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

I. Provide active treatment measures on the Intensive Care Unit (ICU) for 2 of 2 active sample patients (Patients 1-4, I-8) and 9 of 11 non sample patients on the unit (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). The clinical staff was aware that these patients were not participating in their unit activities. There was no evidence that any of the patients were offered alternative therapies. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their clinical improvement. (Refer to B125-1)

2. Ensure that staff reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment, and provide structured alternative treatment as needed in the Intensive Care Unit, affecting 2 active sample patients (Patients 1-4, I-8) and 9 non-sample patients (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). This failure results in patients lying/sleeping in bed, sitting around and idly walking about the day room on the ICU. (Refer to B125 II)

Based on observations, medical record and hospital policy review, and staff interviews it was determined that the facility failed to provide active treatment measures on the Intensive Care Unit (ICU) for 2 of 2 active sample patients (Patients 1-4, I-8) and 9 of 11 non sample patients on the unit (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). This failure results in patients not participating in selected interventions and possibly prolongs their hospital stay. The findings include the following:

I. Failure to ensure active individualized treatment on the Intensive Care Unit (ICU):

A. Observations

The ICU schedule lists 2 therapy groups available per day. Any patient with a Treatment Plan that has the modality "group therapy" as the method of treatment will be expected to attend, as that is all that is available.

1. On 12/17/2012 the "Process Therapy Group" was held from 11:30 AM to 12:30 PM. Although all patients were expected to go to group therapy, only 4 patients of the total 13 patients on ICU attended the group. Patient I-1 left the group within the first ten minutes after the start of the group.

2. On 12/17/2012 at 11:40 AM, accompanied by RN#1, it was observed that patients I-8, I-9, I-10, I-11 and I-13 were each in bed, and the patients I-3, I-4, I-5 and I-7 were either sitting in the day room or in bed sleeping instead of attending the scheduled group therapy.

3. On 12/17/2012 during the "Recreational Therapy Group" scheduled from 2 PM to 3 PM there were 4 patients who attended the group of the total 11 patients on ICU. Patients I-2, I-6, I-10, I-11 and I-13 were in bed. Patient I-3 was meeting with the physician; Patient I-8 was observed as agitated and pacing in the day room.

4. On 12/18/2012 the census had decreased to 11 patients. At 11:45 AM there were 3 patients (I-1, I-7, I-12) in the scheduled "Process Therapy Group." In the company of the DON the other 8 absent patients were located: Patient I-1, Patient I-2, Patient I-12 and Patient I-13 were each in their beds; Patient I-11 was walking in the hallway; Patients I-3 and I-4 were in the day room; I-8 was walking about the dayroom on 1 to 1 with staff.

II. Failure to reinforce the importance of and responsibility for patient attendance and participation in assigned treatment:

A. Observations and staff interview:

1. On 12/18/ 2012 at 2:00 PM the scheduled "Recreational Therapy Group" on the ICU Unit was observed to have 3 patients (I-1, I-4, I-7) of the total 13 patients on the unit at that time in the group. In the company of MHT #1, the surveyor asked to see what some of the other patients who were not attending their scheduled group were doing:
Patient 1-8 was in his/her room on 1:1 observation. The MHT #1 said: "[S/he] is resting. [S/he] needs it. [S/he] gets agitated. [S/he] has been here a couple of days."
Patient I-12 was in bed, as had been noted in the morning. When asked why, MHT #1 said "[S/he] is unsteady. We don't want [him/her] to fall."
Patient I-13 was also found in bed. MHT#1 explained "That is just "X" (referring to Patient I-13) and if "X" has a bad day, [s/he] will lay in bed all day."
Patient I-6 was found in bed. MHT #1explained "[S/he] didn't get any cigarettes, so [s/he] refuses to go to group."
Patient I-2 was found in bed. MHT #1 explained "[s/he's] probably just tired."

B. Staff Interviews and Record Review:

1. On 12/18/2012 at 2:45 PM, the surveyors met with the Clinical Director and the Director of Nursing (DON). The focus was on whether patients attend their assigned therapy groups and, if not, were their Master Treatment Plans (MTPs) revised. Two charts were chosen at random, in order to review documentation, as well as compare to ward observations of patients and staff interviews about patient participation.
Patient I-2's attendance at assigned groups for Dec. 11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the DON acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

Patient I-13's attendance for group therapy was reviewed for the period Dec. 1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012, were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of involvement of the patient in the therapeutic interventions (i.e. group therapies) selected. Both staff members agreed with this finding.

2. In interview with the facility's QI/UR manager on 12/17/2012 at 4:40 PM a review of Patient I-8's MTP dated 12/13/2012 was done. It was confirmed by the QI/UR manager that there were no interventions for Patient I-8's agitated behaviors, given the patient's inability to attend scheduled therapy groups because of the agitation.

3. In interview with the ICU QI/UR manager on 12/17/2012 at 4:40 PM she was questioned about the lack of treatment interventions for patient I-8's agitated behavior and/or group refusals. She stated that management of the milieu was a joint responsibility between Nursing and Social Work: the Social Work staff was responsible for conducting groups and family sessions, and discharge planning. She could not identify who was responsible for designing treatment interventions when patients refused to attend assigned groups.

4. In interview with the group leader SW #1 on 12/17/2012 at noon SW #1 said that patients are asked to go to the scheduled groups, but they refuse.

5. In interview with RN#3 on 12/18/2012 at approximately 2:00 PM, when asked "how do you get patients to group?" she responded "We ask them to attend, but we were told that we can't force them to attend." When asked "what is the alternative for the patients?" she responded "They can do what they want."

III. Policy Review

On 12/19/2012 at approximately 10:00 AM the Director of QI/UR provided the surveyors with the facility policy for revision to MTPs when selected treatment interventions are unsuccessful. The facility's policy titled "Plan for Provision of Care," date issued 2/29/12, states in Section 8 "Evaluation": "This plan for the provision of patient care is reviewed and revised as necessary." In subsection 8.4 the policy details patient care specifically as "Changes in patient care needs/community needs..." Thus, the staff on the facility's ICU failed to follow hospital policy in making revisions to interventions when those interventions were seen to be ineffective.

Based on observations, medical record and hospital policy review, and staff interviews it was determined that the Clinical Director failed to:

I. Ensure that patients on the ICU who were not attending their assigned treatment group theapy interventions were provided alternative interventions.

Findings include:

A. On 12/18/12, two patient records (I-2 and I-13) were randomly chosen for review with the Clinical Director and the Director of Nursing. Patient I-2's attendance at assigned groups for Dec. 11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the Director of Nursing acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

Patient I-13's attendance for group therapy was reviewed for the period Dec. 1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012 were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of success for the therapeutic interventions (i.e. group therapies) selected.

B. Patients were observed sleeping or otherwise avoiding group attendance at multiple times during the survey process. Refer to B125 Parts I & II for details of these observations.

II. Ensure that treatment staff on the ICU followed hospital policy that requires changes be made to the Treatment Plan when selected interventions are unsuccessful.

Findings include:

A. The facility's policy titled "Plan for Provision of Care," date issued 2/29/12, states in Section 8 "Evaluation": "This plan for the provision of patient care is reviewed and revised as necessary."

B. Staff interviews revealed that the staff members were aware patients were not participating, and that treatment plans were not revised in light of those patient failures. See B125 Part II for details. Thus, the staff on the facility's ICU failed to follow hospital policy in making revisions to interventions when those interventions were seen to be ineffective.
These failures can result in patients not participating in available treatment alternatives and can result in a longer than necessary hospitalization.

Based on record review, observation, and interviews, it was determined that the Director of Nursing failed to monitor the quality and appropriate of services and treatment provided by nursing staff. Specifically, the Director of Nursing failed to:

I. Ensure that patients on the Intensive Care Unit participated in assigned treatment, and that, when patients did not participate, nurses documented the reasons and planned ways to effectively involve patients in alternative treatment to that prescribed.

II. Ensure that the Master Treatment Plans (MTPs) of patients on the ICU were modified to include specific nursing intervention/modalities when patients demonstrated that they did not/could not comply with the modalities initially assigned on the MTP. In the case of active sample patient I-8, the patient was demonstrating agitation which precluded his/her attendance at scheduled group therapy, but the plan was not modified. For other patients on the unit, observation revealed that the majority of them did not attend scheduled group therapy modalities; random selection of two (I-2, I-13) of ten records of these patients revealed that the patients did not attend group therapy, yet scheduled MTP reviews by staff did not note this as a problem, and did not include alternate modalities to engage the patients in active treatment.

These deficiencies can result in lack of accountability and fragmented nursing care for patients.

Findings include:


I. Lack of patient participation in therapeutic activity


A. In interview with RN#3 on 12/18/2012 at approximately 2:00 PM, when asked "how do you get patients to group?" she responded "We ask them to attend, but we were told that we can't force them to attend." When asked "what is the alternative for the patients?" she responded "They can do what they want."

B. On 12/17/2012 at 11:40 AM, accompanied by RN#1, it was observed that 9 of 13 patients were not in the scheduled group: patients I-8, I-9, I-10, I-11 and I-13 were in bed, and patients I-3, I-4, I-5 and I-7 were either sitting in the day room or in bed sleeping instead of attending the scheduled group therapy.

C. On 12/18/2012 the census was 11 patients. At 11:45 AM there were 3 patients (I-1, I-7, I-12) in the scheduled "Process Therapy Group." In the company of the DON the other 8 absent patients were located: Patient I-1, Patient I-2, Patient I-12 and Patient I-13 were each in their beds; Patient I-11 was walking in the hallway; Patients I-4 and I-3 were in the day room; I-8 was pacing the dayroom observed by staff.

II. Lack of revision of nursing intervention(s) on the Master Treatment Plans when patients did not/could not attend group therapy.


A. In interview with the facility's QI/UR manager on 12/17/2012 at 4:40 PM a review of Patient I-8's MTP dated 12/14/2012 was done. The manager confirmed that there were no interventions on the plan for Patient I-8's agitated behaviors, other than the prescription of scheduled therapy groups, which the patient was too agitated to be able to attend.

B. On 12/18/2012 at 2:45 PM, the surveyors met with the Clinical Director and the DON. The focus was on whether patients attended their assigned therapy groups and, if not, were their Master Treatment Plans (MTPs) revised. Two charts were randomly chosen for review:

1. Patient I-2's attendance at assigned groups for Dec.11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the DON acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

2. Patient I-13's attendance for group therapy was reviewed for the period Dec.1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012 were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of for the patient's involvement with the therapeutic interventions (i.e. group therapies) selected. Both the Clinical Director and the DON agreed with this finding.