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Based on record review and interviews with hospital staff, the hospital failed to respond to grievances in writing. This occurred in five of five ( # 5, 16, 17, 18 and 19) grievances reviewed.

Findings:

This deficiency was cited during the last recertification survey by the Oklahoma State Department of health (OSDH) on 03/04/2008.

Review of a hospital policy titled, "CONSUMER GRIEVANCES", revised 07/2015, documented, "...After discussing the consumer's concern, the appropriate staff will document all actions taken to resolve the grievance and the form is signed and dated by the consumer and staff member. A copy of the signed forms is given to the consumer..."

Surveyors requested and reviewed hospital grievances on 11/03/2015.

Five of five (# 5, 16, 17, 18 and 19) grievances did not contain evidence written notification was provided to the consumer.

The grievances reviewed did not contain the signature of the consumer in the resolution.

In the morning of 11/03/2015, the grievance coordinator stated no post-resolution signature is obtained from the consumer.

Based on review of hospital documents and interviews with staff, the hospital failed to have a comprehensive and effective quality assessment and performance improvement (QAPI) program to improve health outcomes and involve all hospital departments.

Findings:

1. Surveyors requested and reviewed the hospital's current QAPI Plan and QAPI committee meeting minutes from November 2014 to present.

2. The hospital had chosen four patient improvement initiatives for the current year; improvement of patient satisfaction, improving compliance with restraint and seclusion standards, medication error reduction and improving timeliness of documentation.

3. The QAPI meeting minutes did not contain evidence of data collection with an analysis of the data collected for the chosen initiatives.

4. The QAPI meeting minutes did not contain documentation of an evaluation of the following areas through the QAPI program:

~Contracted services;
~Tracking of medication errors, adverse drug reactions and drug related incompatibilities;
~Patients readmitted within 30 days (See Tag A-843 for further details); and
~Tracking of avoidable healthcare-acquired infections (HAI's) and problems identified by the infection control practitioner (ICP).

5. On the afternoon of 11/04/2015, the QAPI manager stated medication errors and infection control data was not reported to QAPI.

Based on medical record review and interviews with hospital staff, the hospital did not ensure entries in the medical record contain the date and time when they were signed or authenticated in electronic and written form by the person responsible for the services provided. This occurred in thirteen (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) of thirteen medical records reviewed.

Findings:

Surveyors reviewed medical records on the morning of 11/04/2015.

Medical records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 did not contain the time the history and physical was signed.

Medical records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 did not contain the date and time the discharge summary was signed.

During the exit interview on the afternoon of 11/04/2015, Staff C stated she had noticed the line for date and time was missing from the new discharge summary forms.

Based on review of hospital documents and staff interviews the hospital did not maintain a sanitary environment and an active infection control program.

Findings:

Jim Taliaferro is a 14-bed inpatient psychiatric hospital. The hospital had a large number of newly diagnosed and medical history of Hepatitis C and Human Immunodeficiency Virus (HIV) patients.

1. Surveyors conducted a tour of the hospital on 11/02/2015 between 11:50 a.m. and 1:20 p.m.

~During the tour hospital staff was also interviewed.

~The hospital used OneTouch UltraMini blood glucose monitoring system (glucometer). Review of the user guide documented, "...DO NOT use alcohol or another solvent to clean your meter..."

~Staff F stated alcohol was used to clean the glucometer in-between patients.

~In regards to Infection Control of linens CMS recommends, "...Hot water washing at temperatures greater than 160 degrees F for 25 minutes and low temperature washing at 71 to 77 degrees F (22-25 degrees C) with a 125-part-per-million (ppm) chlorine bleach rinse remain effective ways to process laundry..."

~Staff E stated linens and the maroon medical scrubs worn by the patients were laundered on-site. Staff E stated the scrubs were washed in cold water and laundry detergent. Staff E also stated no chlorine bleach was used to launder the scrubs.

~Staff E stated he did not know the water temperatures for the hot and cold settings.

2. Surveyors reviewed the training and education file for the person identified as the infection control practitioner (ICP) on 11/03/2015. The file did not contain evidence of infection control (IC) training, education or certification in infection control.

3. Nine of (B, G, J, L, M, N, P, Q and R) twelve employee health files reviewed did not contain the Centers for Disease Control and Prevention (CDC) recommended vaccines for healthcare workers.

~On the morning of 11/04/2015, the ICP stated she was aware the employee health files did not contain the recommended vaccines.

4. Surveyors requested and reviewed the IC committee meeting minutes from October 2014 to present. The meeting minutes did not contain an analysis of the data collected.

~Meeting minutes did not demonstrate infection control problems were identified and analyzed, corrective action initiated and follow-up provided to ensure the corrective actions were effective and maintained.

~There was no documentation that all chemicals and disinfectants used at the hospital had been reviewed and approved by the ICP or the IC.

~ There was no documentation of any surveillance/monitoring to ensure the infection control policies and procedures were followed.

5. The ICP stated she had not conducted a hospital-wide or Tuberculosis (TB) risk assessment.

6. On the afternoon of 11/04/2015, the hospital quality assessment and performance improvement (QAPI) manager stated problems/issues identified in the IC committee were not addressed in the hospital's QAPI program.

Based on review of hospital documents and medical records and staff interviews, the hospital failed to ensure written discharge instructions, including medications were provided in non-technical language for 11 of 19 (Records #1, 2, 5, 8, 9, 10, 12, 20, 21, 22, and 23) medical records of discharged patient reviewed.

Findings:

The hospital discharge policy recorded duty assigned to both the physician and the nurse as, "...On the day of discharge, gives client discharge instructions for medications (if ordered) and return appointments..."

The eleven medical records listed above contained symbols, such as Q (every), @ (at), HS (hour of sleep/bedtime), in the discharge instructions that a layman might not understand/know.

On 11/04/2015 at 11.00, Staff A stated staff would give a copy of the medical record discharge instructions with no additions.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to review the discharge planning for patients readmitted within 30 days to analyze whether the discharge plans met the patients needs.

Findings:

1. On 11/04/2015, the surveyor requested a list and any documentation of review the hospital had on patients readmitted within a 30-day period for the last 60 days.

~Hospital staff provided a list of three (3) patients that were readmitted to the hospital for the criteria requested.
~The list provided was not accurate. From the total list of discharges provided, the surveyor found two additional names that had been readmitted within a 30-day period.

2. No additional information was provided to the surveyors, including tracking of the reason for readmission.

3. Review of quality (QAPI) meeting minutes did not show the patient readmissions were analyzed to determine if:
a. The discharge plans met the patients needs after discharge;
b. Preventable readmissions could be identified; and/or
c. The discharge planning process needed to modified/changed.

3. On 11/05/2015, Staff D stated analysis of readmissions were not included in QAPI.

Based on medical record reviews, observations, and interviews:

I. 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. (Refer to B121)

II. 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. (Refer to B122)

III. The facility failed to provide active individualized treatment for three (3) of eight (8) active sample patients (A3, A4, and B4). Sample patients A3, A4, and B4 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. In addition, the groups that were provided were non-therapeutic groups consisting of recreational or leisure activities such as playing pool, video games, drawing, arts and craft. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (Refer to B125)

IV. The facility failed to ensure that the discharge summaries for one (1) of six (6) discharged patients (D1) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology, risk was not available to the aftercare providers and potential harm to the patient. (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 10/28/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Mood Disorder NOS, Anxiety Disorder NOS, Psychotic Disorder NOS., and PTSD." The Master treatment Plan dated 10/29/15 identified Short Term Goal (STG) for problems:

"Depression with suicidal ideations" as: "A1 will develop the ability to recognize, accept, and cope with the feelings of depression."

"Anxiety as: A1 will reduce overall level, frequency, and intensity of the anxiety so that daily functioning is not impaired within 7 days."

"Psychosis as: A1 will control or eliminate active psychotic symptoms such that supervise functioning is positive and medication is taken consistently within 7 days."

2. Patient A2 was admitted to the facility on 10/17/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Psychotic Disorder NOS" The Master treatment Plan dated 10/20/2015 identified Short Term Goal (STG) for problems:

"Psychosis as: A2 will control or eliminate active psychotic symptoms such that supervise functioning is positive and medication is taken consistently."

3. Patient A3 was admitted to the facility on 10/13/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Schizoaffective disorder-Bipolar Type" The Master treatment Plan dated 10/15/2015 identified Short Term Goal (STG) for problems:

"Psychosis as: A3 will control or eliminate active psychotic symptoms such that supervise functioning is positive and medication is taken consistently."

4. Patient A4 was admitted to the facility on 10/28/2015. The Master Treatment Plan identified psychiatric diagnoses as: " Major Depressive Disorder-Recurrent with Psychotic Feature, Bereavement, Anxiety Disorder NOS " The Master treatment Plan dated 10/31/2015 identified Short Term Goal (STG) for problems:

"Depression" as: "A4 will develop the ability to recognize, accept, and cope with the feelings of depression."

5. Patient B1 was admitted to the facility on 10/21/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Major Depressive Disorder-Recurrent with Psychotic Feature, Alcohol Use Disorder-Moderate, Anxiety Disorder NOS" The Master treatment Plan dated 10/30/2015 identified Short Term Goal (STG) for problems:

"Depression" as: "B1 will develop the ability to recognize, accept, and cope with the feelings of depression."

"Anxiety as: B1 will reduce overall level, frequency, and intensity of the anxiety so that daily functioning is not impaired within 7 days."

6. Patient B2 was admitted to the facility on 10/22/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Mood Disorder NOS, Alcohol Use Disorder-Severe, Stimulant Use Disorder-Mild, Anxiety Disorder NOS." The Master treatment Plan dated 10/25/2015 identified Short Term Goal (STG) for problems:

"Depression" as: "B2 will develop the ability to recognize, accept, and cope with the feelings of depression."

"Anxiety as: B2 will reduce overall level, frequency, and intensity of the anxiety so that daily functioning is not impaired."

7. Patient B3 was admitted to the facility on 10/24/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Major Depressive Disorder, severe with psychosis, Anxiety Disorder d/o NOS, Opioid Dependence." The Master treatment Plan dated 10/27/2015 identified Short Term Goal (STG) for problems:

"Depression with suicidal ideations" as: "B3 will develop the ability to recognize, accept, and cope with the feelings of depression."

"Anxiety as: B3 will reduce overall level, frequency, and intensity of the anxiety so that daily functioning is not impaired."

8. Patient B4 was admitted to the facility on 10/27/2015. The Master Treatment Plan identified psychiatric diagnoses as: "Psychotic Disorder NOS, H/O Alcohol Dependence, Mood Disorder NOS, Dementia Disorder, NOS" The Master treatment Plan dated 10/28/15 identified Short Term Goal (STG) for problems:

"Psychosis as: B4 will control or eliminate active psychotic symptoms such that supervise functioning is positive and medication is taken consistently."

B. Interviews:

1. In an interview on 11/3/15 at 11: 40 a.m., the lack of individualized and measurable short-term treatment goal was discussed with the Director of Nursing (DON). He acknowledged that the short term goals were identical on the treatment plan for each patient with similar problems of depression, anxiety, suicide and psychosis. He stated "they are not particularly individualized, what you are saying make sense."

2. In an interview on 11/3 15 at 12:00 with the Medical Director regarding the lack of individualized and measurable short-term goals was discussed. He acknowledged that the goals were the same for patients with depression, anxiety, suicide, and psychosis. He further stated they were "routine and not individualized."

3. In an interview on 11/2/2015 at 3:00 p.m. with the Social Work Director regarding the lack of individualized and measurable short-term goals not being individualized and measurable. She acknowledges the treatment plans are created using a standard template for all patient.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included individualized interventions to address specific treatment needs for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, B1, B2, B3, and B4). Listed interventions were routine, generic discipline functions rather than individualized interventions. These deficiencies result in lack of guidance to staff in providing individualized, coordinated treatment in the least restrictive environment, and can result in prolonged hospitalizations for patients.

Findings include:

A. Record Review
Review of the sample patients' Master Treatment Plans (MTPs) revealed that the plans included lists of routine generic discipline functions inappropriately listed as individualized interventions for (8) out of eight (8) sample patients. The facility failed to develop treatment plans that identified clearly delineated interventions to address specific patient problems. Instead, interventions on plans included the following:

1. Patient A1-MTP dated 10/29/2015

For the problem Depression with suicidal ideations:

a. The physician interventions state: "Evaluate for depression, sleep, appetite, and suicidal thoughts 1-2 times a week for 15-30 mins, Referral to AT/RT (activity therapy/recreation therapy), Ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will encourage A1 to attend groups and activities daily to enhance positive coping skills in dealing with depressive thoughts, SW will educate A1 1 time weekly about the importance of following up with outpatient services to continue to enhance positive coping skills."

c. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

a. The physician interventions state: "Evaluate for anxiety, panic, attacks, and triggers for anxiety 1-2 times a week for 15-30 minutes, Referral to AT/RT (activity therapy/recreation therapy), Deep breathing and relaxation."

b. The social work (SW) interventions state: "SW will encourage A1 to attend groups and activities daily to recognize triggers which cause anxiety, SW will educate A1 one time weekly the importance of following-up with OP (outpatient) services to continue improvements in dealing with anxiety."

c. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement. If anxiety is present: reduce external stimuli as needed each shift. If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

For Problem Psychosis:

a. The physician interventions state: "Evaluate for psychosis and bizarre delusions 1-2 times a week for 15-30 minutes, reality focused thought content, referral to AT/RT (activity therapy/recreation therapy), ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will work with A1 1-2 times weekly to develop discharge planning and refer to OP (outpatient) services for follow up care, SW will encourage A1 to take psychotropic medications in dealing with psychosis."

c. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."


2. Patient A2-MTP dated 10/20/2015

For the problem Psychosis:

a. The physician interventions state: "Evaluate for psychosis and bizarre delusions 1-2 times a week for 15-30 minutes, reality focused thought content, referral to AT/RT (activity therapy/recreation therapy), ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will work with A2 1-2 times weekly to develop discharge planning and refer to OP (outpatient) services for follow up care, SW will encourage A2 to take psychotropic medications in dealing with psychosis."

c. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

3. Patient A3-MTP dated 10/15/2015

For the problem Psychosis:

a. The physician interventions state: "Evaluate for psychosis and bizarre delusions 1-2 times a week for 15-30 minutes, reality focused thought content, referral to AT/RT (activity therapy/recreation therapy), ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will work with A3 1-2 times weekly to develop discharge planning and refer to OP (outpatient) services for follow up care, SW will encourage A3 to take psychotropic medications in dealing with psychosis."

c. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

4. Patient A4-MTP dated 10/31/2015

For the problem Depression:

a. The physician interventions state: "Evaluate for depression, sleep, appetite, and suicidal thoughts 1-2 times a week for 15-30 mins. Referral to AT/RT (activity therapy/recreation therapy). Ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will encourage A4 to attend groups and activities daily to enhance positive coping skills in dealing with depressive thoughts, SW will educate A4 1 time weekly about the importance of following up with outpatient services to continue to enhance positive coping skills."

c. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."


5. Patient B1-MTP dated 10/30/2015

For problem Depression:

a. The physician interventions state: "Evaluate for depression, sleep, appetite, and suicidal thoughts 1-2 times a week for 15-30 mins. Referral to AT/RT (activity therapy/recreation therapy). Ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will encourage B1 to attend groups and activities daily to enhance positive coping skills in dealing with depressive thoughts, SW will educate B1 1 time weekly about the importance of following up with outpatient services to continue to enhance positive coping skills."

c. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

a. The physician interventions state: "Evaluate for anxiety, panic, attacks, and triggers for anxiety 1-2 times a week for 15-30 minutes, Referral to AT/RT (activity therapy/recreation therapy), Deep breathing and relaxation."

b. The social work (SW) interventions state: "SW will encourage B1 to attend groups and activities daily to recognize triggers which cause anxiety, SW will educate B1 one time weekly the importance of following-up with OP (outpatient) services to continue improvements in dealing with anxiety."

c. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement. If anxiety is present: reduce external stimuli as needed each shift. If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

6. Patient B2-MTP dated 10/25/2015

For problem Depression:

a. The physician interventions state: "Evaluate for depression, sleep, appetite, and suicidal thoughts 1-2 times a week for 15-30 mins. Referral to AT/RT (activity therapy/recreation therapy). Ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will encourage B2 to attend groups and activities daily to enhance positive coping skills in dealing with depressive thoughts. SW will educate B2 1 time weekly about the importance of following up with outpatient services to continue to enhance positive coping skills.

c. The nursing interventions state: "Nursing staff will sped 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood), The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

a. The physician interventions state: "Evaluate for anxiety, panic, attacks, and triggers for anxiety 1-2 times a week for 15-30 minutes, Referral to AT/RT (activity therapy/recreation therapy), Deep breathing and relaxation."

b. The social work (SW) interventions state: "SW will encourage B2 to attend groups and activities daily to recognize triggers which cause anxiety. SW will educate B2 one time weekly the importance of following-up with OP (outpatient) services to continue improvements in dealing with anxiety.

c. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement. If anxiety is present: reduce external stimuli as needed each shift. If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

7. Patient B3-MTP dated 10/27/2015

For the problem Depression with suicidal ideations:

a. The physician interventions state: "Evaluate for depression, sleep, appetite, and suicidal thoughts 1-2 times a week for 15-30 mins. Referral to AT/RT (activity therapy/recreation therapy). Ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will encourage B3 to attend groups and activities daily to enhance positive coping skills in dealing with depressive thoughts, SW will educate B3 1 time weekly about the importance of following up with outpatient services to continue to enhance positive coping skills."

c. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

a. The physician interventions state: Evaluate for anxiety, panic, attacks, and triggers for anxiety 1-2 times a week for 15-30 minutes. Referral to AT/RT (activity therapy/recreation therapy), Deep breathing and relaxation."

b. The social work (SW) interventions state: "SW will encourage B3 to attend groups and activities daily to recognize triggers which cause anxiety, SW will educate B3 one time weekly the importance of following-up with OP (outpatient) services to continue improvements in dealing with anxiety."

c. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement. If anxiety is present: reduce external stimuli as needed each shift. If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

8. Patient B4-MTP dated 10/28/2015

For the problem Psychosis:

a. The physician interventions state: "Evaluate for psychosis and bizarre delusions 1-2 times a week for 15-30 minutes, reality focused thought content, referral to AT/RT (activity therapy/recreation therapy), ongoing evaluation to assess and monitor need for medication and medication adjustment."

b. The social work (SW) interventions state: "SW will work with B4 1-2 times weekly to develop discharge planning and refer to OP (outpatient) services for follow up care, SW will encourage B4 to take psychotropic medications in dealing with psychosis."

c. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

B. Interviews:

1. In an interview on 11/3/15 at 11:40 a.m., the non-individualized interventions on the Master Treatment Plans were discussed with the Director of Nursing. He acknowledged that interventions were not individualized. He stated, "They are not particularly individualized, they are all the same."

2. In an interview on 11/3/15 at 12:00 noon, the non-individualized interventions on the Master Treatment Plans were reviewed with the Medical Director. He agreed that the interventions were all the same.

Based on observation, staff and patient interviews and medical record review the facility failed to:

Provide active individualized treatment for three (3) of eight (8) active sample patients (A3, A4, and B4). Sample patients A3 and B4 frequently refused to attend scheduled modalities and alternative treatments were not provided to meet their individual treatment goals. Sample patient A4 was restricted to the unit due to being on a 1:1 for suicidal ideation and was not allowed to attend groups or activities off of the unit. There were no alternatives provided to meet his/her 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.

Findings include:

Lack of individual active treatment for three (3) of eight (8) active sample patients, (A3, A4 and B4).

A. Observations:

1. On 11/2/2015 at 10:15 a.m. with a census of 14 patients, surveyor observed six (6) patients did not attend the scheduled activities therapy group conducted by recreation therapist. Sample patient B4 was lying in bed, sample patient A3 was wondering the hall, sample patient A4 was sitting in the day room and neither patients were engaged in any activity or alternative group. Patients were not offered alternative active treatment.

2. On 11/2/2015 at 12:40 p.m. the surveyor observed sample patients A3, A4, and B4 did not attend the social work scheduled group conducted by social worker and no alternatives were offered. Sample patient B4 was laying in bed.

3. On 11/2/2015 at 1:30 p.m. the surveyor observed that sample patients A3, A4, and B4 did not attend the RN Ed/wellness scheduled group conducted by RN and no alternatives were offered. Sample patient B4 was laying in bed.

4. On 11/3/2015 sample patients A3, A4, and B4 did not attend the scheduled activities therapy group conducted by recreation therapist. Sample patient B4 was lying in bed, sample patient A3 was wondering the hall, sample patient A4 was sleeping the day room and neither patients were engaged in any activity or alternative group. Patients were not offered alternative active treatment.

B. Record Review:

1. Sample patient A3 was admitted on 10/13/2015. The facility provided surveyors with hand written calculation of group attendance because this is not tracked. According to the records provided A3 attended 49% of groups and there was no documentation of alternative treatments offered to patient.

2. Sample patient A4 was admitted on 10/28/2015. The facility provided surveyors with
hand written calculation of group attendance because this is not tracked. According to the records provided A4 attended 25% of groups and there was no documentation of alternative treatment offered to patient.

3. Sample patient B4 was admitted on 10/27/2015. The facility provided surveyors with
hand written calculation of group attendance because this is not tracked. According to the records provided B4 attended 0% (zero) of groups and there was no documentation of alternative treatment offered to patient.


C. Interviews:

1. In an interview on 11/3/15 at 10:00 a.m. with RN2 and asked what do patients do when they do not attend group and s/he stated, "whatever they want but they cannot use the phone or watch T.V. they can draw, color or do word puzzles."

2. In an interview on 11/3/15 at 10:45 a.m. with Recreational Therapy Supervisor the lack of participation of sample patient A3, A4, and B4 in groups was discussed. He acknowledged patient's B4 lack of participation stating, "B4 won't get out of bed" and the lack of available of alternative treatment activities for this consumer. He further stated "we can't violate consumer's civil rights and force them."

3. In an interview on 11/3/15 at 11: 40 a.m., the lack of active sample patients A3, A4, and B4's participation in groups was discussed with the DON. He agreed that A3, A4, and B4 does not attend groups and with regards to alternative active treatment activity for B4 and other patients that refused to attend scheduled groups he stated "none."

4. In an interview on 11/3 15 at 12:00 with the Medical Director the lack of participation in groups by active sample patient B4 was discussed. He acknowledged lack of participation by saying "yap" and stated "dementia patients are rare for this facility."

Based on observation, staff and patient interviews and medical record review the facility failed to:

Provide a discharge summary containing information about the status of the patient on the day of discharge, including psychiatric, physical and functional condition. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology, risk was not available to the aftercare providers and potential harm to the patient.

A. Record Review:

Discharge sample patient D1 was admitted on 9/17/2015 and discharged 10/26/2015. D1 was admitted for suicidal ideation on 9/13/2015 and sent to Southwestern Medical Center on 9/15/2015 for seizure activity and re-admitted to Jim Taliaferro Community Mental Health Center on 9/17/2015. Past history states "s/he has history of trying to shoot himself/herself, cut himself/herself, hang himself/herself, and tried to jump out of a building." Discharge diagnosis state "Schizoaffective disorder, bipolar type, amphetamine dependence, bereavement, cannabis dependence, posttraumatic stress disorder, anxiety disorder."

Discharge summary dated 10/26/2015 was signed by the staff psychiatrist but there was no completion date noted. Physician's Discharge Orders were written on 10/23/15 at 10:40 a.m. The nursing note on 10/26/2015 at 7:32 am states, "client left facility at 0732." There was no documentation from the psychiatrist assessing D1 condition at the time of discharge. The last entry by the psychiatrist regarding patient condition was on 10/23/2015 and the discharge summary did not summarize the patient's condition after 10/23/2015.

B. Interview:

In an interview on 11/3/15 at 12:00 noon, with the Medical Director was asked about discharge summaries. He agreed that the psychiatrists are not consistent with assessing the patients' condition at the time of discharge. He further explained the challenges they have with patient's having to travel long distances to get back home. However, he did state that the psychiatrist should assess the patients' condition at least the day before the patient leaves if there is an early morning discharge.

Based on observations, record review and interviews the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the medical staff. Specifically, the Medical Director failed to:

I. 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. (Refer to B121)

II. 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) 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 failed to provide active individualized treatment for three (3) of eight (8) active sample patients (A3, A4, and B4). Sample patients A3, A4, and B4 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. In addition, the groups that were provided were non-therapeutic groups consisting of recreational or leisure activities such as playing pool, video games, drawing, arts and craft. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (Refer to B125)

IV. The facility failed to ensure that the discharge summaries for one (1) of six (6) discharged patients (D1) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology, risk was not available to the aftercare providers and potential harm to the patient.

Based on record review, observation and interview, the Director of Nursing failed to:

l. Ensure that individualized nursing interventions were included in the MTPs for eight (8) of eight (8) sampled patients (A1, A2, A3, A4, B1, B2, B3, and B4). Listed interventions were routine, generic nursing functions rather than individualized interventions. These deficiencies result in lack of guidance to nursing staff in providing individualized, coordinated treatment in the least restrictive environment, and can result in prolonged hospitalizations for patients. (B122)

1. Patient A1-MTP dated 10/29/2015

For the problem Depression with suicidal ideations:

a. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

b. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement, If anxiety is present: reduce external stimuli as needed each shift, If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

For Problem Psychosis:

c. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."


2. Patient A2-MTP dated 10/20/2015

For the problem Psychosis:

a. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

3. Patient A3-MTP dated 10/15/2015

For the problem Psychosis:

a. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

4. Patient A4-MTP dated 10/31/2015

For the problem Depression:

a. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

5. Patient B1-MTP dated 10/30/2015

For problem Depression:

a. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood), The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

b. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement, If anxiety is present: reduce external stimuli as needed each shift, If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

6. Patient B2-MTP dated 10/25/2015

For problem Depression:

b. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

b. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement, If anxiety is present: reduce external stimuli as needed each shift, If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

7. Patient B3-MTP dated 10/27/2015

For the problem Depression with suicidal ideations:

a. The nursing interventions state: "Nursing staff will spend 1:1 time daily to assess symptoms of depression (appetite, sleep, and mood). The nursing staff will spend 1:1 time daily to encourage expression of emotions, provide emotional support, and discuss adaptive ways of copying with feelings of depression. The nursing staff will spend 1:1 time daily to encourage group involvement. The nursing staff will monitor, document, and encourage good hygiene patterns and compliance each shift. The nursing staff will provide a safe, structured environment for each shift, and the nurse will administer medications as ordered and monitored/document response effectiveness each shift."

For Problem Anxiety:

b. The nursing interventions state: "1:1 daily to asses symptoms anxiety, establish trusting relationship, and discuss adaptive ways to coping with feelings of anxiety, 1:1 time daily to encourage group involvement, If anxiety is present: reduce external stimuli as needed each shift, If consumer loses control-maintain calm serene approach and guide to smaller quitter area as needed each shift, speak in short simple sentences with giving directions as needed each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

8. Patient B4-MTP dated 10/28/2015

For the problem Psychosis:

a. The nursing intervention state: "The nursing staff will spend 1:1 5-10 minutes to assist consumer to distinguish real from unreal thoughts each shift, maintain calm directive attitude each shift, redirect focus from inappropriate to appropriate behavior each shift, provide a safe, structured environment each shift, administer medications as ordered and monitor response/effectiveness each shift."

B. Interview:

1. In an interview on 11/3/15 at 11:40 a.m., the non-individualized interventions on the Master Treatment Plans were discussed with the Director of Nursing. He acknowledged that interventions were not individualized. He stated, "They are not particularly individualized, they are all the same."