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Based on record review, observation and interview, the facility failed to provide active treatment, including alternative interventions, for four (4) of 15 active sample patients (B15, C1, C14, and C15). Active sample patient C14 was in continuous locked seclusion since his/her admission without active treatment measures being provided to him/her. Patients B15, C1 and C15 were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

Based on record review, observation and interview, the facility failed to provide active treatment, including alternative interventions for four (4) of 15 active sample patients (B15, C1, C14, and C15). Active sample patient C14 was in continuous locked seclusion since his/her admission without active treatment measures being provided to him/her. Patients B15, C1 and C15 were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Active Sample Patient B15

1. Patient B15 was admitted on 2/24/16. The Psychiatric Evaluation, dated 2/24/16 at 6:20 p.m., documented a diagnosis of "Dementia, Alzheimer's type, with behavioral disturbance including depression and psychosis."..."[Name of patient] does not show any signs of physical distress. There is no psychomotor agitation or retardation noted. Speech is of and is of rambling [sic], [s/he] mumbles throughout the interview, and this writer could not get any information. Attitude remained guarded. Affect remained blunt. Mood was neutral. Unable to assess thoughts of harming self or others. There is no reported history of suicidality. There is a report of the patient hallucinating with increased paranoia. The patient continued to be disorganized and confused."

2. The modalities identified on B15's Master Treatment plan, dated 5/24/16, were "Relax and Renew" 2x [times] weekly for 50 minutes, "Sensa-tional Interventions" 2x weekly x 50 minutes and OT/RT [Occupational Therapy/Recreational Therapy], "Reminisce Theme" 2x weekly 50 minutes, all focus on purposeful talk."

3. On 6/4/16 patient B15 was scheduled for "Sensa- Interaction" group at 10:40 a.m. in the Treatment Mall. The surveyor went to the mall to attend the group but RT2 stated that B15 had been excused from the group because s/he was sleeping. The patient was observed in his/her room #104-2 on B pod unit in bed with a blanket covering the entire body up to the top of his/her head.

4. A review of the patient's group attendance for the week of 6/5/16 showed what the patient was doing during the times the groups were being held. The "Patient and Safety Flow sheet (rounds sheet) for the period of 6/6/16 - 6/11/16 showed the following:

- 6/6/16 - 10:40 a.m. - "Recent & Renew" group - patient "up on ward." 2:30 p.m. - "Reminisce" group - patient "up on ward"

- 6/7/16 - 10:40 a.m. - "Sensa-ational Interaction" - a check mark (no recording of being in group).

- 6/8/16 - 10:40 a.m. - "Relax & Renew" group - patient "in bed." 1:15 p.m. - "Reminisce" group - "Patient at group in treatment mall."

- 6/9/16 - 10:40 a.m. - "Sensa-ational Interaction" group - patient "up on ward."

The patient's group scheduled was blank for Friday, Saturday and Sunday, meaning no groups were scheduled.

5. A review of the updated Master Treatment plan of 5/24/16 did not address any alternative measures in place of the groups provided for the patient. It stated "No change to STG (short-term goal) #2 (psychosis/mood) lability with cog [cognitive] impairment and interventions"---"no change to interventions for STG #1 (self-care deficit)."

6. Nursing progress notes reviewed for patient B15 during the period of 6/6/16 at 2:50 a.m. and 6/13/16 at 6:20 p.m. did not mention any problems with lack of group attendance by this patient.

7. In an interview on 6/14/16 at 11:30 a.m., the lack of alternatives for existing measures of active treatment on the Master Treatment plan for B15 was discussed with RN1. She stated, "We're still having a little struggle getting alternatives on patients' chart."

8. In an interview on 6/13/16 at 11:30 a.m. with RN1 about patients who were not attending groups, s/he stated that patient B15 "just refuses to go."

B. Active sample patient C1

1. Observation:

On June 13, 2016 at 11:00 a.m., the nurse surveyor observed Patient C1 sitting alone at a desk in the dayroom. Staff did not engage this patient nor was [s/he] involved in even a solitary activity. Patient C1 was staring into space until the lunch trays came about 12:15 p.m.

2. Record Review:

a. Patient C1 (psychiatric evaluation dated 5/5/16) was diagnosed with Schizoaffective
Disorder, Mixed Substance Abuse and Antisocial Personality Disorder. This patient "had many delusions related to sexual, religious and satanic themes."

b. The Programming Attendance roster revealed that Patient C1 had attended 20.79% of the groups offered from 5/5/16 until 6/13/16.

c. The Master Treatment Plan dated 5/5/16 did not address Patient C1's failure to attend groups nor did the plan provide individual activities.

3. Interviews:

a. On June 13, 2016 at 1:15 p.m., Patient C1 stated, "I do not go to groups. The patients make it horrible. I like to do art but no one brings me materials."

b. On June 13, 2016 at 11:10 a.m., RN 3 stated, "We do not force the patients to go to groups. We remind them when it is group time. Patients do not receive individual work."

c. On June 15, 2016 at 10:30 a.m., the Director of Nursing stated, "No, we are not providing individual work for patients who do not attend groups."

C. Active sample patient C14

1. Observation:

On June 13, 2016 at 10:42 a.m., the nurse surveyor observed Patient C14 in a locked seclusion room. The nurse stated that the patient had been in the locked seclusion room since admission on 4/18/16.

2. Record Review:

a. Patient C14 (psychiatric evaluation dated 4/18/16) was diagnosed with Schizophrenia and Antisocial Personality Disorder. During past hospital stays this patient "was assaultive towards staff on a number of occasions, as well as assaultive toward other patients."

b. There was no documentation that the patient had been to groups or had been provided individual treatment.

c. The Master Treatment Plan dated 4/18/16 did not indicate that Patient C14 was provided individual treatment.

3. Interviews:

a. On June 13, 2016 at 10:50 a.m., Patient C14 stated to the nurse surveyor, "No, I stay in this room all the time. I am not given individual activities."

b. On June 13, 2016 at 11:30, RN2 stated, "This patient cannot go to groups because of dangerousness. No, we do not provide individual work for this patient."

C. Active sample patient C15

1. Observation:

On June 13, 2016 at 11:40 a.m., the nurse surveyor observed Patient C15 asleep in the dayroom. The patient remained asleep until lunch was served about 12:15 p.m.

2. Record Review:

a. Patient C15 (psychiatric evaluation dated 7/15/15) was diagnosed with Schizoaffective Disorder, Polysubstance Abuse and Antisocial Personality Disorder. The patient was described as being disorganized, delusional and hostile.

b. The Programming Attendance roster revealed that Patient C15 attended 22.15% of the groups offered from 5/14/16 to 6/14/16.

c. The Master Treatment Plan dated 4/20/16 did not address Patient's C15's failure to attend groups nor did the plan provide individual activities.

3. Interviews:

a. On June 13, 2016 at 12:30 p.m., Patient C15 stated, "I never attend groups. No one gives me stuff to do by myself either."

b. On June 15, 2016 at 1:00 p.m., RN4 stated, "No, we do not typically provide individual activities for patients who won't attend groups."

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically, the Medical Director failed to provide active treatment, including alternative interventions for four (4) of 15 active sample patients (B15, C1, C14 and C15). Active sample patient C14 was in continuous locked seclusion since his/her admission without active treatment measures being provided to him/her. Patients B15, C1 and C15 were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all intervention for recovery being provided to them, potentially delaying their improvement. (Refer to B125)