HospitalInspections.org

Based on medical record reviews, observations, and interviews the facility failed:

I. To provide Master Treatment Plans that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sampled patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs. (Refer to B121)

II. To develop Master Treatment Plans that identified physician, nursing, and social work staff interventions to address the specific treatment needs of eight (8) out of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. (Refer to B122)

III. To provide active individualized treatment for two (2) of eight (8) active sample patients (B1 and B2). Sample patients B1 and B2 frequently refused to attend scheduled modalities and alternative treatments were not provided to meet their individual treatment goals. Failure to provide active treatment results in the patients being hospitalized without all interventions for recovery being provided and results in delayed improvement. (Refer to B125)

Based on interview and record review, the facility failed to provide Master Treatment Plans that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sampled patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review:

1. Patient A1 was admitted to the facility on 6/24/2015. The Master Treatment Plan identified psychiatric diagnosis as: "Bipolar, depressed." The Master treatment Plan dated 8/26/15 identified Short Term Goals (STG) for problem "Danger to others" as: "Demonstrate decreased isolation by attending/participation in three (3) groups per shift, per day, x 7 days."

2. Patient A2 was admitted to the facility on 9/1/2015. The Master Treatment Plan dated 9/2/2015 identified psychiatric diagnoses of "Schizophrenia." The Master treatment Plan dated 9/2/15 identified Short Term Goals (STG) for problem Altered Thought Process as "Demonstrate decrease symptoms of isolation by attending two (2) groups with meaningful participation every shift, every day x 7 days."

3. Patient A3 was admitted to the facility on 9/8/2015. The Mater Treatment plan dated 9/9/2015 identified psychiatric diagnoses of Schizophrenia and Cannabis dependence. The Master Treatment Plan dated 9/9/15 identified Short Term Goals (STG) for problem Altered Thought Process as "Demonstrate decrease symptoms of isolation by attending two (2) groups with meaningful participation every shift, every day x 7 days."

4. Patient A4 was admitted to the facility on 9/11/2015. The Mater Treatment plan dated 9/14/2015 identified psychiatric diagnoses of Schizophrenia. The Master treatment Plan dated 9/9/15 identified Short Term Goals (STG) for problem Altered Thought Process as "Demonstrate decrease symptoms of isolation by attending two (2) groups or alterative therapy with meaningful participation every shift, every day x 7 days."

5. Patient B1 was admitted to the facility on 9/10/2015. The Master Treatment Plan dated 9/11/2015 identified psychiatric diagnoses of Major Depressive Disorder, Alcohol dependence and Amphetamine dependence. The Master Treatment Plan dated 9/11/15 identified Short Term Goals (STG) for problem Risk for Self Harm as "Demonstrate decrease symptoms of isolation by attending two (2) groups with meaningful participation every shift, every day x 7 days."

6. Patient B2 was admitted to the facility on 9/1/2015. The Master Treatment Plan dated 9/2/2015 identified psychiatric diagnoses of R/O Schizophrenia. The Master Treatment Plan dated 9/2/15 identified Short Term Goals (STG) for problem Altered Thought Process as "Demonstrate decrease symptoms of isolation by attending two (2) groups with meaningful participation every shift, every day x 7 days."

7. Patient B3 was admitted to the facility on 9/11/2015. The Master Treatment Plan dated 9/14/2015 identified psychiatric diagnoses of Depressive Disorder NOS. The Master treatment Plan dated 9/14/15 identified Short Term Goals (STG) for problem Altered Mood Depressed as "Demonstrate decrease symptoms of isolation by attending four (4) groups or alterative therapy with meaningful participation every shift, every day x 7 days."

8. Patient B4 was admitted to the facility on 9/5/2015. The Master Treatment Plan dated 9/7/2015 identified psychiatric diagnoses of Bipolar I depressed. The Master treatment Plan dated 9/7/15 identified Short Term Goals (STG) for problem Risk for Self Harm and Altered Mood Depressed as "Demonstrate decrease symptoms of isolation by attending two (2) groups with meaningful participation every shift, every day x 7 days."

B. Interviews:

1. In the interview on 9/15/2015 at approximately 8:45 a.m., the nursing supervisor was asked about STG on sample patients. Nursing supervisor agreed with the findings that the goals are not individualized or measurable.

2. In the interview on 9/15/2015 at approximately 8:45 a.m., the Medical Director was asked about STG on sample patients. Medical Director agreed with the findings that the goals are not individualized or measurable.

II. Based on interview and record review, the facility failed to develop Master Treatment Plans that identified physician, nursing, and social work staff interventions to address the specific treatment needs of eight (8) out of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment

Findings:

A. Record Review:

Review of the sample patients' Master Treatment Plans revealed that the plans included lists of generic physician, nursing, and social work interventions for the listed problems of "Danger to other"; "Altered Thought Process" and "Risk for Self Harm." The interventions were the same for each patient having one or more of these identified problems.

1. For problem "Danger to others" Patient A1 MTP dated 8/26/2015 interventions stated:

a. "D/C Planning 5x 7 Days"

b. "Face to face conversation to assess mood/mental status. Allow patient to verbalize concerns/needs each shift each day x 7 days."

c. "Encourage groups each shift each day x 7 days."

2. For problem "Altered Thought Process" Patient A2 MTP dated 9/2/2015 interventions stated:

a. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

b. "Administer meds as ordered by MD. Assess efficacy, side effects, and provide education Q shift, Q day x 7 days."

c. "Prompt to attend groups and monitor participation Q shift, Q day x 7 days."

d. "Prompt ADLs Q shift, Q day x 7 days."


3. For problem "Altered Thought Process" Patient A3 MTP dated 9/9/15 interventions stated:

a. "assess symptoms daily."

b. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

c. "Give meds as ordered by MD. Assess mental status, efficacy, side effects, and provide med education Q shift."

d. "Prompt ADLs Q shift, Q day x 7 days."

4. For problem "Altered Thought Process" Patient A4 MTP dated 9/14/15 interventions stated:

a. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

b. "Give meds as ordered by MD. Assess mental status, efficacy, side effects, and provide med education Q shift."

c. "Prompt ADLs Q shift, Q day x 7 days."

d. "D/C Planning 5x 7 Days."

5. For problem "Risk for Self-Harm" Patient B1 MTP dated 9/11/15 interventions stated:

a. "assess symptoms daily."

b. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

c. "Give meds as ordered by MD. Assess mental status, efficacy, side effects, and provide med education Q shift."

d. "Prompt ADLs Q shift, Q day x 7 days."

6. For problem "Altered Thought Process" Patient B2 MTP dated 9/2/15 interventions stated:

a. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

b. "Administer meds as ordered by MD. Assess efficacy, side effects, and provide education Q shift, Q day x 7 days."

c. "Prompt to attend groups and monitor participation Q shift, Q day x 7 days."

d. "Prompt ADLs Q shift, Q day x 7 days."

7. For problem "Altered Thought Process" Patient B4 MTP dated 9/14/15 interventions stated:

a. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

b. "Give meds as ordered by MD. Assess efficacy, side effects, and provide education Q shift, Q day x 7 days."

c. "D/C Planning 5x 7 Days."

8. For problem "Risk for Self-Harm" Patient B4 MTP dated 9/7/15 interventions stated:

a. "while still acute, daily assess, (sic) of mood, (sic) and medication side effects for 7 days."

b. "D/C Planning 5x 7 Days."

c. "Face to face to assess mood/mental status thought content and affect Q shift, Q day, x 7 days."

d. "Administer meds as ordered by MD. Assess efficacy, side effects, and provide education Q shift, Q day x 7 days."

e. "Prompt to attend groups and monitor participation Q shift, Q day x 7 days."

f. "Prompt ADLs Q shift, Q day x 7 days."

B. Interviews:

1. In the interview on 9/15/2015 at approximately 8:45 a.m., the nursing supervisor was asked about STG on sample patients. Nursing supervisor agreed with the findings that the goals are not individualized or measurable.

2. In the interview on 9/15/2015 at approximately 8:45 a.m., the Medical Director was asked about STG on sample patients. Medical Director agreed with the findings that the goals are not individualized or measurable.

Based on observation, staff and patient interviews and medical record review the facility failed to:
Provide active individualized treatment for two (2) of eight (8) active sample patients (B1 and B2). Sample patients B1 and B2 frequently refused to attend scheduled modalities and alternative treatments were not provided to meet their individual treatment goals. Failure to provide active treatment results in the patients being hospitalized without all interventions for recovery being provided and results in delayed improvement.

Findings include:

A. Observations

1. On 9/14/2015 at 11:00 a.m. the surveyor observed that sample patient B1 was laying in bed and not attending the scheduled Dialectical Behavioral Therapy group conducted by clinical social worker, as was schedule to attend according to treatment plan.

2. On 9/14/2015 at 11:00 a.m. with a census of 16 patients, surveyor observed six (6) other patients were lying in bed and not participating in the group and two (2) patients were wondering the halls or sitting in a day room without interactions with staff.

3. On 9/14/2015 at 11:00 a.m. the surveyor observed that sample patient B2 was laying in bed and not attending the scheduled Dialectical Behavioral Therapy group conducted by clinical social worker as was schedule to attend according to treatment plan.

4. On 9/14/2015 at 1:30 p.m. the surveyor observed that sample patient B2 was laying in bed and did not attend the scheduled Practicing Health Alternatives group.

B. Record Review

1. Patient B1 was diagnosed Major Depression Disorder; Alcohol Dependence, and Amphetamine Dependence according to the psychiatric evaluation completed on 9/11/2015. Based on the Daily Rehabilitative Therapy Progress Notes dated 9/10/15 through 9/14/15, B1 attended three (3) out of 32 groups; which is less than 10%.

a. The only alternative treatment was documented by Rehabilitation Therapy on 9/11/2015 from 11:30 a.m. to 12:15 p.m. The note stated, "Supervised use of computer and Phone." This was the only documented alternative treatment during hospital stay.

b. According to the Daily Flow Sheet from nursing staff, on 9/12/2015 and 9/13/2015 alternative group activity provided were "Face-to-face conversation; "Activity of Daily Living" and "Laundry."

2. Patient B2 was diagnosed with R/O Schizophrenia according to the psychiatric evaluation completed on 9/2/2015. Based on the Daily Rehabilitative Therapy Progress Notes dated 9/9/15 thru 9/13/15 B1 attended three (3) out of 45 groups; which is less than 6%.

a. The alternative treatment was documented by Rehabilitation Therapy on 9/10/2015 from 1:30 p.m. to 1:31 p.m. The note stated, "Asked about music interests." Note showing the only other alternative treatment by Rehabilitation Therapy on 9/11/2015 from 11:27 a.m. to 11: 29 a.m. stated, "Encouragement to identify an alternative therapeutic activity."

b. According to the Daily Flow Sheet from nursing staff, on 9/9/2015, 9/12/2015 and 9/13/2015 alternative group activity provided were "Face-to-face conversation."

C. Interviews:

1. On 9/15/2015 at approximately 9:30 a.m. the Director of Social Work, who is responsible for active treatment program agreed with the surveyor's findings regarding active treatment. Stated, "Often there is only one recreational (RT) staff and they are the ones leading the groups."

2. On 9/15/2015 at approximately 10:00 a.m. MHT/RA 1 was asked about alternative treatment for patients who do not participate in groups. MHT/RA 1 stated, "A lot of patients don't like to participate so they don't."

3. On 9/15/2015 at approximately 2:30 p.m. the Medical Director agreed with the findings regarding lack of active treatment.

Based on medical record reviews, observations, and interviews, the Medical Director failed to ensure that the facility:

I. Provided Master Treatment Plans that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sampled patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs. (Refer to B121)

II. Developed Master Treatment Plans that identified physician, nursing, and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. (Refer to B122)

III. Provided active individualized treatment for two (2) of eight (8) active sample patients (B1 and B2). Sample patients B1 and B2 frequently refused to attend scheduled modalities and alternative treatments were not provided to meet their individual treatment goals. Failure to provide active treatment results in the patients being hospitalized without all interventions for recovery being provided and results in delayed improvement. (Refer to B125)

Based on interview and document review, the facility failed to have a qualified Director of Nursing (DON)

Findings include:

A. Record review

1. According to the DON's resume, she does not have a Master's degree in psychiatric or mental health nursing and holds an associate degree in nursing.

2. There was no documentation and the DON was not able to show evidence of qualifying education in the care of mentally ill patients.

B. Interview

In an interview with the DON on 9/15/2015 at 2:00 PM, she stated, "I do not have a Master's degree in nursing, working on my bachelors degree, and do not seek on-going consultation."

Based on medical record reviews, observations, and interviews, the Director of Nursing (DON) failed to ensure that:

I. The facility provided Master Treatment Plans that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sampled patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs. (Refer to B121)

II. The facility provided develop Master Treatment Plans that identified physician, nursing, and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. (Refer to B122)

III. The facility provided active individualized treatment for two (2) of eight (8) active sample patients (B1 and B2). Sample patients B1 and B2 frequently refused to attend scheduled modalities and alternative treatments were not provided to meet their individual treatment goals. The facility did not provide the needed structured treatment and alternative modalities for these patients. Failure to provide active treatment results in the patients being hospitalized without all interventions for recovery being provided and results in delayed improvement. (Refer to B125)