HospitalInspections.org

Based on document review, medical record review, and staff interviews, it was determined that the facility failed to evaluate, re-assess and show progress to the discharge plan when the Patient no longer needed psychiatric inpatient hospitalization for two (2) out of eleven (11) Patients, Patient #1 and #11. This failure has the potential to negatively impact all Patients receiving services at the facility.

Findings include:

A policy was reviewed titled, "Patient Discharge", last revised 11/24. The policy states, in part, "...Purpose: outline the process by which a Patient is discharged and transitioned to the next level of care. Policy: planning begins at the time of admission as discharge needs are identified. And a plan initiated. Patients and or Family, Legal Guardian will be involved in discharge planning if Patient is agreeable, and Patient choice will be considered when arranging aftercare services. Case manager/social worker will initiate the discharge planning assessment. Information is obtained from the Patient's family or legal guardian, physician medical record and any available previous treatment records. The discharge planning assessment will be completed at the time of discharge. The case manager/social worker will identify any barriers to discharge planning and discharge criteria will be established as part of the treatment planning process. The discharge instructions will include the Patients aftercare plan and will be provided to the Patient's Patients representative and forward to the next level of care at the time of discharge. Discharge planning includes issues related to Patients' living arrangements. Patients' recognition of any need for assistance. Availability of community resources to meet the Patients' needs. Availability of Patient support system...Patient and or family legal guardian will be advised of recommendations for aftercare programs. Your services. Patients will be provided with information about available and appropriate community resources and the Patients' choice will be considered when establishing and arranging aftercare services. If the Patient refuses to allow the team to facilitate the discharge process. As intended, staff shall communicate this refusal to the attending physician treatment team and such refusal will be documented in the medical record. With the consent of the Patient and or legal guardian, information will be provided to the referral source if the referral source is a provider, and the Patient is to return, or a referral will be made to other community providers. The Patient and the family and the legal guardian will be kept informed of the Patient's progress, anticipated discharge date and status of discharge planning as appropriate..."

A review of job description titled, "Social Worker" was reviewed. The job description states in part..."Summary of core job functions: Provides social work case management services for the Patients responsibilities including managing care of the Patients, including treatment and discharge planning, communication with families and external entities, and authorization. Care. Essential core functions: Treatment planning. Discharge. Aftercare planning. Communication with Patients, families, physicians, staff, and external entities. Knowledge, skills and abilities required: Knowledge of community resources. Knowledge of authorization of care, child welfare, and juvenile justice process. Ability to work collaboratively with others. Ability to assess Patient family needs for treatment and discharge planning purposes. Customer service, treatment and discharge planning ..."

A medical record review was completed for Patient #1. The Patient was transferred from another facility, and admitted on 12/12/22, as an involuntary status admission. The Patient had been suffering from homicidal ideation and aggression at the time of the involuntary hospitalization The Patient is deemed incapacitated, and the significant other is the Health Care Surrogate (HCS) for Patient #1. The medical record indicates that the Patient had a magnetic resonance imaging (MRI) completed and it revealed that there are Asymmetrical volume loss in the frontal and temporal lobes bilaterally. The Patient was diagnosed with Dementia, frontotemporal lobar degeneration.

On 02/19/25, a Psychosocial Assessment was completed on Patient #1. Assessment reveals, "[Patient #1] has been in the facility since 2022. [Patient #1] has deteriorated progressively since [admission]. [Patient #1] is no longer aggressive. [Patient #1] is incontinent and unable to care for themself. [Patient #1] is now nonverbal. [Patient #1] is currently on a one-to-one (1:1) [staffing] status. [Patient #1] will be staying at the [facility] for the foreseeable future."

A review of "Master Treatment Plan Update" dated 03/06/25, for Patient #1 states, "The treatment team discussed the Patient. Staff say that the [Patient] is still leaning into people who are with [Patient]. [Patient] still taps their head on things, but not forcefully. Took Patient off lithium due to not making any difference on Patient's overall care. RN (Registered Nurse) went and got Patient. [Patient] came in and sat down. Treatment team asked [Patient] how they're doing. [Patient] was tapping on the table with the tops of their hands with no response. [Patient] then got up and started walking around the table and walked toward the door to exit back to unit. [Patient] sitter denies any new need. Sitter isn't reporting any suicidal ideation or homicidal ideations. [Patient's] [significant other] is still working on trying to get paperwork done so a referral can be made to a skilled nursing facility. [Patients] anxiety continues to be unchanged. [Patients'] manic behavior, mood and lability continue to deteriorate. [Patients] degenerated disease is also deteriorating. [Patients'] nonadherence to treatment is still unchanged. [Patient] psychosis is deteriorating. [Patient] continues to require inpatient level of care and is at high risk of decompensation for discharge at this time. Barriers to discharge plan: Limited support, limited resources and placement. Discharge Plan: Referral to a structured supervised setting when safe and stable for lower level of care."

A review of "Clinical Services Notes," selected from December 2024 to March 2025, was reviewed.

May it be noted, there is no evidence that a referral was completed for Patient #1 by the facility.

Patient #1 remains hospitalized on unit Four West (4W).

A review was conducted of Patient #11's medical record. The Patient was admitted to the facility on 11/12/24, with a diagnosis of ADHD (Attention-deficit Hyperactivity Disorder), and IDD (Intellectual Disability Disorder). A "Psychiatric Evaluation," on 11/13/24, at 1:59 p.m. by Staff #9 states, in part, "...Presenting Problem: [Patient #11] is currently on the waiting list for [name] step down unit ..."

A "Psychiatric Progress Note," on 12/16/24 at 9:51 a.m. by Staff #12 states, in part, "...Summary: [He/She] has been stable in this setting ..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 12/26/24 at 10:19 a.m. by Staff #9 states, in part, "...Summary:...Need to check on IDD status and school records if needed..."

A review of the medical recorded titled, "Clinical Services Progress Note," at 12/26/24 at 12:31 p.m. by Staff #6 states, in part, "...Clinical Summary Narrative:...The plan is to send referrals to IDD waiver group homes..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 12/27/24 at 9:55 a.m. by Staff #12 states, in part, "...Summary:...CM (Case Manager) is currently looking at placement options..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 12/30/24 at 10:54 a.m. by Staff #12 states, in part, "...Summary:...CM is beginning to look into placement options..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 01/07/25 at 11:57 a.m. by Staff #12 states, in part, "...Summary:...CM is looking into possible placement options..."

A review of the medical recorded titled, "Master Treatment Plan Update" on 01/09/25 at 10:22 a.m. states, in part, "...Summary of Patient's overall progress:...Staff reported that pt (Patient) is compliant with Tx (Treatment)...CM tried to call pt's DHHR (Department of Health and Human Resources) and unable to reach them and left a VM (Voicemail). CM is going to work with DHHR worker about group home placement and also finding out if there are any family members..."

A review of the medical recorded titled, "Clinical Services Progress Note" at 01/09/25 at 12:58 p.m. by Staff #6 states, in part, "...Clinical Summary Narrative:...CM has reached out to Pt's DHHR worker in hopes of working on placement to an IDD group home if possible. Once Pt's DHHR worker replies to CM will work on referrals..."

A review of the medical recorded titled, "Psychiatric Progress Note" on 01/17/25 at 9:26 a.m. by Staff #12 states, in part, "...Summary:...CM is still looking into placement options ..."

A review of the medical recorded titled, "Master Treatment Plan Update" on 01/23/25 at 9:11 a.m. states, in part, "...Summary of Patient's overall progress:...CM has spoken with pt's DHHR worker and [he/she] only got pt once pt was in [previous facility] and does not know any history prior to getting to [previous facility]. CM is going to reach out to [prior facility] to see if they have any family information...Discharge Plan: IDD Waiver Group home when ready..."

A review of the medical recorded titled, "Master Treatment Plan Update" on 02/06/25 at 9:19 a.m. states, in part, "...Summary of Patient's overall progress: CM going to try to reach out to WV Disability to see if they can help with getting some kind of paperwork started for IDD ..."

A review of the medical recorded titled, "Clinical Services Progress Note," at 02/07/25 at 4:01 p.m. by Staff #6 states, in part, "...Clinical Summary Narrative:...CM has reached out to Patients DHHR worker. CM is needing Pt's IDD documentation so that CM can possibly make referrals to group home for IDD waiver. When CM spoke with Pt, Pt is unsure of family members or where Pt lived at growing up. CM is going to continue to look for other resources and family..."

A review of the medical recorded titled, "Clinical Services Progress Note," at 02/12/25 at 10:20 a.m. by Staff #6 states, in part, "...Clinical Summary Narrative: CM received a follow-up email from [Name] from [Previous Facility] to call [him/her]. CM called and [name] was able to find the court documents that CM needed and contacted [County] Court to get. CM was not provided with all the legal documentation that was needed for this Pt. CM had tried multiple times to contact [Previous Facility] medical records department and actually spoke with someone and they forwarded the Pt's files, but they still did not provide the missing Court Document information. [Name] found them and emailed them to CM and CM put them in Pt's charts. CM will follow and assist as needed."

A review of the medical recorded titled, "Clinical Services Progress Note," at 02/12/25 at 10:20 a.m. by Staff #6 states, in part, "...Clinical Summary Narrative:...Tx team feels that Pt is ready to start looking for group homes. CM reaching out to WV (West Virginia) disability rights to see if CM can get any assistance for placement as well as talking with DHHR worker..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 03/06/25 at 10:38 a.m. by Staff #9 states, in part, "...Summary:...Needs a supervised living situation ..."

A review of the medical recorded titled, "Master Treatment Plan Update," on 03/06/25 at 10:38 a.m. states, in part, "...Summary of Patient's overall progress:...D/C (Discharge) date has not been determined as Pt continues to require inpatient level of care. Pt is at high risk of decompensation. Tx team will continue to follow and assist as needed. Barriers to discharge plan: homeless and no family to be found. Discharge plan: IDD waiver group home when ready..."

A review of the medical recorded titled, "Clinical Services Progress Note," at 03/06/25 at 11:18 a.m. by Staff #6 states, in part, "...Clinical Summary Narrative:...Pt did ask about d/c. CM informed Pt that CM has reached out to Pt's DHHR worker to discuss this with them. Tx team feels that it is appropriate at this time to work on finding a place for Pt to d/c. CM called and had to leave a voicemail for a return call..."

A review of the medical recorded titled, "Psychiatric Progress Note," on 03/12/25 at 10:09 a.m. states, in part, "...Summary:...Working on finding appropriate placement ..."

Patient #11 remains hospitalized on unit Four West (4W).

An interview was conducted on 03/11/25, at 10:10 a.m., with Staff #6. Regarding referrals, Staff #6 stated, "Most of the interaction has been with the Patients [significant other]. They are trying to get the [Patient] into a skilled nursing facility. I contact them for follow up and to assist them if they need it." When asked if Staff #6 was aware that in the past four (4) years the facility has not completed one (1) referral, Staff #6 stated, "The family is taking care of it. The [significant other] is working with a facility to get the [Patient's] placement without affecting their home and kids. The [significant other] has been the one (1) who has worked on the referrals. No, I have not seen any paperwork on a referral. I think they've been told no on a couple of them. They have. They have not told me the one (1) that they're currently working on. They are working on them with the facility to get Medicaid, so it doesn't affect the house. The [significant other] sees a nursing home and goes and talks to them. I have not received anything to actually fax anything to them. I think they're dragging their feet because they know the Patient is safe here. [Patient] needs a lot of 1:1 care. I don't think there's an agency that can provide the [Patient] with the help they need. [Family member] does attend the treatment meetings and we discuss referrals and how things are going. The latest issue is that the family is waiting on a form to come in the mail so it can be filled out and sent back. [Significant other] is the guardian, and they know that the [Patient] is being well taken care of here and that the needs are being met. Whenever we have the treatment meetings, we tell [family] that it's in the [Patient's] best interest to find a place. My supervisor would tell me when we would need to take further action. Yes, My supervisor would instruct me on filing APS. I would agree it should have been taken care of prior to this. When I came a year ago, I thought it was odd there were no referrals." When asked what had Staff #6 done to facilitate placement, Staff #6 stated, " I've made calls to [significant other] and tried to stay informed. Then, I was told it was [significant others] decision on what to do and when to do it. Yes, I think we should have gotten the ball rolling with the application for Medicaid."

An interview was conducted on 03/11/25, at 12:20 p.m. with Staff #7. Regarding referrals not being completed, Staff #7 stated, "[Patient's] name is on all the assets the family has. [Family member] cannot afford to lose the house with three (3) small children to take care of. The case manager contacts [family member] to find out what's been done and to get updates. They have stated that they wanted to make the referrals. We can't even send out a referral without the [significant others] approval. I know it has been a while. It should be documented in the social worker/case manager's progress notes. We haven't discussed a timeline. It depends on case by case. Yes, we would expect to see some movement on this. All programming, unit schedules, and updating behavior modification plans are in compliance. Compliance and policies are where they need to be. We're meeting regulations with all treatment we are offering."

A telephone interview was conducted with Staff #9 on 03/11/25 at 3:00 p.m. Regarding Patient #1, Staff #9 states, in part, "This Patient has neurodegenerative disease. It is progressive and [he/she] will end up dying from it. [He/She] will be best served in a memory unit at a nursing home. Here [he/she] has to say 1:1 while awake because [he/she] is aggressive. We need to find a place that will be able to take [him/her]. I think that they have looked at a nursing home but there's issues around funding of the nursing home. The Patient is still married and owns a house with their spouse and they have kids. I don't know what all needs to happen with the discharge plan. I don't know if the staff has made any referrals or not. I don't know beyond what the [significant other] has told us that [significant other] has done to help try to find placement. It's difficult for [him/her] to be legally separated because [significant other] doesn't believe in that and [significant other] cares about [his/her][spouse]. [He's/She's] here and [he's/she's] being well taken care of. I don't know if a nursing home would be better for [him/her]. We are providing good care. [He/She] gets 1:1 care here and is safe. [He/She] does have a pretty poor quality of life and will continue to get worse. I wasn't aware that the facility has not taken any action to help with placement with this Patient. We should at least try to pursue placement for the Patient. The [spouse] shouldn't be the one (1) looking, we should be the one trying to find a place. This Patient's frontal temporal dementia for [his/her] age is very rare. I have not seen a case like this before."

An interview was conducted on 03/12/25, at 11:50 a.m. with Staff #12. Regarding Patient #11, Staff #12 states, "We're trying to get approval from the DHHR (Department of Health and Human Resources). The Patient needs referrals sent out or find family to see if it's appropriate to send [him/her] with family."

An interview was conducted on 03/12/25, at 2:11 p.m., with Staff #5. Regarding Patient #1, Staff #5 stated, "When the Patient first came, they were verbal. They have deteriorated and are impulsive and grab at things. [The Patient] does quite well with Staff #4. They have a good repour, but other staff are compassionate and caring with [Patient] too. Staff have brain disease training online yearly for different diagnosis. A lot of the staff have never worked with a Patient like this before, but anyone can be assigned one to one (1:1). They all take turns with Patients. [Patient] is a 1:1 while awake. The staff have to be able to see the [Patient], I'm not sure the criteria. They are to stay arm's length. If the [Patient] is in their room, then the staff can be in the doorway. It's just safety for [Patient]. [Patient] does have recreational therapy groups but [Patient's] attention span doesn't allow them to go. Yes, we try to increase participation to 100% and individualize the groups. If you miss three (3) groups, you have to do an individualized contract, and it goes in the treatment plan to try to increase the participation to 100%. That gets uploaded into the chart. It states the individual's problem, the interventions. I don't know about referrals. Nursing home placement is the goal. Financially, the family is not able to afford nursing home care, so they're looking at options. The Patient doesn't have 1:1 while they're in bed. If the Patient didn't have 1:1 [he/she] would walk into other people's room, eat out of the garbage. [Patient] is very impulsive. We do treatment meetings every 14 (fourteen) days. No, we haven't looked at placement elsewhere. The social worker takes care of referrals but in this case, the family has asked to take care of them. I'm not sure if the family has actually done any referrals. I know at the treatment meetings the family states that they're working on a referral. The social worker wouldn't be involved as the families want to do their referrals. They can help with the referrals."

An additional interview was conducted with Staff #6 on 03/12/25 at 2:11 p.m. Regarding Patient #11, Staff #6 states, "I've been working with a DHHR worker and [he/she] can't get a hold of any family member. To place the Patient in an IDD waiver group home, you have to have documentation from when the Patient was diagnosed with IDD younger than three (3) years old. I did not know that when the Patient came here they were already on a waiting list at [Name] step down unit. I don't know anything about that."

Based on document review, observation, medical record reviews and staff interviews, it was determined that the facility failed to update the Patient's treatment plan with current interventions for eight (8) out of eleven (11) Patients, Patient #1, #4, #6, #7, #8, #9, #10, and #11.This failure has the potential to negatively affect all Patients receiving services at the facility.

Findings include:

A policy was reviewed titled, "Interdisciplinary Patient Centered Care Planning- Acute," last revised 11/2024. The policy states in part, "...Policy: It is the policy of [this facility] to provide therapeutic services based on a Patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the Patient and family/representative to collaboratively identify the Patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the Patient are included in the plan and the treatment plans are routinely reviewed to assess the Patient's progress and determine if any modifications are needed. Each Patient's treatment plan must include: substantiated diagnosis, identification of problems to be treated and the specific behavioral manifestations of those problems in the Patient, short-term and long-term goals for each active problem, developed with Patient input, the specific treatment modalities with individualized Patient focus, the responsibilities of each member of the treatment team...Interdisciplinary treatment plan update: 1. Treatment plan review: the treatment team, including the Patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every 7 (seven) days. Identified problems will be summarized, progress towards goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated. A treatment plan revision can be completed anytime the treatment team decides to alter the proposed strategies based on the Patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision: a new impairment/problem or significant information about existing impairment as identified, a major change occurs in the Patient's clinical condition, such as the need for use of restraint or seclusion, the Patient has successfully completed treatment goals, a Patient fails to reach treatment goals despite reasonable clinical care, a Patient is unable to participate in active treatment interventions outlined in the treatment plan due to complicated psychiatric or medical conditions for a period of greater than 48 (forty-eight) hours, the treatment team determines the Patient's current treatment plan would be more appropriately be delivered on an individual basis rather than group interventions. 2. Resolving, discontinuing or continuing goals and interventions: a. During the treatment plan review, the treatment team will evaluate if goals have been met by established Target dates. Once a goal has been resolved, the date will be identified on the treatment plan. b. If the goal has not been met, the team needs to either re-evaluate the target date and establish a new one or re-evaluate the appropriateness of the goal. c. Staff members upon discharge show either document on remaining goals the date if resolved or ongoing meaning that the problem has not yet been resolved..."

An observation of the Acute Chronic Adult Unit, 4W was completed on March 10, 2025, at 12:20 p.m. The Patients' rooms were locked for safety and sanitary purposes. The rooms were locked and had to be unlocked with each room inspection. Staff #1 stated that the doors are locked between 9:00 a.m. till 4:00 p.m., to encourage Patients to participate in groups and interventions.

A medical record review was completed on 03/10/25, for Patient #1. The Patient was transferred from another facility, and admitted on 12/12/22, as an involuntary status admission. The Patient had been suffering from homicidal ideation and aggression at the time of the involuntary hospitalization. It was reported by family that the Patient's change in condition began about eleven (11) months after having Covid in September of 2021. The Patient is deemed incapacitated, and the significant other is the Health Care Surrogate (HCS) for Patient #1. The medical record indicates that the Patient had a magnetic resonance imaging (MRI) completed and it revealed that there are Asymmetrical volume loss in the frontal and temporal lobes bilaterally. The Patient was diagnosed with Dementia, frontotemporal lobar degeneration. The Patient also suffers from Gastro-esophageal reflux, Hyperlipidemia, and unspecified psychosis.

On 07/21/23, the Neurobehavioral status exam was completed on Patient #1. The examination was to "assess [Patient #1's] neurocognitive status and to assist with differential diagnosis in the presence of significant behavioral and personality changes. Impressions: MRI Brain. (With and Without contrast), dated 11/10/2022, indicates a symmetric volume loss in the frontal and temporal lobes bilaterally, raising concern for front temporal lobar degeneration. Require support for all instrumental ADL's and reminders for basic ADL's, (e.g. bathing, changing clothing). Premorbid IQ is estimated to be in the average range, though formal cognitive testing was discontinued due to significant language deficits and psychomotor agitation. [Patients]' overall presentation suggest clinically significant attenuation in global cognitive cognition, consistent with dementia. Recommendations: Medication management is deferred to her providers. [Patient] lacks capacity for complex decision making. Concur with family's decision to seek full guardianship. Due to significant behavior and cognitive impairment, [Patient] is unlikely able to maintain any form of paid competitive employment. Recommend the family consider filing for disability benefits on [Patients'] behalf. Due to significant safety concerns [Patient] requires 24/7 supervision. [Patient] should not be left alone for any length of time. Concur with decision to continue psychiatric hospitalization. The family may consider placement in a nursing home dementia unit. As dementia progresses, [Patient] becomes less of a danger to [self] and others. Provided the family with resources regarding Marshall Health Dementia caregiver support group. Recommend the family consider individual psychotherapy to address caregiver stress and prolonged grief. Provide the family with psychoeducation regarding by FTD, and dementia. Referral was placed for additional resources from the West Virginia Alzheimer's Association."

On 12/12/23, a psychiatric evaluation update was completed on Patient #1. "[Patient] was only able to sit for a few minutes and then [they] got up to leave. [The Patient] remains impulsive and requires constant supervision from staff. Dangerous, impulsive behavior to self and others, emotional or behavioral conditions and complications require 24 hour medical or nursing care and severely impaired social, family, or occupational functioning. [The Patient] refused to participate in assessments. Memory impaired, Abstract reasoning impaired, Language simple and incoherent, judgment impaired, insight impaired and poor. Activities of daily living moderately impaired. [Patient #1] will continue to require 24/7 supervision. [Patient] will continue hospitalization. [Family] may consider nursing home placement as dementia progresses and [Patient] becomes less of a danger to [self] and others."

On 12/06/24, a Psychiatric Evaluation was completed on Patient #1. "Patient #1 was diagnosed with BV FTD. Will continue current plan of care. [Patient] will continue to require 24/7 supervision. [Patient] will continue hospitalization. Family may consider nursing home placement as dementia progresses and Patient becomes less of a danger to [self] and others. No homicidal ideation is present. [Patient #1's] prognosis is poor. Initial discharge plan is a nursing home. Continued hospitalization and treatment which could reasonably be expected to improve the Patient's condition."

On 02/19/25, a Psychosocial Assessment was completed on Patient #1. Assessment reveals that [Patient #1] "has been in the facility since 2022. Patient #1. has deteriorated progressively since [admission]. [Patient] is no longer aggressive. [The Patient] is incontinent and unable to care for themself. [The Patient] is now nonverbal. [Patient #1] is currently on a one-to-one (1:1) [staffing] status. [Patient] will be staying at the [facility] for the foreseeable future."

A review of a document tilted, "Master Treatment Plan Update," dated 3/6/25 was reviewed. Pages six (6) through eleven (11) is Patient #1's interventions. Psychiatric Inventions: Long term goal started on 10/5/23, short term goal started 10/5/23, target date 10/30/24 and stop date of 11/14/24. There are eight (8) different interventions with start dates of 2023, only one (1) has been updated. Mood liability/manic behaviors: Short term goal hasn't been updated since 2024, There are fifteen (15) interventions with a start date of 2022, 2023 and 2024, and no target dates. None of the fifteen interventions have been updated. Section: Other Psychiatric Problems r/t Nonadherence to treatment. Short term goal is outdated. There are nine (9) interventions, only two (2) have been updated and seven (7) with no target dates or updates. Section: Psychotic Behaviors, Short term goal is outdated. There are fourteen (14) interventions from 2022 and 2023, no target dates or updates. Section: Obesity. There are four (4) interventions with no target dates or updates. Section: UTI. There are seven (7) interventions with no target date and no updates. Section: Anxiety. There are eight (8) interventions, only one (1) update.

May it be noted- Patient #1's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

A review of documents titled, "Nursing Progress Note," selected from February 2025 to March 6, 2025, was reviewed. Notes address medication education.

May it be noted, there is no evidence that Patient #1 is actively participating in the education or whether there are modifications to the intervention to address Patient #1's inability to stay focused, verbalize understanding or comprehend.

A document review of "Clinical Services Progress Note" selected from February 2025 to March 6, 2025, was reviewed. The documentation reveals that Patient #1 was unable to participate in group therapies or individual therapies. Patient's nonparticipation is due to deterioration in the Patient's medical status.

May it be noted, there was no evidence noted that any changes or modifications to interventions have been determined.

A review was conducted of Patient #4's medical record. The Patient was admitted to the facility on 10/04/22 with a diagnosis of schizophrenia. A "Master Treatment Plan" update on 03/06/25 at 10:09 a.m. States in part, "...Summary of Patient's overall status/progress: Tx (treatment team) met and discussed Pt (Patient). Staff report that Pt is staying in their room more now. Staff feels that Pt and roommate (Patient #5) are taking turns staying in bed to keep their door unlocked ..."

A review was conducted of Patient #5's medical record. The Patient was admitted to the facility on 11/09/20 with a diagnosis of Bipolar Disorder, unspecified. The "Treatment Items" was reviewed, last updated 03/06/25 and states in part, "Other Psychiatric Problem r/t (related to) Alternative active treatment contract (non-adherence to treatment, lack of participation and unit activities and lack of participation in treatment plan):... Nurse will conduct a daily assessment to address mood and energy. Keep room door locked during group times ..."

Patient # 6's "Treatment Plan" was reviewed. May it be noted- Patient #6's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

Patient # 7's "Treatment Plan" was reviewed. May it be noted- Patient #7's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

Patient # 8's "Treatment Plan" was reviewed. May it be noted- Patient #8's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

Patient # 9's "Treatment Plan" was reviewed. May it be noted- Patient #9's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

Patient # 10's "Treatment Plan" was reviewed. May it be noted- Patient #10's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

Patient # 11's "Treatment Plan" was reviewed. May it be noted- Patient #11's Treatment Plan did not include any interventions mentioning keeping the doors locked during group therapy.

An interview was conducted on 03/11/25, at 1:22 p.m., with Staff #8. Regarding care of the Patient #1, Staff #8 stated, in part, "Yes, they do lock the doors to the Patient's rooms. That's supposed to encourage them to participate in groups and keep the Patients safe. All staff have keys to the doors so the Patients can get in if they truly need to. Yes, some of the Patients complain about the doors being locked and having to go to therapy."

On 03/11/25 at approximately 2:00 p.m., no policy or written information could be provided to this surveyor regarding locked Patient room doors. Staff #1 explained, it is just a procedure, the staff is trained on it upon hire to keep the room doors locked during group time to encourage group participation.

A telephone interview was conducted with Staff #9 on 03/11/25 at 3:00 p.m. Regarding Patient #1, Staff #9 states, "This Patient has neurodegenerative disease. It is progressive and [he/she] will end up dying from it. [He/She] will be best served in a memory unit at a nursing home. Here [he/she] has to stay one on one (1:1) while awake because [he/she] is aggressive. We need to find a place that will be able to take [him/her]. We have been trying to whittle back [his/her] medications because those didn't work for [him/her]. I think that they have looked at a nursing home but there's issues around funding of the nursing home. The Patient is still married and owns a house with their spouse and they have kids. I don't know what all needs to happen with the discharge plan. I don't know if the staff has made any referrals or not. I don't know beyond what [significant other] has told us that [significant other] has done to help try to find placement. It's difficult for [him/her] to be legally separated because [significant other] doesn't believe in that and [significant other] cares about [his/her][spouse]. [He's/She's] here and [he/she's] being well taken care of. I don't know if a nursing home would be better for [him/her]. We are providing good care. [He/she] gets 1:1 care here and is safe. [He/she] does have a pretty poor quality of life and will continue to get worse. There's not a therapy to fix [him/her] so there's no therapeutic interventions we can do to try to help. Every day we try to provide things for [him/her] to do and they do try to work to redirect [him/her]. I agree [his/her] treatment plan should reflect [his/her] current abilities. We haven't modified [his/her] treatment plan since [he/she] just progressively got worse and can't participate in therapy anymore. I didn't know about the 1:1 policy to stay at the doorway while the Patients were in the room. We surely can place an order that they can stay within arm's length of [him/her]. We do the best that we can for the situation and it's not going to get any better for this Patient. We have not tried to use a helmet for self-harming behavior where [he/she] hits the head off the wall since [he/she] does have a 1:1. The 1:1 staff should switch off on a pretty regular basis; this should not be the same staff all the time. I wasn't aware that the facility has not taken any action to help with placement with this Patient. We should at least try to pursue placement for the Patient. The [spouse] shouldn't be the one (1) looking, we should be the one (1) trying to find a place. This Patient's frontal temporal dementia for [his/her] age is very rare. I have not seen a case like this before."


An interview was conducted on 03/12/25, at 11:50 a.m. with Staff #12. Regarding interventions, Staff #14 stated, "At the treatment meetings we discussed goals. Goals can be updated or modified based on Patient need. The case manager updates the treatment plan. The nurse updates the nursing section. It would be the therapists that work on the interventions. All these areas are supposed to be discussed at the treatment meeting, but it doesn't always happen. If interventions are no longer working then yes, the intervention should be changed or modified. The therapist would know more about changing and modifying the interventions than I do." When asked about locking Patient room doors, Staff #12 states, "I don't schedule the unit programming. Patient doors are supposed to be locked during programming time. There are Patients that do participate in groups, and I can tell the staff they can leave their door open, but it's not an order or in their treatment plan or anything."

An interview was conducted on 03/12/25, at 1:45 p.m. with Staff #14. Regarding interventions, Staff #14 stated, "Yes, the goals and the interventions for the therapist need updated. Interventions are supposed to be reviewed at treatment meetings and any changes made at that time. I know my interventions and notes need updates. I'm working on them. Other modalities update their own. We tell the Patients as long as they come to group, we will let them back in the room. Yes, I agree that locking the door is an intervention. I don't have the authority to make it an intervention on the plan though."