diagnosis Schizophrenia AEB: inappropriate affect, delusions of grandeur, sleep disturbance, impaired insight, impaired judgment, impaired impulse," the generic nursing interventions were: "Provide a safe environment"; "avoid excessive activity or stimulation"; "praise desired behaviors"; "assess for effectiveness, SEs(side- effects) of medications"; "encourage group participation" and "Provide nursing groups 3-4 times per week."

6. Patient A10 (MTP dated 6/22/11)

For the identified problem "Alterations in Thought Processes R/T Dementia, agitation, aggression," the generic nursing interventions were "Provide freq. (frequent) orientation to facility, date, time & situation"; "Give positive feedback for appro. (appropriate) thinking & behaviors"; "Use simple explanations with face to face interactions" and "Re-direct false ideas."

For the identified problem "Self-care deficit R/T Recent falls, Disability, Confusion," the generic nursing interventions were "Provide safe environment"; "Provide assistance for identified self-care deficits"; "Allow plenty of time to perform tasks"; "Provide structured schedule for ADL's (activities of daily living)" and "Allow Pt to provide all self-care within physical limits."

7. Patient A11 (MTP dated 6/13/11)

For the problem, "disturbed thought processes AEB pt's increased anxiety regarding colostomy bag, and obsessed with cutting his catheter," the generic nursing interventions were: "Use simple direct questions"; "give positive feedback"; "listen to pt's concern regarding his care" and "provide nursing groups 3 - 4 times per week."

8. Patient A13 (MTP dated 6/21/11)

For problem, "altered thought processes R/T (related to) dementia AEB increased confusion, agitation, and hallucinations," the generic nursing interventions were "Provide frequent orientation, to facility, date, time, situation" and "give positive feedback for appropriate thinking and behaviors"

B. Staff Interviews

In an interview on 6/28/11 at 4:30p.m., the DON acknowledged that nursing interventions on the above sample patient's treatment plans were generic nursing functions, not individualized interventions.

II. Assure that nurses followed restraint procedures, including needed documentation, for the use of physical holds for 1 of 5 discharged patients (E6) whose record was initially reviewed for the occurrence of a fall. Nursing staff used physical holds (restraint) to administer medications to this patient without a physician order for the restraint. There also was no documentation of the nursing and physician assessments required for restraint use. The use of physical restraint without physician orders and documentation of required assessments can be dangerous for the patient. It also is a violation of patient rights. (Refer to B125-II)

Based on record review and interview, the Director of Social Services failed to ensure that the Master Treatment Plans of 6 of 8 active sample patients (A1, A5, A9, A10, A11 and A13) included social work interventions that were individualized for the patients. The listed interventions on the MTPs of these patients were non-specific generic social work functions. This failure hampers staff's ability to provide individualized patient care.

Findings include:

A. Record Review

1. Patient A1 (MTP dated 6/15/11)

For the identified problem of "Disturbed sensory perception AEB (as evidenced by) hallucinations, mania, delusions, constant singing, insomnia, poor intake food & hydration RT (related to) Dx (diagnosis) of dementia," the generic social work interventions were "Gather history & assess level of function; (CIA during 1st 72 hrs (hours)"; "Develop multidisciplinary treatment Integration (MTI) Plan in 72 hrs)"; "Engage Pt's (patient's) family/significant other in continued support and participation of tx (treatment)"; "Provide Psychotherapy Group session daily"; "Provide Indiv. (individual) therapy PRN (as needed)"; "Complete D/C (discharge) planning" and "Contact family weekly to provide status report of progress or lack thereof.":

2. Patient A5 (MTP dated 6/28/11)

For the problem, "Altered thought processes R/T (related to) MDD (Major Depressive Disorder) and GAD (generalized anxiety disorder) AEB (as evidenced by): uncontrollable crying, worrying, expression of grief, increased anxiety, fatigue, trembling," the generic social work interventions were: "gather history and assess level of function"; "develop Multidisciplinary Treatment Integration plan within 72 hours"; "provide psychotherapy group daily" and "provide individual therapy PRN (as needed)."

3. Patient A9 (MTP dated 6/15/11)

For the problem, "Disturbed thought process R/T diagnosis Schizophrenia AEB: inappropriate affect, delusions of grandeur, sleep disturbance, impaired insight, impaired judgment, impaired impulse," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

4. Patient A10 (MTP dated 6/22/11)

For the identified problem of "Alterations in Thought Processes R/T Dementia, agitation, aggression," the generic social work interventions were identical to those for Patient A1.

5. Patient A11 (MTP dated 6/13/11)

For the problem, "disturbed thought processes AEB pt's increased anxiety regarding colostomy bag, and obsessed with cutting his catheter," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

6. Patient A13 (MTP dated 6/21/11)

For problem, "altered thought processes R/T (related to) dementia AEB increased confusion, agitation, and hallucinations," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily"; "provide individual therapy PRN" and "complete d/c planning."

B. Staff Interviews

During an interview on 6/28/11 at 1:15p.m., the Director of Social Work acknowledged that social work interventions on the above patient's treatment plans were generic social work functions and were identical or very similar for the patients.