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Based on record review and interview, the facility failed to psychiatric evaluations that provided an adequate estimate of intellectual and memory functioning or describe methods used for testing for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure compromises the data base from which changes in a patient condition can be measured throughout the course of treatment, and it impedes the ability of the clinical team to develop treatment goals and interventions that are concordant with the patient's estimated cognitive functioning.

A. Record Review

Findings include:

1. Record A1

A psychiatric evaluation was done on 1-20-12, i.e. one day after admission, but the mental status examination only provided summary information on intellectual and memory function, stating, "Fund of knowledge is intact and age appropriate. Short and long term memory are intact." There was no information regarding the clinical findings on which those declarative statements were based.

2. Record A2

A psychiatric evaluation was done on 1-16-12, i.e. two days after admission, but the mental status examination only provided summary information on intellectual and memory function, stating, "Fund of knowledge is intact and age appropriate. Short and long term memory are intact." There was no information regarding the clinical findings on which those declarative statements were based.

3. Record A3

A psychiatric evaluation was done on 1-19-12, i.e. two days after admission, but the mental status examination only provided summary information on intellectual and memory function, stating, "Vocabulary and fund of knowledge indicate cognitive functioning in the normal range." There was no information regarding the clinical findings on which those declarative statements were based.

4. Record A4

A psychiatric evaluation was done on 1-20-12, i.e. one day after admission, but the mental status examination contained no reference to cognitive functions of any kind. Specifically, there was no estimate of intellectual and memory functioning.

5. Record A5

A psychiatric evaluation was done on 1-19-12, i.e. one day after admission, but the mental status examination only provided the comment "Cognitive functioning was not formally tested today but appears clinically to be unchanged from previous examinations."

6. Record A6

A psychiatric evaluation was done on 1-11-12, i.e. one day after admission, but the mental status examination only provided summary information on intellectual and memory function, stating, "Cognitive functioning and fund of knowledge is intact and age appropriate. Short and long term memory are intact." There was no information regarding the clinical findings on which those declarative statements were based.

7. Record A7

A psychiatric evaluation was done on 1-16-12, i.e. the day of admission, but the mental status examination only provided summary information on memory function, stating, "Memory - grossly intact." There was no information regarding the clinical findings on which this declarative statement was based. Intellectual function was not mentioned.

8. Record A8

A psychiatric evaluation was done on 1-13-12, i.e. one day after admission, but the mental status examination contained no reference to cognitive functions of any kind. Specifically, there was no estimate of intellectual and memory functioning.

B. Interview

1. In an interview on 1-24-12 at 10AM, the Medical Director acknowledged that the PE included no information about how the assessment of memory function and intellectual function were done.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for 7 of 8 sample patients (A1, A2, A3, A4, A5, A6 and A8). The failure to identify patient assets impairs the treatment team's ability to develop treatment plans that utilize the patient's positive attributes.

Findings include:

A. Record Review

1. Record A1

A psychiatric evaluation was done on 1-20-12, i.e. one day after admission, but it failed to include any reference to patient strengths or assets.

2. Record A2

A psychiatric evaluation was done on 1-16-12, i.e. two days after admission, but it failed to include any reference to patient's strengths or assets.

3. Record A3

A psychiatric evaluation was done on 1-19-12, i.e. two days after admission, but it failed to include any reference to patient's strengths or assets.

4. Record A4

A psychiatric evaluation was done on 1-20-12, i.e. one day after admission, but it failed to include any reference to patient's strengths or assets.

5. Record A5

A psychiatric evaluation was done on 1-19-12, i.e. one day after admission, but it failed to include any reference to patient's strengths or assets.

6. Record A6

A psychiatric evaluation was done on 1-11-12, i.e. one day after admission, but it failed to include any reference to patient's strengths or assets.

7. Record A8

A psychiatric evaluation was done on 1-13-12, i.e. one day after admission, but it failed to include any reference to patient's strengths or assets.

B. Interview

In an interview 1-24-12 at 10AM, the Medical Director acknowledged that inventories of patients' assets are not part of the initial psychiatric assessments.

Based on record review and interview, the facility failed to develop and document comprehensive Interdisciplinary Inpatient Treatment Plans (IITPs) based on individual patient needs. Specifically, the facility failed to develop and document treatment plans that:

I. Included patient-specific measurable goals, based on the individual needs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure results in treatment plans that do not identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

II. Included individualized interventions, based on the assessed needs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8.) The interventions were stated as routine generic discipline functions and were the same for all patients, irrespective of their listed problems. The generic interventions also failed to include frequency and/or delivery method. This hampers staff's ability to provide consistent and focused treatment. (Refer to B122)

3. Identified the name and discipline of the treatment team members responsible for treatment interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Identification of those staff members responsible for ensuring compliance with particular aspects of a patient's IITP is essential to the provision of care. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient ' s discharge and recovery. (Refer to B123)

Based on record review and interview, the facility failed to develop Interdisciplinary Inpatient Treatment Plans (IITPs) for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8) that identified patient specific and measurable patient goals. The goals on the IITPs, labeled "Discharge Criteria," were the same or very similar for all patients, irrespective of the patients identified problems. In addition, the stated goals were not measurable. This failure results in treatment plans that do not identify expected treatment outcomes in a manner that can be used by the treatment team to measure individual patients' progress in care.

A. Record Review

Findings include:

1. Record A1

The IITP was generated on 1-23-12, i.e. three days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, improve stabilization in mood, thinking and/or behavior, withdrawal symptoms are absent or sub-acute and managed without 24 hour nursing intervention, need for consent [sic] or close observation no longer present, medical problem requires only outpatient monitoring, verbal commitment to aftercare and medication compliance."

2. Record A2

The IITP was generated on 1-16-12, i.e. two days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, improve stabilization in mood, thinking and/or behavior, verbal commitment to aftercare and medication compliance."

3. Record A3

The IITP was generated on 1-19-12, i.e. two days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, improve stabilization in mood, thinking and/or behavior, patient monitoring, verbal commitment to aftercare and medication compliance."

4. Record A4

The IITP was generated on 1-23-12, i.e. three days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, improve stabilization in mood, thinking and/or behavior, withdrawal symptoms are absent or sub-acute and managed without 24 hour nursing intervention, need for consent [sic] or close observation no longer present, verbal commitment to aftercare and medication compliance."

5. Record A5

The IITP was generated on 1-20-12, i.e. two days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, need for consent [sic] or close observation no longer present, medical problem requires only outpatient monitoring."

6. Record A6

The IITP was generated on 1-12-12, i.e. two days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, improve stabilization in mood, thinking and/or behavior, medical problem requires only outpatient monitoring, verbal commitment to aftercare and medication compliance."

7. Record A7

The IITP was generated on 1-18-12, i.e. two days after admission. Goals were, "Reduction of life-threatening or endangering symptoms to within safe limits, ability to meet basic life and health needs, adequate post discharge arrangements, improve stabilization in mood, thinking and/or behavior, need for consent [sic] or close observation no longer present, verbal commitment to aftercare and medication compliance."

8. Record A8

The IITP was generated on 1-13-12, i.e. one day after admission. Goals were, "Ability to meet basic life and health needs, improve stabilization in mood, thinking and/or behavior, need for consent [sic] or close observation no longer present, medical problem requires only outpatient monitoring, verbal commitment to aftercare and medication compliance."

B. Interviews

1. In an interview on 1-24-12 at 9AM the Director of Social Services stated "Our goals are a checklist." She acknowledged that the listed goals in the Interdisciplinary Inpatient Treatment Plans were not stated as individual patient goals.

2. In an interview on 1-23-12 at 1:45PM, Patient A2 was unaware of the specific goals on his/her treatment plan. S/he said the goal was "to get better."

3. In an interview on 1-23-12 at 2 PM, Patient A3 said that his/her goal was "to stop cutting on myself." This was not a stated goal on the patient's treatment plan.

4. In an interview on 1-23/12, RN 4 stated, "The goal for A3 is to stop... self-harm behavior." This was not the stated goal on the patient's treatment plan.

Based on record review and interview, the facility failed to provide Interdisciplinary Inpatient Treatment Plans (IITPs) for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and 8) that delineated individualized treatment modalities. The interventions on the treatment plans were routine generic discipline functions that were the same for all patients, irrespective of the listed problems. They also did not include the frequency and/or delivery method. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

A. Record Review

Findings include:

1. Record A1

The IITP was generated on 1-23-12, i.e. three days after admission. The identified patient problem was "Depressed Mood/Pot. (potential) for self-harm." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

2. Record A2

The IITP was generated on 1-16-12, i.e. two days after admission. The identified patient problem was "Depressive symptoms." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

3. Record A3

The IITP was generated on 1-19-12, i.e. two days after admission. The identified patient problem was: "Depressed mood/ potential self-harm." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skill"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

4. Record A4

The IITP was generated on 1-23-12, i.e. three days after admission. The identified patient problem was "Alteration in Mood: Depressed mood/potential for self- harm." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

5. Record A5

The IITP was generated on 1-20-12, i.e. two days after admission. The identified patient problem was "Depressed Mood/ Pot. (potential) for self-harm." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

6. Record A6

The IITP was generated on 1-12-12, i.e. two days after admission. The identified patient problem was "Depressed Mood/ Pot. (potential) for self-harm." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

7. Record A7

The IITP was generated on 1-18-12, i.e. two days after admission. The identified patient problem was "Depressed Mood-Potential Self-harm". The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

8. Record A8.

The IITP was generated on 1-13-12, i.e. one day after admission. The identified patient problem was "Out of contact with reality." The interventions were the following routine, generic discipline functions with no listed frequency and/or delivery method: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills"; "patient education regarding illness to promote self care and prevent relapse"; "process groups to proved [sic] patient skills in expressing thoughts & feelings" and "adjunctive therapy groups to provide patient skills in mood management." These are discipline roles, not individualized treatment modalities.

B. Interviews

1. In an interview on 1-23-12 at approximately 3PM, Patient A6 said that s/he attends groups because "there is nothing else to do." When asked if s/he had seen the treatment plan, the response was "no."

2. In an interview on 1-24-12 at approximately 1:40 PM, the Director of Nursing (DON) described the treatment plan interventions as "cookie-cutter interventions, not specific interventions." In addition, the DON stated "The first three interventions would be nursing interventions, the fourth intervention would be the social work intervention, and the fifth the adjunctive therapy intervention."

Based on record review and interview, the facility failed to develop Interdisciplinary Inpatient Treatment Plans (IITPs) that identified the name and discipline of staff persons responsible for specific aspects of care for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Review of the following IITPs (dates in parentheses) revealed that the facility did not delineate the names or disciplines of treatment team members responsible for the listed interventions for the following active sample patients. Patient A1 (1-23-12); Patient A2 (1-16-12); Patient A3 (1-19-12); Patient A4 (1-23-12); Patient A5 (1-20-12); Patient A6 (1-12-12); Patient A7 (1-18-12); and Patient A8 (1-13-12).

B. Interviews

1. In an interview on 1-24-12 at approximately 2:20 PM, RN2 stated "We do list the names of the team at the end of the treatment plan. The names are not specific to the interventions; it's the team creating the treatment plan."

2. In as interview on 1-25-12 at approximately 9:45 AM, the DON stated, "The interventions are a check list; I don't know who is specifically responsible by name."

Based on record review and interview, the Medical Director failed to monitor and evaluate the quality and appropriateness of services and treatment provided to patients by the medical staff. These failures were evidenced by:
I. The Psychiatric Evaluations of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 A8) failed to document the patients' intellectual and memory functioning and describe the testing methods used for the assessments. This failure compromises the data base from which changes in a patient condition can be measured and it hampers the ability of the clinical team to develop treatment goals and interventions that are concordant with the patient's estimated cognitive functioning. (Refer to B116)

II. The Psychiatric Evaluations of 7 of 8 active sample patients (A1, A2, A3, A4, A5, A6 and A8) failed to include patient strengths/assets. Failure to identify patient assets impairs the treatment team's ability to develop treatment plans that utilize the patient's positive attributes. (Refer to B117)

III. The Interdisciplinary Inpatient Treatment Plans (IITPs) of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to include measurable patient goals, based on the individual needs of the patients. This failure results in treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

IV. The Interdisciplinary Inpatient Treatment Plans (IITPs) of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to document individualized treatment interventions, based on the assessed needs of the patients. The interventions were routine generic discipline functions. The interventions also did not include the frequency and/or delivery method. This failure hampers staff's ability to provide consistent and focused treatment. (Refer to B122)

5. The Interdisciplinary Inpatient Treatment Plans (IITPs) of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to identify the assigned treatment team members responsible for the listed interventions. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient's discharge and recovery. (Refer to B123)

Based on record review and interview, the Director of Nurses failed to ensure that there was adequate nursing input in the formulation of the Interdisciplinary Inpatient Treatment Plans (IITPs) for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically,

I. The IITPs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to include nursing interventions that were based on the individual nursing needs of the patients. The IITPs only listed generic interventions that were typical functions for psychiatric nursing staff on inpatient units. The interventions had the exact same wording for all sample patients.

II. The IITPs of all 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to include names of nursing staff responsible for any of the listed interventions that are typical nursing functions.

These failures result in treatment plans that fail to clearly delineate the nursing role in patient care, potentially leading to uncoordinated care and lack of staff accountability.

Findings include:

I. Lack of individualized nursing interventions on IITPs

A. Record Review (IITP dates in parentheses)

The following 8 sample patients' treatment plans were reviewed: Patient A1 (1-23-12); Patient A2 (1-16-12); Patient A3 (1-19-12); Patient A4 (1-23-12); Patient A5 (1-20-12); Patient A6 (1-12-12); Patient A7 (1-18-12); and Patient A8 (1-13-12).

The review revealed that all of the patients' treatment plans had the following identically worded interventions that are typical generic functions for psychiatric nurses: "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills" and "patient education regarding illness to promote self care and prevent relapse." None of the plans identified these interventions as specific nursing interventions.

B. Interviews

In an interview on 1-24-12 at approximately 1:40PM, the Director of Nursing (DON) described the treatment plan interventions as "cookie-cutter interventions, not specific interventions." The DON also added, "The first three interventions would be nursing interventions..."

II. Lack of nursing staff names on patients' IITPs

A. Record Review (IITP dates in parentheses)


The following 8 sample patients' IITPs (dates in parentheses) were reviewed: Patient A1 (1-23-12); Patient A2 (1-16-12); Patient A3 (1-19-12); Patient A4 (1-23-12); Patient A5 (1-20-12); Patient A6 (1-12-12); Patient A7 (1-18-12); and Patient A8 (1-13-12).

The review revealed no treatment plans that included the names of nursing staff responsible for any of the listed interventions, including those that are typical nursing functions such as "Goals and wrap-up group to assist patient in setting productive goals"; "psycho-educational groups on medication & side effects to develop self care skills" and "patient education regarding illness to promote self care and prevent relapse."

B. Interviews

1. In an interview on 1-25-12 at approximately 9:45AM, the DON stated "The interventions are a check list; I don't know who is specifically responsible by name."

2. In an interview on 1-24-12 at approximately 2:20PM, RN2 stated "We do list the names of the team at the end of the treatment plan. The names are not specific to the interventions; it's the team creating the treatment plan."