HospitalInspections.org

Based on record review and interview it was determined that the hospital failed to protect and promote each patient's rights. Specifically, the hospital failed to provide care in a safe setting that resulted in harm to the patients.

Findings include:

The hospital failed to give care in a safe setting. Two patients of the 20 patient sample suffered multiple falls while in the hospital. One of the 2 patients broke his hip as a result of one of the falls. (Refer to tag A-144)

Based on record review and interview it was determined that the hospital failed to give care in a safe setting. Two patients of the 20 patient sample suffered multiple falls while in the hospital. (Patient identifiers: 6 and 7)

Findings include:

Patient 6

1. Patient 6 was involuntarily admitted to the hospital on 11/4/2014 with diagnoses that included Major depression, anxiety, suicidal ideation and dementia. He was identified as a high fall risk and saw physical therapy 2 times on 11/6/2014 and on 11/13/2014.

On 12/4/2014, patient 6's medical chart and incident reports were reviewed.

Incident Reports

First Fall
It was documented that on 11/11/2014, patient 6 fell to the floor at 2:30 AM, in his room, while ambulating with a walker to the bathroom. He was found on the floor. It was documented that he was a one person assist. No injuries were noted.

On 11/11/14 at 3:46 AM, the care plan included the following interventions for falls:
"Nurse will ensure ambulation assistance as needed. This will occur daily and last."
"Nurse will have patient evaluation for assistive device This will occur AS NEEDED and will last."
"Recommend continuing the current intervention....It is felt that more time in needed for the intervention to work."

Patient 6 already had a walker and no description of how or what kind of assistance the patient needed was documented.

Second Fall
It was documented that on 11/12/2014, at 11:23 patient 6 was in the dayroom sitting in a chair when he stood up and tripped over his walker and fell onto his left side. No injuries were noted.

In a progress note dated 11/12/14 at 12:48 PM, the patient was quoted as saying, "I tripped again on my walker and fell. I didn't hit anything or hurt myself. I have to be more careful. I am not used to this walker."

On 11/12/2014, the following interventions for falls were documented in the patient's chart:

The nurse has "reiterated with the pt (patient) several times that he should call for help with ambulation if necessary."

No intervention were listed to help the patient utilize his walker safely.

Third Fall
It was documented that on 11/17/2014 at 4:00 PM, patient 6 had an unwitnessed fall while walking with his walker.

On 11/17/2014, at 6:31 PM, the following nurses note was written: "It was observed by staff that he was extremely unstable on his feet, more so than usual....it was determined (patient) should be sent to the (hospital) for testing to rule out serious injury."

On a "Post Fall Assessment" form dated 11/17/14, it was documented that "to prevent future falls" there was a need to "evaluate for proper assistive device".

This was five days after patient 6 had told the staff after a fall that he was not used to the walker

On 11/18/14 at 2:18 AM, the following interventions for falls were documented in the patient's chart:
"Nurse will ensure ambulation assistance as needed. This will occur daily and last."
"Nurse will have patient evaluation for assistive device This will occur AS NEEDED and will last."

Fourth Fall
It was documented that on 11/21/2014 at 5:30 PM, patient 6 was sitting on the seat of his walker and slipped off the seat of the walker and fell on his buttock. This was witnessed by staff.

This was another fall associated with patient 6's walker.

On 11/21/14, the following intervention for falls was documented in the patient's chart:

There was a physician's order dated 11/21/14 at 5:52 PM to "initiate chair and bed alarm".

Fifth Fall

It was documented on 11/23/2014 at 2:15 AM, that patient 6 ambulated with his walker to the bathroom by himself and fell at the bathroom doorway. It was unwitnessed. It was documented that the certified nursing assistant forgot to put the bed alarm on.

Patient 7

Patient 7 was an 82 year old male admitted to the hospital on 10/28/14, with the diagnoses of Neurocognitive disorder, Alzheimer's, and Post Tramatic Stress Disorder (PTSD). On admission the family informed the staff that the patient had frequent angry outbursts which included yelling, throwing objects and on occasion he would physically assault others.

Patient 7 had three falls from his admission on 10/28/14 through 11/30/14, when he was hospitalized for a fractured hip.

1. Review of the nurse's notes revealed the following information:

10/28/14: Patient 7 was admitted to the hospital on 10/28/14. At 2:26 PM the nurse documented a complete evaluation of patient 7. A fall assessment was completed. The patient was noted to have an altered mental state with confusion, agitation, disorientation, cognitive limitations and impulsivity. Patient 7 had impaired balance, unsteady gait and a history of falls. The nurse documented that patient 7 was at high risk for falls. The fall prevention recommendations were: Refer for exercise program with balance training, refer for medication management, order toileting with supervision only, toilet every 2 hours and as needed with supervision.

10/29/14, the nurse documented on the care plan that there was a problem due to risk of falls. The short term goals were as follows: The patient will accept prescribed medications, the patient will request ambulation assistance from staff, the patient will call for ambulation help when getting up out of bed daily.

Date of the first fall was 11/1/14. An incident report was completed. Review of the incident report revealed that patient 7 had an unwitnessed fall. Patient 7 told the nurse that he had tripped on another patient's blanket. The patient was alert and there were no apparent injuries.

11/25/14 at 10:48 AM: The nurse documented that patient 7 was independent with ambulation on the unit with a slow, slightly unsteady gait and staff supervision for safety. The nursing care plan included falls. Patient 7 was assessed to be at high risk for falls.

At 9:42 PM. the nurse documented that the care plan included the problem of fall risk. The short term goals were as follows: The patient will accept prescribed medications, the patient will request ambulation assistance from staff, the patient will call for ambulation help when getting up out of bed daily.

The nursing interventions were to ensure ambulation assistance as needed and to apply a bed alarm at night.

11/27/14 at 3:59 PM, the nurse documented that patient 7 had been ambulatory around the unit with an unsteady gait and contact guard (hands on) with a staff member.

Second fall on 11/28/14 at 4:42 PM, the nurse documented the following: Patient 7 was positioned in his bed on his left side. Patient 7 got out of bed and walked out of his room unobserved and approached the dining room chair and fell onto his backside. No injuries were noted.

On 11/28/14, the nurse obtained a telephone order from the physician for a bed and chair alarm for patient safety. (The alarm sounds when a patient starts to get up).

On 11/29/14, the nurse documented the same care plan for falls that had been in place prior to the 11/28/14. The care plan interventions were that staff would provide assistance with ambulation and a bed alarm would be in place at night for safety. The care plan did not mention the use of a chair alarm, which was part of the 11/28/14, physician's order.

Third fall on 11/30/14. Review of a nurse's note dated 11/30/14, revealed that patient 7 fell at 1:45 PM. Patient 7 had accused another patient of kicking him. Patient 7 stood with the other patient's coat and shook the coat at the other patient. Patient 7 swung at the other patient and fell backwards landing on his left hip and hitting the back of his head on the wall. Patient 7 was assessed by the nurse and the physician was notified. Patient 7 was transferred to the hospital at 2:42 PM.

2. Review of an incident report dated 11/30/14, revealed the following information: Patient 7 was in the dining room when he fell. The staff had last seen patient 7 sitting in a recliner. The incident was described. "Pt. swung at another pt. lost his footing and fell backwards landing on left side, hitting his head on wall. The incident report documented that patient 7 was attempting to ambulate by himself. At the bottom of the form was a note which stated that an investigation was done. "Report to follow. Many concerns with the employee." There was no documentation on the incident report indicating that a chair alarm was in place.

The portion of the incident report titled: Post Fall Assessment was reviewed. Item #4 on the form dealt with staff non-compliance with the fall prevention program being a contributing factor in the fall. The written response was "Yes, there was no chair alarm placed on pt. while sitting in the recliner."

Item 7 dealt with what could have been done differently to prevent future falls. The written response was "Making sure proper alarms are in place. Increase pt. supervision as staffing allows". This intervention is based on staffing rather than patient need.

3. A copy of the emergency room report dated 11/30/14, was obtained on 12/3/14, from the hospital where patient 7 was sent after his fall. Review of the emergency physician's report revealed the following: "My concern for the patient is likely for a hip fracture. Exam of his body does not show any signs that are more worrisome than a hip fracture. X-rays are obtained and to my eye show a comminuted surgical neck fracture with at least 3 fragments." Patient 7 was admitted to the hospital for orthopedic surgery.

4. Interview with the Director of Nurses (DON) on 12/2/14, in the presence of the federal surveyor, revealed the following information:

The DON stated that she had been investigating patient 7's fall which occurred during a fight with another patient. The DON stated that the nurse on duty would be let go because the appropriate interventions were not done. The DON stated that low staffing may have contributed to the patient's falls.

5. On 12/4/14, the hospital administrator provided the survey team with a copy of the facility's final investigation of the 11/30/14 fall. The investigation date was 12/2/14. Review of the investigation report revealed the following:

Summary and Conclusion:

During the facility's investigation interviews were conducted with the nurse and aide separately (staff who were on duty when the fall occurred). The investigation report stated that both of the patients were in close proximity and visual site of nurse and the aide. When the patient got up from recliner yelling and began approaching the female patient who he was accusing of kicking him. The nurse got up and started around the desk, when the patient grabbed the females coat and swung. The nurse protected the female and the patient fell to the ground and struck his head on the way down. Both the nurse and aide were right there. The nurse then began her assessment. Due to the patient's agitation and refusal to remain on the floor, the patient was placed in the wheelchair. After the patient was in the wheelchair he started to complain of pain in his upper thigh. The physician was notified and the patient was transported to the hospital.

The investigation report documented the following: "Based upon the final investigation, the conclusion is that the hospital could not have prevented this fall, that staffing was adequate for acuity and census on the unit, that the appropriate procedures were followed, and that there is no evidence of abuse or neglect.

The report conclusion did not indicate whether the chair alarm was in place when patient 7 got out of the recliner

The investigation report was signed by the administrator and the newly appointed DON. The date by the signature was 12/3/14.


04804

Based on review of of the facility's "Annual Quality Improvement Plan for 2014", interview and record review it was determined that the hospital failed to maintain an effective data driven quality assessment and performance improvement program.

Findings include:

1. The hospital failed to monitor the effectiveness and safety of services and the hospital's governing body failed to specify the frequency and detail of data collection. (Refer to tag A-273)

2. The hospital failed to set priorities for its performance improvement activities. (Refer to tag A- 283)

3. The hospital failed to conduct effective performance improvement projects. (Refer to tag A-297)

4. The hospital's governing body failed to ensure that the facility's QAPI program addressed priorities for improved quality of care and patient safety and that the determination of the number of distinct improvement projects is conducted annually. (Refer to tag A-309)

Based on review of the facility's Quality Assurance and Performance Improvement Program (QAPI) it was determined that the hospital failed to monitor the effectiveness and safety of services and the hospital's governing body failed to specify the frequency and detail of data collection.

Findings include:

A review of the facilities QAPI Program for 2014 revealed that the hospital did not monitor the effectiveness and safety of services and the hospital's governing body failed to specify the frequency and details of data collection. There was no documentation that the hospital's governing body approved the QAPI program. There was no documentation of QAPI meeting minutes for 2013 or 2014. There was no documentation available of interventions based on the data collected to improve the safety of services.

On 12/1/2014, RN 1 was interviewed. She stated that she collects data for the Director of Nursing (DON). She stated that she gives the data to the DON to analyze. RN 1 was asked if she attended QAPI meetings and she stated, no I only collect the data. RN 1 then gave the surveyor a document labeled "Compliance Audits" 2014.

A document labeled "Compliance Audits" 2014 was reviewed. It had 28 performance improvement activities listed and the percentages of compliance for the months of January through August. For 4 of the quality activities, data was available and reviewed. For the other 24 activities no data was available.

During a previous abbreviated survey that ended on 9/30/2014, it was substantiated that a patient had developed a pressure ulcer in July of 2014. Review of a form titled "Compliance Audits" for 2014, revealed that
during the month of July there were "0" hospital acquired pressure ulcers. There was no additional data discussing the fact that a patient had developed a pressure sore.

On 12/2/2014 at 1:20 PM, the Administrator handed the surveyor a folder with QAPI Committee Meeting minutes in it. The only documented meetings in the folder were from the year 2012. When the Administrator was asked if he had any other QAPI meeting notes he replied no. Later on, the Administrator gave the surveyor a document titled "Annual Quality Management Plan for 2014".

Based on review of the facility's Quality Assurance and Performance Improvement Program (QAPI) it was determined that the hospital failed to set priorities for its performance improvement activities.

Findings include:

A review of the facilities QAPI Program for 2014 revealed that the hospital did not set priorities for its performance improvement activities. For the activities selected there was no information as to the reasons why they were selected. There was no documentation that the hospital's governing body approved the quality performance improvement activities. There was no documentation that QAPI meetings were held during 2013 or 2014.

On 12/1/2014, a document labeled "Compliance Audits" 2014 was reviewed. It had 28 performance improvement activities listed. There was no documentation that the performance activities were prioritized to address which areas were most in need of improvement.


On 12/2/2014 at 1:20 PM, the Administrator handed the surveyor a folder with QAPI Committee Meeting minutes in it. The only documentation in the folder was from meetings held in 2012. There was no further documentation provided by the facility indicating that meetings had been conducted since 2012.

Based on a review of the facility's Quality Assessment and Performance Improvement Program (QAPI) for 2014, and interview, it was determined that the facility failed to conduct effective performance improvement projects.

Findings include:

A review of the facilities QAPI Program for 2014 revealed that the facility did not document what quality improvement projects needed to be conducted, the reasons for conducting these projects, how to conduct the projects and how to collect data.

On 12/2/2014 at 1:20 PM, the Administrator provided the survey team with a folder which the administrator stated contained QAPI Committee Meeting minutes. The only documentation in the folder was from January of 2012. The administrator stated there was no other QAPI meeting minutes available.

Based on record review and interview it was determined that the hospital's governing body failed to ensure that the hospital's QAPI program addressed priorities for improved quality of care and patient safety and that the determination of the number of distinct improvement projects was conducted annually.

Findings include:

A review of the facilities QAPI Program for 2014, revealed that the hospital did not document which quality improvement projects needed to be conducted, the reasons for conducting these projects, how to conduct the projects and how to collect data. There was no documentation that the hospital's governing body approved the quality performance improvement activities. There was no documentation of QAPI meeting minutes for 2013 or 2014. There was no documentation that the governing body was involved in the QAPI program.

On 12/1/2014, a document labeled "Compliance Audits" 2014 was reviewed. It had 28 performance improvement activities listed. There was no documentation that the quality improvement activities were prioritized.

The was no evidence that the medical staff was involved in QAPI activities.

On 12/2/2014 at 1:20 PM, the Administrator handed the surveyor a folder with QAPI Committee Meeting minutes in it. The only documentation in the folder was from January of 2012. When the Administrator was asked if he had any other QAPI meeting notes he replied no.

An interview was conducted with the hospital's medical director on 12/2/14 at 9:30 am. The medical director stated that they had not had a medical staff meeting since March. He stated that he was planning to start having them again. He stated that with a small hospital they had questioned the need for monthly or quarterly meetings. He stated there had been no medical staff meetings since March of 2014. There was no evidence that the medical staff was involved in QAPI activities.

Based on review of the medical staff meeting minutes and interview with the hospital's Medical Director it was determined that the hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients in the hospital.

Findings include:

The hospital failed to provide a well organized medical staff accountable to the governing body for the quality of medical care provided to the patients.
(Refer toTag A347).

Based on review of the Medical Executive Committee meeting minutes and interview with the hospital's medical director it was determined that the hospital failed to maintain a medical staff which was well organized and accountable to the governing body for the quality of the medical care provided to the patients.


Findings include:

The hospital provided a list of doctors who had privileges at the hospital. There were four physicians on the medical staff.

1. Review of the Medical Executive Committee Meeting minutes covering the months of January, February, and March of 2014, revealed that two doctors and the Director of Nurses were in attendance. Two items were discussed. One was discussing the new treatment team which was increased from 2 days to 5 days a week. And the process was going well. The second concerned the amount of meetings which would be needed for size of the facility (14 beds). It was determined that the meetings did not need to be held monthly or quarterly. "We can determine when to hold meetings. We discuss a lot of thing going on during our daily morning meeting and in our staff meetings. Will move Med Executive, P&T (Pharmaceuticals and Therapeutics), and Quality to every 6 months. However, data will be provided to staff monthly in staff meetings." The meeting was adjourned. "No scheduled future date yet"

2. There were no other meeting minutes provided by the Administrator. There was no documentation that a medical staff meeting had been held during the eight months since the first quarter of 2014.

3. An interview was conducted with the hospital's medical director on 12/2/14 at 9:30 AM. The medical director stated that they had not had a medical staff meeting since March. He stated that he was planning to start having them again. He stated that with a small hospital they had questioned the need for monthly or quarterly meetings. He stated that they checked with the accrediting organization and found that there was no prescribed interval for meetings. He stated that they had decided to hold a meeting every six months.

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

I. Ensure that psychosocial assessments included treatment plan recommendations and role of social work in treatment and discharge planning of five (5) of five (5) sample patients (A1, A2, A3, A4, and A5). This failure has the potential of prolonging hospitalization. (Refer to B108).

II. Ensure that Master Treatment Plans (MTPS) were comprehensive, individualized, and behavioral descriptive with all necessary components for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). Specifically, the MTPs did not include the following: 1) behaviorally descriptive psychiatric problem statements based on clinical information noted in assessments. (Refer to B119); 2) individualized treatment interventions. (Refer to B122); and 3) the name and specific discipline responsible for each intervention (Refer to B123). Failure to develop individualized MTPs with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

III. Ensure a highly structured treatment program based on the needs of the patient population. This failure results in patients lying in bed, roaming about the unit, and being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B125 Part I)

IV. Ensure that scheduled treatment modalities were provided as scheduled for all patients on the acute geropsychiatric unit. Some scheduled groups/activities were cancelled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B125 Part II)

V. Ensure that active individualized psychiatric treatment was provided for four (4) of five (5) active sample patients (A1, A3, A4, and A5). There was failure to provide structured treatment for these patients' specialized needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. The failure results in the patients being hospitalized without relevant interventions to assist them in their recovery. (Refer to B125 Part III)

VI. Provide a concise discharge summary that summarized the course of hospitalization to include a review of all the treatment received in the hospital and the patient's response to that treatment for five (5) of seven (7) discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). In addition, the facility failed to include a complete discharge summary for two (2) of seven (7) patients (D6 and D7), who were discharged to an acute hospital for medical treatment. These failures compromise the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

Based on record review and interview, the facility failed to provide social work assessments that included conclusions and recommendations of the anticipated necessary steps for discharge to occur and the anticipated social work role in treatment and discharge planning for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). As a result, the social work role, conclusions regarding clinical information collected, and specific recommendations regarding treatment of patients' psychosocial problems are not described for the treatment team.

A. Record Review

The social work assessments for the following patients were reviewed (dates of plans in parentheses): A1 (10/14/14), A2 (11/29/14), A3 (11/13/14), A4 (10/10/14), and A5 (11/10/14). This review revealed that none of the Psychosocial Assessments included a summary or conclusion based on the clinical data collected. These Psychosocial Assessments also did not describe or spell out specific recommendations for social work treatment interventions and discharge plans based on the patient's presenting problems, needs, and/or issues.

B. Policy Review

The facility's procedure titled, "Assessment of Patients" stipulated under V. Psychosocial Assessment, that, "The LCSW [Licensed Clinical Social Worker] or designee completes the psychosocial assessment with 72 hours building on data/findings of other disciplines and including...Bio-psychosocial summary." Social work staff failed to follow their own policy regarding the inclusion of a summary in the psychosocial assessment.

C. Staff Interview

In an interview on 12/4/14 at 3:00 p.m., the lack of inclusion of the social worker's role, summary of clinical information and recommendations regarding discharge and treatment planning in the Psychosocial Assessments was discussed with the Director of Social Work. He agreed with the findings and noted that he thought this [recommendations] was achieved when they [social workers] included their input on the treatment plan.

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations included an inventory of specific patient assets for four (4) of five (5) active sample patients (A1, A2, A4, and A5). The failure to identify patient assets potentially impairs the psychiatrist's ability to plan and select treatment modalities that best utilize the patient's strengths.

Findings include:

A. Record Review

The admission psychiatric evaluations (dates in parentheses) for the following patients did not contain specific patient strengths or assets: Patient A1 (10/12/14), Patient A2 (11/29/14), Patient A4 (10/10/14), and Patient A5 (11/9/14).

B. Interview

During an interview with the Medical Director on 12/3/14 at 9:00 a.m., he acknowledged that the psychiatric evaluations did not include specific patient strengths or assets to be used in the treatment of patients. He demonstrated that the electronic medical record system had a tab for strengths but noted that physicians conducting the psychiatric evaluation had not been including this information.

Based on record review and staff interview, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPS). Instead, the stated problems on the treatment plans included diagnoses and/or generalized lists of statements or symptoms, rather than behaviorally descriptive clinical information based on patients' presenting symptoms which had to be resolved or reduced prior to discharge for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.


Findings include:

A. Record review

1. The MTP for Patient A1 dated 11/25/14 had the following psychiatric problem statement: "Psychotic Symptoms - [Patient's name] psychotic symptoms...manifested by: Disorganized Speech - manifested by tangentiality that impairs normal communications - manifested by loose associations that impairs normal communications - with incoherence to the point of 'word salad'..." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested psychotic symptoms.

2. The MTP for Patient A2 dated (12/1/14) had the following psychiatric problem statement: "Depressed Mood - [Patient's name] depressed mood...manifested by: Feeling of Worthlessness, Social Withdrawn. Thought of Death or Suicide or Self Injury, Depressed Mood."

The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested depressed mood symptoms including descriptive information regarding the patient being social withdrawn. Patient A2's Psychiatric Evaluation dated 11/29/14 had the following clinical information, "...has made comments about wanting to die in the past 2 years...on Zoloft 3 weeks for depression, crying spells, stays in bed, ruminates over life losses...Has loss 8# [pounds]."

3. The MTP for Patient A3 dated 11/25/14 had two psychiatric problems, findings regarding intervention statements were associated with the psychiatric problem statement regarding "Cognitive Impairment - [Patient's name] cognitive impairment...manifested by: Severe Functional impairment -and is vulnerable to safety risks and needs careful supervision...unable to recognize family members in the ER."

This problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested the severe functional impairment. Patient A3's Psychiatric Evaluation dated 11/13/14 had the following clinical information, "Familiar people are not recognized or misidentified...safety issues when left alone...may wander. Repeating certain words or stories...confabulates stories or details to hide defects in memory."

4. The MTP for Patient A4 dated 11/25/14 had the following psychiatric problem statement: "Cognitive Impairment - [Patient's name] cognitive impairment mood...manifested by: Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia. Self injurious Behavior - but with no injuries to others by being a wander risk in [his/her] hometown...Delirium - with reduced awareness of the environment - with cognitive and behavioral disturbances...has grossly impaired executive functioning."

The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested cognitive impairment, self-injurious behavior and a description of impaired executive functions. Patient A4's Psychiatric Evaluation dated 10/10/14 reported diagnoses of "Schizotypal (Personality) Disorder and Major Neurocognitive Disorder...with behavioral disturbance." There was limited clinical information regarding cognitive impairment.

5. The MTP for Patient A5 dated 11/26/14 had the following psychiatric problem statement: "Cognitive Impairment - [Patient's name] cognitive impairment...manifested by: Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law...- and is vulnerable to safety risks...Patient is having problems with memory...unclear regarding [his/her] medications. Agitated episodes..." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested cognitive impairment, aggressive behavior and agitated episodes. Patient A5's Psychiatric Evaluation dated 11/9/14 had the following clinical information, "...Pt [patient] has made numerous phone calls to 911...up pacing early hours of the morning and [son-in-law] asked [him/her] to be quiet...became more restless and agitated...throwing self on the floor...There is difficulty naming objects. Difficulty repeating phrases...Word retrieval problems...Mild but diffuse memory loss with difficulty remembering recent events..."

B. Staff Interviews


1. In an interview on 12/2/14 at 12:50 p.m. with the Medical Director, the MTPs for Patient A1 and A2 were discussed. He agreed with the findings and acknowledged treatment plans contained problem statements that did not include descriptive information from clinical assessments.

2. In an interview on 12/2/14 at 3:00 p.m. with the Director of Social Work, the MTPs for Patients A1 and A2 were reviewed. He acknowledged that some statements on the treatment plans were not described in behavioral terms and did not use descriptive information from clinical assessments.

Based on observation, record review, and interview, the facility failed to provide five (5) of five (5) active sample patients (A1,A2, A3, A4, and A5) with Master Treatment Plans (MTPs) that included individualized interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Instead, the MTPs included routine discipline functions and/or tasks written as treatment interventions. In addition, treatment interventions statements failed to identify a method of delivery and the frequency of contact with the patient. There were no treatment interventions identified at all to be implemented by the recreational therapist and no treatment intervention to be implemented by the psychiatrist and registered nurses for two (2) of five (5) active sample patients (A3 and A5). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that the MTPs from the electronic medical record included but not limited to the following treatment interventions formulated, for psychiatric problems, which were routine and generic discipline functions (such as assessing patients, ordering laboratory work, explaining unit rules, and encouraging patients) written as treatment interventions. In addition, this review also revealed treatment interventions on the MTPs that failed to include the frequency of contact and did not identify how interventions would be delivered by clinical staff. Most of the intervention statements were identical or similarly worded for these patients despite different presenting clinical history.

1. Patient A1 had the following interventions statements formulated for the problem, "Psychotic Symptoms - [Patient's name] psychotic symptoms has been identified as an active problem in need of treatment. It is primarily manifested by: Disorganized Speech- manifested by tangentiality that impairs normal communications. - manifested by loose associations that impairs normal communications. - with incoherence to the point of 'word salad'...."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will educate patient (patient's family) as to the RISK AND BENEFITS of treatment and obtain inform consent, if appropriate." 3. "Prescriber will examine patient assess condition and order lab and appropriate consultations to determine if PHYSICAL DISEASE is present to explain psychotic symptoms." 4. "Prescriber to prescribe medications, monitor side effect, and adjust dosage to minimize or eliminate psychotic symptoms and minimize side effects."

SW Interventions: 5. "Case Manager to discuss Rules of the unit and role of each staff member to the patient." 6. "Therapist will attempt to establish a trusting relationship with patient. "

RN Interventions: 7. "Nurse will actively engage patient and encourage participation in ACTIVITES." 8. "Nurse will encourage participation in organized ACTIVITIES." 9. "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION with other patients and in activities," 10. "Nursing staff to encourage attention to DRESSING AND GROOMING and hygiene, and the maintenance of personal area."

There were no interventions that identified what recreational therapist would do to assist this patient with psychotic symptoms identified in clinical assessments. Intervention statements 1 and 3-10 were actually generic and routine discipline functions that would be provided this patient regardless of his/her presenting symptoms. Intervention 2 was a treatment intervention but failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient.

2. Patient A2 had the following interventions statements formulated for the problem, "Depressed Mood - [Patient's name] depressed mood has been identified as an active problem in need of treatment. It is primarily manifested by: Feeling of Worthlessness, Social Withdrawn."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will examine patient assess condition and order lab and appropriate consultations to determine if PHYSICAL DISEASE is present to explain mood disorder." 3. "Prescriber will examine patient, assess condition and order lab and appropriate consultants to determine if if [sic] there is imminent DANGER TO SELF due to depressive symptoms." 4. "Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABLIZE MOOD and minimize side effects."

SW Interventions: 5. "Therapist/Counselor will provide emotional SUPPORT and encourage, and help patient focus on sources of pleasure and meaning." 6. Therapist/Counselor will help patient EXPLORE behaviors and reactions that lead to feelings of depression." 7. "Family sessions to allow patient to come to CONFLICT RESOLUTION with family member." 8. "Therapist/Counselor will help patient EXPLORE behaviors and reactions that lead to feelings of depression." 9. "Clinician will meet with [him/her] create a safety plan and resources to access after [s/he] discharges if feeling depressed or suicidal..."

RN Interventions: 10. "Nurse will actively engage patient and encourage participation in ACTIVITES." 11. Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS." 12. "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION with other patients and in activities," 13. "Nursing staff to encourage and support attendance at all MEALS."

There were no interventions that identified what recreational therapist would do to assist this patient with the symptoms of depressed mood. Intervention statements 1 -5 and 10 - 13 were actually generic and routine discipline functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms. Interventions 6, 8 and 9 were treatment interventions that failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient. Intervention 7 did not include the frequency of contact for the family therapy sessions.

3. Patient A3 had two psychiatric problems with the following interventions statements:
"Psychotic Disorder NOS [Not Otherwise Specified] - [Patient's name] psychotic symptoms manifested by: Disorganized Behaviors - Hallucinations - auditory hallucinations. [S/he] believes that [his/her] dog talks to [him/her]. Delusions - paranoid. [S/he] believes that people have moved into [his/her] basement..."

There were no interventions that identified what the psychiatrist, registered nurse, and recreational therapists would do to assist this patient with the psychotic symptoms identified in the problem statement.

"Cognitive Impairment - [Patient's name] cognitive impairment manifested by: "Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law...- and is vulnerable to safety risks. Patient is having problems with memory...unclear regarding her medications. Agitated episodes..."

There were no interventions that identified what the psychiatrist, registered nurse, and recreational therapists would provide to assist this patient.

4. Patient A4 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment Mood - [Patient's name] cognitive impairment mood has been identified as an active problem in need of treatment. It is primarily manifested by: Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia. Self injurious Behavior - but with no injuries to others by being a wander risk in [his/her] hometown...Delirium - with reduced awareness of the environment - with cognitive and behavioral disturbances...has grossly impaired executive functioning."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will educate patient (patient's family) as to the RISK AND BENEFITS of treatment and obtain inform consent, if appropriate." 3. "Prescriber to prescribe medication, monitor side effects and adjust dosage to control symptoms."

SW Interventions: 4. "Case Manager to explain rules of practice and the roles of various staff members." 5. "Case Manager to maintain contact with family for informational reasons and to keep them engaged in the treatment process." 6. "Therapist to provide emotional support and help patient create strategies for dealing with cognitive limitations."

RN Interventions: 7. "Nurse to encourage and support attention to ADLs, attendance at meals and activities." 8. "Nurse to dispense medication, monitor and record compliance, side effects, and responses to treatment." 9. "Nursing staff to provide a safe environment and monitor risk of falls."

There were no interventions that identified what recreational therapist would do to assist this patient with behaviors associated with cognitive impairment. Intervention statements 1, 3-5, and 7-9 were not individualized to reflect this patient's presenting symptoms. These statements were actually generic and routine discipline functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms. Interventions 2 and 6 were treatment intervention statements but failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient.

5. Patient A5 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment - [Patient's name] cognitive impairment has been identified as an active problem in need of treatment. It is primarily manifested by: "Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law...- and is vulnerable to safety risks. Patient is having problems with memory...unclear regarding [her/his] medications. Agitated episodes..."

SW Interventions: 1. "Group therapy to provide emotional support and to share feelings with others. This will occur 1-3 times per day and will last 30 minutes." 2. "Family sessions to encourage communication and to help devise strategies for dealing with cognitive deficits."

There were no interventions that identified what the psychiatrist, registered nurse, and recreational therapists would provide to assist this patient with the symptoms of cognitive impairment. Intervention 1 was a global statement that was not specifically related to the symptoms of cognitive impairment identified. Intervention 2 did not include the number of family sessions to be held.

B. Staff Interviews

1. During interview on 12/2/14 at 9:00 a.m., the Director of Nursing stated, "There are no specific nursing interventions in the treatment plans."

2. During interview on 12/2/14 at 11:00 a.m. including a discussion of treatment plans, the Medical Director (primary physician for all patients), he stated "I need to add physician interventions in the treatment plans."

3. In an interview on 12/2/14 at 12:50 p.m. with the Medical Director, the MTPs for Patient A1 and A2 were discussed. He acknowledged treatment plans contained routine clinical functions instead of specific individualized treatment interventions based of the patient's presenting symptoms.

4. In an interview on 12/2/14 at 3:00 p.m. with the Director of Social Work, the MTPs for Patients A1 and A2 were reviewed. He agreed these plans contained routine staff functions instead of specific interventions to address the patients presenting symptoms.

Based on record and interview, the facility failed to provide MTPs that specified both the name and discipline of staff responsible for implementing interventions for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). Failure to assign specific staff members for intervention modalities results in an inability to determine what staff member is responsible for ensuring the interventions are implemented, potentially hampering the effective coordination of treatment modalities.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that MTPs failed to consistently include both the name and discipline of clinical staff responsible for implementing interventions outlined on the MTPs.

B. Staff Interviews

1. During an interview with the Medical Director on 12:50 p.m., he agreed with the findings and acknowledged that MTPs for Patients A1 and A2 did not contain the names of staff responsible for implementing treatment interventions.

2. In an interview on 12/12/14 at 3:00 p.m. with the Director of Social Work, the MTPs for Patients A1 and A2 were reviewed. He acknowledged that interventions did not include the name of staff responsible for implementing interventions identified on the treatment plan.

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

I. Ensure a highly structured treatment program based on the needs of the patient population. This failure results in patients lying in bed, roaming about the unit and being hospitalized without all interventions for recovery being provided in a timely fashion. .

II. Ensure that treatment modalities were provided as scheduled for all patients on the acute geropsychiatric unit. Some scheduled groups/activities were cancelled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement.

III. Ensure that active individualized psychiatric treatment was provided for four (4) of five (5) active sample patients (A1, A3, A4, and A5). There was failure to provide structured treatment for these patients' specialized needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. The failure results in the patients being hospitalized without interventions to assist them in their recovery.

Findings include:

I. Failure to provide a structured treatment program based on the needs of the patient population:

A. The Marian Center has one unit (capacity of 14 patients) described as providing treatment for acute geropsychiatric patients. During the survey the patient population consisted of patients with a wide array of symptoms including severe cognitive deficits. Most patients also presented with medical/physical disabilities. Some patients also presented psychotic/emotional symptoms. These patients required a structured schedule with a high level of cognitive and sensory treatment interventions.

B. Review of the program schedules provided by administrative staff revealed the following information:

1. The weekday schedule (Monday through Friday) included a) two groups conducted by recreation staff, b) one "group therapy" session conducted by social work and 3) two 30-minute groups listed as "Cognitive Abilities and Orientation Skills, two fifteen minute walk sessions and a community meeting conducted by Certified Nursing Assistants." The remainder of the schedule from 6:00 a.m. to 10:00 p.m. included times for functional activities as hygiene care, meals, quiet time, bed time, and visiting hours.

2. The weekend schedule (Saturday and Sunday) listed only one leisure activity conducted by recreation staff.

C. Interviews:

1. During interview on 12/1/14 at 1:10 p.m., CNA (Certified Nursing Assistant) W2 reported that she does not receive direction from an RN regarding content of assigned group sessions. She stated, "We choose what we want to do each day from materials that are available for us."

2. During interview on 12/1/14 at 3:35 p.m., when asked if there is a unit schedule for week-end activities, RN W1 reported that activities on the week-end are more "mellow." She added, "There are usually a social work and a recreation group."

3. During interview on 12/2/14 at 11:40 a.m., the Director of Recreation related that there is no time allotted for individual time with patients; however, one of the recreation staff members provides this service if they see the need or if individual time with a patient is requested by the unit staff. She reported that such sessions are not documented in the medical record. The Director of Recreation stated that the Saturday and Sunday groups are always leisure oriented.

II. Failure to ensure that groups/activities occur as scheduled:

A. Observations on the unit revealed that the group therapy sessions by social work from 1:00-1:30 p.m. on 12/1/14 and 12/2/14 were canceled.

B. During observation on 12/1/14 at 4:30 p.m., the unit's "Weekday Program Schedule" showed that an activity listed as, "CNA Activity stimulating Cognitive Abilities and Orientation Skills" was scheduled to be conducted from 4:30 p.m.to 5:00 p.m. This activity was not held as scheduled.

C. During observation on 12/2/14 at 11:35 a.m., the unit's "Weekday Program Schedule" showed that an activity listed as, "Group Walk" was scheduled to be conducted from 11:30 a.m. - 11:45 a.m. This activity was not held as scheduled.

C. Interviews:

1. During interview on 12/1/14 at 3:35 p.m., RN W1 verified that the group session scheduled from 1:00-1:30 p.m. on week-days is supposed to be conducted by a social worker.

2. During interview on 12/2/14 at 3:55 p.m., the Director of Social Work stated that the group schedule that included social work was developed by the DON and "has not really been implemented."

3. During discussion on 12/1/14 at 4:45 p.m., RN W3, after looking at the schedule, stated that the group should have been held and asked the CNA to do the group. However, the CNA was not able to get the patients to the table until 5:00 p.m. when the dinner trays were arriving.

4. During interview on 12/2/14 at 1:20 p.m. RN W1 reported that the scheduled 1:00-1:30 p.m. group by social work is "frequently" canceled.

III. Failure to provide treatment based on individual patients' needs:

A. Patient Findings:

1. Patient A1 was a 60-year old patient admitted on 10/12/14.

a. The Psychiatric Evaluation dated 10/12/14 documented that, "[S/he] is oriented to person only...attempts to answer some questions but quickly devolves either into paranoid comments or word salad...patient was found wandering, in a confused state..."

b. During observation on 12/1/14 at 11:30 a.m., Patient A1 attended an activity conducted by a Certified Nursing Assistant. Patient A1 sat and listen but answers to some questions were not related to the question asked especially if the patient had to respond with more than a yes or no statement.

c. During observation on 12/2/14 from 8:45 - 9:25 a.m., Patient A1 attended an activity listed on the "Weekday Schedule" as "Stretching the Mind and your Muscles. Discussing Daily Events in Newspaper and Stretching Exercises" and was conducted by a recreational therapist. Patient A1 had difficulty responding to the puzzle the therapist read from the newspaper and had problems finding words when the response required more than a yes or no.

d. During interview on 12/2/14 at 9:30 a.m. after the group session, the therapist admitted that some of the content from the newspaper was too difficult for the patients attending the group.

2. Patient A3 is an 83-year old patient admitted on 11/12/14.

a. As documented in the psychiatric evaluation (11/13/14) Patient A3 "exhibits symptoms of brain injury, dementia or delirium...recent symptoms suggest that cognitive deficits are severe ...Diagnoses: Psychotic Disorder...Major Neurocognitive Disorder Due to Alzheimer's, without behavioral disturbance." This evaluation stated, "Has had a significant decline in cognitive function over the past several months."

b. Observation of a group activity on 12/1/14 at 11:30 a.m. conducted by a Certified Nursing Assistant revealed Patient A3 as being confused and unable to answer direction questions.

c. Review of most recent treatment plan (11/25/14): For problem stated as "Cognitive Impairment...manifested by...much more confused over the last few months. Unable to recognize family members in the ER (Emergency Room)," the only intervention was listed as "Family sessions to encourage communication and to help devise strategies for dealing with cognitive deficits."

d. Even though this patient needed highly structured treatment, Patient A3 was observed on 12/1/14 at 1:00-1:30 p.m. sitting alone in the dayroom "staring into space." On 12/2/14 Patient A3 was observed from 3:40-4:00 p.m. roaming about the unit "worrying with objects" on tables, etc. During the time that a scheduled group on 12/1/14 from 1:00-130 p.m. was cancelled, Patient 3 was observed to sitting alone "staring into space."

2. Patient A4 is a 65 year-old patient admitted on 10/9/14.

a. As documented in the psychiatric evaluation (10/10/14) Patient A4 was admitted from the VA (hospital) after telling social worker that s/he told his social worker that "(mate) tried to stab (him/her) and (s/he) didn't feel safe going home...there was concern of delusional disorder...Diagnoses..." Schizotypal (Personality) Disorder...Major Neurocognitive Disorder."

b. During interview on 12/1/14 at 12:00 p.m., Patient A4 was not aware of his/her reason for admission to this hospital. S/he stated, "I'm here because of my Diabetes." All Patient A4 talked about was his/her earlier years of work and service experience in Viet Nam.

c. During interview on 12/1/14 at 12:10 p.m. RN W1 reported that Patient A4 continues to want to go home. She stated that the patient refuses to wear hearing aid as s/he thinks that batteries are dead (not true). According to RN W1 this patient does not understand why s/he is unable to go home and that the process for guardianship by his/her son is in progress.

d. Review of most recent treatment plan (11/24/14): For problem stated as "Cognitive Impairment...manifested by Inattention and Impulsivity...being a wander risk in [his/her] hometown...cognitive and behavioral disturbances...," the only intervention related to this specific problem was non-individualized and stated as "Nurse will help structure daily activities in accord with patient's cognitive abilities."

e. Even though this patient needed highly structured treatment, Patient A4 was observed on 12/1/14 from 10:45 to 11:30 a.m. sitting in front of the television. During the time that a scheduled group on 12/1/14 from 1:00-130 p.m. was cancelled, Patient 3 was observed to sitting/sleeping in front of the television.

4. Patient A5 is an 88 year-old patient admitted on 11/8/14.

a. As documented in the psychiatric evaluation (11/9/14) Patient A5 was admitted due to "getting agitated and upset because [s/he] feels that [his/her] daughter is trying to keep [him/her] in prison...periods of confusion with fund of knowledge indicate cognitive functioning in the borderline range...Diagnoses:...Major Neurocognitive Disorder due to Alzheimer's, with behavioral disturbance."

b. Review of most recent treatment plan (11/26/14): For problem stated as "Cognitive Impairment...manifested by Inattention and Impulsivity ...recently being aggressive. Verbally abusive towards daughter and son-in-law, the only interventions were listed as "Group therapy to provide emotional support and to share feelings with others." and "Family sessions to encourage communication and to help devise strategies for dealing with cognitive deficits."

c. Even though this Patient A5 needed highly structured treatment, Patient A5 was observed on 12/1/14 sitting in his/her room alone at 11:40 a.m. after refusing to attend a group activity. Also observed sitting in room on 12/1/14 from 12:50-1:00 p.m.

d. During the time that a scheduled group on 12/1/14 from 1:00-1:30 p.m. was cancelled, Patient A5 was observed to be sitting/walking around his/her room and dayroom. At 1:20 p.m. on this date, Patient A5 became agitated, fussing at staff and grumbling to self in the dayroom. Observation on 12/1/14 from 3:45-4:00 p.m. revealed Patient A5 sitting on the seat of his/her walker rapidly pushing self backward around the dayroom. During the time that a group on 12/2/12 from 1:00-1:30 p.m. was cancelled, Patient A5 was lying in his/her bed.

Based on record review and interview, the facility failed to provide a concise discharge summary that summarized the course of hospitalization to include a review of all the treatment received in the hospital and the patient's response to treatment for five (5) of seven (7) discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). In addition, the facility failed to include a complete discharge summary for two (2) of seven (7) patients (D6 and D7), who were discharged to an acute hospital for medical treatment. These failures compromise the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

1. Patient D1 was admitted 10/5/14 with a diagnosis of "Major Depressive Disorder, Recurrent Episode, Severe." In a discharge summary dated 11/31/14, under the section titled "Course in Hospital," the Biopsychosocial Assessment dated 10/5/14 and Medical History and Physical Exam [Examination] dated 10/5/14 were included to provide information regarding the reason for the patient's admission. However, these assessments were not summarized and included almost all of the information on the assessment completed at the time of admission. There was no information included in the discharge summary regarding treatment services provided by social work, medical, nursing, and recreational therapy and the patient's response to these services during the patient's 60 days of hospitalization.

2. Patient D2 was admitted 8/9/14 with a diagnosis of "Psychotic Disorder [with] hallucinations, other disorder." In a discharge summary dated 8/25/14, the section titled "Course in Hospital" included the Initial Psychiatric Assessment dated 8/19/14 and progress notes by the physician dated 8/21/14, 8/22/14, and 8/23/14. The Initial Psychiatric Assessment was not summarized and included information not relevant to the patient's discharge, such as, "Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available." The section titled "Clinician's Narrative" had the following notation: "Patient sent to ER [emergency room] due to change in mental status. [S/he] was admitted for further observation and treatment." There was no further information regarding this transfer to an acute care hospital for medical treatment. In addition, there was no information included in the discharge summary regarding treatment services provided by social work, medical, nursing, and recreational therapy and the patient ' s response to these services during the patient's 14 days of hospitalization.

3. Patient D3 was admitted 9/17/14 with a diagnosis of "Bipolar 1, Current or most recent episode Manic, Severe with Psychotic Features." A discharge summary dated 9/21/14) included: the Initial Psychiatric Assessment dated 9/18/14; under the section titled "Course in Hospital," included the "Medical History and Physical Exam [examination]"; Nursing notes by the registered nurse stating, "Patient found unresponsive with head back in wheelchair sitting at table...EMS [Emergency Medical Services] called...and patient transferred...Dr. [Physician name] notified and order received to transfer to [Hospital's name]; Progress notes by the physician dated 9/21/14 noting the patient's condition and transfer to a medical facility. There was no information included in the discharge summary regarding treatment services provided by social work, medical, nursing, and recreational therapy and the patient's response to these services during the patient's 4 days of hospitalization.

4. Patient D4 was admitted 10/13/14 with a diagnosis of "Major Neurocognitive Disorder due to Parkinson's Disease with behavioral disturbance." The discharge summary dated 10/20/14 included: the Initial Psychiatric Assessment dated 10/13/14; and under the section titled "Course in Hospital," and progress notes by the physician dated 10/15/14, 10/17/14, 10/18/14, and 10/20/14. The Initial Psychiatric Assessment was not summarized and included information not relevant to the patient's discharge, such as, "This session the therapeutic focus was on assessing the type and severity of the problem." The progress notes documented the physician contact with the patients, a description of the physician's interventions including medication management, and the patient's condition. However, there was no information included regarding treatment services provided by social work, medical, nursing, and recreational therapy provided and the patient's response to these services during the patient's 7 days of hospitalization.

5. Patient D5 was admitted 11/12/14 with a diagnosis of "Major Depressive Disorder, Single Episode, Severe." The discharge summary dated 11/19/14 included under the section titled "Course in Hospital," Progress notes by the physician dated 11/14/14, 11/15/14, 11/17/14, 11/18/17, and 11/19/14. The final progress note on the day of discharge [11/19/14] documented the physician contact with the patients, a description of the physician's interventions including medication management, and the patient's condition. However, did not document a summary of the patient's treatment other than medications. There was no information included regarding treatment services provided by social work, medical, nursing, and recreational therapy and the patient's response to these services during the patient's 7 days of hospitalization.

6. Patient D6 was admitted 9/25/14 and discharged 10/5/14 to an acute hospital for medical treatment. The nursing notes submitted provided information regarding the patient's condition at time of discharge but there was no other information generated from the electronic medical record that provided a summary which included the reason for admission, the patient's response to treatment interventions, medication management, and services provided by clinical staff during the patient's hospitalization. This discharge occurred on the weekend.

7. Patient D7 was admitted 7/29/14 and discharged 8/7/14 to an acute hospital for medical treatment. Information generated from the electronic medical record for the discharge summary included progress notes dated 8/7/14 by the physician, nursing notes dated 8/7/13 and a medical consultation dated 8/6/14. Although, the physician's documented about medication management, there was no information that provided a summary that included the reason for admission, the patient's response to treatment interventions and services provided by other clinical staff during the patient's hospitalization.

B. Policy Review

The facility failed to follow its own policy regarding discharge summaries. The facility's Policy "Discharge Summary" updated 7/2011, stipulated that, "The Discharge Summary includes a clinical resume that concisely reviews:....The clinical course of treatment and progress of the patient with regard to each identified clinical problem...A summary of services provided and the client's progress toward goals since admission."

C. Interview

1. During interviews on 12/2/14 at 12:50 a.m. and on 12/3/14 at 9:00 a.m., the Medical Director was shown the deficiencies noted in the discharge summaries and he agreed with the findings. He noted that there was a problem with physician not completing discharge information when a patient is transferred to an acute medical facility for treatment on weekends.

2. During a contact on 12/3/14 at 9:00 a.m., the Medical Director was shown information included in discharge summaries that were not relevant to the discharge of the patient. He agreed with the findings and added that the electronic medical record allowed them to easily remove this information.

Based on interview and document review, the facility failed to assure that the Medical
Director and the Director of Nursing monitored active treatment and took corrective actions. Specifically,

I. The Medical Director failed to:

A. Ensure that psychosocial assessments included treatment plan recommendations and role of social work in treatment of five (5) of five (5) sample patients (A1, A2, A3, A4, and A5). This failure has the potential of prolonging hospitalization. (Refer to B144, Part I)

B. Ensure that individualized psychiatric problem statements written in behavioral and descriptive terms were included on Master Treatment Plans (MTPS) based on clinical assessment data. Instead, the stated problems on the treatment plans included diagnoses, lists of symptoms and generalized statements, rather than behaviorally descriptive problem statements based on patients' presenting psychiatric symptoms which had to be resolved or reduced prior to discharge for five (5) of five (5) active sample patients for (A1, A2, A3, A4, and A5). These failures result in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B144, Part III)

C. Include Master Treatment Plans (MTPs) that evidenced individualized physician treatment interventions with specific focus based on individual needs and abilities of five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). This deficiency results in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and potentially results in inconsistent and/or ineffective treatment. (Refer to B144, Part IV).

D. Provide MTPs that specified both the name and discipline of staff responsible for implementing interventions for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). Failure to assign specific staff members for intervention modalities results in an inability to determine what staff member is responsible for ensuring the interventions are implemented, potentially hampering the effective coordination of treatment modalities. (Refer to B144, Part V).

E. Ensure a highly structured treatment program based on the needs of the patient population. This failure results in patients lying in bed, roaming about the unit and being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B144, Part VI).

F. Ensure that treatment modalities were provided as scheduled for all patients on 1 of 1 (acute geropsychiatric) units. Some scheduled groups/activities were cancelled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B144, Part VII).

G. Ensure that active individualized psychiatric treatment was provided for four (4) of five (5) active sample patients (A1, A3, A4, and A5). There was failure to provide structured treatment for these patients' specialized needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. The failure results in the patients being hospitalized without interventions to assist them in their recovery. (Refer to B144, Part VIII).

H. Provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment, other than medication usage, for five (5) of seven (7) discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). In addition, the facility failed to include a discharge summary for two (2) of seven (7) patients (D6 and D7), who were discharged to an acute hospital for medical treatment. These failures compromise the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer B144, Part IX)

II. The Director of Nursing failed to:

A. Ensure that treatment plans included individualized nursing interventions for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5). This failure prevented nursing personnel from providing safe, consistent focused treatment. (Refer to B148, Part I)

II. Provide sufficient numbers of nursing personnel on the geropsychiatric unit based on the numbers and acuity needs of patients on both day and night (12 hour) shifts of duty. These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and preventive interventions and in actual/ potential safety risks for patients and staff. (Refer to B148, Part II)

Based on observation, record review, and interview, the Medical Director failed to monitor to ensure quality psychiatric services. Specifically, the Medical Director failed to:

I. Ensure that psychosocial assessments included treatment plan recommendations and role of social work in treatment of five (5) of five (5) sample patients (A1, A2, A3, A4, and A5). This failure has the potential of prolonging hospitalization. (Refer to B108)

II. Ensure that psychiatric evaluations included an inventory of specific patient assets for four (4) of five (5) active sample patients (A1, A2, A4, and A5). The failure to identify patient assets potentially impairs the psychiatrist's ability to plan and select treatment modalities that best utilize the patient's strengths. (Refer to B117)

III. Ensure that individualized psychiatric problem statements written in behavioral and descriptive terms were included on Master Treatment Plans (MTPs) based on clinical assessment data. Instead, the stated psychiatric problems on the treatment plans included diagnoses, lists of symptoms and generalized statements, rather than behaviorally descriptive problem statements based on patients' presenting psychiatric symptoms which had to be resolved or reduced prior to discharge for five (5) of five (5) active sample patients for (A1, A2, A3, A4, and A5). These failures result in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B119)

IV. Include Master Treatment Plans (MTPs) that evidenced individualized physician treatment interventions with specific focus based on individual needs and abilities of five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). Specifically, interventions formulated for the physician were routine physician functions and/or tasks written as treatment interventions. In addition, treatment interventions statements failed to identify a method of delivery and the frequency of contact with the patient. There were no physician interventions included for some of the psychiatric problems on the MTPs for two (2) of five (5) active sample patients (A3 and A5). This deficiency results in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that the MTPs from the electronic medical record included but not limited to the following treatment interventions formulated, for psychiatric problems, which were routine and generic discipline functions (such as assessing patients and ordering laboratory work) written as physician's treatment interventions. In addition, this review also revealed treatment interventions on the MTPs that failed to include the frequency of contact and did not identify how interventions would be delivered by the physician. Most of the intervention statements were identical or similarly worded for these patients despite different presenting clinical history.

1. Patient A1 had the following interventions statements formulated for the problem, "Psychotic Symptoms - [Patient's name] psychotic symptoms...manifested by: Disorganized Speech- manifested by tangentiality that impairs normal communications - manifested by loose associations that impairs normal communications. - with incoherence to the point of 'word salad'..."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will educate patient (patient's family) as to the RISK AND BENEFITS of treatment and obtain inform consent, if appropriate." 3. "Prescriber will examine patient assess condition and order lab and appropriate consultations to determine if PHYSICAL DISEASE is present to explain psychotic symptoms." 4. "Prescriber to prescribe medications, monitor side effect, and adjust dosage to minimize or eliminate psychotic symptoms and minimize side effects."

Intervention statements 1, 3 and 4 were actually generic and routine physician functions and tasks that would be provided this patient regardless of his/her presenting symptoms. Intervention 2 was a treatment intervention but failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient.

2. Patient A2 had the following interventions statements formulated for the problem, "Depressed Mood - [Patient's name] depressed mood...manifested by: Feeling of Worthlessness, Social Withdrawn."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will examine patient assess condition and order lab and appropriate consultations to determine if PHYSICAL DISEASE is present to explain mood disorder." 3. "Prescriber will examine patient, assess condition and order lab and appropriate consultants to determine if [if] there is imminent DANGER TO SELF due to depressive symptoms." 4. "Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABLIZE MOOD and minimize side effects.

Intervention statements 1-5 were actually generic and routine physician functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms.

3. Patient A3 had two psychiatric problems with the following documentation:

"Psychotic Disorder NOS [Not Otherwise Specified] - [Patient's name] psychotic symptoms ... manifested by: Disorganized Behaviors - Hallucinations - auditory hallucinations. [S/he] believes that [his/her] dog talks to [him/her]. Delusions - paranoid. [S/he] believes that people have moved into [his/her] basement..."

There were no interventions that identified what the psychiatrist would do to assist this patient with the psychotic symptoms identified in the problem statement.

"Cognitive Impairment - [Patient's name] cognitive impairment... manifested by: "Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law... - and is vulnerable to safety risks. Patient is having problems with memory....unclear regarding her medications. Agitated episodes..."

There were no interventions that identified what the psychiatrist would provide to assist this patient with the symptoms of cognitive impairment.

4. Patient A4 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment Mood - [Patient's name] cognitive impairment mood... manifested by: Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia. Self injurious Behavior - but with no injuries to others by being a wander risk in [his/her] hometown...Delirium - with reduced awareness of the environment - with cognitive and behavioral disturbances...has grossly impaired executive functioning."

MD Interventions: 1. "Prescriber will examine patient and order consultants and lab as needed to arrive at all appropriate DIAGNOSES." 2. "Prescriber will educate patient (patient's family) as to the RISK AND BENEFITS of treatment and obtain inform consent, if appropriate." 3. "Prescriber to prescribe medication, monitor side effects and adjust dosage to control symptoms."

Intervention statements 1 and 3-5 were not individualized to reflect this patient's presenting symptoms. The above statements were actually generic and routine physician functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms. Interventions 2 was a treatment intervention statements but failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient.

5. Patient A5 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment" - [Patient's name] cognitive impairment...manifested by: "Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law...- and is vulnerable to safety risks. Patient is having problems with memory... unclear regarding [her/his] medications. Agitated episodes..."

There were no interventions that identified what the psychiatrist would provide to assist this patient with the symptoms of cognitive impairment.

B. Interviews

1. During interview on 12/2/14 at 11:00 a.m. including a discussion of treatment plans, the Director of Clinical Services (primary physician for all patients), he stated "I need to add physician interventions in the treatment plans."

2. In an interview on 12/2/14 at 12:50 p.m. with the medical director, the MTPs for Patient A1 and A2 were discussed. He acknowledged treatment plans contained routine clinical functions instead of specific individualized treatment interventions based of the patient's presenting symptoms.

V. Provide MTPs that specified both the name and discipline of staff responsible for implementing interventions for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). Failure to assign specific staff members for intervention modalities results in an inability to determine what staff member is responsible for ensuring the interventions are implemented, potentially hampering the effective coordination of treatment modalities. (Refer to B123)

VI. Ensure a highly structured treatment program based on the needs of the patient population. This failure results in patients lying in bed, roaming about the unit and being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125, Part I)

VII. Ensure that scheduled treatment modalities were provided as scheduled for all patients on 1 of 1 (acute neuropsychiatric) units. Some scheduled groups/activities were cancelled. This deficient practice results in fragmented treatment for patients and potentially delays their improvement. (Refer to B125, Part II)

V1II. Ensure that active individualized psychiatric treatment was provided for four (4) of five (5) active sample patients (A1, A3, A4 and A5). There was failure to provide structured treatment for these patients' specialized needs. These patients functioned at low cognitive and social levels, yet adequate modalities to address their problems were not provided. The failure results in the patients being hospitalized without interventions to assist them in their recovery. (Refer to B125, Part III)

IX. Provide a concise discharge summary that summarized the course of hospitalization to include a review of all the treatment received in the hospital and the patient's response to treatment for five (5) of seven (7) discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). In addition, the facility failed to include a complete discharge summary for two (2) of seven (7) patients (D6 and D7), who were discharged to an acute hospital for medical treatment. These failures compromise the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

Based on observation, interview, and record review, it was determined that the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that treatment plans included individualized nursing interventions for five (5) of five (5) active sample patients (A1, A2, A3, A4, and A5). This failure prevented nursing personnel from providing safe, consistent focused treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that the MTPs failed to include nursing interventions or listed generic discipline functions written as treatment interventions. In addition, this review also revealed treatment interventions on the MTPs that failed to include the frequency of contact and did not identify how interventions would be delivered by clinical staff. Most of the intervention statements were identical or similarly worded for these patients despite different presenting clinical history.

1. Patient A1: The psychiatric problem was identified as "Psychotic Symptoms... manifested by: Disorganized Speech- manifested by tangentiality that impairs normal communications. - manifested by loose associations that impairs normal communications. - with incoherence to the point of 'word salad'..." The identified RN interventions were stated as, "Nurse will actively engage patient and encourage participation in ACTIVITES." "Nurse will encourage participation in organized ACTIVITIES." "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION with other patients and in activities," "Nursing staff to encourage attention to DRESSING AND GROOMING and hygiene, and the maintenance of personal area."

There were no nursing interventions to address the patient's psychotic behaviors.

2. Patient A2: For problem identified as "Depressed Mood... manifested by: Feeling of Worthlessness, Social Withdrawn," the RN Interventions were stated as: "Nurse will actively engage patient and encourage participation in ACTIVITES." "Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS." "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION with other patients and in activities," "Nursing staff to encourage and support attendance at all MEALS."

There were no specific nursing interventions to address the mood behaviors presented by the patient.

3. Patient A3: For problem listed as "Psychotic Disorder NOS [Not Otherwise Specified] ... manifested by: Disorganized Behaviors - Hallucinations - auditory hallucinations. [S/he] believes that [his/her] dog talks to [him/her]. Delusions - paranoid. [S/he] believes that people have moved into [his/her] basement...," there were no identified nursing interventions.

For problem listed as "Cognitive Impairment...manifested by manifested by: "Inattention and Impulsivity...has recently been aggressive. Verbally abusive toward daughter and son-in-law... - and is vulnerable to safety risks. Patient is having problems with memory...Agitated episodes...," there were no identified nursing interventions.

4. Patient A4: For problem identified as "Cognitive Impairment...manifested by: Inattention and Impulsivity...wander risk in [his/her] hometown... Delirium - with reduced awareness of the environment - with cognitive and behavioral disturbances...has grossly impaired executive functioning," RN Interventions were listed as "Nurse to encourage and support attention to ADLs, attendance at meals and activities." "Nurse to dispense medication, monitor and record compliance, side effects, and responses to treatment." "Nursing staff to provide a safe environment and monitor risk of falls."

There were no specific nursing interventions to address the patient's cognitive issues.

5. Patient A5: For problem identified as "Cognitive Impairment...manifested by: Inattention and Impulsivity...has recently been aggressive. Verbally abusive toward daughter and son-in-law...-and is vulnerable to safety risks. Patient is having problems with memory...Agitated episodes," there were no identified nursing interventions

B. Interview

During interview on 12/2/14 at 9:00 a.m., the Director of Nursing stated, "There are no specific nursing interventions in the treatment plans."

II. Provide sufficient numbers of nursing personnel on the geropsychiatric unit based on the numbers and acuity needs of patients on both day and night (12 hour) shifts of duty. These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and preventive interventions and in actual/ potential safety risks for patients and staff. (Refer to B150)

Based on observation, interview and document review, the Director of Nursing failed to staff sufficient numbers of nursing personnel on the geropsychiatric unit based on the numbers and acuity needs of patients on both day and night (12 hour) shifts of duty. These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and preventive interventions and in actual/ potential safety risks for patients and staff.

Findings include:

A. On the first day of the survey, the patient census was 5. Review of the Patient Need Assessment for these patients that was completed by nursing on the first day of survey (12/1/14) revealed the following information:

1. Five (5) of five (5) patients required partial assistant for bathing, feeding, and toileting.

2. Two (2) of five (5) patients required assistance with mobility.

3. Five (5) of five (5) patients required skin care and 1 of 5 required diabetic checks.

4. One (1) of five (5) patients was assaultive and 1 of 5 was potentially assaultive.

5. One (1) of five (5) patients was a low risk for suicide.

6. Two (2) of five (5) patients were experiencing active hallucinations/delusions.

7. One (1) of five (5) patients presented difficulty in taking medications.

8. Five (5) of five (5) patients were on fall and elopement precautions.

9. Five (5) of five (5) patients were on every 15 minute monitoring checks.

10.Two (2) of five (5) patients constantly demanding staff time.

B. Review of the staffing schedule for the unit for 11/25/14 through 12/1/14 (first day of the survey) revealed only 1 RN and 1 Certified Nursing Assistant (CNA) on duty for both the day and night 12-hour tours of duty for a census of 5-7 patients. This staffing pattern did not allow for staff to leave the unit for any purpose, including scheduled meal breaks. When one nursing staff member left the unit, there was only one staff member to monitor and care for patients and to respond to patient events.

C. The Nursing Policy, "Staffing, Adequate," dated 05/2007 stated, "As a general rule, 1- 7-8 patients is 1 nurse and 1 CNA. Above 8 patients is [sic] 2 CNAs and 1 nurse. Additional aides may be brought in for one-on-ones as needed, or based on acuity."

1. On 12/2/14 the nursing personnel on duty for days when the patient census was above 8 from October 1 through November 30, 2014 was reviewed with the DON and RN W3. The actual staffing for 2 days during this time period failed to meet the policy requirement as stated in the above paragraph for staff based on patient census:

2. On October 27, 2014 on the day tour of duty one of the 2 assigned CNAs went off duty leaving the RN and only one CNA from 6:30 to 8:00 p.m. with a patient census of 10.

3. On November 15, 2014 on the day tour of duty there was a RN and only 1 CNA for a patient census of 9.

4. On November 18, 2014 on the day tour of duty one of the 2 assigned CNAs went off duty leaving the RN and only one CNA from 11:30 a.m. 8:00 p.m. with a patient census of 9.

5. On the night tour of duty there was only 1 RN and 1 CNA with a patient census
of 9.

D. Unit and Patient Observations:

1. Observations of the unit on 12/1/14 revealed only 1 staff member (RN) left on the unit for 5 patients. On 12/1/14 at 1:10 p.m. there were only 2 staff members on the unit (1 RN, 1 CNA). At this time the CNA left the unit stating, "I'm going on my break," leaving the RN on the unit. The RN was alone on the unit until 1:28 p.m. when RN W3 entered the unit. The only other staff members entering the unit during this time period was a social worker and a unit clerk for 2-3 minutes each.

Rounds during this time period revealed Patients 1 and 4 asleep in front of the television. Patient 3 was sitting in dayroom. Patient 2 was in bed. At 1:15 p.m. Patient 5 who was on fall precaution and used a walker was in the bathroom and then moving about his/her room and the unit. At the time s/he was in the bathroom, there was a heavy plastic caution sign for "wet floor" lying on the floor next to the toilet.

2. During the time that a scheduled group on 12/1/14 from 1:00-1:30 p.m. was cancelled, Patient A5 was observed to be sitting/walking around his/her room and dayroom. At 1:20 p.m. on this date, Patient A5 became agitated, fussing at staff and grumbling to self in the dayroom. Observation on 12/1/14 from 3:45-4:00 p.m. revealed Patient A5 sitting on the seat of his/her walker rapidly pushing self backward around the dayroom. During the time that a group on 12/2/12 from 1:00-1:30 p.m. was cancelled, Patient A5 was lying in his/her bed.

3. On 12/2/14 at 8:40 a.m. Patient A5 was observed sitting on the seat of his/her walker, rapidly pushing self backward around the dayroom. S/he almost ran into surveyor standing against the wall.

E. According to an incident report (11/30/14) and a RN progress note (11/30/14 at 3:19 p.m.) non-sample discharged Patient C1 "accused other patient of 'kicking him.' Stood with other patients coat and shook the coat at other patient. Swung at other patient and fell backwards landing on left hip and hitting back of head on wall...received order to transfer patient via ambulance to VA Hospital." On 12/2/14 at 3:30 p.m., the DON stated that she talked with the doctor in the emergency room on 11/30/14. The doctor related to her that Patient C1 had a fractured hip and was going to be admitted for surgery. Review of staffing revealed only 1 RN and 1 CNA on duty at this time.

This patient incident was discussed with the DON on 12/2/14 at 9:40 a.m. When asked if the fact that there were only 2 nursing personnel on duty at the time of the incident may have been a factor in this patient incident, she replied, "Yes."

F. Staff Interviews:

1. During interview on 12/1/14 at 1:10 p.m., CNA W2 stated that she leaves the unit for a break (leaving the RN on duty alone), stating I take 30 minutes. RN W1 stated "If there is myself and another staff member, there wouldn't be breaks. I don't feel good leaving the unit. I might run to the snack machines for 5 minutes."

2. During interview on 12/2/14 at 11:00 a.m. the DON reported that if there are only 2 nursing staff members on the unit at staff meal time "one would go (meal break), leaving one on the unit."

3. During interview on the afternoon of 12/2/14, the DON reported that staffing of nursing personnel is based on patient census, rather than patient acuity. She stated, "There is 1 additional staff member for a patient requiring 1:1 supervision if a physician's order is written."

4. During a confidential interview on 12/2/14, a staff member reported, "We were told not to count a non-funded (without hospital payment source) patient on the census."

Based on staff interviews and policy review, the facility failed to ensure the availability of services by a licensed psychologist for patients in its care. This deficiency potentially results in patients not receiving the full array of diagnostic and intervention services needed, and patients' needs not being met in a timely manner.

Findings include:

A. Staff Interview

During an interview on 12/2/14 at 12:40 p.m., the Medical Director stated that he had been at the facility on and off for 12 years and during this time he had not had access to a psychologist, and no psychological services had been provided for patients at the facility. He noted that he had recently discharged a patient who could have received benefits from a neuropsychological assessment.

B. Policy Review

The facility's procedure titled, "Assessment of Patients" stipulated that "Additional Assessment are completed when indicated and ordered by the attending LIP. These assessments may include:...Psychological Assessment including intellectual, projective, neuropsychological and personality testing.

Based on record review and interview, the Director of Social Work failed to:

I. Ensure that social work assessments included conclusions and recommendations of the anticipated necessary steps for discharge to occur and the anticipated social work role in treatment and discharge planning for five (5) of five (5) active sample patients (A2, A3, A4, A5, A7, B1, and B2). As a result, the social work role, summary, conclusions, and specific recommendations regarding treatment of patient's psychosocial problems are not described for the treatment team. (Refer to B108.)

II. Include Master Treatment Plans (MTPs) that evidenced individualized social work treatment interventions with specific focus based on individual needs and abilities of four (4) of five (5) active sample patients (A1, A2, A4, and A5). Specifically, interventions formulated for social workers were routine social work functions and/or tasks written as treatment interventions. In addition, some social work treatment interventions failed to identify a method of delivery and the frequency of contact with the patient. This deficiency results in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and potentially results in inconsistent and/or ineffective social work treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that the MTPs from the electronic medical record included but not limited to the following intervention statements formulated, for psychiatric problems, which were routine and generic social work functions and/or tasks (such as explaining unit rules and encouraging patients) written as treatment interventions. In addition, this review also revealed that some social work treatment interventions on the MTPs failed to include the frequency of contact and did not identify how interventions would be delivered by clinical staff.

1. Patient A1 had the following interventions statements formulated for the problem, "Psychotic Symptoms - [Patient's name] psychotic symptoms ... manifested by: Disorganized Speech- manifested by tangentiality that impairs normal communications. - manifested by loose associations that impairs normal communications. - with incoherence to the point of word salad."

SW Interventions: 5. "Case Manager to discuss Rules of the unit and role of each staff member to the patient." 6. "Therapist will attempt to establish a trusting relationship with patient."

Intervention statements 5 and 6 were actually generic and routine social work functions or tasks that would be provided this patient regardless of his/her presenting symptoms.

2. Patient A2 had the following interventions statements formulated for the problem, "Depressed Mood - [Patient's name] depressed mood...manifested by: Feeling of Worthlessness, Social Withdrawn."

SW Interventions: 5. "Therapist/Counselor will provide emotional SUPPORT and encourage, and help patient focus on sources of pleasure and meaning." 6. Therapist/Counselor will help patient EXPLORE behaviors and reactions that lead to feelings of depression." 7. "Family sessions to allow patient to come to CONFLICT RESOLUTION with family member." 8. Therapist/Counselor will help patient EXPLORE behaviors and reactions that lead to feelings of depression." 9. "Clinician will meet with [him/her] create a safety plan and resources to access after [s/he] discharges if feeling depressed or suicidal..."

Intervention statement 5 was a generic and routine social work functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms. Interventions 6, 8 and 9 were treatment interventions that failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient. Intervention 7 did not include the frequency of contact for the family therapy sessions.

3. Patient A4 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment Mood - [Patient's name] cognitive impairment mood... manifested by: Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia. Self injurious Behavior - but with no injuries to others by being a wander risk in [his/her] hometown...Delirium - with reduced awareness of the environment - with cognitive and behavioral disturbances...has grossly impaired executive functioning."

SW Interventions: 4. "Case Manager to explain rules of practice and the roles of various staff members." 5. "Case Manager to maintain contact with family for informational reasons and to keep them engaged in the treatment process." 6. "Therapist to provide emotional support and help patient create strategies for dealing with cognitive limitations."

Intervention statements 4 and 5 were not individualized to reflect this patient's presenting symptoms. These statements were actually generic and routine social work functions and/or tasks that would be provided this patient regardless of his/her presenting symptoms. Intervention 6 was a treatment intervention statement but failed to identify whether the intervention would be provided in group or individual sessions and did not include a frequency of contact with the patient.

5. Patient A5 had the following interventions statements formulated for the psychiatric problem, "Cognitive Impairment - [Patient's name] cognitive impairment... manifested by: "Inattention and Impulsivity - and needs careful supervision to determine cognitive impairment vs dementia - and has recently been aggressive. Verbally abusive toward daughter and son-in-law... - and is vulnerable to safety risks. Patient is having problems with memory...unclear regarding [her/his] medications. Agitated episodes..."

SW Interventions: 1. "Group therapy to provide emotional support and to share feelings with others. This will occur 1-3 times per day and will last 30 minutes." 2. "Family sessions to encourage communication and to help devise strategies for dealing with cognitive deficits."

Intervention 1 was a global statement that was not specifically related to the symptoms of cognitive impairment identified. Intervention 2 did not include the number of family sessions to be held.

B. Interviews

1. In an interview on 12/2/14 at 3:00 p.m. with the Director of Social Work, the MTPs for Patients A1 and A2 were reviewed. He agreed these plans contained routine staff functions instead of specific interventions to address the patients presenting symptoms.

Based on interview and document review, the hospital failed to provide adequate numbers of qualified therapeutic activity staff to offer services to meet the needs of the patient population.

This failure resulted in fragmented treatment for the patients and hindered patients ' progress towards treatment goals.

Findings Include:

A. The Marian Center has one unit (capacity of 14 patients) for acute geropsychiatric patients. These patients required a structured schedule with a high level of cognitive and sensory treatment interventions.

B. Review of the program schedules provided by administrative staff revealed the following services scheduled by recreation staff:

1. The weekday schedule (Monday through Friday) included two groups for a total of 1 hour and 45 minutes conducted by recreation staff: "Stretching the Mind and your Muscles..." which was described as "discussing daily events in newspaper and stretching exercises" and "Leisure Skill Development: Crafts, Games, etc."

2. The weekend schedule listed only one leisure activity for Saturday and Sunday for a total of 2 hours conducted by recreation staff.

C. Review of the medical record for Patients A1, A2, A3, A4 and A5 revealed no patient assessments or treatment plan interventions for these team members.

D. During interview on 12/2/14 at 11:40 a.m., the Director of Recreation provided the following information:

1. There are only 2 activities by rec staff on week-days for a total of 10 hours and only one 1 hour group which is leisure oriented leisure on Saturday and Sundays.

2. Written patient assessments are not completed by Recreation staff.

3. There is no scheduled time for individual patient treatment.

4. Week-end services provided by recreation staff are leisure oriented.

5. The Director of Recreation spends approximately 2-3 hours weekly providing direction and supervision to the recreation staff for their services provided to the Marian Center.