HospitalInspections.org

Based on record review and interview the facility failed to provide psychosocial assessments that contained recommendations for the social worker's role in treatment of patients which were individualized to the patients' needs for eight (8) of eight (8) active sample patients (#2, 4, 5, 7, 8, 10, 11, and 13). Instead, the recommendations for the treatment were generic roles for social work, preprinted on the form, or when typed in, were almost word- for- word identical to the preprinted wording. In addition, in four (4) of the eight (8) records reviewed (#4, 5, 10, and 13), the social service assessment consisted of a "Social History Update," rather than a complete assessment. However, there was no evidence in the record that the social service staff member who had completed the update incorporated the facts contained in the original psychosocial assessment stored in the patients' closed records.

Findings include:

A. Record Review:

1. All eight (8) active sample records (#2, 4, 5, 7, 8, 10, 11, and 13) reviewed concluded with recommendations with the following wording, or slight variations thereof:

"1. Coordinate discharge placement, aftercare and community resources with the patient and or family members.

2. Have family meeting (if applicable/and requested) to inform of hospital process, provide information regarding diagnosis, to discuss/plan disposition and to provide list of possible placements if needed.

3. Update family & facility on status.

4. Encourage patient to engage in the therapeutic milieu (Reality & Transitional) to provide structure to decrease behaviors, learn coping skills, and to promote socialization as well as preparation for disposition."

This wording does not identify any individualized patient needs for any patient whose record was reviewed.

2. The "Social History Update" done for patients #4, 5, 10 and 13, who had been in the facility previously, consisted of "Current Living Situation," "Identification," "Presenting Problem," "History of Presenting Problem," "Personal Strengths and Assets," "Limitations," "Discharge Plans," and the same "Recommendations" as all other Social History Plans. Sections related to the psychosocial background of the patient, which are found in the full Social Histories done when patients have a first admission to the hospital, were not present, and the original assessments were not found in the current records.

B. Interview

In an interview with the Director of Social Services on 12/17/14 at noon, she stated that the facility policy allows the use of a Social Update when the patient has been previously admitted within the prior year. The Director stated that the social worker performing the update always reviews the prior information found in the closed record, and also reviews the information found in the history obtained at the current admission that is in the Psychiatric Evaluation, but agreed the prior social histories are not brought forward and are not available in the current record.

During an interview on 12/17/14, 1:00 p.m. - 1:30 p.m. with the Social Service Director, the Nurse Surveyor noted that social service interventions were identical for the sample patients. The Social Service Director said, "they should not be identical."

C. Policy Review

There was no written policy the facility could present to show that it is hospital policy to allow only updates to be necessary for patients readmitted within one year of prior admits.

Based on record review and interview, the facility failed to provide screening neurological exams (neurologicals) that included a gross exam of the major areas of the nervous system for all eight (8) of eight (8) active sample records reviewed (#2, 4, 5, 7, 8, 10, 11, and 13). The records had complete evaluations of the cranial nerves, but were lacking in various other aspects of the exam. In addition, for patient #2, who had persistent symptoms of bowel and bladder dysfunction, the exams did not mention the symptoms, and did not assess whether or not a more detailed medical or neurological exam was needed to assess their cause.

Findings include:

A. Record Review:

1. Patient #2 had daily recurrent bouts of urinary and bowel incontinence from the date of admission, 11/26/14, up to and including the days of the survey. However, there was no mention of these severe symptoms, which were precluding the patient's discharge from the hospital, in the record of the physical exam. The neurological exam of patient #2 consisted of evaluation of muscle strength, cranial nerve exam, and cerebellar exam. Other areas of the neurological exam were not addressed, nor was there any assessment that the patient's symptoms should be evaluated more in depth than a partial screening exam would cover.

2. Patient #4, admitted 12/4/14; Patient #5 admitted 12/7/14; Patient #7 admitted 12/10/14; Patient #8 admitted 12/9/14 had screening neurologicals that covered muscle strength, cranial nerves, and cerebellar function. Other areas were not examined.

3. Patients #10, admitted 12/9/14, had a neurological exam that consisted of gross examination of the cranial nerves, and observation that there were "no focal deficits."

4. Patient 11, admitted 12/8/14, had a history of seizures related to drug withdrawal; patient #13, admitted 12/8/14, had no neurological history. Both patients had the same screening neurological exam which covered only cranial nerve exam and exam for muscle rigidity. All other elements were left out of the exam.

B. Interview

In a phone interview with the Medical Director on 12/18/14 at 9:30 a.m., he stated that the neurologicals done at the facility are "the standard of care" in the community. He did agree that the screening neurologicals should contain more than a cranial nerve exam and exam of the cerebellar functioning.

He stated that the facility did not have a means to do a more thorough medical evaluation of the "chronic" problems of incontinence of patient #2.

Based on record review and interview, the facility failed to document the onset of symptoms and a thorough medical and psychiatric history on one (1) of eight (8) active sample patients (patient #2). This patient had symptoms of urinary and bowel incontinence, and questionable cognitive decline. However, the history of these symptoms were not addressed in the psychiatric evaluation. These failures impact the ability of the facility to design treatment modalities specific to the patient's needs, and therefore delay discharge and appropriate follow-up care.

Findings include:

A. Record Review

Review of daily nursing and psych tech nursing staff notes from the day of patient #2's admission on 11/26/14 through the days of the survey revealed that the patient had daily bouts of both urinary and fecal incontinence, day and night. Review of the patient's Master Treatment Plan revealed that not only were these problems not listed on the plan, but an opposite problem of "constipation" was listed.

Review of the Psychiatric Assessment done on 11/27/14 revealed that the history of the present illness only stated "Patient...inappropriately defecating and urinating, not allowing [his/her] Attends to be changed...." The history also says "The patient is noted to be of less than average intelligence."

There is no past psychiatric history on the assessment. The Health History consisted of a list of medical diagnoses. The only ones related to GI or GU issues was #4 "Urinary retention."

In spite of an assessment in the history of the present illness of less than average intelligence, an education history in the same assessment states he attended college for two (2) years.

Based on this information, the diagnoses on the assessment included "Cognitive Disorder NOS" and "Urinary retention."

B. Interview

In an interview with the patient's attending Nurse Practitioner on 11/16/14 at 4:30 p.m., she stated that she has known and followed the patient at his previous living situation for several years, and his symptoms existed then. She did not realize she had not included them in the current assessment. She did not know if the patient had ever had a workup of a medical or neurological nature to rule out physical causes of his medical symptoms, but she thought they were behavioral. She also did not know any background information on the nature or timeline of his cognitive disorder.

Based on record review, the facility failed to assure that evaluation of memory function was included in the mental status examination of three (3) of eight (8) active sample patients (#2, 4 and 10).

Findings include:

1. Although patient #2, admitted 11/26/14, was noted to have a background that included two (2) years of college, the psychiatric evaluation noted him/her to have "concrete thinking," and less than average intelligence. There was no assessment of memory in the exam.

2. Patient #4, admitted 12/4/14, and patient #10, admitted 12/9/14, had no evaluation of memory functioning in the mental status exam.

I. Based on observation, record review and interview, the facility failed to assure for one (1) of eight (8) active sample patients (Patient #2) that significant problems that were impacting patient's care and ability to be discharged were included in the Master Treatment Plan. This prevents the facility from adequately identifying goals, interventions, and responsible staff to carry out treatment directed at these problems.

II. Based on interview and record review, the facility failed to document individualized treatment modalities for patient problems on the treatment plan. Instead, all psychiatric problems listed, which in themselves were generalized (such as "Mood," "Anxiety," and "Psychosis"), had the same generic modalities across all problem types and across all patients. (See B122). In addition, the facility failed to list any individualized responsible staff member for any modality on the plans. The staff were divided only as "NSG" (nursing), "ALL" (meaning all members of all disciplines), or "SS" (social services). (See B123). These failures result in treatment plans that give no direction as to the target symptoms, the individualized interventions used to treat them, or the responsible staff who is to implement them.

Findings include:

I. Failure to identify and develop treatment for Patient #2

A. Record Review

Pt. #2 was admitted 11/26/14. The Psychiatric Evaluation dated 11/27/14 stated s/he was admitted after "forcefully kissed another resident and then demonstrated physical aggression towards care providers...." The report went on to say the patient had a "history of noncompliance, not doing well in assisted living, inappropriately defecating and urinating, not allowing [his/her] Attends to be changed, constantly demanding food."

The Axis III diagnoses on the Psychiatric Evaluation included "urinary retention," but did not mention urinary or bowel incontinence. Review of nursing notes by the psychiatric technicians on the unit revealed multiple entries every shift since the patient was admitted of his/her being incontinent of urine and stool day and night, sometimes cooperating with being changed, and sometimes denying s/he had soiled him/herself and refusing to be changed for long periods of time.

B. Observation

The patient was observed sitting in the hallway immediately adjacent to the nursing station 9:30 a.m. on 9/17/14. A strong odor of feces permeated the area, and s/he made no move to go to the restroom or to ask for staff assistance. Ten minutes later, when the patient was no longer in the area, the odor was gone.

C. Interview

An interview was conducted with the Psychiatric Nurse Practitioner (PNP) who was his/her primary provider on 12/16/14 at 4:30 p.m. She stated that she believed it was nursing's responsibility to add the problems related to incontinence to the Master Treatment Plan, since it was a "nursing issue." When asked if the patient had ever had a medical workup to assess the problems, the PNP, who did the initial psychiatric evaluation, stated she did not know. She also did not know how long the problem had been going on; she stated "for several years", but did not know how it originated. She agreed it was a major roadblock to the patient's discharge.

In addition, the NP noted that during the current hospitalization, it was necessary to chemically restrain the patient on one occasion. No mention of this modality was present in the Master Treatment Plan.

Based on record review and interview the facility failed to assure the diagnoses on the Master Treatment Plan reflected the problems the patient was experiencing for one (1) of eight (8) active sample patients (Patient #2). Diagnoses were contradictory with those listed on the psychiatric and medical evaluations, or were listed without having been named in assessments. These discrepancies make it difficult for staff to agree on correct areas of focus for patient treatment.

Findings include:

A. Record Review:

Pt. #2 was admitted 11/26/14. The psychiatric evaluation dated 11/27/14 noted symptoms of urinary and bowel incontinence; the diagnoses listed however included "urinary retention," not incontinence. The medical consultation done 11/27/14 did not mention any concern related to bowel or bladder control. The nursing assessment on admission 11/27/14 checked "urinary incontinence" in review, but did not list urinary or bowel incontinence as diagnoses (page 10) on the assessment.

The Master Treatment Plan (MTP) listed "urinary retention" as an Axis III diagnoses, and listed "constipation" as a problem (Problem #4).

B. Interview:

Interview with the Psychiatric Nurse Practitioner (PNP), the patient's primary care provider, on 12/16/14 at 4:30 p.m. revealed that she was not aware of the inconsistencies in the diagnoses and problem list on the patients' MTP.

II. Failure to develop individualized modalities and to identify responsible staff.

A. Interventions listed on the MTPs for eight (8) of eight (8) sample patients (#2, 4, 5, 7, 8, 10, 11, and 13) did not reflect individualized care; interventions rather included those that would be expected to be regularly provided by staff for all patients. The listed interventions did not specify the focus of individual and group treatment modalities. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning. See B122 for details.

B. The facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (patients 2, 4, 5, 7, 8, 10, 11, and 13) that identified the names of the medical staff, registered nurse, social worker, mental health technician, or activity therapy staff responsible to implement treatment modalities for each patient's plan. This failure can result in lack of staff accountability to deliver all required interventions and could negatively impact discharge. See B123.

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP), which the facility calls "Interdisciplinary Comprehensive Treatment Plan (ICTP)", included identification of specific treatment modalities for each patient's individualized problem list. Interventions listed on the MTPs for eight (8) of eight (8) sample patients (#2, 4, 5, 7, 8, 10, 11, and 13) did not reflect individualized care; interventions rather included those that would be expected to be regularly provided by staff for all patients. The listed interventions did not specify the focus of individual and group treatment modalities. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning.

Findings include:

A. Policy Review

The facility ICTP policy does not have a specific statement that plan will be "individualized". The policy is broken down into sections, "Introduction, Comprehensive, Preliminary, Goals and Objectives, Patient/ Family Participation, Post-Discharge Plan, Problem Identification List, Substantiated Dx, Updating the ICTP, Using the ICTP." The facility policy entitled "Interdisciplinary Comprehensive Treatment Plan (ICTP), Comprehensive," (the facility's title for the Master Treatment Plan), effective date 05/01/2013, includes the following statements: "Interventions and treatment goals will be derived by reviewing the patient's strength's and limitations, history and physical, psychiatric evaluations, past medical history, clinical exams, lab values and patient interviews; and it will address the strengths and disabilities of the patient. Other variables affecting patient care will also be considered." The facility policy entitled "ICTP, Problem Identification List", effective date 05/01/2013 states, "Included on the problem identification sheet is the comprehensive list of strength's and limitations, which will provide the primary impetus for modalities and treatment." The facility policy entitled "ICTP, Updating the ICTP", effective date 05/01/2013, states that "Each problem on the ICTP will be monitored for appropriate interventions and goals which may be changed as necessary to better reflect the patient's progress toward stated goals." The statements listed are the only sections that state Interventions and Tx Goals will be derived from patient information: strengths, limitations, history, physical, clinical exams, medical history, psychiatric, lab values, interviews. In the Problem Identification List section there is reference to problems, modalities and treatment being linked to the patient's strengths and weakness.

B. Record Review

1. Patient #2 (admitted 11/26/2014, ICTP or Master Treatment Plan (MTP) dated 11/27/2014). Problem #1, initiated 11/27/2014: "Mood."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept.(department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #8, initiated 11/27/2014: "DC (discharge) planning."

Intervention description:

"1. Social Services will meet with the patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social services).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1, "Mood," are identical for other patients listed as having "Mood" on their problem list (see examples below). In addition, these same interventions are listed for the various problems listed as "Mood," "Anxiety," "Suicidal Ideation/Depression," "Audio Hallucinations[sic]," "Homicidal ideations," and "Psychosis" on all patients treatment plans. In addition, the intervention descriptions listed for "discharge planning" are generic and identical for all the sample patients (see below for each additional patient).

2. Patient #4 (admitted 12/04/2014, MTP 12/05/2014).

Problem #1, initiated 12/05/2014: "Suicidal Ideation/Depression."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #2, initiated 12/05/2014: "Anxiety."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on the unit Dept. ALL."

Problem #3, initiated 12/05/2014: "Audio Hallucinations [sic],"

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions as ordered by M.D., staff to monitor patient Q15 minute observations to ensure safety on the unit, Dept. ALL."

Problem #6, initiated 12/05/2014: "D/C (discharge) Planning."

Intervention description:

"1. Social Services will meet with the patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC plan. Dept. SS."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for "Suicidal Ideation/Depression," "Anxiety," "Audio Hallucinations" and "Psychosis" problems are identical for interventions 1, 2, and 4. The intervention descriptions are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal ideations" and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

3. Patient #5 (admitted 12/07/2014, MTP 12/07/2014).

Problem #1, (date initiated blank): "Suicidal ideation."

Intervention description:

"1. Patient will be assessed for suicidal ideations every shift by an R.N. (registered nurse) and documented on nursing progress. Dept. (department) NSG (nursing).

2. Observation levels will be increased to LOS (line of sight) or 1:1 needed for suicidal ideations."

Problem #2 (initiated 12/07/2014): "Homocidal [sic] ideation."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #3 (initiated 12/07/2014): "Audio hallucinations [sic]."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

Problem #4, (date initiated blank): "Discharge planning."

Intervention description:

"1. Social Services will meet with the patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social services).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC (discharge) plan. Dept. SS.

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for "Suicidal ideation," "Homicidal ideation" and "Audio hallucination" problems are identical for interventions 1, 2, and 4. The interventions listed are identical for other patients listed as having problems "Suicidal ideation/depression," "Anxiety," "Mood," "Homicidal ideation," "Audio hallucinations" and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

4. Patient #7 (admitted 12/10/2014, MTP 12/11/2014).

Problem #1 initiated 12/11/2014: "Suicidal ideation with two (2) plans."
Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (Department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4 Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on the unit. Dept. ALL."

Problem # 2 initiated 12/11/2014: "Anxiety."

Intervention Description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #6 initiated 12/11/2014: "DC (discharge) planning."

Intervention description:

"1. Social Services will meet with the patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC plan. Dept. SS."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Suicidal Ideation and Anxiety problems are identical for interventions 1, 2, and 4. The interventions listed are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal ideation," and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

5. Patient #8 (admitted 12/09/2014, MTP 12/09/2014).

Problem #1 initiated 12/10/2014: "Suicidal Ideation with Plan."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #2 initiated 12/10/2014: "Anxiety."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #3 initiated 12/10/14: "Mood."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL."

Problem #8 (date initiated blank): "D/C (discharge) Planning."

Intervention description:

"1. Social Services will meet with the patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC (discharge) plan. Dept. SS.

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Suicidal Ideation, Anxiety and Mood problems are identical for interventions 1, 2, and 4. The interventions listed are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

6. Patient 10 (admitted 12/09/2014, MTP 12/10/2014).

Problem #1 initiated 12/10/2014: "Suicidal Ideation/Depression."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. ( department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

Problem #2 initiated 12/10/2014: "Anxiety."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

Problem #3 initiated 12/10/2014: "Mood."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

Problem #4 initiated 12/10/2014: "Psychosis."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

"Problem #10, (initiated date blank): "D/C (discharge) Planning."

Intervention description:

"1. Social Services will meet with patient and/ or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC plan. Dept. SS.

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for "Suicidal Ideation/Depression," "Anxiety," "Mood" and "Psychosis" problems are identical for interventions 1, 2, and 4. The interventions listed are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

7. Patient #11 (admitted 12/08/2014, MTP 12/09/2014).

Problem #1 initiated 12/09/2014: "Suicidal Ideation."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL.

Problem #2 initiated 12/09/2014: "Anxiety."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #3 initiated 12/09/2014, "Mood."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #10 (initiated date blank): "D/C (discharge) Planning."

Intervention description:

"1. Social Services will meet with patient and/ or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC plan. Dept. SS."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for "Suicidal Ideation," "Anxiety," and "Mood" are identical for interventions. The interventions listed are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

8. Patient #13 (admitted 12/12/2014, MTP 12/13/2014).

Problem #1 initiated 12/13/2014: "Suicidal Ideation."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #2 initiated 12/13/2014: "Anxiety."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #3 initiated 12/13/2014: "Command Hallucinations."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #4 initiated 12/13/2014: "Homicidal Ideation."

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #5 initiated 12/13/2014 "Mood":

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. NSG.

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL.

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

Problem #10 (initiated date blank): "D/C (discharge) Planning."

Intervention description:

"1. Social Services will meet with patient and/or family within 72 hours of admission to gather information and complete a psychosocial assessment. Dept. SS (social service).

2. Social Services will assist in scheduling follow-up appointments and provide this information to patient prior to discharge. Dept. SS.

3. Social services will meet with pt (patient) within 24 hours of admission to set up a tentative DC plan. Dept. SS."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for "Suicidal Ideation," "Anxiety," "Command Hallucinations," "Homicidal ideations," and "Mood" are identical for interventions. The interventions listed are identical for other patients listed as having problems "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis." The intervention descriptions listed for "discharge planning" are identical for the sample patients.

C. Interviews

1. An interview was conducted on 12/17/14, at 1:00 p.m. with the Social Service Director. The Nurse Surveyor noted that interventions identified in the Master Treatment Plan were identical for the sample patients, and reviewed examples. The Social Service Director said, "they should not be identical."

2. In an interview on 12/17/2014, 2:00 p.m. with the Nursing Director, the Nurse Surveyor stated that the interventions for patients having problems for suicidal ideation/depression, anxiety, mood, audio hallucinations, and psychosis were identical. The Nurse Director said, "that is not what is expected."

Based on policy review, record review and interviews, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (patients 2, 4, 5, 7, 8, 10, 11, and 13) that identified the names of the medical staff, registered nurse, social worker, mental health technician, or activity therapy staff responsible to implement treatment modalities for each patient's plan. Since physician interventions were missing from the listed interventions on the plans, no physician names were listed with any interventions. This failure can result in lack of staff accountability to deliver all required interventions and could negatively impact discharge.

Findings include:

A. Policy Review

The facility policy entitled "Interdisciplinary Comprehensive Treatment Plan (ICTP) Comprehensive," effective date 05/01/2013, includes the following statement, "The ICTP (the facility's name for the Master Treatment Plan) will include the name and credentials of the staff member responsible for each modality developed to treat each specific problem."

B. Record Review

1. Patient #2 (admitted 11/26/2014, MTP 11/27/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy staff on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

2. Patient #4 (admitted 12/04/2014, MTP 12/05/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy staff on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

3. Patient #5 (admitted12/07/2014, MTP 12/07/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

4. Patient #7 (admitted 12/10/2014, MTP 12/11/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

5. Patient #8 (admitted 12/09/2014, MTP 12/09/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" ( medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

6. Patient #10 (admitted 12/09/2014, MTP 12/10/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet form the weekly treatment planning meeting.

7. Patient #11 (admitted 12/08/2014, MTP 12/09/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

8. Patient #13 (admitted 12/12/2014, MTP 12/13/2014). The MTP only identified Dept. (department): "NSG" (nursing), "ALL" (medical staff, nursing, social work, activity therapy) and "SS" (social service) for listed interventions. There were no names of staff for physicians, nurse practitioners, physician assistant, nursing staff, social work or activity therapy on the listed interventions. The assigned attending physician could only be identified from the participant signature sheet from the weekly treatment planning meeting.

C. Staff Interviews

In an interview with the Nursing Director on 12/17/2014, at 2:00 p.m., the Nursing Director reviewed the policy related to the interventions in the Master Treatment Plans which reads "Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department) NSG (nursing)." She stated this policy referred to interventions by registered nurses and did not include physicians. She agreed that the MTP did not identify staff names for any identified interventions and instead listed "Dept." (department).

Based on interview and record review the facility failed to assure that Patient #2 received treatments which would address some of the main problems with which s/he presented. The patient had symptoms related to aggressiveness and to incontinence of bowel and bladder, mentioned in the initial psychiatric evaluation dated 11/27/14, and also mentioned repeatedly in daily notes by the psychiatric technicians. However, the Master Treatment Plan (MTP) did not note the patient to have a problem with aggression, nor a problem with incontinence. Since these problems were not addressed on the treatment plan, there were no goals, modalities, or responsible staff noted on the MTP, and progress notes did not assess whether or not the patient was improving, regressing or static, nor did they mention possible changes to treatment approaches related to the problems.

Findings include:

A. Record Review:

Pt. #2 was admitted 11/26/14. The psychiatric evaluation, dated 11/27/14, noted the patient had a recent history of aggressive behavior at the patient's former residence, and also noted incontinence of bowel and bladder and refusal to be cleaned up following these episodes. Shift notes by the psychiatric technicians and by the nursing staff noted daily repeated episodes, day and night, of the patient being soiled, and often refusing to be changed while still soiled. In some instances the patient forcefully told staff to not attempt to change his/her soiled clothes or bedding. The MTP did not list either problem on the MTP, and listed as discharge criteria the following global statement: "Pt's discharge is currently contingent on a decrease in behavioral symptoms."

The MTP did list as a problem "Constipation," for which there was no substantiation in assessments (see B120) and the weekly MTP reviews stated: "Pt's last BM was 11/28/14, pt. is incontinent" (review date 11/28); "Patient has been having BM's on a daily basis" (review date 12/1); "Pt. has been having zero s/s (signs/symptoms) of constipation and having daily bowel movements." (Review date 12/9); "[Pt's name] last BM was 12/16/14." (review date 12/16).

B. Interview:

Interview on 12/16/14 at 4:30 p.m. with the Psychiatric Nurse Practitioner (PNP) providing services to the patient revealed that she was unaware of the lack of listing of problems on the MTP, but she stated the problems related to incontinence were nursing's responsibility to list. She stated she had ordered every two (2) hour toileting for the patient, but the patient did not cooperate much of the time. She had no other ideas how to address these problems, and stated they were there for many years. She stated she did not know if there had ever been a medical evaluation of the problems, but thought they were behavioral in origin.

A phone interview was held on 12/18/14 at 9:30 a.m. with the Medical Director, who also supervises the work of the PNP. He stated that the facility was doing behavioral management via the every two (2) hour toileting, and admitted it was not very successful. When asked if consultation with the psychologist on staff at the facility was considered to assess and determine if a behavioral plan was appropriate, the Medical Director stated that the psychologist on staff would not agree to see the patient if asked because the patient is on Medicaid and the psychologist does not see Medicaid patients.

Based on record review and interview the facility failed to have in place discharge summaries for four (4) of seven (7) randomly selected discharged patients whose records were chosen for review (A, C, E, and G). This prevents the facility from being able to share important patient information regarding the patients' course of treatment in the hospital.

Findings include:

A. Record Review:

Pt. A was admitted 11/4/14 and discharged 11/7/14. No Discharge Summary was found in the chart.

Pt. C was admitted 11/1/14 and discharged on 11/10/14. No Discharge Summary was found in the chart.

Pt. E was admitted 10/8/14 and discharged 11/4/14. No Discharge Summary was found in the chart.

Pt. G was admitted 11/4/14 and discharged on 11/11/14. No Discharge Summary was found in the chart.

Review of the Medical Bylaws reveals that discharge summaries are to be completed within 15 days after discharge.

B. Interview:

The Medical Records director was interviewed on several different occasions the afternoon of 12/17/14. She agreed that the records noted above did not have discharge summaries in the chart. She stated she was new to doing medical records, and had not developed a system to assure the summaries were in the chart in a timely manner.

Based on record review and interview the facility failed to have in place discharge summaries for four (4) of seven (7) randomly selected discharged patients whose records were chosen for review (A, C, E, and G). This prevents the facility from being able to share recommendations for follow-up care with those entities which may be charged with outpatient services to the patient after discharge.

Findings include:

A. Record Review:

Pt. A was admitted 11/4/14 and discharged 11/7/14. No Discharge Summary was found in the chart.

Pt. C was admitted 11/1/14 and discharged on 11/10/14. No Discharge Summary was found in the chart.

Pt. E was admitted 10/8/14 and discharged 11/4/14. No Discharge Summary was found in the chart.

Pt. G was admitted 11/4/14 and discharged on 11/11/14. No Discharge Summary was found in the chart.

Review of the Medical Bylaws reveals that discharge summaries are to be completed within 15 days after discharge.

B. Interview:

The Medical Records director was interviewed on several different occasions the afternoon of 12/17/14. She agreed that the records noted above did not have discharge summaries in the chart. She stated she was new to doing medical records, and had not developed a system to assure the summaries were in the chart in a timely manner.

Based on record review and interview the facility failed to have in place discharge summaries for four (4) of seven (7) randomly selected discharged patients whose records were chosen for review (A, C, E, and G). This prevents the facility from being able to share with outpatient providers anticipated problems after discharge and suggested means for intervention, as well as special problems related to the patient's functional ability to participate in aftercare planning.


Findings include:

A. Record Review:

Pt. A was admitted 11/4/14 and discharged 11/7/14. No Discharge Summary was found in the chart.

Pt. C was admitted 11/1/14 and discharged on 11/10/14. No Discharge Summary was found in the chart.

Pt. E was admitted 10/8/14 and discharged 11/4/14. No Discharge Summary was found in the chart.

Pt. G was admitted 11/4/14 and discharged on 11/11/14. No Discharge Summary was found in the chart.

Review of the Medical Bylaws reveals that discharge summaries are to be completed within 15 days after discharge.

B. Interview:

The Medical Records director was interviewed on several different occasions the afternoon of 12/17/14. She agreed that the records noted above did not have discharge summaries in the chart. She stated she was new to doing medical records, and had not developed a system to assure the summaries were in the chart in a timely manner.

Based on record review and interview, the Medical Director has failed to assure that the records maintained by the facility adequately reflect assessments done and master treatment plans developed for eight (8) of eight (8) active sample patients (#2, 4, 5, 7, 8, 10, 11, and 13), and discharge summaries were completed for four (4) of seven (7) discharge patients (A, C, E, and G) whose records were randomly selected for review. These failures prevent the facility from having the correct information to inform treatment on both an inpatient and outpatient basis.

Findings include:

Record Review:

A. Neurological evaluations done as part as the baseline medical evaluation were incomplete for eight (8) of eight (8) active sample patients. The facility failed to provide screening neurological exams that included a gross exam of the major areas of the nervous system for all eight (8) of eight (8) active sample records reviewed (#2, 4, 5, 7, 8, 10, 11, and 13). The records had complete evaluations of the cranial nerves, but were lacking in various other aspects of the exam. In addition, for patient #2, who had persistent symptoms of bowel and bladder dysfunction, the exams did not mention the symptoms, and did not assess whether or not a more detailed medical or neurological exam was needed to assess their cause. Refer to B109 for details.

B. Psychiatric evaluations lacked assessment of memory function for three (3) of eight (8) active sample patients (#2, 4, and 10). Refer to B116.

In addition, the psychiatric assessment of sample patient #2 lacked significant historical information related to several symptoms with which he presented, thus making proper diagnosis and treatment difficult. Refer to B114.

C. Master Treatment plans of all eight (8) active sample patients (#2, 4, 5, 7, 8, 10, 11, and 13) lacked individualized modalities to guide treatment, and lacked identification of responsible staff for each modality. No role for the physician was ever noted in the treatment plan of any patient whose chart was reviewed. (Refer to B122 and B123).

D. Discharge summaries were not dictated in a timely manner, according to hospital bylaws, for four (4) of seven (7) discharged patients (A, C, E, and G) whose records were randomly selected for review. (Refer to B133, B134 and B135).

Interview:

The Medical Director, in a phone interview on 12/17 at 1:00 p.m. stated he was responsible for the peer review of medical staff areas of performance.

A subsequent interview with the Medical Director by phone on 12/18 at 9:30 a.m. took place. The Medical Director believed the neurological exam notes on the charts met the community standards, but did agree they should include more than cranial nerve exam and cerebellar function exam.

Based on record review and staff interview, it was determined that the Director of Nursing (DON) does not have sufficient education and experience for her current administrative position as Nurse Executive in the facility. This deficient practice can result in lack of adequate oversight and leadership of quality nursing care for the patients.

Findings include:

A. Document Review

Review of the Director of Nursing's curriculum vitae revealed that the Director of Nursing (hired to these duties on 12/01/2014) has three Bachelor Degrees: Bachelor of Science in Biology, University of Idaho 1998; Bachelor of Science in Electrical Engineering, Boise State University, 2002; and Bachelor of Science in Nursing, Idaho State University, 2010. Work experience highlighted the DON's work in Psychiatric Mental Health Nursing starting as a psychiatric tech in April 2010 and then working as a registered nurse upon passing NCLEX in 2010. Registered Nurse experience included working as the day charge nurse on the intensive care mental health unit at another psychiatric hospital. Additionally she worked as the relief supervisor on the weekends overseeing the staff and patient activities for that other facility, accepting the position of DON, 12/01/2014. The DON also worked part time at Safe Haven of Treasure Valley from 08/2013-12/2014.

B. Interview

During an interview on 12/17/2014 at 2:00 p.m., the Director of Nursing (DON) stated that she had three Bachelor Degrees, with a Bachelor of Science in Nursing. She said that she did not have documented continuing education for psychiatric mental health nursing beyond the employee orientations to hospital duties at her employment. She said that since beginning in the DON position 12/01/2014, she did not have any documented consultation with a Nurse Specialist having a Master's Degree in Psychiatric Mental Health Nursing.

Based on record review and interview, it was determined that the Director of Nursing (DON) failed to ensure the quality of nursing input in the development of the Master Treatment Plan (MTP). The MTP's for eight (8) of eight (8) active sample patients (#2, 4, 5, 7, 8, 10, 11, and 13) lacked individualized nursing interventions. The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility.

A. Record Review

1. Patient #2 (admitted 11/26/2014, MTP 11/27/2014).

Problem #1 "Mood."

Intervention descriptions:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Mood" are identical for other patients listed as having "Mood" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

2. Patient #4 (admitted 12/04/2014, MTP 12/05/2014).

Problem #1 "Suicidal Ideation/ Depression," Problem #2 "Anxiety," and Problem #3 "Audio Hallucinations [sic]": the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL ( medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation/Depression," Problem #2 "Anxiety," and Problem #3 "Audio Hallucinations" are identical for other patients listed as having "Suicidal Ideation/ Depression," "Anxiety" or "Audio Hallucinations" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

3. Patient #5 (admitted12/07/2014, MTP 12/07/2014).

Problem #1 "Suicidal Ideation," Problem #2 "Homicidal Ideation," and Problem #3 "Audio Hallucinations": the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation," Problem #2 "Homicidal Ideation," and Problem #3 "Audio Hallucinations" are identical for other patients listed as having "Suicidal Ideation," "Homicidal Ideation" or "Audio Hallucinations" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

4. Patient #7 (admitted 12/10/2014, MTP 12/11/2014).

Problem #1 "Suicidal Ideation with two (2) plans," Problem #2 "Anxiety," the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL ( medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation" and Problem #2 "Anxiety" are identical for other patients listed as having "Suicidal Ideation" and "Anxiety" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

5. Patient #8 (admitted 12/09/2014, MTP 12/09/2014).

Problem #1 "Suicidal Ideation with plan," Problem #2 "Anxiety," and Problem #3 "Mood," the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department responsible) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation," Problem #2 "Anxiety," and Problem #3 "Mood" are identical for other patients listed as having "Suicidal Ideation," "Anxiety" and "Mood" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

6. Patient #10 (admitted 12/09/2014, MTP 12/10/2014).

Problem #1 "Suicidal Ideation/Depression," Problem #2 "Anxiety," Problem #3 "Mood," and #4 "Psychosis," the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation/Depression," Problem #2 "Anxiety," Problem #3 "Mood" and Problem #4 "Psychosis" are identical for other patients listed as having "Suicidal Ideation/Depression," "Anxiety," "Mood," and "Psychosis" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

7. Patient #11 (admitted 12/08/2014, MTP 12/09/2014).

Problem #1 "Suicidal Ideation," Problem #2 "Anxiety," and Problem #3 "Mood," the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation," Problem #2 "Anxiety," and Problem #3 "Mood" are identical for other patients listed as having "Suicidal Ideation," "Anxiety," and "Mood" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

8. Patient #13 (admitted 12/12/2014, MTP 12/13/2014).

Problem #1 "Suicidal Ideation," Problem #2 "Anxiety," Problem #3 "Command Hallucinations" and Problem #4 "Homicidal Ideation" the interventions for each of these problems were identical.

Intervention description:

"1. Licensed staff to administer and educate patient on expected uses and benefits of prescribed medications, monitor for compliance and assess effectiveness. Dept. (department) NSG (nursing).

2. Staff to provide a safe and low stimulus environment in order for patient to feel comfortable on unit and better able to focus on treatment goals. Dept. ALL (medical staff, nursing, social work, activity therapy).

4. Precautions per M.D. orders, staff to monitor patient Q15 minute observations to ensure safety on unit. Dept. ALL."

The interventions listed are considered routine interventions that would be provided for all patients receiving care in a hospital setting. The interventions in the MTP do not specify the therapeutic group modalities and frequency, related to the patient's program schedule provided by the facility. Interventions listed for Problem #1 "Suicidal Ideation," Problem #2 "Anxiety," Problem #3 "Command Hallucinations" and Problem #4 "Homicidal Ideation" are identical for other patients listed as having "Suicidal Ideation," "Anxiety," "Command Hallucinations," and "Homicidal Ideation" on their problem list. These same interventions were identical for problems including "Suicidal Ideation/ Depression," "Anxiety," "Mood," "Audio Hallucinations," "Homicidal Ideations," and "Psychosis" for all sample patients.

B. Interviews

In an interview with the Nursing Director on 12/17/2014, at 2:00 p.m., the Nursing Director agreed that the intervention descriptions in the Master Treatment Plans of the sample patients for listed problems were identical and that interventions such as administering medications, providing medication education and monitoring effectiveness of medications; providing safe and low stimulus environment; and precautions/staff Q15 minute observations are routine interventions that would be provided for all patients receiving care in a hospital setting. She stated the interventions in the MTP do not include the therapeutic group modalities and frequency, related to the posted unit schedule or the patients' problems.

Based on record review and interview, the facility failed to have a psychologist available for all patients who may benefit from psychological services. Although there is a psychologist on staff, he is not available to patients with Medicaid insurance. This prevents the hospital from using expert services in complex diagnostic and treatment areas where the psychologist's expertise would enhance patient care.

Findings include:

A. Record Review:

Active sample Pt. #2 has problems that have not been clearly delineated as to whether they are medical or behavioral in nature. Chart review revealed that a history of the problems related to urinary and bowel incontinence has not been obtained. (Refer to B114). In addition, further chart review revealed that staff have been attempting an every two (2) hour toileting procedure, with very limited success.

Chart review also revealed that the patient has a diagnosis of "Cognitive Disorder NOS (not otherwise specified), again without supporting history. (Refer to B114).

Further chart review revealed no input from a psychologist either for the purpose of clarifying diagnoses, or for developing a behavioral plan to manage the patient's incontinence.

B. Interview

Interview with the patient on 12/18/14 at 10:30 a.m. revealed that the patient, at first very terse in responses, was able to hold a prolonged discussion about his/her favorite professional football team, as well as about the standings of several teams currently playing this season. All of this information was detailed and accurate, and in fact, the patient corrected the interviewer at one point.

A phone interview was held on 12/18/14 at 9:30 a.m. with the Medical Director, who also supervises the work of the Psychiatric Nurse Practitioner who is the "attending" for patient #2. The Medical Director stated that the facility was doing behavioral management via the every two (2) our toileting, and admitted it was not very successful. When asked if consultation with the psychologist on staff at the facility was considered to assess and determine if a behavioral plan was appropriate, the Medical Director stated that the psychologist on staff would not agree to see the patient if asked because the patient is on Medicaid and the psychologist does not see Medicaid patients.

I. Based on record review and interview the Director of Social Services has failed to assure that psychosocial updates in records for patient previously admitted contain sufficient psychosocial information to give a full picture of the patients' status, or to assure the current chart has this information available from previous admission records for four (4) of the eight (8) active sample records reviewed (#4, 5, 10, and 13).

II. In addition, the Director failed to assure recommendations on the assessments were individualized to the patients' needs for eight (8) of eight (8) active sample patients (#2, 4, 5, 7, 8, 10, 11, and 13). Instead, the recommendations for treatment were generic roles for social work, preprinted on the form, or when typed in, were almost word- for- word identical to the preprinted wording.

Findings include:

I. Failure to assure availability of psychosocial information in current records for patients readmitted to the facility.

A. Record Review

The "Social History Update" done for patients #4, 5, 10, and 13, who had been in the facility previously, consisted of "Current Living Situation," "Identification," "Presenting Problem," "History of Presenting Problem," "Personal Strengths and Assets," "Limitations," "Discharge Plans," and the same "Recommendations" as all other Social History Plans. Sections related to the psychosocial background of the patient, which are found in the full Social Histories done when patients have a first admission to the hospital, were not present, and the original assessments were not found in the current records.

B. Interview

In an interview with the Director of Social Services on 12/17/14 at noon, she stated that the facility policy allows the use of a Social Update when the patient has been previously admitted within the prior year. The Director stated that the social worker performing the update always reviews the prior information found in the closed record, and also reviews the information found in the history obtained at the current admission that is in the Psychiatric Evaluation, but agreed the prior social histories are not brought forward and are not available in the current record.

C. Policy Review

There was no written policy the facility could present to show that it is hospital policy to allow only Updates to be necessary for patients readmitted within one year of prior admits.

II. Failure to provide individualized treatment recommendations for social service roles in patients' care.

A. Record Review

1. All eight (8) active sample records (#2, 4, 5, 7, 8, 10, 11, and 13) reviewed concluded with recommendations with the following wording, or slight variations thereof:

"1. Coordinate discharge placement, aftercare and community resources with the patient and or family members.

2. Have family meeting (if applicable/and requested) to inform of hospital process, provide information regarding diagnosis, to discuss/plan disposition and to provide list of possible placements if needed.

3. Update Family & facility on status.

4. Encourage patient to engage in the therapeutic milieu (Reality & Transitional) to provide structure to decrease behaviors, learn coping skills, and to promote socialization as well as preparation for disposition."

This wording does not identify any individualized patient needs for any patient whose record was reviewed.

B. Interview

During an interview on 12/17/14, 1:00 p.m. - 1:30 p.m. with the Social Service Director, the Nurse Surveyor noted that interventions identified were identical for the sample patients. The Social Service Director said, "they should not be identical."