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Based on clinical record review and staff interview, the facility failed to provide evidence that 2 of 2 patients (Patient # 21 and 23 ) reviewed for the Outpatient Partial Hospitalization Program participated in the development, implementation and revision of their treatment plans.

The findings include:

1. Review of the clinical record on 7/27/2012 for Patient # 21 discloses that the patient was discharged from inpatient services and admitted to the Partial Hospitalization Outpatient Program on 6/28/2012. The Interdisciplinary Team initiated the Partial Hospitalization Program Treatment Plan on 6/28/2012. The treatment plan identified problems of Depression, Chemical Dependence and chronic neck and back pain, however the plans failed to provide evidence the patient participated in the development and implementation of the established treatment plan. The plans did not contain the patient's signature acknowledging the patient received the Treatment Plan and is in agreement to participate in the course of treatment prescribed by the treatment plan. Furthermore, the facility conducted weekly treatment team meetings and reviewed the treatment plan on 7/5/2012, 7/12/2012 and 7/19/2012. However, the weekly review of the treatment plan also failed to provide evidence of the patient's participation in the plan. The weekly Treatment Plan review did not contain the patient's signature acknowledging the treatment plan was discussed with the patient and the patient was given an opportunity to ask questions and make suggestions.

An interview was conducted on 7/27/2012 at 9:50 AM with the Partial Hospitalization Program Registered Nurse who confirmed that the Patient's Treatment Plan was not signed by the patient acknowledging his participation in the treatment plan.

2. Review of the clinical record for Patient # 23 discloses the patient was admitted to the Partial Hospitalization Program on 7/13/2012. The Interdisciplinary team initiated the Partial Hospitalization Program Treatment plan on 7/13/2012. The plan identified problems of Chemical Dependence and Depression, however the plans failed to provide evidence the patient participated in the development and implementation of the established treatment plan. The plans did not contain the patient's signature.

An interview was conducted on 7/27/2012 at approximately 10:15 AM with the Outpatient Partial Hospitalization Program Nurse who again confirmed that the Treatment Plan for Patient # 23 was unsigned. She further added that obtaining the patient's signature is a unit failure. She stated the team (Nurse, Director) meet to review the issues concerning the patient then they develop the plan. The plan is then reviewed with the physician when she visits weekly on Wednesday. The Treatment Plan is reviewed with the patient when we can "catch up with them". The patients attend the Partial Hospitalization Program for 5 days a week (Monday through Friday) from 9:30 AM to 1:00 PM. She further stated groups are continuously being conducted, so they try to review the plans during breaks and after breaks.

Based on record review and interview, the facility failed to implement policies and procedures related to medication administration for four (4) of 30 patient records reviewed, Patients #15, #18, #30 and #7. Patients #15, #18 & #30 did not have evidence medications were administered as per the physician orders. Patient #7 did not have the medication ordered, transcribed correctly therefore there was no evidence it was administered as ordered.

The findings include:

1. Review of the facility's policy regarding Medication: Documentation, Administration and Storage, # NUR - 7:006 documents the following: "Documenting Medication Administration on the MAR": 1. The initials of the medication nurse administering the medication will be in black ink only and in the appropriate box for the date and time of administration."
Further review of the facility policy for 'Medication Administration' revealed " all medications will be administered by an RN or LPN in accordance with the physician ' s orders and will be documented on approved medication administration forms. Errors in medication administration will be documented on an incident report and forwarded to Risk Management. The attending physician, the Director of Nursing and the Pharmacist as appropriate will be notified of all medication errors. "

Review of the physician orders for Patient #18 revealed an admit date of 07/13/2012. Review of the physician orders revealed orders as follows: of 7/13/12 for MVI one tablet daily, Folic Acid 1 mg daily & Thiamine 100 mg daily; of 7/14/12 for Amolodipine 10 mg daily (antihypertensive), and of 7/26/12 for Peroxide soaks 10 minutes twice daily for 2 days. Review of the medication (MAR) & treatment (TAR) sheets for these medications & treatments revealed the following: On 7/22/2012, there was no evidence the MVI, Folic Acid and Thiamine was administered; for 7/24/12, no evidence of Amolodipine being administered; and for 7/26 at 6:00 PM or on 7/27/12 at 6 AM there was no evidence or documentation that the peroxide soaks were provided to the patients. There was no documentation or evidence as to the reason the medications were not administered or why the treatment was not done. Interview with the nurse on duty, on 7/27/12 at 12:50 PM revealed she does not know why they were not done. Further Interview with the LPN / nurse on duty on 7/27/12 at approximately 1:35 PM revealed the 3 medications were available in stock and pharmacy can be accessed by the nursing supervisor if needed.
Further review of the physician orders for Patient #18 revealed an order for Lithium Carbonate 300 mg twice a day. Review of the MAR revealed that on 7/26/12, the Lithium Carbonate 300 mg was held by the nurse for a Lithium level (lab work). The nurse said when a Lithium level is done we hold the medications and then resume it the next day. The nurse said our protocol is to do this. The protocol was requested. The chart and orders were reviewed with the nurse and there was no order to hold or resume the medication. Interview with the director of nurses and the day-nurse supervisor revealed there is no protocol but the physician order is followed & should say what we are to do. Review of the labs revealed the Lithium level results were not back from the lab yet.

2. Review of the clinical record for Patient #30 revealed an admit date of 7/10/2012. Review of the physician orders for Patient #30 revealed an order of 7/20/12 for Metamucil 17gm in glass of water daily. Review of the MAR revealed the medication was not provided to the patient until 7/22/12. The physician order for Atenolol 25mg daily on admission (7/11/12) was changed on 7/20/12 to 50 mg daily. There was no evidence or documentation on 7/21/2012 that the 6 AM daily dose of the 25 mg or the 50mg dose was provided to the patient.
Further review of the admission physician orders of 7/11/12 at 0055 hours (00:55 AM) revealed Vitamin one tab daily, Folic Acid 1 mg daily, and Thiamine 100 mg daily were ordered. There was no documentation or evidence these 3 medications were provided to the patient until 7/13/12. There was no documentation or evidence as to the reason the medications were not administered. Interview with the LPN / nurse on duty on 7/27/12 at approximately 1:35 PM revealed the 3 medications were available in stock and pharmacy can be accessed by the nursing supervisor if needed. The documented B/P on 7/20/12 at 6 AM was 140/84. The B/P on 7/21 was 136/91.

3. Review of the clinical record for Patient #15 revealed an admission date of 7/3/2012. Review of the clinical record of Patient #15 revealed the medication administrator record (MAR) had lack of documentation or evidence that all medications ordered by the physician were administered to the patient.
Review of the physician orders revealed orders for: 7/3/12 - Isentress 400 mg orally twice daily (BID) & Propranolol 10 mg orally BID; and for 7/5/12 - Lithium 300 mg orally twice daily; and Vistaril 50mg orally three times a day (TID).
Review of the MAR revealed: On 7/9/12, the nurse circles initial indicating Propranolol was not given; On 7/18/12 at 6:00 PM, there was no evidence the nurse gave the Isentress or the Propranolol; On 7/7/12, 7/8/12, and 7/19/12, there was no evidence the Lithium was administered at 6:00 PM; and On 7/9/12 & 7/11/12, there was no evidence Vistaril was administered to the patient. There was no additional documentation of why the nurse did not administer the medications. The documentation and lack of documentation was reviewed with the Risk Manager on 7/26/12 at approximately 3:18 PM who agreed there was lack of documentation or evidence these medications were administered. She said she would speak with nursing to see what happened.



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4. Review of the clinical record for Patient # 7 discloses an admission physician order of 7/23/2012 prescribing an Albuterol Inhaler 2 puffs 90 mcg every 6 hours. Further review of the Medication Administration Record (MAR) on 7/26/2012 failed to provide evidence of the physician order on the routine medication sheet. However there was an entry of Albuterol Inhaler 2 puffs 90 mcg every 6 hours on the as needed MAR. The patient did not receive medication as prescribed on the admission orders.

Interviews were conducted on 7/26/2012 at 1:15 PM with the Licensed Practical Nurse and the Registered Charge Nurse who confirmed the physician order is written as a routine medication to be administered every 6 hours daily but the medication has not been administered as prescribed on the physician orders. The medication is noted as an as needed medication. The RN stated she would verify the correct way the medication is to be administered. She further confirmed that the order was transcribed wrong and the nurses should have caught the transcription error in their 24 hour chart checks. The order was written 3 days ago and no one identified the transcription error. She will clarify the order and also complete a medication variance regarding the transcription error.

Review of the facility's policy and procedure regarding Medication: Documentation, Administration and Storage, # NUR - 7:006 documents the following:
"6). Orders are transcribed by the LPN or RN to the MAR and Kardex as needed. All orders are to be checked and co-signed by another nurse. Always use ID #.
E. The LPN or RN responsible for transcription of the physician's order and/or checking the MAR shall place his/her initials, signature, and title in the area provided. 7). A second check of the transcription must be performed by another LPN/RN. The second check is noted by co-signing the original sign-off with the date and time. The second check must include the MAR and the Medication Referral Sheet. 8). A transcription check is done once every 24 hour period by an RN on the night shift. The physician orders are checked against the MAR, Medication Referral Sheet, and Lab Slips. The 24 hour check and second check may not be performed by the same individual. The nurse checking the transcription signs the appropriate box on the MAR, the "24 hour Check". Any discrepancies between the physician order and the transcription shall be immediately brought to the attention of the Supervisor and an Incident Report will be completed."

Review of the patient's physician orders and MAR provided evidence of the nurse's initials and signatures acknowledging the orders were checked. However the nurses failed to identify discrepancies in the order and what was documented on the MAR until the surveyor's intervention, 3 days after the original admission order was written.

Further review of the clinical record for Patient # 7 discloses a 7/23/2012 physician prescription prescribing for the patient to receive Trazadone 100 mg at bedtime (HS) and Risperdal 1 mg by mouth at bedtime. Further review of the MAR failed to provide evidence that the nurse administered the above medications (Trazadone and Risperdal) on 7/25/2012. The MAR did not contain the nurses' initials in the appropriate boxes for the stated medications.

Another interview was conducted on 7/26/2012 at 1:04 PM with the Registered Nurse who confirmed the MAR did not provide evidence the nurse administered the above medications. She further stated the facility's protocol mandates that the day nurse is to contact the night nurse to verify if the medication was given or not. She confirmed this has not been done but she would contact the nurse and verify if the medication was administered or not.

Review of the facility's policy regarding Medication: Documentation, Administration and Storage, # NUR - 7:006 documents the following:
Documenting Medication Administration on the MAR:
1. The initials of the medication nurse administering the medication will be in black ink only and in the appropriate box for the date and time of administration."

Based on observation & interview, the facility failed to maintain an environment that was clean & sanitary for the patients.

The findings include:

Tour of the facility with two surveyors and accompanied by the administrator and the Day Nurse Supervisor, and joined by the Director of Plant Operations, on 7/24/2012 at approximately 10:45 AM to 11:58 AM revealed the following:
1. In the ASU (Adult Senior Unit), the floor in the area where staff and patients walk between patient rooms, the nursing station and the sitting area had scuff marks and was dull appearing; the administrator said it was scheduled to be buffed tonight.
2. In the ASU unit, there were two (2) large tables utilized by the patients for therapy and activities that were dirty with the edges broken in places, and the formica broken off.
3. In the ITS (Intensive Treatment Stabilization) unit, in the patient receiving area, the floor was very dirty and stained; the room door signs at the patient ' s doors had old, dirty tape left on them. This was reviewed with the Nurse Supervisor who said she would have them cleaned & have the old tape marks removed. The swing doors into the nursing station and offices were dirty with black streaks; paint chips were seen coming off parts of the walls, and the wall behind the sofa where patients sit was markedly stained. In the laundry room on this unit, the floor was dirty with stains and dirt accumulation; the sink in this room was stained with blackened areas and the nurse supervisor said it was "nasty". In the nourishment room, the floor had multiple stains with dirt accumulated in the corners and on the baseboards surrounding the room; part of the baseboards were separating from the wall. The administrator and the nurse supervisor agreed it was dirty & disgusting. When asked if the facility patient areas are terminally clean, the administrator said it was more than annually. The administrator also said, it must be kept clean for the patients.
4. In the Dual I unit, the nourishment room floor was very dirty and dirt accumulated in the corners and on the baseboards; the cupboard had 3 shelves that had food condiments in the cupboard such as jelly packets, sugar packets, sweetener packets, and creamers. The shelves were dirty & stained with formica pieces coming off and dust was gathered on the shelves. The wall behind the sink was stained with multiple steaks up & down the wall. Interview with the Nurse supervisor & Administrator revealed they agreed the shelves and nourishment room were dirty. Further observation on the Dual I unit revealed two (2) tables in the center of the room that are utilized by the patients for therapy and activities. These tables were dirty, had broken formica around the edges, missing pieces of formica, and ragged. These tables were ' beat up ' per the director of plant operations. The soiled utility room on this unit was overall dirty looking with 4 biohazard containers, two of which had no biohazard bag in them. In the storage room on the Dual I unit, there was a mattress leaning against the wall and the paint on the wall was peeling with multiple nicks notes. Interview with the Director of Plant Operations during the tour revealed the floors in the facility are buffed at least every 2 weeks. Interview with the housekeeping staff revealed the floors are moped every day.
5. On the Dual II unit, the cart containing videos for the patients (3 drawer cart), was dusty, fingers wiped over it were dust coated. The administrator said it was dirty. There were two tables in the center of the room for patient therapy & activities that also had broken formica around the edges, ragged, stains and the tops were peeling. The board on the wall, used for patient education per the nurse supervisor, was stained. The floors on the unit were stained and dirty looking.
6. Observation of 2 of the patient bathrooms (in their rooms) revealed the area behind the toilet had a copper / braze, approximate 18 X 18 inch piece installed that was blackened. The administrator used his thumb nail to scrape it and black substance came off.
All areas were observed with the Administrator, the Nursing Supervisor or the Director of Plant Operations during the tour. They agreed the floors and overall environment was dirty.

Based on record review and interviews, the facility failed to ensure that Master Treatment Plans (MTPs) included nursing interventions that had a specific focus based on the individual needs of patient for 5 of 8 active sample patients (A2, A4, A5, A7 and A8). The listed nursing interventions were generic monitoring and routine discipline functions with identical or similar wording for patients with different problems and needs. Failure to provide nursing interventions to address individualized patient needs can result in unmet patient needs which can potentially lead to longer hospitalization.

Findings include:

A. Record Review

1. Patient A2 was admitted on 7/16/2012 with a diagnosis of "Major Depression, severe." On the MTP dated 7/17/2012 for the identified problem, "Patient needs to be detoxed from ETOH(alcohol)," the nursing intervention was "Staff will alert the physician to any changes in symptomatology that occur."

2. Patient A4 was admitted 7/07/2012 with a diagnosis of "Bipolar Disorder and Opiate Dependence." On the MTP dated 7/09/2012 for the identified problem, "Hypertension," the nursing intervention was "Administer medication as ordered by physician."

3. Patient A5 was admitted on 7/02/2012 with a diagnosis of "Schizoaffective Disorder, depressed and Borderline Personality Disorder." On the MTP dated 7/4/2012 for the problem, "Self Injury Behavior", the nursing intervention was "nursing to monitor for A/O(as ordered)."

4. Patient A7 was admitted on 7/10/2012 with a diagnosis of "Bipolar Disorder Mixed". On the MTP dated 7/11/2012 for the problem, "Hypertension," the nursing intervention was "Assess blood pressure every morning." The standard practice for the facility was to take each patient's blood pressure every morning.

5. Patient A8 was admitted on 7/16/2012 with a diagnosis of "Major Depressive Disorder and Drug Dependency." On the MTP dated 7/17/2012 for the problem, "Hx (history) of Paranoid Schizophrenia," the nursing intervention was "ensure maintenance of physical status, nutrition, hygiene and rest to promote wellness."

B. Interviews

1. In an interview on 7/24/2012 at 2:00 PM, the Nurse Supervisor, after reviewing the Master Treatment Plans for patients A4 and A5, the Nurse Supervisor stated the nursing interventions were routine nursing care given to all patients and did not address the individual needs of the patients.

2. In interview on 7/25/2012 at 11:15 AM, RN3 agreed that the nursing interventions listed on the Master Treatment Plans were routine nursing interventions and were not individualized to patient needs.

Based on record review and interview, the facility failed to ensure that the names of nursing staff responsible for specific aspects of care were listed on the Master Treatment Plans (MTP) for 6 of 8 active sample patients (A1, A2, A3, A4, A5, A6) and failed to ensure discipline identity for staff assigned to specific interventions for 5 of 8 active sample patients (A1, A2, A3, A6, A8). This practice results in the facility's inability to monitor staff accountability for providing specific treatment modalities.

Findings include:

A. Record Review

1. Patient A1 was admitted on 7/06/2012 with a diagnosis of "Schizoaffective Disorder, Generalized Anxiety Disorder and Cocaine Abuse." On the Master Treatment Plan (MTP) dated 7/16/2012 for the intervention, "Nursing staff will teach patient about stimulants increasing potential for seizures, e.g. caffeine, nicotine, etc.," there was no specific nursing staff identified. For the intervention, "In CD (Chemical Dependency) Group 1 time per day for 1 hour with '[first name only]' (name written in blank) staff will help patient to identify 3 various triggers that caused pt. (patient) to use crack/cocaine," the staff member, '[first name only]', was not identified by discipline.

2. Patient A2 was admitted on 7/16/2012 with a diagnosis of "Major Depression, severe." On the MTP dated 7/17/2012 for the intervention, "Initiate Fall Risk Identification," the responsible staff was listed as "all nsg (nursing) staff." For the intervention, "In CD Group 1 time per day for 1 hour with '[first name only]' (name written in blank space) staff will help patient to identify and be able to identify (blank space not filled in with number) different strategies and coping techniques to be able to stay clean/sober after discharge," the staff member, '[first name only]', was not identified by discipline.

3. Patient A3 was admitted on 7/16/2012 with a diagnosis of "Generalized Anxiety Disorder and Benzodiazepine Dependency." On the MTP dated 7/16/2012 for the intervention, "Staff member will provide patient time in daily goals group that is held for 1 hour time to focus on depression either identifying triggers or identifying new coping skills," the responsible staff listed was "all nurses." For the intervention, "In Discharge Planning Group 1 time per day for 1 hour with '[first name only]' (name written in blank space) staff will review discharge plans with patient to supports [sic] a clean/sober lifestyle," the staff member, '[first name only]', was not identified by discipline.

4. Patient A4 was admitted 7/07/2012 with a diagnosis of "Bipolar Disorder and Opiate Dependence." On the MTP dated 7/09/2012 for the nursing intervention, "Once weekly during Med Education for one hour, nursing will educate patient on symptoms to report," there was no responsible staff name listed.

5. Patient A5 was admitted on 7/02/2012 with a diagnosis of "Schizoaffective Disorder, depressed and Borderline Personality Disorder." On the MTP dated 7/4/2012 for the intervention, "Nursing to monitor A/O (As Ordered)," there was no responsible staff name listed.

6. Patient A6 was admitted on 7/13/2012 with a diagnosis of "Bipolar Disorder, NOS (Not Otherwise Specified), Benzodiazepine Dependence and Opiate Dependence." On the MTP dated 7/14/2012 for the intervention (related to sleep difficulty), "Explore with patient potential contributing factors," the responsible staff was listed as "Nsg (Nursing)." For the intervention, "In Process Group held 1x weekly for 1 hour staff member '[first name only]' (name written in blank space) will educate patient on signs and symptoms of depression and when to seek help," the staff member, '[first name only]', was not identified by discipline.

7. Patient A8 was admitted on 7/16/2012 with a diagnosis of "Major Depressive Disorder and Drug Dependency." On the MTP dated 7/17/2012 for the intervention, "In Process Group held 1x weekly for 1 hour, staff member '[first name only]' (name written in blank space) will educate patient on signs and symptoms of depression and when to seek help," the staff member, '[first name only]' was not identified by discipline.

B. Interviews

1. In an interview on 7/24/2012 at 2:00 PM, the Nurse Supervisor reviewed the Master Treatment Plans for patients A1 and A3. The Nurse Supervisor acknowledged that nursing staff was not identified by name and that when names were present, the disciplines were at times missing.

2. In an interview on 7/25/2012 at 11:15 AM, RN3 stated "Yes I see what you mean" when the surveyor pointed out the lack of staff names and discipline identification on the Master Treatment Plans.

Based on record review and interview, the hospital failed to assure in 3 of 5 discharge records (D2, D4, and D5) that patient discharge summaries included a recapitulation of the patient's hospitalization that demonstrated the extent to which the patient's treatment plan goals had been met. This failure hinders the effective transfer of clinical information about the patient to aftercare providers.

Findings include:

A. Record Review

1. Patient D2's discharge summary (discharged on 6/26/12) described the patient's history of present illness in the section labeled Hospital Course. No recapitulation of the patient's hospital course/progress toward goals was provided in this section or elsewhere in the discharge summary.

2. Patient D3's discharge summary (discharged 5/25/12) contained the following, general, nonspecific data under the section labeled Hospital Course: "client was admitted to the unit for medication management, group therapy, and discharge planning. While on the unit medications were adjusted to target and treat symptomatology and withdrawal. The client was stabilized, teaching completed, and the client was discharged. Discharge plans discussed with the patient and treatment team and all agreed with the discharge plans."

3. Patient D4's discharge summary (discharged 5/31/12), contained the following, general, nonspecific data under the section labeled Hospital Course: "client was admitted to the unit for medication management, group therapy, and discharge planning. While on the unit medications were adjusted to target and treat symptomatology and withdrawal. The client was stabilized, teaching completed, and the client was discharged. Discharge plans discussed with the patient and treatment team and all agreed with the discharge plans." The discharge summary contained a similarly nonspecific description of the detoxification procedure provided during the admission, though the patient had no substance abuse diagnoses listed on the discharge summary.

4. Patient D5's discharge summary (discharged 5/30/12), contained the following, general, nonspecific data under the section labeled Hospital Course: "client was admitted to the unit for medication management, group therapy, and discharge planning. While on the unit medications were adjusted to target and treat symptomatology and withdrawal. The client was stabilized, teaching completed, and the client was discharged."

B. Interviews

1. In an interview on 7/25/12 at 9:00 AM, the surveyor presented these findings to the Medical Director who then confirmed the findings.