HospitalInspections.org

Based on record review and patient and staff interview, the Hospital failed to ensure the activity program was appropriate to the needs and interests of patients as evidenced by:
1) Failing to identify and provide individualized therapeutic activities directed toward restoring and maintaining optimal levels of functioning for 5 of 5 (#1-#5) sampled patients, and;
2) Failing to develop an individualized treatment plan related to therapeutic activities for 5 of 5 (#1-#5) sampled patients.

Findings:

Review of the Hospital's policy titled, PC-109: Activity Therapy, provided by S2DON as the only policy related to Therapeutic Activities revealed in part the following:
The objective of the Therapeutic Activity Program is to restore and maintain optimal levels of physical and psychosocial functioning based on the patient's needs and interests. Therapeutic Activity is focus upon the development and maintenance of adaptive skills that will improve the patient's functioning and provides the patient with individualized opportunities to acquire knowledge, skills and attitudes with the goal for crossover to post discharge environment.
Activity Groups will be structured groups provided by designated staff under the written plan and supervision of Activities Director. Activity assessments will be completed within 72 hours of admission. The assessment will be used to identify problems, set goals and implement specific treatment modalities in the patient's multidisciplinary treatment plan...

1) Failing to identify and provide individualized therapeutic activities directed toward restoring and maintaining optimal levels of functioning:

Patient #1
Review of the medical record for Patient #1 revealed the patient was an 84 year old admitted to the hospital on 10/24/16 with a diagnosis of Severe Recurrent Major Depressive Disorder with Psychotic Symptoms.

Review of the Activity Assessment dated 10/25/16 at 8:00 a.m. and documented by S4AT revealed the patient had current and past participation in painting/drawing, arts and crafts, reading, visiting, parties, gardening, sports, walking, exercising, movies, radio/music, bingo, cooking, and animals (cat). The assessment revealed the patient was alert and oriented and was independent in physical activity. The section titled, Barriers that effect leisure time was left blank. Further review of the assessment revealed Treatment Plan Adaptation needed was marked "No."

Review of the Treatment Plan dated 10/24/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show an increase in concentration and cognitive thought process in AT group within 7 days. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the Activity Therapy note provided by S4AT revealed only one group progress note had been documented on 10/27/16 at 11:30 a.m. Review of the note revealed the following: "Leisure activity using positive methods to increase focus and concentration. Response: Patient was alert and attentive. Patient. actively participated in leisure activity. Patient. was calm and content. Patient. had good eye contact." There was no documented evidence of the specific intervention or activity that was conducted and there was no documented evidence of the patient's progress toward the identified goal.

In an interview on 10/31/16 at 1:00 p.m. the patient was observed sitting in the group room watching TV. Patient #1 was asked if she had participated in activity therapy. The patient stated she had done a coloring sheet and pointed to one posted on the wall. When asked if she liked to color, she stated no, but she did it anyway. When asked if she participated in any other activities, Patient #1 confirmed she had participated in making the fall poster that was displayed on the wall, and she stated she had played bingo.

In an interview on 10/31/16 at 1:22 p.m. S4AT confirmed she had documented the above note and that was the only note she had done for this patient. She confirmed the specific activity conducted was not documented in the note.

In an interview on 10/31/16 at 3:45 p.m. S9SSD reviewed the activity therapy notes and confirmed there was no documentation of the type of activity used in the group. S9SSD confirmed the note did not reflect the patient's progress toward the goal to increase focus and concentration. S9SSD confirmed there was only 1 AT note documented by S4AT and stated S4ST was not here on Wednesday, and was here only a half a day on Tuesday, Thursday, and Friday. S9SSD indicated the MHTs conducted the activity groups on the days S4AT was not at the hospital.


Patient #2
Review of the medical record for Patient #2 revealed the patient was a 75 year old admitted to the hospital on 10/07/16 with a diagnosis of Paranoid Schizophrenia under a PEC for gravely disabled and unable to seek voluntary admission.

Review of the Activity Assessment dated 10/07/16 at 8:00 a.m. and documented by S4AT revealed the patient had current and past participation in reading, visiting, parties, sports, walking, exercising, movies, and radio/music. The assessment revealed the patient was alert and oriented and was independent in physical activity. The section titled, Barriers that effect leisure time was left blank. Further review of the assessment revealed Treatment Plan Adaptation needed was marked "No."

Review of the Treatment Plans dated 10/07/16, 10/12/16, 10/29/16, and 10/31/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process within 7 days in AT group. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes 1 time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT revealed the notes dated 10/07/16 through 10/27/16 revealed the interventions were documented as Leisure activity using relaxation methods, or tactile methods, or positive methods to decrease stress and anxiety or to increase focus and concentration. There was no documented evidence of the specific activity that was conducted with the patient. Review of the same activity notes revealed the patient's response was documented as Patient was alert and attentive. Patient actively participated in leisure activity. Patient had good eye contact. Patient was calm and content. There was no documented evidence on any of the notes of the patient's progress toward the identified goal.

In an interview on 10/31/16 at 3:45 p.m. S9SSD reviewed the activity therapy notes and confirmed there was no documentation of the activity used in the group and the activity therapy notes documented the same interventions (not specific) for every group and the same as for Patient #1. S9SSD confirmed the notes did not indicate the patient's progress toward the identified goal, other than the patient participated.

In an interview on 11/01/16 at 12:50 p.m., Patient #2 confirmed he participated in the activity group this morning with exercises. He stated he liked to do exercises, but this was the first time they provided exercises since he has been here (10/07/16). Stated he did color a pumpkin sheet and it was on the wall in the group room. Patient #2 stated they have groups and ask questions. Patient #2 stated he answers the best he can with what he knows.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 10/25/16 with a diagnosis of Bipolar Disorder with Psychosis.

Review of the Activity Assessment dated 10/27/16 and documented by S4AT revealed the patient had current and past participation in reading, visiting, parties, sports, walking, exercising, movies, radio/music, TV, Bingo, table games, and cooking. The assessment revealed the patient was alert and oriented and was independent in physical activity. The section titled, Barriers that effect leisure time was left blank. Further review of the assessment revealed Treatment Plan Adaptation needed was marked "No."

Review of the Treatment Plan dated 10/25/16 and 10/31/16 revealed the only goals/interventions related to activity therapy were under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process in AT group within 7 days (same as Patient #2). The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT dated 10/27/16 and 10/31/16 revealed the following intervention: Leisure activity using positive methods to increase focus and concentration. There was no documented evidence of the specific activity that was conducted with the patient. Review of the patient response dated 10/27/16 documented the following: Patient was alert and attentive. Patient actively participated in leisure activity. Patient was calm and content. Patient had good eye contact. The patient response documented on the note dated 10/31/16 revealed the following: Patient was alert and attentive. Patient actively participated in leisure activity. Patient was calm and content. Patient had good eye contact. Patient had good insight of the topic. Patient was talkative. Patient was appreciative to staff. Patient had good communication with peers and staff. There was no documented evidence on any of the notes of the patient's progress toward the identified goal.

In an interview on 11/01/16 at 1:15 p.m., S2DON confirmed the activity notes did not have the specific activity that was conducted documented on the notes and the notes contained the same interventions. S2DON confirmed the treatment plans and the activity notes contained the same interventions and patient response for activity therapy. She confirmed the activity therapy was not individualized.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 51 year old admitted on 10/18/16 with a diagnosis of Schizoaffective Disorder.
Review of the treatment plan, activity assessment and the activity notes revealed they were the same as Patients #1, #2, and #3. There was no documented evidence of an individualized activity assessment, activity notes with specific interventions and patient progress toward goals, or individualized treatment plan for activity therapy.


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old admitted to the hospital on 10/10/16 with a diagnosis of Major Depression, Severe Recurrent with Psychosis.

Review of the treatment plan, activity assessment and the activity notes revealed they were the same as Patients #1, #2, #3, and #4. There was no documented evidence of an individualized activity assessment, activity notes with specific interventions and patient progress toward goals, or individualized treatment plan for activity therapy.

In an interview on 11/01/16 at 1:15 p.m., S2DON reviewed the above sampled patient records and confirmed the activity assessments, activity notes and treatment plans were the same as other sampled patients and not individualized to meet each patient's needs.


2) Failing to develop an individualized treatment plan related to therapeutic activities:


Patient #1
Review of the medical record for Patient #1 revealed the patient was an 84 year old admitted to the hospital on 10/24/16 with a diagnosis of Severe Recurrent Major Depressive Disorder with Psychotic Symptoms.

Review of the Treatment Plan dated 10/24/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show an increase in concentration and cognitive thought process in AT group within 7 days. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 75 year old admitted to the hospital on 10/07/16 with a diagnosis of Paranoid Schizophrenia under a PEC for gravely disabled and unable to seek voluntary admission.

Review of the Treatment Plans dated 10/07/16, 10/12/16, 10/29/16, and 10/31/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process within 7 days in AT group. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes 1 time daily for 7-10 days."

In an interview on 10/31/16 at 3:45 p.m. S9SSD reviewed the treatment plans for Patients #1 and #2 and confirmed the treatment plan objectives and interventions related to activity therapy was the same for both patients and the patients did not have the same diagnosis. S9SSD confirmed the treatment plans were not individualized for each patient.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 10/25/16 with a diagnosis of Bipolar Disorder with Psychosis.

Review of the Treatment Plan dated 10/25/16 and 10/31/16 revealed the only goals/interventions related to activity therapy were under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process in AT group within 7 days (same as Patient #2). The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 51 year old admitted on 10/18/16 with a diagnosis of Schizoaffective Disorder.
Review of the treatment plan revealed the objectives and interventions for activity therapy were the same as Patients #1, #2, and #3. There was no documented evidence of an individualized treatment plan for activity therapy.


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old admitted to the hospital on 10/10/16 with a diagnosis of Major Depression, Severe Recurrent with Psychosis.

Review of the treatment plan revealed the objectives and interventions for activity therapy were the same as Patients #1, #2, #3, and #4. There was no documented evidence of an individualized treatment plan for activity therapy.

In an interview on 11/01/16 at 1:15 p.m., S2DON reviewed the above sampled patient records and confirmed the objectives and interventions on the treatment plans were the same for Patients #1, #2, #3, #4, and #5, and the treatment plans were not individualized to meet each patient's needs.

In an interview on 11/01/16 at 2:50 p.m., S1ADM stated he had reviewed the treatment plans for the above sampled patients and agreed the treatment plans were not individualized for activity therapy goals and interventions.

Based on record review and staff interview, the Hospital failed to ensure comprehensive therapeutic activities consistent with each patient's treatment plan were provided by qualified therapists as evidenced by:
1) Failing to provide therapeutic activities in accordance with patient's treatment plan for 5 of 5 (#1-#5) sampled patients;
2) Failing to ensure a qualified activity therapist provided therapeutic activities as evidenced by MHTs and LPNs providing activity therapy for 5 of 5 (#1-#5) sampled patients;
3) Failing to ensure current activity schedules were clearly posted for patient and staff use.
Findings:

Review of the Hospital's policy titled, PC-109: Activity Therapy, provided by S2DON as the only policy related to Therapeutic Activities revealed in part the following:
The objective of the Therapeutic Activity Program is to restore and maintain optimal levels of physical and psychosocial functioning based on the patient's needs and interests. Therapeutic Activity is focus upon the development and maintenance of adaptive skills that will improve the patient's functioning and provides the patient with individualized opportunities to acquire knowledge, skills and attitudes with the goal for crossover to post discharge environment.
Activity Groups will be structured groups provided by designated staff under the written plan and supervision of Activities Director. Activity assessments will be completed within 72 hours of admission. The assessment will be used to identify problems, set goals and implement specific treatment modalities in the patient's multidisciplinary treatment plan....


1) Failing to provide therapeutic activities in accordance with patient's treatment plan:

Patient #1
Review of the medical record for Patient #1 revealed the patient was an 84 year old admitted to the hospital on 10/24/16 with a diagnosis of Severe Recurrent Major Depressive Disorder with Psychotic Symptoms.

Review of the Treatment Plan dated 10/24/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show an increase in concentration and cognitive thought process in AT group within 7 days. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the Activity Therapy note provided by S4AT revealed only one group progress note had been documented on 10/27/16 at 11:30 a.m. Review of the note revealed the following: "Leisure activity using positive methods to increase focus and concentration. Response: Patient was alert and attentive. Patient actively participated in leisure activity. Patient was calm and content. Patient had good eye contact."

In an interview on 10/31/16 at 1:22 p.m., S4AT confirmed the above note was the only note she had documented on Patient #1.

In an interview on 10/31/16 at 3:45 p.m., S3SSD reviewed the activity therapist notes and confirmed there was only one AT note documented by S4AT. S3SSD confirmed the activity therapy had not been provided daily as indicated in the treatment plan.




Patient #2
Review of the medical record for Patient #2 revealed the patient was a 75 year old admitted to the hospital on 10/07/16 with a diagnosis of Paranoid Schizophrenia under a PEC for gravely disabled and unable to seek voluntary admission.

Review of the Treatment Plans dated 10/07/16, 10/12/16, 10/29/16, and 10/31/16 revealed the only goals/interventions related to activity therapy was under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process within 7 days in AT group. The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes 1 time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT revealed the S4AT documented an activity therapy note for the following dates:
10/11/16 (Monday), 10/14/16 (Friday), 10/18/16 (Tuesday), 10/21/16 (Friday), 10/24/16 (Monday), 10/25/16 (Tuesday), and 10/27/16 (Thursday).
There was no documented evidence of any activity therapy notes for 10/10/16 (Monday), 10/12/16 (Wednesday), 10/13/16 (Thursday), 10/17/16 (Monday), 10/19/16 (Wednesday), 10/20/16 (Thursday), 10/26/16 (Wednesday), 10/28/16 (Friday).

In an interview on 10/31/16 at 3:45 p.m. S3SSD reviewed the medical record for Patient #2 and confirmed there was no documentation of AT notes for all the days S4AT was scheduled to work. She confirmed the Activity Therapist was not here every day and stated the only day she is here all day is Monday. S3SSD confirmed she is not here on Wednesday and is here only half a day on Tuesday, Thursday, and Friday. S3SSD confirmed the activity therapy had not been provided daily as indicated in the treatment plan.


In an interview on 10/31/16 at 3:45 p.m. S3SSD reviewed the activity therapy notes and confirmed there was no documentation of the activity used in the group and the activity therapy notes documented the same interventions (not specific) for every group and the same as for Patient #1. S3SSD confirmed the notes did not indicate the patient's progress toward the identified goal, other than the patient participated.




Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 10/25/16 with a diagnosis of Bipolar Disorder with Psychosis.

Review of the Treatment Plan dated 10/25/16 and 10/31/16 revealed the only goals/interventions related to activity therapy were under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process in AT group within 7 days (same as Patient #2). The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided was on 10/27/16 (Thursday), and 10/31/16 (Monday).
There was no documented evidence of an activity therapy on 10/28/16 (Friday), 10/29/16 (Saturday), or 10/30/16 (Sunday).

In an interview on 11/01/16 at 1:15 p.m., S2DON stated S4AT had missed some days lately due to a family illness. She confirmed the Activity Therapist was not here every day all day and stated they needed a full time AT. S2DON confirmed activity therapy had not been provided daily as directed in the treatment plan.



Patient #4
Review of the medical record for Patient #4 revealed the patient was a 51 year old admitted on 10/18/16 with a diagnosis of Schizoaffective Disorder.

Review of the Treatment Plan dated 10/25/16 and 10/31/16 revealed the only goals/interventions related to activity therapy were under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process in AT group within 7 days (same as Patient #2). The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided was on 10/21/16 (Friday), 10/24/16 (Monday), 10/25/16 (Tuesday), 10/27/16 (Thursday), and 10/31/16 (Monday).
There was no documented evidence of activity therapy on 10/22/16 (Saturday), 10/23/16 (Sunday), 10/26/16 (Wednesday), 10/28/16 (Friday), and 10/29/16 (Saturday), and 10/30/16 (Sunday) as directed in the treatment plan.

Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old admitted to the hospital on 10/10/16 with a diagnosis of Major Depression, Severe Recurrent with Psychosis.

Review of the Treatment Plan dated 10/13/16, 10/17/16, and 10/24/16 revealed the only goals/interventions related to activity therapy were under the problem, "Altered Thoughts." The objective (goal) was as follows: Patient will show decrease in irritability and an increase in cognitive thought process in AT group within 7 days (same as Patient #2). The only intervention related to activity therapy was as follows: "5. AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days."

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided was on 10/11/16 (Tuesday), 10/14/16 (Friday), 10/18/16 (Tuesday), 10/21/16 (Friday), 10/25/16 (Tuesday).
There was no documented evidence of activity therapy by S4AT on 10/12/16 (Wednesday), 10/13/16 (Thursday), 10/15/16 (Saturday), 10/16/16 (Sunday), 10/17/16 (Monday), 10/19/16 (Wednesday), 10/20/16 (Thursday), 10/22/16 (Saturday), 10/23/16 (Sunday), 10/24/16 (Monday), 10/26/16 (Wednesday), 10/27/16 (Thursday), 10/28/16 (Friday), 10/29/16 (Saturday), or 10/30/16 (Sunday).

In an interview on 11/01/16 at 1:15 p.m., S2DON reviewed the medical records for Patient #4 and #5 and confirmed the activity therapy was not provided daily as directed in the treatment plan. S2DON confirmed the AT was only onsite all day on Mondays, half a day on Tuesday, Thursday, and Friday. S2DON stated S4AT was not onsite at all on Wednesdays.



2) Failing to ensure a qualified activity therapist provided therapeutic activities as evidenced by MHTs and LPNs providing activity therapy:

Patient #1
Review of the medical record for Patient #1 revealed the patient was an 84 year old admitted to the hospital on 10/24/16 with a diagnosis of Severe Recurrent Major Depressive Disorder with Psychotic Symptoms.

Review of the Treatment Plan dated 10/24/16 revealed the AT would provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days.

Review of the Group Notes documented by the MHTs for Patient #1 revealed the MHTs had documented "Activity Group" on the following dates:
10/26/16: 10:15 a.m.-11:00 a.m.: Activity to help memory. Participated with reminders.
10/28/16 10:15 a.m.-11:00 a.m.: Activity for socialization. Participated with help.

Review of the Group Progress Notes documented by the RNs and LPNs revealed the following:
10/29/16 at 9:15 a.m. - Music Therapy to decrease depression and improve mood.
10/29/16 at 10:00 a.m. - Structured activity to promote interaction.
10/29/16 at 6:45 p.m. - Leisure activity using relaxation methods to decrease stress and anxiety.
10/30/16 at 9:15 a.m. - Patient instructed on group activities to increase social interaction with peers.


Review of the Activity Therapy note provided by S4AT revealed only one group progress note had been documented by the Activity Therapist on 10/27/16 at 11:30 a.m.

In an interview on 10/31/16 at 12:10 p.m., S4AT stated she was the current Activity Director and had been employed at this Hospital for 2 years. She stated she also worked at another hospital. S4AT stated her work schedule was as follows: Monday-8:00 a.m.-4:30 p.m., Tuesday, Thursday, and Friday-8:00 a.m.-12:00 p.m., Wednesday-works at another hospital all day. S4AT stated she does not work on Saturday or Sunday. S4AT stated the days she was not here the MHTs do the activity therapy. She stated the MHTs do the Activity Therapy on the weekends also. S4AT stated she also does discharge planning for this hospital.

In an interview on 10/31/16 at 3:45 p.m. S3SSD, confirmed there was only 1 Activity Therapy note documented by S4AT on 10/27/16. S3SSD confirmed the MHTs conduct activity therapy groups and stated that is the only group they can do. She confirmed the Activity Therapist did not work at this hospital every day and stated the only day S4AT was onsite all day was Monday. S3SSD confirmed S4AT was not here on Wednesday and only worked half a day on Tuesday, Thursday, and Friday. When asked if the MHTs have training in conducting the activity groups, she stated no. She stated, "They learn from watching us."

In a telephone interview on 11/01/16 at 12:11 p.m. S14CTRS (contracted with the hospital to provide education and training for the Activity Therapist) stated MHTs cannot be doing or documenting any activity therapy. She stated MHTs can provide divisional activity only.



Patient #2
Review of the medical record for Patient #2 revealed the patient was a 75 year old admitted to the hospital on 10/07/16 with a diagnosis of Paranoid Schizophrenia under a PEC for gravely disabled and unable to seek voluntary admission.

Review of the Treatment Plans dated 10/07/16, 10/12/16, 10/29/16, and 10/31/16 revealed the AT would provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days.

Review of the Group Notes documented by the MHTs for Patient #2 revealed the MHTs had documented "Activity Group" on the following dates:
10/12/16 10:15 a.m.-11:00 a.m.: Activity Reminiscing. Participated without prompting.
10/19/16 10:15 a.m.-11:00 a.m.: Activity to Reflect on History. Participated with reminders.
10/26/16 10:15 a.m.-11:00 a.m.: Activity to help memory. Participated without reminders.
10/28/16 10:15 a.m.-11:00 a.m.: Activity for socialization. Participated without help.

Review of the Group Progress Notes documented by the RNs and LPNs revealed the following:
10/08/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/09/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/15/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/16/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/22/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/23/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/29/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/30/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.

Review of the activity therapy notes documented by S4AT revealed the S4AT documented an activity therapy note for the following dates only: 10/11/16 (Monday), 10/14/16 (Friday), 10/18/16 (Tuesday), 10/21/16 (Friday), 10/24/16 (Monday), 10/25/16 (Tuesday), and 10/27/16 (Thursday).

In an interview on 11/01/16 at 1:15 p.m. S2DON stated she had instructed the MHTs to document the activities they are doing with the patients. After reviewing the MHT notes she confirmed the MHT had documented the activities as Activity Group. She stated the LPNs were doing the groups on weekends and not the MHTs. S2DON confirmed the Activity Therapist was not here every day all day and stated they needed a full time AT. After reviewing the documentation of activities by the LPNs on weekends for the sampled patients, she confirmed there was no specific activity documented, only " structured activities. " S2DON confirmed the nursing staff was not qualified or trained to conduct therapeutic activities.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 10/25/16 with a diagnosis of Bipolar Disorder with Psychosis.

Review of the Group Notes documented by the MHTs for Patient #3 revealed the MHTs had documented "Activity Group" on the following dates:
10/26/16 at 10:15 a.m.-11:00 a.m.: Activity to help memory. Participated with help.
10/28/16 at 10:15 a.m.-11:00 a.m.: Activity for socialization. Participated without reminders.

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided was on 10/27/16 (Thursday), and 10/31/16 (Monday).

In an interview on 11/01/16 at 1:15 p.m. S2DON stated she had instructed the MHTs to document the activities they are doing with the patients. After reviewing the MHT notes she confirmed the MHT had documented the activities as Activity Group.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 51 year old admitted on 10/18/16 with a diagnosis of Schizoaffective Disorder.

Review of the Treatment Plan dated 10/25/16 and 10/31/16 revealed the AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days.

Review of the Group Notes documented by the MHTs for Patient #4 revealed the MHTs had documented "Activity Group" on the following dates:
10/22/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/23/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/29/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/30/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided by S4AT was on 10/21/16 (Friday), 10/24/16 (Monday), 10/25/16 (Tuesday), 10/27/16 (Thursday), and 10/31/16 (Monday).

In an interview on 11/01/16 at 1:15 p.m. S2DON confirmed the MHTs and LPNs had documented activity therapy groups as above.


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old admitted to the hospital on 10/10/16 with a diagnosis of Major Depression, Severe Recurrent with Psychosis.

Review of the Treatment Plan dated 10/13/16, 10/17/16, and 10/24/16 revealed the AT will provide cognitive skills group to increase attention and concentration 45 minutes one time daily for 7-10 days.

Review of the Group Notes documented by the MHTs for Patient #5 revealed the MHTs had documented "Activity Group" on the following dates:
10/12/16 at 10:15 a.m.-11:00 a.m.: Activity-Reminiscing. Participated without reminders.
10/17/16 at 10:15 a.m.-11:00 a.m.: Activity for relaxation. Participated with reminders.
10/19/16 at 10:15 a.m.-11:00 a.m.: Activity to reflect on history. Participated with few reminders.
10/26/16 at 10:15 a.m.-11:00 a.m.: Activity to help memory. Did not participate.
10/28/16 at 10:15 a.m.-11:00 a.m.: Activity for socialization. Participated without reminders.

Review of the Group Progress Notes documented by the LPNs revealed the following:
10/15/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/16/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/22/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/23/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/29/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.
10/30/16 at 10:00 a.m. - Structured activity to promote interaction. Participated appropriately with minimal prompting.

Review of the activity therapy notes documented by S4AT revealed the only activity therapy provided by S4AT was on 10/11/16 (Tuesday), 10/14/16 (Friday), 10/18/16 (Tuesday), 10/21/16 (Friday), 10/25/16 (Tuesday).

In an interview on 11/01/16 at 1:15 p.m. S2DON confirmed the MHTs and LPNs had documented activity therapy groups as above. S2DON confirmed the MHTs and LPNs were not qualified to provide therapeutic activity groups.


3) Failing to ensure current activity schedules were clearly posted for patient and staff use:
In an interview on 10/31/16 at 12:10 p.m., S4AT stated she was the current Activity Director and she had been employed for 2 years. S4AT provided a desk pad calendar indicating what therapeutic activity therapy was provided on each day. Review of the calendar revealed after July, 2016, nothing was documented on the calendar daily. S4AT stated a couple of months ago they started putting all the activities on the chalk board in the group room. She confirmed there was no calendar to provide that indicated the activities provided since July as the chalk board is erased at the end of the month and a new one put up.

On 10/31/16 at 1:25 p.m., an observation of the Activity Calendar in the group room revealed the monthly calendar was dated from 09/29/16 to 10/31/16. The board was observed to be a dry erase board. Observation of the board revealed there was no documented evidence of any activities on these dates: 10/01/16, 10/02/16, 10/04/16, 10/07/16, 10/08/16, 10/09/16, 10/10/16, 10/11/16, and 10/27/16-10/31/16. Observation of the board revealed the following activities were included: Sponge painting, celebrate September birthdays, listen to country music, creative art community group (every Wednesday), movie with popcorn, exercise with music, thank you cards, bingo, ice cream floats, coloring sheets, word search, and decorate book marks and picture frames.

On 11/01/16 at 9:20 a.m. an observation of the calendar of activity in the group room revealed every day now had an activity listed. The calendar revealed every Wednesday had Creative Art - Community group as the activity. Other activities listed on the board included the same activities as for October.

In an interview on 11/01/16 at 1:15 p.m., S2DON stated the schedule of activities on the board in the group room were suggestions for the MHTs and not the structured activity group done by the activity therapist. She stated many of the activities listed on the board are not really therapeutic activities but fun activities. She stated she implemented the board a few months ago to give the MHTs ideas of activities to do with patients. S2DON confirmed they were divisional activities and not therapeutic. She stated the board in the group room " Is not her schedule (S4AT). Her schedule is on the desk pad. " S2DON confirmed there was no schedule posted for the therapeutic activities that were to be provided for the patients by the Activity Therapist.