HospitalInspections.org

Based on record review, document review and interviews, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment of 8 of 8 sample active patients (A, B, C, D, E, F, G and H). Specifically, the hospital failed to:

I. Provide social work assessments for 3 of 3 child and adolescent patients (A, B and C) that included conclusions and recommendations for anticipated social work roles in treatment and discharge planning. This failed practice can result in a lack of professional social work services for patients, potentially delaying the patients' improvement and timely discharge. (Refer to B108).

II. Develop and document comprehensive multidisciplinary treatment plans based on multidisciplinary assessments and treatment planning for 8 of 8 sample patients (A, B, C, D, E, F, G and H) (Refer to B118). The Master Treatment Plans also failed to: a) include a substantiated diagnosis for sample patients A, B, C, D, E, F, G and H (Refer to B120); b) identify individualized and measurable short-term and long-term goals for patients A, B, C, D, F and G (Refer to B121); c) specify physician interventions for patients A, B, C, D, E, F, G and H, and individualized treatment modalities for patients A, B, C, D, F, G and H (Refer to B122); and d) include the name and discipline of staff responsible for the listed interventions for patients A, B, C, D, E, F, G and H. (Refer to B123) These deficiencies result in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

III. Provide active psychiatric treatment throughout the hospitalizations of 3 of 8 sample patients (F, G and H). These patients were hospitalized on the psychiatric intensive care unit (PICU). On that unit, there was only 45 to 75 minutes of group therapy and activities scheduled each weekday and none on weekends. Inadequate active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

Based on record review and interview, the facility failed to provide social work assessments that included conclusions and recommendations describing anticipated social work roles in treatment and discharge planning for 3 of 3 active sample child and adolescent patients. This failed practice results in lack of professional social work treatment services for patients, potentially delaying their improvement and timely discharge.

Findings include:

A. Record Review

1. Patient A: The "Child Addendum," which contained psychosocial history given by the patient's mother, was completed on 6/9/11 by a counselor with a bachelor's degree and no social work education. There was no other psychosocial assessment.

2. Patient B: The "Child Addendum," which contained psychosocial history given by the patient ' s mother, was completed on 6/9/11 by a counselor with a bachelor's degree and no social work education. There was no other psychosocial assessment.

3. Patient C: The "Child Addendum," which contained psychosocial history given by the patient's father, was completed on 6/10/11 by a registered nurse with no social work education. There was no other psychosocial assessment.

B. Interview

In an interview on 6/14/11 at 11a.m., the Team Leader for Nursing Operations, who served as the DON and also was responsible for social work and AT, stated that there was no master's level social worker who was functioning in a social work role and who provided oversight of evaluations on the child or adolescent units.

Based on observation, policy review, interview and record review, the facility failed to develop and document comprehensive multidisciplinary treatment plans based on a multidisciplinary planning process that included all disciplines for 8 of 8 active sample patients (A, B, C, D, E, F, G and H). The absence of comprehensive multidisciplinary treatment planning results in a lack of coordinated and organized treatment.

Findings include:

A. Observations

1. During observations of a treatment team meetings on the Adolescent Unit on 6-13-11 at 10:00a.m. and on 6-14-11 at 10:00a.m., the adolescent unit therapist, who in a later interview identified himself as the staff member who provides "all the psychotherapy for the patients," was not present at either of the treatment team meetings.

2. During an observation of a multi-disciplinary treatment team meeting for the Adult patients on 6-13-11 at 12:15p.m., no psychiatrist was present at the meeting.

B. Document Review

The facility's treatment planning policy, "BHS-BPC, # 081, revised 4/09" includes the following statement: "g. the collaboration of treatment team members may be formal or informal, but there must be evidence that collaboration has occurred..." Observations of the treatment planning meetings (noted in A above), interviews (noted in C below), and patient record review (noted in D below) did not reveal evidence of sufficient collaboration.

C. Interviews

1. In an interview on 6-13-11 at 9:30a.m., the Team Leader of Nursing Operations stated that a team meeting on the Children & Adolescent Unit is not a scheduled meeting. "The doctor has an hour's drive and the team meets every morning whenever he rolls in."

2. In an interview on 6-13-11 at 3:20p.m., the adolescent unit therapist, who is a social worker, stated, "I am the primary provider for all the psychotherapy for the patients on this unit. I am 100% psychotherapist. All my notations are in the electronic record. I do not sign the treatment plan and do not participate in the treatment team meeting because I speak directly to the psychiatrist."

3. In an interview on 6-13-11 at 1:30p.m., Social Worker 1 confirmed that nurses, occupational therapists, and social workers, but not physicians attend the 12:15 daily treatment team.

4. In an interview on 6-14-11 at 9:00a.m. with the Staff Educator and the Adult Unit Team Facilitator and the Child & Adolescent Team Facilitator, the interviewees explained that the facility's Master Treatment Plan document consists of four individual documents: the Multidisciplinary Treatment Plan completed on admission, the Learning Needs Assessment completed on admission, the Tracking Form which is on-going, and the Multidisciplinary Staffing Review Sheet completed every 72 hours. They stated that all four documents needed to be reviewed as one treatment plan.

5. In an interview on 6-14-11 at 10a.m., the Chief of Medical Staff (Clinical Director) stated, "We do not have a multidisciplinary treatment plan." He further explained that, in his opinion, adequate treatment planning required that all team members sit down together and discuss the case and that this procedure did not occur on the adult psychiatric units.

6. In an interview on 6-14-11, at 2:20p.m., the Team Leader for Nursing Operations stated that the treatment team considers the psychiatric evaluation to also be part of the treatment plan.

D. Record Review (MTP dates in parentheses)

The following 8 active sample patient's Master Treatment Plans were reviewed: Patient A: (6-9-11); Patient B (6-9-11); Patient C (6-10-11); Patient D (6-10-11); Patient E (5-31-11); Patient F (6-12-11); Patient G (6-11-11) and Patient H (6-12-11). The review revealed the following deficiencies: a) lack of a substantiated diagnosis for sample patients A, B, C, D, E, F, G and H (Refer to B120); b) lack of individualized and measurable short-term and long-term goals for patients A, B, C, D, F and G (Refer to B121); c) lack of physician interventions for patients A, B, C, D, E, F, G and H, and individualized treatment modalities for patients A, B, C, D, F, G and H (Refer to B122); and d) failure to include the name and discipline of staff responsible for the listed interventions for patients A, B, C, D, E, F, G and H. (Refer to B123)

Based on record review, document review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (A, B, C, D, E, F, G and H) included substantiated diagnoses. Absence of a substantiated diagnosis compromises the treatment team's ability to deliver clinically focused treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

None of the following 8 sample patients' Master Treatment Plans included any documentation regarding the patient's diagnosis: Patient A: (6-9-11); Patient B(6-9-11); Patient C (6-10-11); Patient D (6-10-11); Patient E (5-31-11); Patient F (6-12-11); Patient G (6-11-11) and Patient H (6-12-11).

B. Policy Review

The facility's treatment plan policy, "BHS-BPC.081, revised 4/09," identified one of the "treatment plan components" as ..."Diagnostic information using Axis I - V consistent with the DSM-IV."

C. Staff Interviews:

1. In an interview on 6-14-11 at 1:50p.m., the President of the facility (a master's prepared nurse) stated that the patient's diagnosis "should be in the treatment plan."

2. In an interview on 6-14-11 at 2:20p.m., the Team Leader for Nursing Operations stated that the multidisciplinary treatment plan "does not have a place for the diagnosis." He also stated that the diagnosis identified in the psychiatric evaluation constitutes having the diagnosis in the treatment plan.

Based on interview, record review, and document review the facility failed to provide a Master Treatment Plan (MTP) for 6 of 8 active sample patients (A, B, C, D, F and G) that identified individualized short-term and long-term goals stated in observable, measurable, behavioral terms. The listed "outcomes" or "goals" were either not individualized to the patient, were not measurable, or were missing. These failures result in treatment plans that do not identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure an individual's progress in treatment.

Findings include:

A. Record/Document Review (MTP dates in parentheses)

1. The treatment plan forms used by the facility included prompts for short term and long term treatment "outcomes" or "goals" (terminology varied with units), with lines to write in recommendations to individualize the goals/outcomes for patients. An example of a prompt for the short term outcome/goal was: "Short-Term Outcome: Patient identifies age-appropriate goal(s) for treatment." An example of a prompt for a long term goal was: "Long-Term Outcome: Patient identifies and/or demonstrates behaviors that promote health." The written in outcome/goals were not measurable, and some were not goals for inpatient treatment. Specific findings from the patient's MTPs were as follows:

2. Patient A: The MTP (6-9-11) identified no short-term or long-term outcomes for the patient. The lines following the prompts for the short-term and long-term outcomes were left blank.

3. Patient B: The MTP (6-9-11) identified one short term goal -- "start on varsity football team" and one long-term goal -- "Have a family and good job." Neither of these goals were goals for in-patient treatment.

4. Patient C: The MTP (6-10-11) identified one short-term goal as --"getting drivers license" and one long-term goal "Go to college." Neither of these goals were goals for in-patient treatment.

5. The MTPs for Patients D (6-10-11), F (6-12-11), and G (6-11-11) identified one short-term outcome that was preprinted on the MTP form -- "Patient identifies ineffective coping behaviors." Nothing was written on any of the three patients' MTPs to individualize the short-term treatment goals. The MTPs for these patients also identified one long-term outcome that was preprinted on the form -- "Patient identifies and/or demonstrates behaviors that promote health." Nothing was written on any of the three forms to individualize the long-term treatment goals. In addition, the stated goal was not measurable.

B. Policy Review

The facility's treatment plan policy, "BHS-BPC.081, revised 4/09, states: "...The treatment plan components" include..."a. Short- [sic] and long-term objectives that are measurable."

C. Interview:

1. In an interview on 6/13/11 at 4:30p.m., the President of the facility acknowledged that the treatment goals written for adolescents were "personal goals rather than treatment goals. The President also stated, "Patient B is clearly not going to start on the varsity football team while he is here."

2. In an interview on 6/14/11 at 10a.m., the Chief of Medical Staff confirmed the absence of appropriate goals on the sample patient's treatment plans.

Based on record review and document review, the facility failed to develop Master Treatment Plans that clearly delineated discipline specific interventions to address identified patient problems. Specifically, the facility failed to ensure that the MTPs of 8 of 8 active sample patients (A, B, C, D, E, F, G and H) identified the treatment role of physicians, and that treatment plans of 7 of 8 active sample patients (A, B, C, D, F, G and H) included individualized modalities that addressed identified patient problems. These deficiencies result in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record Review (MTP dates in parentheses)

Review of the sample patients Master Treatment Plans revealed the following

1. None of the 8 sample patients' MTPs identified any role for the physician. The MTP dates were: Patient A (6-9-11); Patient B (6-9-11); Patient C (6-10-11); Patient D 6-10-11); Patient E (5-31-11); Patient F (6-12-11); Patient G (6-11-11) and Patient H (6-12-11).

2. Additional Findings

a. Patient A (MTP=6-9-11): All interventions on the MTP were pre-printed, and none were individualized for the patient. Generic interventions included: "Involve in Token Economy System to reinforce positive behavior; Occupational Therapy to promote independence, health, and wellness through self-expression or group activity; Group Therapy to encourage expression of feelings and enhance problem solving skills; Learning labs to focus on identified learning needs; Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner; Explore previously successful coping methods." The prompt lines for adding treatment team recommendations were left blank.

b. Patient B (MTP=6/9/11): All interventions on the MTP were pre-printed with no individualization. Generic interventions included: "Involve in Level System to reinforce positive behavior; Occupational Therapy to promote independence, health, and wellness through self-expression or group activity; Group Therapy to encourage expression of feelings and enhance problem-solving skills; Learning labs to focus on identified learning needs; Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner; Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Encourage patient to focus on strengths rather than weaknesses; Encourage patient to adhere to program rules. Carry out consequences in a matter-of-fact manner." The prompt lines for adding treatment team recommendations were left blank.

c. Patient C (MTP=6-10-11): All interventions on the MTP were pre-printed and included no individualization. Generic interventions were identical to the ones identified for Patient B: "Involve in Level System to reinforce positive behavior; Occupational Therapy to promote independence, health, and wellness through self-expression or group activity; Group Therapy to encourage expression of feelings and enhance problem-solving skills; Learning labs to focus on identified learning needs; Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner; Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Encourage patient to focus on strengths rather than weaknesses; Encourage patient to adhere to program rules. Carry out consequences in a matter-of-fact manner." The prompt lines for adding treatment team recommendations were left blank.

d. Patient D (MTP=6-10-11): Interventions on the MTP were pre-printed and included no individualization, with the exception of a list of coping mechanisms identified at admission. Generic interventions included: "Occupational Therapy to promote independence, health, and wellness through self-expression or group activity; Group Therapy to encourage expression of feelings and enhance problem-solving skills; Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner; Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Assist patient to focus on strengths rather than weaknesses; Assist patient to adhere to program rules. Carry out consequences in a matter-of-fact manner." The prompt lines for adding "Treatment Team Direction" were left blank.

e. Patient F (6-12-11): Interventions were absent from the MTP provided.

f. Patient G (6-11-11) Interventions were: "Depression Documentation Protocol; Fall Safe Yellow Program; Teach High Risk for Injury (Falls) Protocol."

g. Patient H (6-12-11): Interventions were absent from the MTP provided.

B. Document Review

The facility's treatment plan policy, "BHS-BPC., #081, revised 4/09" states: "...The treatment plan components are: ...g...there must be evidence that . . . the treatment plan is individualized.

C. Interview

1. In an interview on 6-13-11 at 2p.m., RN1 stated, "The expectation is that all patients go to all programs. There is no alternative treatment."

2. In an interview on 6/14/11 at 10a.m., the Chief of Medical Staff confirmed the absence of individualized modalities in the sample patients' treatment plans as well as the absence of specific physician treatment modalities in the plans.

Based on record review and interview, the facility failed to ensure that the name and discipline of the staff persons responsible for interventions and/or treatment modalities were listed on the Master Treatment Plans of 8 of 8 active sample patients (A, B, C, D, E, F, G and H). This failed practice results in lack of staff accountability for specific treatment modalities.

Findings include:

A. Record Review (MTP dates in parentheses)

Review of the following sample patients Master Treatment Plans revealed that the plans failed to list, by name and discipline, the staff members who were responsible for treatment interventions: Patient A (6-9-11); Patient B (6-9-11); Patient C (6-10-11); Patient D (6-10-11); Patient E (5-31-11); Patient F (6-12-11); Patient G (6-11-11) and Patient H (6-12-11).

B. Interview:

In an interview on 6-13-11 at 2p.m., RN1 stated that the person responsible for the interventions identified on the Master Treatment Plans would be "whoever is working with the patient at any given time."

Based on document review and interview, it was determined that the facility failed to provide active psychiatric treatment throughout the hospitalizations of 3 of 8 sample patients (F, G and H). These patients were hospitalized on the psychiatric intensive care unit (PICU). On that unit there was only 45 to 75 minutes of group therapy and activities scheduled each weekday and none on weekends. Insufficient active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Document review:

The program schedule for the psychiatric intensive care unit (PICU) for the week of 6/13/11 to 6/19/11 included a total of 75 minutes per day of programming (an occupational therapy class) for 4 weekdays, and 45 minutes of "group/class" on the 5th weekday. There was no scheduled programming for Saturday or Sunday.

B. Interviews:

1. In an interview on 6/13/11 at 12p.m., patient F stated, "I wanted to be a voluntary patient but they just laughed at me" and "I was over there [the PICU] last night but I was very uncomfortable."

2. In an interview on 6/13/11 at 2p.m., RN 4 stated "There is no programming (group therapy or structured activities) on weekends." She also stated that in the case of patient F, "the reason he was transferred [to the other adult unit] was so that he could get the programming."

3. In an interview on 6/14/11 at 10a.m., the Chief of Medical Staff acknowledged the relative lack of structured activities on the PICU. He explained that the rationale for this was to help decrease the amount of stimulation experienced by acutely ill patients. He also stated that all involuntarily admitted adult patients are admitted to the PICU and remain there until such time as they either become voluntary or have a court appearance. The court appearance may take up to 6 days.

Based on observation, record review, policy review and interview, the Chief of Medical Staff failed to:

I. Assure the development of comprehensive multidisciplinary treatment plans based on a multidisciplinary assessments and planning process for 8 of 8 sample patients (A, B, C, D, E, F, G, H) (Refer to B118). The Master Treatment Plans also failed to: a) include a substantiated diagnosis for sample patients A, B, C, D, E, F, G and H (Refer to B120); b) identify individualized and measurable short-term and long-term goals for patients A, B, C, D, F and G (Refer to B121); c) specify physician interventions for patients A, B, C, D, E, F, G and H, and include individualized interventions for patients A, B, C, D, F, G and H (Refer to B122); and d) specify the name and discipline of staff responsible for interventions listed on the treatment plans for patients A, B, C, D, E, F, G and H. (Refer to B123) These deficiencies result in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

II. Assure the provision of active psychiatric treatment throughout the hospitalizations of 3 of 8 sample patients (F, G and H). These patients were hospitalized on the psychiatric intensive care unit (PICU). On that unit, there was only 45 to 75 minutes of group therapy and activities scheduled each weekday, and none scheduled for weekends. Insufficient treatment programming results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

Based on record review, document review and interview, it was determined that the Team Leader of Nursing Operations (Director of Nursing) failed to adequately direct and monitor nursing staff's participation in the treatment planning process.

Specifically, the DON failed to:

I. Ensure that nursing modalities on the Master Treatment Plans of 7 of 8 active sample patients (A, B, C, D, F, G and H) were individualized and addressed identified patient problems. Nursing interventions on these patients' treatment plans were missing or were generic nursing tasks that were identical or very similar for patients. These deficiencies result in a lack of guidance for nursing staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A (6-9-11): Interventions on the MTP were pre-printed, and none were individualized for the patient. Generic (nursing) interventions included: "Involve in Token Economy System to reinforce positive behavior; ...Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner: Explore previously successful coping methods."

2. Patient B (6/9/11): Interventions on the MTP were pre-printed, and none were individualized for the patient. Generic nursing interventions included: "Involve in Token Economy System to reinforce positive behavior;...Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner: Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Encourage patient to focus on strengths rather than weaknesses; Encourage patient to adhere to program rules. Carry out consequences in a matter-of-fact manner."

3. Patient C (6-10-11): Interventions on the MTP were pre-printed, and none were individualized for the patient. Generic nursing interventions included: "Involve in Token Economy System to reinforce positive behavior;...Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner: Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Encourage patient to focus on strengths rather than weaknesses; Encourage patient to adhere to program rules. Carry out consequences in a matter-of-fact manner."

4. Patient D (6-10-11): Interventions on the MTP were pre-printed, and none were individualized for the patient. Generic nursing interventions included: "Involve in Token Economy System to reinforce positive behavior;...Provide therapeutic unit milieu: Encourage participation in unit activities as tolerated; Interact with patient in a calm, direct, non authoritarian manner: Explore previously successful coping methods with patient; Help patient identify alternative adaptive coping methods (relaxation, exercise, deep breathing, positive self-talk, etc.); Offer positive reinforcement when patient demonstrates use of coping skills or appropriate social skills; Encourage patient to focus on strengths rather than weaknesses; Encourage patient to adhere to program rules. Carry out consequences in a matter-of-fact manner."

5. Patient F (6-12-11): Interventions, including those for nursing, were absent from the MTP provided.

6. Patient G (6-11-11) Interventions on the MTP, including those for nursing, were listed as: "Depression Documentation Protocol; Fall Safe Yellow Program; Teach High Risk for Injury (Falls) Protocol." The listed protocols were not attached to the MTP.

7. Patient H (6-12-11): Interventions, including those for nursing, were absent from the MTP provided.

B. Document Review

The facility's treatment plan policy, "BHS-BPC., #081, revised 4/09" states: "...The treatment plan components are: ...g...there must be evidence that...the treatment plan is individualized.

II. Ensure that the name and discipline of the nursing staff responsible for specific aspects of care were listed on the Master Treatment Plans of 8 of 8 active sample patients (A, B, C, D, E, F, G and H). This failed practice results in lack of nursing staff accountability for specific nursing interventions.

Findings include:

A. Record Review (MTP dates in parentheses)

Review of the following 8 sample patients Master Treatment Plans revealed that the plans failed to list, by name and discipline, the nursing staff members who were responsible for treatment interventions: Patient A (6-9-11); Patient B (6-9-11); Patient C (6-10-11); Patient D (6-10-11); Patient E (5-31-11); Patient F (6-12-11); Patient G (6-11-11) and Patient H (6-12-11).

B. Staff Interview

In an interview on 6-13-11 at 2p.m., RN1 stated that the person responsible for the interventions identified on the Master Treatment Plans would be "whoever is working with the patient at any given time."

Based on document review, record review and interview, the facility failed to provide a Director of Social Work to oversee social services or to assign one of its 3 MSW staff to fulfill the duties, functions, and responsibilities of the Director or Social Work. This failure results in lack of professionally directed social work services patients.

Findings include:

A. Document review

1. The hospital's table of organization showed no place within the organization for a Director of Social Work or for any social work services.

B. Record Review

1. Patient A: The "Child Addendum," which contained psychosocial history given by the patient's mother, was completed on 6/9/11 by a counselor with a bachelor's degree and no social work education. There was no other psychosocial assessment.

2. Patient B: The "Child Addendum," which contained psychosocial history given by the patient's mother, was completed on 6/9/11 by a counselor with a bachelor's degree and no social work education.. There was no other psychosocial assessment.

3. Patient C: The "Child Addendum," which contained psychosocial history given by the patient's father, was completed on 6/10/11 by a registered nurse with no social work education.. There was no other psychosocial assessment.

C. Interview

1. In an interview on 6/14/11 at 11a.m., the Team Leader for Nursing Operations, who served as the DON and also was responsible for social work and AT, stated that there was no master's level social worker who was functioning in a social work role and who provided oversight of evaluations on the child or adolescent units.

2. In the same interview as above (6/14/11; 11a.m.), the Team Leader for Nursing Operations stated that he had overall responsibility for social work services provided by the 3 MSW staff on the adult unit and that he had no education/degree in social work.

Based on interview and document review, the facility failed to provide sufficient hours of activity therapy which focused on restoring optimal levels of physical and psychosocial functioning during the weekday evening hours and throughout the weekends for 8 or 8 active sample patients (A, B, C, D, E, F, G and H). This deficient practice results in patients being hospitalized without receiving adequate activity therapy, potentially delaying their improvement.

Findings include:

A. Interviews

1. In an interview on 6-13-11 at 10:30a.m., Occupational Therapist OT1 stated that two staff members constituted the therapeutic activities department -- one working 0.8 FTE and the other working 0.9 FTE. OT1 stated that one OT person reports directly to the unit facilitator of the Adolescent and Child Unit, and the other OT (a COTA therapist) reports directly to the unit facilitator of the Adult Unit; however both the OTR and the COTA staff cover programs throughout the hospital. OT1 also reported that there is no therapeutic activity programming on weekends or evenings.

2. In an interview on 6-13-11 at 12:30p.m., Patient B stated, "Saturday and Sunday don't count as a day of being here because we don't do much on the weekends. We watch videos and go to the gym. Not everything that happens applies to all the patients. I had to stay in my room on Saturday and Sunday until 9:30a.m. because the wake-up time on weekends is later. But I don't like to sleep late and I wanted to get up and leave my room and be in the day room, but a staff told me in a mean way I had to stay in my room until the schedule said it was time to get up. Also activities don't really apply to everyone. Yesterday, I was in an anger management group, but I was the only one in the group who has an anger problem, so it felt really uncomfortable."

3. In an interview on 6-14-11, at 2:20p.m., the Team Leader for Nursing Operations, who functions as the Director of Social Services and Therapeutic Activities as well as the DON, stated that there is a "gap for weekends and evenings" and that there is no scheduled weekend therapeutic activity programming.

B. Document Review:

1. The weekly schedule for 06-13-11 through 06-19-11 provided to the surveyors for the PICU unit had no activities scheduled for the weekend or the evenings.

2. The weekly schedule for week of 06-13-11 through 06-19-11 on the Adolescent Unit identified wake-up time as 9 - 10a.m. The remaining 13 hours of the 16-hour day included: Free Time, Room Time, Meals, and Staff Choice time. The schedule also showed a lack of weekend programming