HospitalInspections.org

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to protect patient's rights by failing to implement the use of restraints and/or close observation in accordance with safe and appropriate practices, and failed to provide personal privacy to restrained patients (A167), failed to obtain a physician's order for the use of restraints (A168), and by failing to discontinue the use of restraints at the earliest possible time. (A174)

Findings include:

A review of facility policy "Use of Restraints/Seclusion on Inpatient Units, Effective date February 2, 2010, revealed "I. Policy: A. Each of our patients has the right to be free from physical and mental abuse and corporal punishment. Restraints and/or seclusion will only be used when necessary and required to treat the patient's symptoms...V. Criteria for Use of Restraints and /or Seclusion: ...B. Restraints/ seclusion will be discontiuned when the patient's behavior no longer meets criteria for restraints/ seclusion... 2. IV. Procedure for Monitoring and Care of the Patient in Restraints:...B. The Registered Nurse will: ... 5. Patients who have been sleeping for at least 30 minutes prior to nurse's assessment meet criteria for restraint reduction or release...V. Procedure for Removal of Restraints: A. The Registered Nurse will: 1. Assure the patient is released from restraints when release criteria are met. a. The RN may discontinure restraints if the patient's behavior meets release criteria prior to the expiration of the physician's order... II. Each restraint/seclusion episode requires a physician's order. ... . "

A review of facility policy "Care of the Patient on Suicide/ Violence/Close Observation Precautions," effective January 4, 2012, revealed, " ... III. Definitions .. .Violence Precautions -(VP2): The patient is considered a severe violence risk. The patient is maintained on constant observation - 1:1 eyesight at all times. ... Close Observation -1:1. The patient is observed continually by a staff member. A minimum distance of 12 feet is maintained between the staff and patient with no barriers between them. An example of a barrier would be a glass window or partial wall. ... ."

1) A review of MR21 revealed a physician's order for VP2 1:2 eyesight (one patient is on constant observation by two staff members). (A167)

2) During a tour of Belmont 3 South on January 25, 2012, at 1:30 PM, two staff members were observed sitting at the entrance to a patient's (MR21) room. It was observed that the patient was not visible from the doorway of the room. (A167)

3) An interview was conducted with EMP2 on January 25, 20102, at 1:30 PM. EMP2 confirmed that the patient was not visible from the doorway and that the patient was ordered close observation. (A167)

4) A review of MR3 on January 25, 2012, revealed the patient was placed in four point restraints on January 20, 2012. Further review of the medical record revealed a physician's order dated January 24, 2012, "Late entry" 4 point restraints on January 20,2012, not to exceed 2 hours." (A168)

5) An interview was conducted with EMP2 on January 25, 2012, 11:20 AM. EMP2 stated that the facility did have an order for the restraint episode, however the order was obtained four days after the restraint episode.(A168)

6) A review of MR21 revealed an "Inpatient Restraint and Seclusion Episode Record", dated January 17, 2012, at 8:15 PM through January 19, 2012, at 10:00AM, indicating the patient remained in restraints during that time. Further review of the "Behavior and Interventions" documentation revealed that the patient was "calm and/or resting" from January 17, 2012, at 10:15 PM, until January 18, 2012, at 12:00 AM. (A174)

A review of MR21 physician orders revealed an order to renew use of restraints dated January 18, 2012, at 4:15 PM. "4-point restraints for protection self and others." The "Behavior and Interventions" documentation revealed that from January 18, 2012 at 12:30 AM, until January 18, 2012, at 4:00AM, "Pt awake lying in bed," or "Pt awake lying in bed quietly," or " Pt calm and resting." (A174)

The restraint order was renewed on January 18, 2012, at 4:15 AM, "Place Pt in walking restraints for safety of self and others NTE (not to exceed) 4 hours." The "Behavior and Interventions" documentation revealed that from January 18, 2012, at 4:15 AM, until January 18, 2012, at 8:00 AM, " "Pt resting quietly," or "Pt awake, lying in bed". (A174)

The restraint order was renewed on January 18,2012, at 8:00 AM, "Place pt in walking restraints for safety of self and others NTE 4 hours." The "Behavior and Interventions" documentation revealed that from January 18, 2012, at 8:00 AM, until January 18, 2012, at 12:00 PM, "Pt resting quietly," and/or "sleeping quietly." (A174)

The restraint order was renewed on January 18, 2012, at 12:15 PM, "PADS (brand name of restraint that facility uses) for protection of self and others up to 4 hours." The "Behavior and Interventions" documentation revealed that from January 18, 2012, at 12:15 PM, until January 18, 2012, at 4:00 PM, "Pt lying in bed sleeping." (A174)

The restraint order was renewed on January 18, 2012, at 4:15 PM, "PADS for protection of self or others for up to 4 hours." The "Behavior and Interventions" documentation revealed that from January 18, 2012, at 4:15 PM, until January 18, 2012, at 8:00 PM, " Pt in bed quiet", "Pt in shower", "reading quietly in room", and "pacing, responding, yelling", and /or "rapping, singing, pacing in room." (A174)

The restraint order was renewed January 18, 2012, at 8:15 PM, "Place patient in walking restraints for safety - ambulatory soft restraints - NTE 4 hours." The "Behavior and Interventions" documentation revealed that from January 18, 2012, at 8:15 PM, until January 18, 2012, at 12:00 AM, "Pt in bed also walking around room", "restless, pacing" and /or "watching TV." (A174)

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to follow their adopted policy related to assessing patient health status, care needs, and response following an intervention (Electro Convulsive Therapy) for three of three MRs reviewed (MR27, MR28 and MR29).

Findings include:

A review was conducted on January 27, 2012, of facility policy, No. 640-031.2 "Electro-Convulsive Therapy," Effective Date: 5/12/11, "Upon Return from Treatment: a. The Unit RN will: 1. Assesses the patient upon return from ECT. 2. Ensure Vital signs are monitored upon return to unit and will be repeated every 15 minutes until stable. Vital signs will be noted in medical record. 3 Continue monitoring the patient to ensure patient safety. ..... Post ECT documentation in Progress Notes include: 1. Vital signs, and an assessment of patient's condition upon return from ECT. 2. Progress notes from all three shifts are to indicate a. Mental status, b. behavior c. activity d. patient complaints and/or reactions e. any other observations of the patient's response to the ECT treatment."

1) A review conducted on January 27, 2012, of MR27, revealed that the patient received ECT on November 16, 2011, at 11:45 AM. There was no documentation that the patient had been assessed by an RN on either the 3-11 or the 11-7 shift, following the treatment. There was no record that the patient's vital signs had been assessed on the 11-7 shift.

A review conducted on January 27, 2012, of MR28 revealed that the patient received ECT on December 2, 2012, at 12:00 PM. There was no documentation that the patient had been assessed by an RN on return from ECT on the 7-3 shift or on the 11-7 shift. There was no documentation that the patient's vital signs had been assessed on the 11-7 shift.

A review conducted on January 27, 2012, of MR29, revealed that the patient received ECT on November 4, 2012, at 11:05 AM. There was no documentation that the patient had been assessed by an RN on return from ECT or on the 11-7 shift. There was no documentation that the patient's vital signs had been assessed on the 11-7 shift.

2) An interview was conducted with EMP3 on January 27, 2012, at 10:00 AM. EMP3 confirmed that there was no documentation that the patients (MR27, MR28, MR29) had been assessed for three consecutive shifts following ECT.

Based on review of facility policy, medical records (MR) and staff interview (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to ensure patient safety when reviewing medication orders to include all elements of an order : dose, strength, units, route, frequency and rate, as required for four of 29 medical records (MR21,MR24, MR25, MR26).

Findings include:

1) A review of MR21, MR24, MR25, MR26, conducted on January 24-27, 2012, revealed pre-printed admission orders that provided a choice for route of administration of a medication. The physician did not order a specific route of administration for Diphenhydramine. It was ordered as "IM/po" (intramuscular or by mouth).

An interview was conducted with EMP1 on January 27, 2012, at 9:30 AM. EMP1 confirmed the facility uses preprinted physician orders that do not specify the exact route ordered for the medication.

The facility was unable to provide documentation that addressed complete physician orders that specified an exact route of administration.

2) A review of MR21, MR24, MR25, and MR26, conducted on January 24-27, 2012, revealed pre-printed, PRN (as needed) , MAR (medication administration record) that contained a designated space for nursing to indicate the reason for the PRN medication administration. A number "1" was used to indicate patient agitation and a "2" was used to indicate patient anxiety. There was no further clarification as to the definition or the extent of agitation or anxiety.

An interview was conducted with EMP1 on January 27, 2012, at 9:30 AM. EMP1 confirmed there was no further clarification as to the definition or the extent of agitation or anxiety.

The facility was unable to provide a policy that addressed the definitions or levels of patient agitation/anxiety.

Based on observation and staff interview, it was determined that Belmont Center for Comprehensive Treatment failed to establish a policy for disposing of opened medications.

Findings include:

Observation on January 24, 2012, at 10:30 AM of the Medication Room on the Pediatric Unit revealed an opened 500 ml. bottle of Normal Saline Solution dated October 14, 2011, and a 16 oz. bottle of Hydrogen Peroxide dated September10, 2011.

An interview was conducted with EMP2 on January 24, 2012, at 10:30 AM. EMP2 confirmed that there were opened bottles of Normal Saline Solution, dated October 14, 2011 and Hydrogen Peroxide dated September10, 2011 in the Medication Room. EMP2 was unable to confirm the date on which the medications should be disposed of.

Observation on January 26, 2012, at 10:00 AM of the Medication Room on 3-South revealed an opened 500 ml. bottle of Normal Saline Solution, an opened 16 oz. bottle of Betadine and an opened 16 oz. bottle of Hydrogen Peroxide. None of these bottles were labeled to indicate when they were opened or when they should be disposed of.

An interview was conducted with EMP4 on January 26, 2012, at 10:00 AM. EMP4 confirmed the opened bottles of Normal Saline Solution, Betadine and Hydrogen Peroxide failed to contain a label to indicate when they were opened or when they should be disposed of.

An interview was conducted with EMP5 on January 26, 2012 at 1:00 PM. EMP5 revealed that the facility does not have a policy for labeling medications to indicate when they were opened or when they should be disposed of.

Based on review of facility policy, personnel files (PF) and staff interview (EMP), it was determined the facility failed to educate staff on donation issues.

Findings include:

Review of "Belmont Center For Comprehensive Treatment, Policy and Procedure Manual ... Subject: Administrator - On - Call: Notification of Events," revised June 2, 2009, revealed "... 6. Death or Imminent Death - CMS Conditions of Participation require that an Organ Procurement Organization (OPO) be notified in the event of a death or imminent death of a patient. ... ."

1) An interview was conducted with EMP9 on January 26, 2012 at approximately 9:20 AM. "It is the responsibility of the nursing supervisor on duty at the time to notify the OPO. No one is assigned to it, it is who ever is on duty."

Review of PF1, PF2, PF3 and PF4 on January 24, 2012, revealed no documented evidence of education related to donation issues.

2) An interview was conducted with EMP7 on January 26, 2012 at approximately 12:00 PM. "My understanding is, if there is a death, I am to call the OPO. I do not recall any education for myself or others on the donor program."

Based on record review, observations and interviews, the facility failed to:

I. Initiate significant revisions in the Master Treatment Plans for 1 of 1 active sample patient (I5) and 1 of 1 non-sample patient (R2) who had multiple restraint episodes over several days. The restraint episodes that were documented in the Master Treatment Plan reviews were basically the same, with little change from one review to the next to address the repetitiveness of the restraint incidents. Failure to plan alternative approaches for the prevention of restraint episodes can lead to delays in improvement and discharge of patients. (Refer to B118)

II. Develop Master Treatment Plans for 12 of 12 active sample patients (A7, A12, B9, C4, E6, F11, G14, G20, H1, H14, I5 and J3) that included modalities (interventions) which were individualized and addressed the specific needs of each patient. The facility had one pre-printed treatment plan form for all inpatients on the 9 units which consisted of services for Children, Adolescents, Geriatrics, and adults with Affective and Eating Disorders, substance abuse, and general psychiatric problems. The modalities on the treatment plans were generic and identical or very similar for all sample patients regardless of differing presentations, diagnosis or problems. This deficiency results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. It also provides no guidance to staff regarding the specific modality needed and the purpose for each, which can result in inconsistent and/or ineffective treatment. (Refer to B122)

III. Provide active treatment measures for 3 of 12 active sample patients (A12, H14 and I5). Patient A12 was an older adult on a geriatric unit, Patient H14 was an adult on an open adult unit, and Patient I5 was a young adult on a closed (locked) adult unit. All three patients were observed in their rooms during the survey while their assigned treatment modalities were in progress. The clinical staff was aware that these patients were not participating in their respective unit activities. There was no evidence that any of the patients were offered alternative therapies. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their clinical improvement. (Refer to B125-I)

IV. Follow proper release criteria per facility policy for 1 of 5 active sample patients (I5) whose record was reviewed for restraint policy and procedure compliance. Patient I5 was kept in restraints after meeting the criteria for release. This deficient practice results in failure to ensure the patient's right to be free from restriction of movement without adequate justification. (Refer to B125-II)

V. Ensure that a physician's order was written for a physical hold (restraint) within one hour of the incident per facility policy for 1 of 4 non-sample patients (R3) whose records were reviewed for restraint policy and procedure compliance. This failure results in a restriction of the patient's right to be free from restraint without adequate justification. (Refer to B125-III)

Based on record review and staff interview, the facility failed to provide a psychiatric evaluation that contained a sufficiently complete record of mental status for 1 of 12 active sample patients (G14). A Mental Status Examination was not performed on admission. This deficiency results in the staff's inability to track serial changes in a patient's mental status while the patient is in treatment.

Findings include:

A. Record Review

In the Psychiatric Summary (facility's name for the Psychiatric Evaluation) of 1/14/12, under the section titled "Mental Status Examination," none of the preprinted check boxes were marked off. Within the lined section for hand written information, the following was noted: "(pt. sleeping at time of admission eval)."

B. Interview

During an interview on 1/26/12 at 2:20p.m., the Medical Director agreed with the findings and stated, "This is not acceptable."

Based on record review and interview, the facility failed to make significant revisions in the Master Treatment Plans (MTPs) for 1 of 1 active sample patient (I5) and 1 of 1 non-sample patient (R2) who had multiple restraint episodes over several days. The restraint episodes documented in the Master Treatment Plan reviews were basically the same, with little change from one review to the next to address the repetitiveness of the restraint incidents. Failure to plan alternative approaches for the prevention of restraint episodes can lead to possible delays in the improvement and discharge of patients.

Findings include:

A. Record Review

1. The facility policy and procedure, titled "Use of Restraints/Seclusion on Inpatient Units," dated 1/1/10, states the following in the section of revision of the interdisciplinary treatment plan: "A written interdisciplinary treatment plan revision is required once in a 24 hour period for patients who experience more than one restraint episode in that 24 hour period."

2. Active sample Patient I5. According to the "Restraint and Seclusion Episode Record," for the period of 1/17/12 at 8a.m. through 1/19/12 4p.m., patient I5 had 12 episodes in either 4 point or walking restraints (most continuously) for "repeated verbal threat to staff and protection of self and others."

The listed intervention approaches on the MTP for the 3 days of the patient's restraints were as follows:
1/17/12: "place in 4 points when aggressive toward self and/or others. Discuss/teach positive coping skills, provide support & [and] safety."
1/18/12: "Offer support, redirecting as needed. Encouraged structured groups re [about] positive coping skills, offer prn [as needed] meds [medication] to address agitation."
1/19/12: "Assist with identification of positive coping skills, provide support and redirection, offer prn meds as indicated."
None of these interventions provided any alternative approaches to address I5's acting out behavior.

3. Non-sample Patient R2. According to the "Restraint and Seclusion Episode Record," for the period of 1/8/12 at 10:20a.m. through 1/10/12 at 4:15p.m., Patient R2 had 6 episodes of restraints for "agitation, verbalizing intent to self harm."

The MTP (last review 1/10/12) addressed the restraint episodes under "interventions." The interventions for the patient's restraint episodes were as follows:
1/8/12 (10a.m.): "check in verbally and ID [identify] need for safer boundaries, use prn meds earlier to help contain anxiety. Work with staff on ways to channel frustrations, use of restraints as a last resort to contain behavior when all else fails."
1/8/12 (10:20p.m.): "check in verbally and ID [identify] need for safer boundaries, use prn meds earlier to help contain anxiety. Work with staff on ways to channel frustrations, use of restraints as a last resort to contain behavior when all else fails."
1/9/12 (6:20a.m.): "check in verbally and ID [identify] need for safer boundaries, use prn meds earlier to help contain anxiety. Work with staff on ways to channel frustrations, use of restraints as a last resort to contain behavior when all else fails."
1/9/12 (10:30a.m.): "use prn medication, maintain sp (suicide precautions). Discuss triggers & help id them."
1/9/12 (6p.m.): "See behavior plans 1/8/12 2p.m."
1/10/12 (4:15p.m.): "Encourage talking with staff, medication for anxiety."
None of the interventions offered alternative approaches to address the patient's acting out behavior.

B. Interviews

1. In an interview on 1/26/12 at 2:25p.m., the lack of alternative interventions on the Master Treatment plans for patients who experience multiple restraint episodes was discussed with the Nursing Director. The Nursing Director agreed that more alternative approaches should have been considered.

2. In an interview on 1/26/12 at 2:30p.m., the Medical Director agreed with the findings and stated, "We should do a better job of documenting alternatives with difficult patients."

Based on record review and interview, the facility failed to provide Master Treatment plans that included a substantiated diagnosis for 12 of 12 active sample patients (A7, A12, B9, C4, E6, F11, G14, G20, H7, H14, I5 and J3). The pre-printed Master Treatment plans did not include a space on the form for a diagnosis. Absence of a substantiated diagnosis (or diagnoses) on patients' treatment plans hinders the treatment team from focusing on specific treatment issues. This can result in all the patients' problems not being adequately addressed during the hospitalization.

Findings include:

A. Record review

The following patients' Master Treatment Plans (dates of plans in parenthesis) did not include a diagnosis on the plan: [A7 (1/11/12), A12 (1/20/12), B9 (1/12/12), C4 (12/31/11), E6 (11/1/11, F11 (12/21/11, G14 (1/12/12), G20 (1/4/12), H7 (1/6/12), H14 (1/14/12), I5 (11/19/11), and J3 (1/6/12).

B Interview

During an interview on 1/26/12 at 2:30p.m., the Medical Director was shown a copy of a blank Master Treatment Plan. He acknowledged that there was no section on the form dedicated for entry of the patient's diagnosis.

Based on record review and interviews, the facility failed to develop Master Treatment Plans for 12 of 12 active sample patients (A7, A12, B9, C4, E6, F11, G14, G20, H7, H14, I5 and J3) that included modalities (interventions) which were individualized and addressed the specific needs of each patient. Instead, the facility had one pre-printed treatment plan form for all inpatients on the 9 units which consisted of services for Children, Adolescents, Geriatrics, and adults with Affective and Eating Disorders, substance abuse, and general psychiatric problems. The interventions were identical or very similar for all sample patients, regardless of the differing presentations, diagnoses or problems. This deficiency results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. It also results in a lack of guidance to staff on the specific modalities needed and the purpose for each modality, which can lead to inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. The facility's policy and procedure, no 550-001.4, dated 1/5/12, and titled "Inpatient Interdisciplinary Treatment Plans" states, "Interventions are multidisciplinary and describe the specific treatment and the frequency that it will be provided."

2. The facility used a pre-printed treatment plan form. Six of the intervention choices for the clinical staff were already pre-checked on the form. All of these choices were generic interventions. They were the exact same for all patients, and were tasks that the clinicians would be expected to carry out regardless of each patient's specific problem(s). The additional interventions selected for each patient spoke of "group sessions" without addressing specific types of groups, and "Family sessions to...address family issues or needs', which was also non-specific.

3. Specific Patient Findings

A. Patient A7, Master Treatment plan (MTP) dated 1/11/12

Primary problems - "Suicidal/self-injurious behavior as evidenced by: 'made statement to family about wanting to die'" and "Inability to function or care for his/her self as evidenced by - helpless, decreased ADLs [activities of daily living], decreased activities, walking, ambulating."

The standard pre-checked interventions on the MTP were:
- "Provide safe, structured environment" (physician, RN/nursing, case manager [social worker], rehab therapist).
- "Provide appropriate level of observation to prevent harm to self or others" (no designated disciplines).
- "Psychiatric evaluation and prescribe appropriate medication" (physician)
- "Assess for progress/improvement of symptoms" - (physician, RN/nursing, case manager, rehab therapist)
- "Provide education about diagnosis" (physician, RN/nursing, case manager, rehab therapist)
- "Provide education about medication" - (physician and RN/nursing)
The only additional selected intervention was "Group sessions up to 3 times daily to increase coping skills" (no designated discipline)

B. Patient A12, MTP dated 1/20/12

Primary problem - "Suicidal/self-injurious behaviors as evidenced by: not eating/drinking," and "Inability to function or care for his/her self as evidenced by: decreased eating, disheveled, decreased sleep, decreased ADLs."

The standard pre-checked interventions on the MTP were the exact same as those cited for patient A7 above.
The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to facilitate coping" (no designated discipline)
- "Group sessions up to 5 times daily to increase socialization, structure" (no designated discipline)

C. Patient B9, MTP dated 1/12/12

Primary problem - "Suicidal/self injurious behaviors as evidenced by: "Verbalization - 'I want to die.'" Aggressive/assaultive behavior as evidenced by: verbally threatening foster mom, HI [homicidal ideations] toward her."

The standard pre-checked interventions on the MTP were the exact same as those cited for patient A7 above
The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to develop coping skills" (physician, RN/nursing, case manager, rehab therapist)
- "Group sessions up to 5 times per week to develop coping skills" (all 4 clinician choices checked)
- "Family sessions up to 1 times weekly to address family issues or needs" (Physician, case manager)

4. Patient C4, MTP dated 12/31/11

Primary problems - "Suicidal/self-injurious behaviors as evidenced by: thoughts of self harm 2 nights ago," "aggressive/assaultive behavior as evidenced by: trying to attack m [mother] and hx [history] of attacking teacher in class", and "injurious behavior without regard to consequence as evidence by: running away."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7 above.
The additional selected (generic) interventions were:
- "Supportive psych. Therapy 2 times per week to [check] peer support" (all 4 clinicians)
- "Group sessions up to 5 times daily to manage anger" (physician and case manager)
- "Family sessions up to 2 times weekly to address family issues or needs" (physician, case manager)

5. Patient E6, MTP dated 11/1/11

Primary problem - "Inability to function as evidenced by: inability to maintain weight."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7above.
The additional selected (generic) interventions were:
- "Supportive psychotherapy 2 times per week" (rehab therapist)
- "Group sessions up to 7 times daily to improve mood" (case manager)
- "Family sessions up to 1 times weekly to address family issues or needs" (case manager)

6. Patient F11, MTP dated 12/21/11

Primary problems - "Aggressive/assaultive behavior as evidenced by: threaten to strangle sister." "Inability to function or care for his/her self as evidenced by: medication, noncompliance, treatment noncompliance."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7 above.
The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to identify anger management skills" (physician, rehab therapist)
- "Group sessions up to 3 times daily to develop positive coping skills" (RN/nursing, rehab therapist)
- "Family sessions up to 1 times weekly to address family issues or needs" (case manager)

7. Patient G14, MTP dated 1/12/12

Primary problems - "Aggressive/assaultive behaviors as evidenced by: fighting with his landlord, threatened behavior." "Impulsive behavior without regard to consequence as evidenced by: poor judgment, paranoid ideation."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7 above.
The additional selected (generic) intervention was:
- "Group sessions up to [blank] times weekly to stress[sic] mgmt [management] ID [identify] coping skills." (RN/nursing)

8. Patient G20, MTP dated 1/14/12

Primary problem - "Suicidal/self injurious behavior as evidenced by: OD [overdose] on 20 Ambien pills in SA [suicide attempt] R/T [related to] stress of sister's CA [cancer] diagnosis and job stress."

The standard pre-checked interventions were the exact same as those for patient A4 above.

The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to increase coping skills" (physician)
- "Group sessions up to 3 times daily to increase insight, develop [illegible word] coping" (RN/nursing, case manager, rehab therapy)

9. Patient H7, MTP dated 1/6/12

Primary problems - "Aggressive/assaultive behavior as evidenced by attacked [sic] people, threatening." "Impulsive behavior without regard to consequence as evidenced by: going into others cars, disrobing."

The standard pre-checked interventions were the exact same as those for patient A7 above.
The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to increase coping" (physician)
- "Group sessions up to 3 times daily to discuss anger triggers, gain insight in to coping/social skills." (rehab therapist)

10. Patient H14, MTP dated 1/14/12

Primary problems - "Aggressive/assaultive behavior as evidenced by: punched mom on her face." "Impulsive behavior without regard to consequence as evidenced by: destroy [sic] mom's property, threw TV at the window."

The standard pre-checked interventions were the exact same as those for patient A7 above.
The additional selected (generic) intervention was:
- "Supportive psychotherapy 5 times per week to increase coping" (physician)

11. Patient I5, MTP dated 11/19/11

Primary problem - "Aggressive/assaultive behavior as evidenced by: recently pushed in window at NSG [nursing] station at [name of facility], spit at [name of the facility] staff."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7 above. The additional selected (generic) interventions were:
- "Supportive psychotherapy 5 times per week to gain insight & [and] support" (all 4 clinicians)
- "Group sessions up to 2 times daily to learn + [positive] coping skills" (all 4 clinicians)

12. Patient J3, MTP dated 1/16/12

Primary problems - "Suicidal/self injurious behavior as evidenced by: jumped out of moving car prior to admission", "aggressive/assaultive behavior as evidenced by: owns gun, threatens to attack/kill others, attempt to assault older female patient per admission note". "Inability to function or care for his/her self as evidenced by: exposed self to others."

The standard pre-checked interventions on the MTP were the exact same as those for patient A7 above.
The additional selected (generic) interventions were:
- "Supportive psychotherapy 1 times per week to decrease S/HI [suicidal/homicidal ideations], impulsivity" (case manager)
- "Group sessions up to 3 times daily in realty orientation, decrease symptoms, increase coping" (RN/nursing, case manager, rehab therapist)
- "Family sessions up to 1 times weekly to address family issues or need" (physician, case manager)

B. Interviews

1. In an interview on 1/26/12 at 10:20a.m., RN2 "...They [the interventions] focus on the problems and needs relevant to all patients."

2. In an interview on 1/26/12 at 2:25p.m., the Nursing Director acknowledged that the interventions on the Master Treatment plans were generic. The DON said, "I agree that they need to be more specific."

3. In an interview on 1/26/12 at 2:30p.m., the Medical Director agreed that the preprinted interventions on the Master Treatment Plan form were generic discipline functions and were not individualized for the each patient.

Based on record review and interview, the facility failed to ensure that the staff members responsible for specific aspects of care were identified by name and discipline on the Master Treatment Plans for 6 of 12 active sample patients (A7, A12, B9, C4, E6 and F11). This practice results in the facility's inability to monitor staff accountability for specific treatment interventions.

Findings include:

A. Record Review

1. Facility policy No.550-001.4, Titled "Inpatient Interdisciplinary Treatment Plan," dated 1/5/12, states, "Interventions are multidisciplinary and describe the specific treatment and frequency that it will be provided. Clinicians responsible for providing each intervention are identified."

2. Review of the sample patients' Master Treatment Plans revealed the following:

a. The pre-checked standard intervention "provide appropriate level of observation to prevent harm to self or others" did not have an identified discipline assigned on the following 6 patients' MTPs (plan dates in parenthesis): A7(1/11/12; A12(1/20/12); B9(1/12/12); C4(12/31/11); E6(11/1/11) and F11(12/21/11).

3. The MTP of patient A7 (dated 1/11/12) did not identify responsible staff for "Group sessions 3 times daily."

4. The MTP of A12 (dated1/20/12) did not identify responsible staff for "Supportive psychotherapy" and "Group Sessions."

B. Interview

2. In an interview on 1/26/12 at 2:25p.m., the Nursing Director acknowledged the deficiencies on the Master Treatment Plans and said, "I agree that they need to be more specific."

3. In an interview on 1/26/12 at 2:30p.m., the Medical Director acknowledged the needed improvements in the facility's Master Treatment Plans.

I. Based on observation, document review, and interview, the facility failed to provide active treatment measures for 3 of 12 active sample patients (A12, H14, and I5). Patient A12 was an older adult on a geriatric unit, Patient H14 was an adult on an open adult unit, and Patient I5 was a young adult on a closed (locked) adult unit. All three patients were observed to be in their rooms during the survey while their assigned treatment modalities were in progress. The clinical staff was aware that these patients were not participating in their respective unit activities. There was no evidence that any of the patients were offered alternative therapies. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their clinical improvement.

II. Based on record review and interview, the facility failed to follow proper release criteria per facility policy for 1 of 5 active sample patients (I5) whose record was reviewed for restraint policy and procedure compliance. Patient I5 was kept in restraints after meeting the criteria for release. This deficient practice results in failure to ensure the patient's right to be free from restriction of movement without adequate justification.

III. Based on record review and interview, the facility failed to ensure that a physician's order was written for a physical hold (restraint) within an hour of the incident per facility policy for 1 of 4 non-sample patients (R3) whose record was reviewed for restraint policy and procedure compliance. Failure to provide alternative approaches to prevent multiple occurrences of restraints can lead to possible delays in the discharge of patients.

Findings include:

I. Lack of Active Treatment

A. Active sample patient A12

1. Record Review

a. The patient was admitted on 1/20/12 with a diagnosis of "Schizoaffective DO [disorder]". The Psychiatric Summary, dated 1/20/12, described this geriatric patient as "non verbal with poor eye contact, disheveled, filthy and unkempt with weight loss. Speech mute, severe psycho motor retardation"... "Catatonic, affect paranoid, delusional with auditory hallucinations."

b. Review of the Master Treatment Plan, dated 1/20/12, listed A12's barriers to treatment as "history of non-adherence to treatment, poor motivation for treatment, lack of social resources, and communication deficit [mute]." The standard interventions on the MTP were "Provide safe, structured environment"; "Provide appropriate level of observation to prevent harm to self or others"; "Psychiatric evaluation and prescribe appropriate medication"; "Assess for progress/improvement of symptoms"; "Provide education about diagnosis" and "Provide education about medication." The only other interventions were "supportive psychotherapy 5 times per week to facilitate coping" and "group sessions up to 5 times daily to increase socialization structure." None of these interventions addressed the listed barriers to treatment on the MTP.

c. A review of the unit activity schedule [there were no individual patient schedules] showed 2 to 3 therapeutic activities a day between the hours of 10a.m. and 3:30p.m. There were no scheduled groups on Saturday, and there was only 1 group (Rehab [rehabilitation] on Sunday from 1p.m. to 2p.m. There were approximately a total of 14 scheduled therapeutic groups offered for the 7 day period, with no scheduled groups after 3p.m.

d. A review of patient A12's progress notes for the period of 1/23/12 to 1/25/12 showed the following lack of participation in unit activities:

[1/23/12] Nursing Note
1:35p.m. - "[Patient] spent most of the shift in [A12] room. [A12] did come out upon request for meals, but otherwise did not initiate any contact."
[1/23/12] Nursing Note
No time listed - "[Patient] spent most of the shift in [A12] room. [A12] accepted meds [medication] & [and] did come out for dinner, but otherwise did not initiate any comments."
[1/24/12] Nursing Note
[2130]- "Pt [patient] was in room most of shift. Pt. ate all meals. Pt. appeared depressed. Pt. refused invitation to group activities. Pt. laid in bed most of shift."
[1/25/12] Nursing Note
[2:25p.m] - "Pt only visible on the unit for meals and group activity. Appetite is 100%. ADLs [activity of daily living] remain poor." --- "Pt spends all of [A12] free moments in bed - difficult to engage. Pt. did attend groups with minimal panic potion."

2. Observations

a. On 1/24/12 at 1p.m. on Unit 1 Center, patient A12 was observed lying in bed with a visitor sitting by the bed. The patient responded to brief questions from the surveyor, but otherwise lay quietly. The visitor stated that A12 spent most of the day at home in bed, not eating, or taking care of basic physical needs (activities of daily living). The patient was observed still in bed around 2:20p.m. on 1/24/12.

b. Patient A12 was observed attending only two groups during the survey- "Rehab Group" on 1/25/12 from 10:30a.m. to 11:30a.m., and "Music Therapy Group" on 1/26/12 from 11a.m. to 12 noon. During the "Rehab Group," A12 sat quietly staring straight ahead, and only responded "yes" or "no" when asked a question. During the "Music Group," in which most patients played simple musical instructions along with the group leader, A12 did not participate in the activity. The patient sat quietly staring straight ahead.

3. Interviews

a. In an interview on 1/24/12 at 10:51a.m., RN2 stated that patient A12 could be prompted to get up for meals, but was difficult to get up for groups.

b. During an interview on 1/25/12 at 12/15p.m., MHT1, who was assigned to patient A12 stated, "I encourage [Patient A12] to come to groups, but the patient is not spontaneous. You have to really press hard to get [patient] to respond."

c. In an interview on 1/25/12 at 12:25p.m., when asked if A12 attended any of OT1's Occupational Therapy groups, OT1 stated, "Patient [A12] is in [his/her bedroom] most of time."

d. In an interview on 1/26/12 at 2p.m., MD1 (the patient's attending physician) said that she knew about patient A12 not attending groups. She stated, "I don't want to push [A12] too much at this time."

B. Active Sample Patient H14

1. Observations

During an observation on 1/25/12 at 1p.m. on Unit 3 East, Patient H14 was lying in bed. During another observation on 1/26/12 at 10a.m., Patient H14 was again in bed. The other patients on the 3 East Unit were attending group activities on both of the above dates and times.

2. Document Review

a. According to the psychiatric evaluation, Patient H14 was admitted to the facility on 1/14/12. The evaluation stated that the patient's diagnosis was Schizophrenia, paranoid type.

b. The Interdisciplinary Treatment Plan developed on 1/14/12 stated that the patient had "aggressive and impulsive behavior" and that interventions should include participating in "group sessions up to 3 times a week to discuss stressors with relationship...and gain insight/coping skill."

c. A review of the patient's progress notes from 1/15/12 through 1/25/12 revealed no evidence that the patient had attended any group activities on the unit.

3. Interviews

a. In an interview on 1/25/12 at 1p.m., the Unit Nurse Case Manager for patient H14 stated, "We try to encourage group activity involvement; yet sometimes it doesn't happen."

b. During an interview on 1/26/12 at 2p.m. which included a discussion of the care for Patient H14, RN1 stated: "The patient spends a lot of time in [H14]'s room and in bed, isolated from activities. We try to encourage participation."

c. During an interview on 1/26/12 at 4p.m., SW1 stated, "The patient (H14) has resisted involvement in therapeutic and group activities and stays isolated. The patient (H14) does get dressed and comes into the hall and does talk to staff at the nursing station at times, and even can have cigarettes at scheduled times, yet refuses to participate for the most part." When asked if alternative activities were attempted by staff to support this patient's needs, the SW1 stated "none were provided as yet."

C. Patient I5

1. Observations

a. During observations on Unit 3 South on 1/24/12 between 1p.m. and 3p.m., Patient I5 was in his/her bedroom with two staff members providing 2:1 observation. During this timeframe, Patient I5 did not leave the room and did not participate in unit activities that were occurring in the day room.

b. During observations on Unit 3 South on 1/25/12 between 9:30a.m. and 12p.m., patient I5 was in his/her bedroom with two staff members providing 2:1 observation. Patient I5 was not observed participating in the unit activities that were scheduled that morning. The patient's lack of participation in unit activities was also noted during an observation later that day at 2p.m. During the entire survey, from the morning of 1/24/12 to the afternoon of 1/26/12, Patient I5 was never observed outside of his/her bedroom.

2. Interviews

a. During an interview on 1/24/12 at 11:45a.m., Patient I5 stated, "I haven't been going to groups." When asked if alternative activities were being provided if s/he missed group/unit activities, Patient I5 said "no."

b. During the interview on 1/24/12 at 11:45a.m., MHT6 stated "[I5] isn't safe to go to groups. We don't know when [I5] is going to hit someone." When asked if Patient I5 was receiving therapeutic activities or other forms of individual therapy while in his/her bedroom, MHT6 stated, "I haven't seen any."

c. During an interview on 1/25/12 at 2:15p.m., the Nurse Manager for Unit 3 South confirmed that Patient I5 was not being provided with alternative therapy while on 2:1 observation in his/her room. When asked how long this has been going on, the Unit Nurse Manager stated, "At least a couple of weeks now."

d. During an interview on 1/26/12 at 9:15a.m., MD4 (attending psychiatrist for Patient I5) acknowledged that Patient I5 wasn't receiving any alternative therapy while in his/her bedroom. MD4 said, "The staff is afraid of [I5] and no one knows when they'll get hit by [I5]." MD4 was asked if the patient ' s Master Treatment Plan had been modified to provide for alternative therapies or to deal with the continued assaultive behaviors, MD4 stated "No, not that I know of."

3. Record Review

Review of all staff and physician progress notes in Patient I5's chart failed to identify any group notes or evidence that Patient I5 had attended any unit activities between 1/17/12 and 1/26/12. The physician and case management notes also did not document that any individual therapy had been provided in place of unit activities.

II. Failure to follow release criteria

A. Active patient I5

1. According to the "Restraint and Seclusion Episode record" dated 1/17/12, Patient I5 was placed in walking wrist restraints at 8a.m. for the following reasons: "Repeatedly approaches staff with verbal threats"; "Will not back away from staff"; "Will not follow verbal redirection." Each restraint order was written for up to 4 hours. The restraint orders, which alternated between "walking restraints" and "4 point restraints" were reviewed every 4 hours by the physician "for safety of self and others."

2. The "Restraint and Seclusion Episode Record sheet provided documentation of a patient assessment every 15 minutes. It described the patient as "sleeping or appears to be sleeping" from 9:30a.m. to 11:30a.m. (two hours) and from 1:30p.m. to 3:05p.m. (1 hour and 15 minutes) on 1/17/12. During some of the sleeping periods, in the area where the Restraint and Seclusion Episode Record asks if the patient has met criteria for release, the answer was "no."

3. The facility's policy and procedure titled "Use of Restraint/Seclusion on Inpatient Units," no: G40-050.3, dated 2/2/10, states "The registered nurse will assure the patient is released from restraints when release criteria are met." "Patients who have been sleeping for at least 30 minutes prior to nurse's assessment meet criteria for restraint reduction or release" and "restraint will be discontinued when patient's behavior no longer meets criteria for restraints." The stated criteria for Patient I5's release from restraints were "no longer demonstrates aggressive behavior" and "can verbalize ability and willingness to maintain control." The release from restraint criteria "asleep" and "others" were left blank.

B. Interview

1. During an interview on 1/25/12 at 2:26p.m., RN3 stated that the staff didn't want to release the patient from restraints until they could see whether the patient was still agitated after s/he woke up.

2. In an interview on 1/26/12 at 2:25p.m., which included a discussion of the failure of the nursing staff to release patient I5 from restraints after several hours of continuous sleeping, the Nursing Director acknowledged that the facility's seclusion/restraint policy contained "sleep" as a requirement for release from restraint.

III. Failure to Obtain a Physician ' s Order

A. According to the "Restraint and Seclusion Episode Record" dated 1/10/12, from 2:45p.m. to 2:50p.m., non-sample Patient R3 was documented as "out of control, assaulting staff, redirected to Quiet room and continues to spit at, bite, kick, punch staff. Offered po [by mouth] medications, refused & [and] attempted to kick them out of staff hands." The patient was placed in a therapeutic hold. The physician's documentation on the "Restraint and Seclusion Record" stated the following: "[Patient] cursing, threatening, and assaulting staff. Refused po medications. Received IM [intramuscular] Benadryl and continued to be out of control."

B. The physician's order sheet did not show a written order for the 1/10/12 restraint (therapeutic hold) incident on that day. There was a late entry written on 1/11/12 at 7:15p.m. [about 27 hours after the incident]. The order read, "Late entry 1/10/12 - therapeutic hold NTE [not to exceed] 10 min [minutes] for safety to self and others."

C. The facility's policy and procedure on "Use of Restraints/Seclusion" states, "Each restraint episode requires a physician's order. This order may be provided as a verbal order"... "The physician will perform a face-to-face assessment of the restrained patient within 1 hour initiation of the restraint episode".... "If the restrain order was a verbal order, it must be signed at this time."

C. During an interview on 1/26/12 at 2:30p.m., the Medical Director agreed with the findings noted above and stated, "Our documentation should be better."

Based on record review and interview, the facility failed to ensure that discharge summaries for 3 of 5 discharged patients whose records were reviewed (DC2, DC4 and DC5) contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge. This failure results in a lack of critical clinical information concerning the patient's psychiatric symptomatology and risk being readily available to aftercare providers.

Findings include:

A. Record Review

1. Patient DC2: In a Discharge Summary dated 10/17/11, there was no information provided in the Discharge Summary aftercare instructions that included anticipated problems.

2. Patient DC4: In a Discharge Summary dated 12/8/11, under the section titled "Disposition and Aftercare Recommendations," the only entry was "The Patient was discharged into the care of DHS and it is recommended that [DC4] obtain stable housing as well as re-enrollment in school."

3. Patient DC5: In a Discharge Summary dated 12/23/11, under the section titled "Disposition" the only entry was "The patient was discharged home with significant improvement on 12/22/11. [DC5]'s aftercare was scheduled at American Day partial hospitalization program on 12/27/11."

B. Interview

In an interview on 1/26/12 at 2:30p.m., after reviewing the discharge summaries noted above, the Medical Director agreed with the findings and acknowledged the deficiency.

I. Based on record review and interview, the Medical Director failed to ensure that procedure/methods for external control of aggressive and agitated behavior were available to staff and were appropriately utilized for patients needing these procedures. The facility had high use of restraints. Patients were restrained in their beds in their bedrooms, which they often shared with roommates, a violation of patient rights' to privacy and dignity. The facility had a policy and procedure in place to support the use of less restrictive means than mechanical restraints when needed. However, with the exception of the Children's Unit, the facility had no seclusion rooms, thus had no ability to use the less restrictive measure of seclusion rather than restraint when a patient needed to be protected from harming self or others in the facility. These failures result in a lack of privacy for patients placed in restraint beds and exposes them to potential harm from unnecessary restraints. It also violates patients' right to safe treatment in the least restrictive manner possible.

Findings include:

A. Record Review

1. The facility's policy and procedure, no.: 640-050.3, titled "Use of Restraints/Seclusion on Inpatient Units," dated 2/1/10, consists of 18 pages of instruction for staff. The definition of seclusion is "The involuntary confinement of a patient in a room or area from which the patient is physically prevented from leaving." Of the 9 units at the facility, the only unit that has a designated room to seclude or restrain a patient is 1 South (the Children's program).

2. Upon request, the facility provided a list of restraint episodes for the period of 12/1/11 through 1/23/12. There were 45 episodes on the list.

3. Minutes from the Nurse Manager Meeting of 12/27/11 and 1/3/11 addressed the concern about lack of patient privacy during restraint episodes and the problem of patients being restrained in a room with other patients.

B. Interviews

1. On 1/24/12 at 1:19p.m., RN2 was asked where the seclusion/restraint room was on the unit. RN2 stated that there was no designated seclusion/restraint room. "We restrain patients in their bedrooms using their own beds. We don't have a seclusion room." When asked what they do about other patients assigned to the room, RN2 stated, "We have them sit in the dayroom if the restraint is during the day. If the restraint is at night, the other patient(s) sleep in their own beds. We do have a staff member stay with the restrained patients at all times for their safety."

2. In an interview on 1/25/12 at 1p.m., the 2 East/North Nurse Manager stated the following regarding the current practice of restraint of patients: "Years ago, we had a specific seclusion and restraint room for patients. However, currently those rooms are gone and the practice in most units is to restrain the patient in their own bedrooms. The problem here is that most patient rooms have two or three roommate beds in them, and during the day time we can ask the other roommates to stay out of their room while the patient is restrained. However, when the patient needs to be in restraints in the evening or night, then the patients' roommates may be asked to leave the room during the restraint episode."

3. During an interview on 1/26/12 at 3p.m., the Medical Director acknowledged that restrained patients' roommates are not always moved out of the restrained patient's room, and in some instances, the roommates remain overnight in the room with a restrained patient. The Medical Director also stated that the restrained patients' roommates occasionally sleep in the unit dayroom if there wasn't another bed available on the unit.

Additionally, the Medical Director failed to ensure that:

II. Physicians provided a psychiatric evaluation that contained a sufficiently complete record of mental status for 1 of 12 active sample patients (G14). A Mental Status Examination was not performed for this patient on admission. This deficiency makes it impossible to track serial changes in mental status while a patient is in treatment. (Refer to B113)

III. Clinical staff made significant revisions in the Master Treatment Plans for 1 of 1 active sample patient (I5) and 1 of 1 non-sample patient (R2) who had multiple restraint episodes over several days. The restraint episodes in the Master Treatment Plan Reviews were basically the same with little change from one review to the next to address the repetitiveness of the restraint incidents. Failure to provide alternative approaches for the prevention of restraint episodes can lead to possible delays in the improvement and discharge of patients. (Refer to B118)

IV. Clinical staff provided a Master Treatment plan that included a substantiated diagnosis for 12 of 12 active sample patients (A7, A12, B9, C4, E6, F11, G14, G20, H7, H14, I5 and J3). The pre-printed Master Treatment Plans did not include a space on the form for a diagnosis. Absence of a substantiated diagnosis (or diagnoses) on patients' treatment plans hamper's the treatment team's ability to focus on specific treatment issues. This can result in patients' problems not being adequately addressed during the hospitalization. (Refer to B120)