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Based on record review and interview, the facility failed to ensure that psychosocial assessments included treatment plan recommendations for eight (8) of eight (8) sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). This failure has the potential of prolonging hospitalization.

Findings include:

A. Record review

1. Patient A2 - psychosocial assessment dated 8/12/14 did not contain treatment plan recommendations.

2. Patient A4 - psychosocial assessment dated 9/5/14 did not contain treatment plan recommendations.

3. Patient A6 - psychosocial assessment dated 8/28/14 did not contain treatment plan recommendations.

4. Patient A8 - psychosocial assessment dated 8/25/14 did not contain treatment plan recommendations.

5. Patient A10 - psychosocial assessment dated 8/25/14 did not contain treatment plan recommendations.

6. Patient A12 - psychosocial assessment dated 8/20/14 did not contain treatment plan recommendations.

7. Patient A13 - psychosocial assessment dated 8/29/14 did not contain treatment plan recommendations.

8. Patient A14 - psychosocial assessment dated 8/27/14 did not contain treatment plan recommendations.

B. Interview

During a 9/9/14 3:30 pm interview, the Director of Social Work confirmed the findings.

Based on record review and staff interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs), that were individualized and included all required components for eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Failure to develop individualized Master Treatment Plans by the team with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's treatment needs not being met.

Findings include:

A. Record Review

Review of the MTPs of the eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14) revealed that the facility assigned registered nurses (RN), the Director of Nursing (DON), and/or Assistant DON to complete the initial treatment plan at the time of admission and the Master Treatment Plan (MTP) at the treatment plan review meeting 7 days after the patient's admission. This treatment plan review meeting was attended primarily by the MD, DON or ADON, and social worker. During this review, minor or no changes were made in the treatment plan resulting in a treatment plan that did not include comprehensive information from clinical assessments and treatment recommendations from social work and activity therapy staff. These MTPs failed to:

1. Include individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs) based on clinical assessment data. Instead, the stated problems on the treatment plans included diagnoses or diagnostic terms and generalized statements, rather than behaviorally descriptive problem statements based on patients' presenting psychiatric symptoms which had to be resolved or reduced prior to discharge for eight (8) of eight (8) active sample patients for (A2, A4, A6, A8, A10, A12, A13, and A14). Refer to B119

2. Include appropriate long-term and short-term goals for eight (8) of eight (8) sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Furthermore, the facility failed to ensure staff followed the Treatment Plan policy. The MTPs had identical long term goals of a check-off menu and short term goals which were not patient oriented goals. This failure results in treatment plans that do not identify expected patient outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment and may result in prolonged hospitalization. Refer to B121

3. Include individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Specifically, interventions formulated for the physician and registered nurses were stated as routine monitoring and discipline functions written as treatment interventions. MTPs also failed to include the specific focus for interventions and whether interventions would be delivered in group or individual sessions for those interventions formulated for activity therapists and social workers. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment. Refer to B122

B. Interviews

1. During interview on 9/9/14 at 2:15 p.m. with the Director of Nursing (DON) and Assistant DON, the treatment plans for A10, A12, A13, and A14 were reviewed. They acknowledged that the problem statements, treatment goals, and interventions on the treatment were not individualized. However, the DON contented that more information was found in the progress notes rather than on the MTPs but agreed that MTPs must also be individualized.

2. During interview on 9/10/14 at 9:05 a.m. with the DON ADON, and Director of Hospital Quality, the facility's process for formulating the master treatment plan was discussed. The Director of Hospital Quality stated, "I agree, these treatment goals are not that good."

3. During interview on 9/9/14 at 3:25 p.m., AT1 stated, "I use the psychosocial assessment to set up goals" and stated that nursing was responsible for writing goals and interventions on the MTPs.

Based on record review and interview, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs) based on clinical assessment data and presenting symptoms. Instead, the stated problems on the treatment plans included diagnoses or diagnostic terms and generalized statements, rather than behaviorally descriptive psychiatric problem statements which had to be resolved or reduced prior to discharge for eight (8) of eight (8) active sample patients for (A2, A4, A6, A8, A10, A12, A13, and A14).

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A2 (8/18/14), A4 (9/4/14), A6 (9/2/14), A8 (8/28/14), A10 (8/28/14), A12 (8/26/14), A13 (9/4/14) and A14 (9/2/14). This review revealed that the MTPs had the following psychiatric problem statement with diagnostic terms and/or generalized symptoms with no supporting documentation to reflect how these were manifested for each patient.

1. Patient A2 - The MTPs included the following psychiatric problems and diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Impaired memory R/T CV [Vascular] Dementia, Depression, Poor Appetite." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

2. Patient A4 - The MTPs included the following problems and diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Risk for Combativeness with ADL, Risk for Assault to Others, Impaired memory R/T [related to] CV [Vascular] Dementia." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

3. Patient A6 - The MTPs included the following psychiatric problems and diagnostic terms on the problem Suicide, "Risk for Combativeness [with] ADL [Activities of Daily Living], Depression, Impaired Memory R/T [related to] Dementia, Disturbed Sleep Pattern." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

4. Patient A8 - The MTPs included the following psychiatric diagnostic terms on the problem list and repeated on the forms which were used to formulate the short term goal and interventions for each problem: "Depression, Impaired memory R/T [related to] Dementia." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

5. Patient A10 - The MTPs included the following psychiatric problems and diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Risk for Combativeness with ADL, Impaired memory R/T CV [Vascular] Dementia, Disturbed thoughts content related to Delusions/Paranoia." There was no documentation which provided behavioral descriptions of how this patient individually manifested these symptoms.

6. Patient A12 - The MTPs included the following psychiatric problems and diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Risk for Combativeness with ADL, Anxiety/Agitation, Disturbed thought Content (Paranoia), Impaired Memory R/T [related to] Dementia, Depression..." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

7. Patient A13 - The MTPs included the following diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Depression" and "Impaired memory R/T [related to] CV [Vascular] Dementia." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

8. Patient A14 - The MTPs included the following psychiatric problems and diagnostic terms on the problem list and repeated on the forms which included the short term goal and interventions: "Risk for Combativeness with ADL, Non-Compliance [with] Med [medication] Regimen, Anxiety [with] Agitation, Impaired Memory R/T [related to] [sic] Dementia, Depression." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems.

B. Interview

During interview on 9/9/10 at 2:15 p.m., the treatment plans for A10, A12, A13, and A14 were reviewed with the Director of Nursing and Assistant Director of Nursing. They acknowledged that the psychiatric problems were not individualized and did provide a description of the how these patients manifested problems identified on the MTPs.

Based on record review, policy review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included appropriate long-term and short-term goals for eight (8) of eight (8) sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Furthermore, the facility failed to ensure staff followed the facility's Treatment Plan Policy. The MTPs had identical long term goals of a check-off menu and short term goals which were not patient oriented goals. This failure results in treatment plans that do not identify expected patient outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment and may result in prolonged hospitalization.

Findings include:

A. Record review

1. Patient A2 - master treatment plan dated 8/18/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #6 listed as "Depression" has a short term goal "assess strengths and weaknesses realistically over the next 10 days."

2. Patient A4 - master treatment plan dated 9/4/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #5, "Foley Catheter d/t BPH w/urinary obstruction" did not have a listed short term goal although interventions which listed. Problem #7, "Impaired memory R/T CV Dementia" had a list goal of "Pt will participate in 5/5 groups x 5-7 days."

3. Patient A6 - master treatment plan dated 9/2/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #5 listed as "Depression" has a short term goal "assess strengths and weaknesses realistically over next 10 days."

4. Patient A8 - master treatment plan dated 8/28/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #8 listed as "Depression" has a short term goal "assess strengths and weaknesses realistically over next 10 days."

5. Patient A10 - master treatment plan dated 8/28/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #10 listed as "Impaired memory R/T CV Dementia" has a short term goal "Pt will participate in 5/5 groups x 5-7 days."

6. Patient A12 - master treatment plan dated 8/26/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #7 listed as "Depression" has a short term goal "Assess strengths and weaknesses realistically over next 10 days."

7. Patient A13 - master treatment plan dated 9/4/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #4 "Depression" has a short term goal "Assess strengths and weaknesses realistically over next 10 days."

8. Patient A14 - master treatment plan dated 9/2/14 has a checklist of long term goals consisting of eight (8) potential items which are not specific to this individual patient. Problem #9 "Depression" has a short term goal "Assess strengths and weaknesses realistically over next 10 days."

B. Policy Review

The facility's "Administrative Policy & Procedure Treatment Plan" revised 3-2010 on page 1 of 2 under procedure #5 (b) stipulated that, "Treatment goals which are measureable (describing the desired action or behavior to be achieved)." A review of the MTPs showed that treatment goals did not meet this policy requirement by the facility.

C. Interview

During a 9/10/14 interview at 9:00 am, the Administrator, who also serves as the Quality Improvement Officer, confirmed the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Specifically, interventions formulated for the physician and registered nurses were stated as routine monitoring and discipline functions written as treatment interventions. For those interventions formulated for activity therapists and social workers, MTPs also failed to include the specific focus for interventions, and whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A2 (8/18/14), A4 (9/4/14), A6 (9/2/14), A8 (8/28/14), A10 (8/28/14), A12 (8/26/14), A13 (9/4/14) and A14 (9/2/14). This review revealed that the MTPs had the following routine and generic statements (monitoring, assessing, and evaluating tasks) and/or other generic discipline functions written as treatment interventions to be delivered by the psychiatrist (MD) and registered nurse. Additionally, treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions) and 2) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms. Intervention statements were identical or similarly worded.

1. Patients A2, A6, A8, A12, A13, and A14 all had "Depression" listed on the MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history.

Intervention 1: MD and RN - "Encourage to openly discuss her thoughts and feelings"

Intervention 2: RN - "Provide a safe environment for the patient"

Intervention 3: RN and AT - "Therapeutic Activities - (see daily activity progress notes)."

Intervention 1 & 2 were actually generic and routine functions that would be provided these patients regardless of their presenting symptoms. Intervention 3 failed to include how "Therapeutic Activities" would be delivered and also did not include the focus of contact based on each patient needs and level of functioning.

2. Patients A4, A10, and A12 all had "Risk for Combativeness [with] ADL's [activities of daily living] listed on the MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history.

Intervention 1: RN - "ADL's [activity of daily living] precautions every 30 minutes."

Intervention 2: RN and AT - "Therapeutic Activities - (see daily activity progress notes)."

Intervention 3 - 4: RN - "2 staff to provide care to decrease injury to staff or patients as needed "; "Talk calmly, provide reassurance, allow to express fears, feelings"; "May need to return at later time if behaviors not calming"; and "Use simple directions."

None of these interventions were individualized to reflect specific needs based on each patient's presenting symptoms. Interventions 1and 3-4 were generic and routine nursing functions and were actually instructions for staff while providing care. Intervention 2 did not include the specific "Therapeutic Activities" that were to be provided by AT and nursing staff and also failed to include how "Therapeutic Activities" would be delivered and the focus of contact based on each patient needs and level of functioning.


3. Patients A6 and A12 had "Risk for Suicide" or "Suicide" listed on their MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical picture of suicide.

Intervention 1 - 2: RN - "Assess suicide thoughts q [every] shift" and "Maintain hazard free environment."

Intervention 3: RN and AT - "Therapeutic Activities - (see daily activity progress notes)."

Interventions 4 - 6: RN - "Monitor effectiveness of meds [medications]"; "Suicide precautions q [every] 15 min. [minutes]"; and "Call light secured to rail."

These interventions were not individualized to reflect a specific need based on each patient's presenting symptoms of suicide. Interventions 1and 3-4 were generic and routine nursing functions regarding maintaining patient safety and were actually instructions for staff while providing care. Intervention 2 did not include the specific "Therapeutic Activities that were to be provided by AT and nursing staff and also failed to include how "Therapeutic Activities" would be delivered and also did not include the focus of contact based on each patient needs and level of functioning.

4. Patients A2, A4, A6, A8, A10, A12, A13, and A14 had the following identical or similarly stated problem listed on their MTP: "Impaired Memory...R/T [related to]..." The intervention statements were identical for these patients despite different presenting clinical picture of dementia.

Intervention 1: RN and MD - "Monitor effectiveness of med [medications]"

Intervention 2: RN and AT - "Therapeutic Activities - (see daily activity progress notes)."

Interventions 3 - 5: RN - "Provide opportunities for reminiscence or recall of past events"; "Provide simple instructions when instructions are needed"; and "Ask for responses that you have confidence pt [patient] can answer."

Intervention 6 - SW - "Cognitive Stimulation - pt [patient] will recognize when caregivers are giving assistance."

These interventions were not individualized to reflect a specific need based on each patient's presenting symptoms of dementia. Interventions 1 and 3-5 were generic and routine discipline functions and/or instructions for staff while providing care. Intervention 2 did not include the specific "therapeutic Activities" that were to be provided by AT and nursing staff and also failed to include how "Therapeutic Activities" would be delivered and also did not include the focus of contact based on each patient needs and level of functioning.

B. Policy Review

The facility's "Administrative Policy & Procedure Treatment Plan" revised 3-2010 on page 1 of 2 under procedure #5 (c) stipulated that, "...The treatment plan should include: Methods and individualized approaches of treatment." A review of the MTPs showed that treatment interventions (methods and approaches) did not meet this policy requirement by the facility.

C. Interview

During interview on 9/9/14 at 2:15 p.m. with the Director of Nursing (DON) and Assistant DON, the Master Treatment Plans for Patient A10, A12, A13, and A14 were reviewed. The DON and ADON acknowledged that interventions on the MTPs were routine tasks and/or instructions for staff to provide care.

Based on interview and document review, the Medical Director failed to monitor to:

I. Ensure that psychosocial assessments included treatment plan recommendations for eight (8) of eight (8) sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). This failure has the potential of prolonging hospitalization. Refer to B108

1. Include individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPS) based on clinical assessment data. Instead, the stated problems on the treatment plans included diagnoses, lists of symptoms and generalized statements, rather than behaviorally descriptive problem statements based on patients' presenting psychiatric symptoms which had to be resolved or reduced prior to discharge for eight (8) of eight (8) active sample patients for (A2, A4, A6, A8, A10, A12, A13, and A14). Refer to B119

II. Include Master Treatment Plans (MTPs) that included appropriate long-term and short-term goals for eight (8) of eight (8) sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Furthermore, the facility failed to ensure staff followed the Treatment Plan policy. The MTPs had identical long term goals of a check-off menu and short term goals which were not patient oriented goals. This failure results in treatment plans that do not identify expected patient outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment and may result in prolonged hospitalization. Refer to B121

III. Include Master Treatment Plans (MTPs) that evidenced individualized physician treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14). Specifically, interventions formulated for the physician were stated as routine monitoring and physician functions written as treatment interventions. This deficiency results in treatment plans that fail to reflect an individualized approach to interdisciplinary treatment and potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A2 (8/18/14), A4 (9/4/14), A6 (9/2/14), A8 (8/28/14), A10 (8/28/14), A12 (8/26/14), A13 (9/4/14) and A14 (9/2/14). This review revealed that the MTPs had the following routine and generic statements (monitoring, assessing, and evaluating tasks) and/or other generic physician functions written as treatment interventions. Intervention statements were identical or similarly worded.

1. Patients A2, A6, A8, A12, A13, and A14 all had "Depression" listed on the MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history and picture.

Intervention 1: MD - "Encourage to openly discuss her thoughts and feelings"

Intervention 1 was actually a generic and routine physician function that would be provided these patients regardless of their presenting symptoms.

2. Patients A4, A10, and A12 all had "Risk for Combativeness [with] ADL's [activities of daily living] listed on the MTP as a problem. There were no physician intervention statements included for this problem on the MTPs.

3. Patients A6 and A12 had "Risk for Suicide" or "Suicide" listed on their MTP as a problem. There were no intervention statements identified for the physician.

4. Patients A2, A4, A6, A8, A10, A12, A13, and A14 had the following identical or similarly stated problem listed on their MTP: "Impaired Memory...R/T [related to]..." The intervention statements were identical for these patients despite different presenting clinical history and picture of dementia.

Intervention 1: MD - "Monitor effectiveness of med [medications]"

These interventions were not individualized to reflect a specific need based on each patient's presenting symptoms of dementia. Interventions 1was a generic and routine physician function that would be provided these patients regardless of their presenting symptoms.

B. Policy Review

The facility's "Administrative Policy & Procedure Treatment Plan" revised 3-2010 on page 1 of 2 under procedure #5 (c) stipulated that, "...The treatment plan should include: Methods and individualized approaches of treatment." A review of the MTPs showed that treatment interventions (methods and approaches) did not meet this policy requirement by the facility.

Based on record review and interview, the Director of Nursing failed to monitor to:

I. Ensure that nursing interventions on the Master Treatment plans for eight (8) of eight (8) active sample patients (A2, A4, A6, A8, A10, A12, A13, and A14) were individualized to meet specific patient needs. Nursing interventions were generic and routine tasks that would be performed regardless of the different patients' problems and needs. This failure results in Master Treatment Plans that fail to reflect an individualized approach to patient care and fail to guide the nursing staff in providing treatment with a specific focus.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A2 (8/18/14), A4 (9/4/14), A6 (9/2/14), A8 (8/28/14), A10 (8/28/14), A12 (8/26/14), A13 (9/4/14) and A14 (9/2/14). This review revealed that the MTPs had the following routine and generic statements (monitoring, assessing, and evaluating tasks) and/or other generic nursing functions written as treatment interventions to be delivered by registered nurses (RN). Additionally, treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions) and 2) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms. Intervention statements were identical or similarly worded.

1. Patients A2, A6, A8, A12, A13, and A14 all had "Depression" listed on the MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history and picture.

Intervention 1: RN - "Encourage to openly discuss her thoughts and feelings."

Intervention 2: RN - "Provide a safe environment for the patient."

Intervention 3: RN - "Therapeutic Activities - (see daily activity progress notes)."

Intervention 1 & 2 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 3 failed to include how "Therapeutic Activities" would be delivered and the focus of contact based on each patient needs and level of functioning.

2. Patients A4, A10, and A12 all had "Risk for Combativeness [with] ADL's [activities of daily living] listed on the MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history.

Intervention 1: RN - "ADL's [activity of daily living] precautions every 30 minutes."

Intervention 2: RN - "Therapeutic Activities - (see daily activity progress notes)."

Intervention 3 - 4: RN - "2 staff to provide care to decrease injury to staff or patients as needed"; "Talk calmly, provide reassurance, allow to express fears, feelings"; "May need to return at later time if behaviors not calming"; and "Use simple directions."

None of these interventions were individualized to reflect specific needs based on each patient's presenting symptoms. Interventions 1and 3-4 were generic and routine nursing functions and were actually instructions for staff while providing care. Intervention 2 did not include the specific "Therapeutic Activities" that were to be provided by nursing staff and also failed to include how "Therapeutic Activities" would be delivered and the focus of contact based on each patient needs and level of functioning.

3. Patients A6 and A12 had "Risk for Suicide" or "Suicide" listed on their MTP as a problem. The intervention statements were identical for these patients despite different presenting clinical history picture of suicide.

Intervention 1 - 2: RN - "Assess suicide thoughts q [every] shift" and "Maintain hazard free environment."

Intervention 3: RN - "Therapeutic Activities - (see daily activity progress notes)."

Interventions 4 - 6: RN - "Monitor effectiveness of meds [medications]"; "Suicide precautions q [every] 15 min. [minutes]"; and "Call light secured to rail."

These interventions were not individualized to reflect a specific need based on each patient's presenting symptoms of suicide. Interventions 1 and 3-4 were generic and routine nursing functions regarding maintaining patient safety and were actually instructions for staff while providing care. Intervention 2 did not include the specific "Therapeutic Activities" that were to be provided by nursing staff and also failed to include how "Therapeutic Activities" would be delivered and the focus of contact based on each patient needs and level of functioning.

4. Patients A2, A4, A6, A8, A10, A12, A13, and A14 had the following identical or similarly stated problem listed on their MTP: "Impaired Memory...R/T [related to]..." The intervention statements were identical for these patients despite different presenting clinical history and picture of dementia.

Intervention 1: RN - "Monitor effectiveness of med [medications]"

Intervention 2: RN - "Therapeutic Activities - (see daily activity progress notes)."

Interventions 3 - 5: RN - "Provide opportunities for reminiscence or recall of past events"; "Provide simple instructions when instructions are needed"; and "Ask for responses that you have confidence pt [patient] can answer."

These interventions were not individualized to reflect a specific need based on each patient's presenting symptoms of dementia. Interventions 1 and 3-5 were generic and routine nursing functions and/or instructions for nursing staff while providing care. Intervention 2 did not include the specific "Therapeutic Activities" that were to be provided by nursing staff and also failed to include how "Therapeutic Activities" would be delivered and the focus of contact based on each patient needs and level of functioning.

B. Interview

During interview on 9/9/14 at 2:15 p.m. with the Director of Nursing (DON) and Assistant DON, the Master Treatment Plans for Patient A10, A12, A13, and A14 were reviewed. The DON and ADON acknowledged that interventions on the MTPs were routine tasks and/or instructions for staff to provide care.

II. Provide adequate training of registered nurses (RNs) assigned to conduct the 1-hour face-to-face assessments of three (3) of three (3) non-sample patients (C1, C2, and C3) placed in physical holds to give forced medication(s). Specifically, all registered nurses (RN) at the facility were considered to be qualified to complete the one hour face-to-face assessment in place of a Licensed Independent Practitioner (LIP) or physician. The facility failed to show evidence of a comprehensive training with detailed information, written evaluations, and return demonstrations to show each RN's competency to conduct a comprehensive behavioral and physical assessment after use of a restrictive procedure. The lack of an adequate RN training program potentially results in a failure to conduct a comprehensive review of the patient's condition and failure to determine whether factors such as medication side effects and/or medical problems may have led to the patient's behavior. In addition, inadequate training may potentially lead to a failure to document appropriate information needed for the treatment team decisions about appropriate interventions to minimize the use of restrictive procedures.

Findings include:

A. Document Review

1. A review of incidents of restraints (Physical Holds) from June 2014 through October 2011 through June 2012 revealed the following findings:

a. Patient C1 was placed in a physical hold on 6/23/14 at 8:50 a.m. for 30 seconds to administer an IM injection. Patient C1 was also placed in a physical hold on 7/3/14 at 3:00 p.m. for 60 seconds to administer medications. There was no documentation regarding an assessment of body systems and no documentation regarding a review for possible side effects and drug interactions. On both of the one hour face-to-face assessments called by the facility "Initial Face-to-Face for Behavioral or Seclusion Assessment by RN," the section "Medical Assessment - Review of Systems" was left blank. The section "Medication Reviewed for drug interaction?" noted that "[MD's name] to review medications."

b. Patient C2 was placed in a physical restraint on 7/12/14 at 4:00 p.m. for "30 seconds" to administer an IM injection. On the one hour face-to-face assessments called by the facility "Initial Face-to-Face for Behavioral or Seclusion Assessment by RN," the section "Medical Assessment - Review of Systems" noted, "Pt [Patient] refused assessment and attempted to strike staff..." There was no documentation regarding which systems the RN attempted to assess.

c. Patient C3 was placed in a physical hold on 8/7/14 [start and end time not documented] for "60 seconds." The patient was noted to become, "agitated, combative..." when she saw her sister leave the building...There was no documentation regarding an assessment of body systems and no documentation regarding a review for possible side effects and drug interactions. On the one hour face-to-face assessments called by the facility "Initial Face-to-Face for Behavioral or Seclusion Assessment by RN," the section "Medical Assessment - Review of Systems" noted, "Pt [Patient] was in the admission process." The section "Medication Reviewed for drug interaction?" noted that "[MD's name] reviewing medications [sic]."

2. A review of the training program and competency assessment for seclusion and restraint revealed that the facility had no training program to determine the competency of registered nurses who were considered by the facility to be qualified to perform the one hour face-to-face assessment. The facility only provided RN with the seclusion and restraint training received by all staff and they also reviewed the hospital policy entitled, "Seclusion and Restraint Process: Violent or Self Destructive Restraint."

3. A review of the "Restraint Training Requirements Competency Form- RN/LPN" revealed that the assessment only evaluated competency regarding "application of restraints, the initiation of seclusion, and documentation on seclusion/restraint log and orders." There was no documented assessment evaluations and return demonstrations to show evidence of the registered nurse's competency to perform the one hour face-to-assessment in place of the LIP or physician. Specifically, there was no written assessment and return demonstration to show the RN's competency to complete a comprehensive review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, medications, and the most recent laboratory results.

B. Interview

During discussions on 9/10/14 between 9:00 a.m. and 10:00 a.m. with Director of Nursing, ADON, and Director of Hospital Quality, the training program for RNs to perform the one hour face-to-face assessment was discussion. They acknowledged that their training program did not meet the intent of the standards regarding the one hour face-to-face assessment performed by registered nurses in place of the LIP or physician.