HospitalInspections.org

Based on interview, clinical record review and document review, the facility failed to ensure compliance with the following Conditions of Participation: Medical Staff (A-0338) and Nursing Services (A-0385).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record review, interview and policy review the facility failed to ensure the Treatment and Medication Consent form was completed for 2 of 47 sampled patients (Patient #5, #2).

Findings include:

Patient #5 was admitted to the outpatient clinic on 4/17/13, with diagnoses including schizophrenia paranoid type.

On 6/11/13 at 2:11 PM, review of Patient #5's clinical record revealed a psychiatrist's note dated 4/17/13. The psychiatrist note indicated the patient to continue the following medications:

- Haldol deconate 200 mg (milligrams) IM (intramuscular) q (every) 2 weeks.
- Prazosin 1 mg po (by mouth) qHS (every bedtime)
- Seroquel XR 200 mg po qAM (every morning)
- Seroquel 600 mg po qHS

The psychiatrist note documented, "Patient understands treatment plan, including potential risks of prescribed medications and agrees and gives verbal consent."

Further review of Patient #5 clinical record revealed a "Treatment and Medication Consent Form" for Haldol, Seroquel and Prazosin. The consent form was not signed by the patient or a legal guardian nor was the consent form dated. The form included an option to be checked if the patient had given verbal consent. This option was left blank. The consent form did not contain the physician's signature.

On 6/1/13 at 3:08 PM, the Outpatient Clinical Director explained the physician is responsible for ensuring the treatment medication consent is on the chart. The Clinical Director acknowledged the consent was not signed. The Clinical Director stated, "the client will be in on 6/12/13 and will sign the consent."

The facility policy entitled, Client Rights and Responsibilities effective date 07/11 indicated:

"... IV. Procedures: ... 2... a. Before instituting a plan of care, treatment (including medication) or training, or carrying out any necessary surgical procedure, expressed and informed consent must be obtained in writing from: i. The Client, if he/she is 18 years of age or over or legally emancipated and competent to give consent, and form his/her legal guardian, if any; ..."




33047

Patient #2 was admitted on 6/4/13 to the facility's Psychiatric Observation Unit on a legal psychiatric hold due to hearing voices and physically threatening behavior. The patient's diagnoses included Autism Spectrum Disorder, Obsessive Compulsive Disorder, and Pervasive Developmental Disorder. Prior to admission the patient was residing in a group home. The patient had legal guardians which was known prior to admission and guardianship documents were included in the medical record.

A review of Patient #2's medical record revealed Haldol 5 Mg PO (by mouth), Ativan 2 Mg PO, and Benadryl 50 Mg PO were administered on 6/4/13 at 08:45 PM for agitation. The patient's medical record contained an unsigned "Treatment/Medication Consent" dated 6/4/13 identifying Haldol, Ativan, and Benadryl were administered. The patient had not signed the consent form, but had verbally and/or behaviorally indicated voluntary and informed consent to taking the psychotropic medications. On 6/5/13 at 5:30 PM, Klonopin 0.5 Mg PO was administered for anxiety. There was no consent in the patient's medical record. There was no documentation to support the facility contacted the legal guardians to obtain medication consent for administration.

The facility policy number PF-RRE-05, dated 4/0/13 entitled Medication: Informed Consent for Administration and Protocol for Involuntary Administration indicated:
"....1. Policy: A. Recognizing the therapeutic importance of mutual collaboration between physician and patient, as well as the potential for serious side effects caused by psychotropic medication, it shall be the practice of facility staff physicians to obtain informed consent prior to administering medication. IV. Procedures: A. Legally effective informed consent requires fulfillment of three basic requirements: 1. Competency to Grant Consent: An individual is considered legally competent to grant informed consent, unless a minor by age or otherwise adjudicated incompetent and lacking in legal capacity to knowingly grant consent. See NRS 433.033 and 433A.460. B. Appropriate significant persons to grant consent are: 2. The legal guardian of a patient who lacks the mental or legal capacity if said guardian has the proper legal authority. C. Documentation 2. The patients or guardian with the proper legal authority is encouraged to confirm in writing give their informed consent by signing the "Treatment/Medication Consent Form"."

On 6/5/13 at 10:50 AM, the physician ordered, "Guardian to sign all consents today."

On 6/11/13, the Utilization Review Nurse verified there were no signed medication consents and indicated the patient had given verbal permission for the 6/4/13 medication administration and obtaining consent from the legal guardians may not have been required.

Based on interview, clinical record review and document review, the facility failed to ensure the medical was accountable to the governing body for the quality of medical care provided to the patients (A-0347); and failed to ensure the medical staff must adopt and enforce bylaws to carry out its responsibilities (A-0353).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record review, interview and document review, the facility failed to ensure the medical staff communicated pertinent medical problems to appropriate medical staff and incorporated the pertinent medial problems into the treatment plan for 1 of 47 sampled patients (Patient #1); and failed to ensure 4 of 47 sampled patients (Patient's #31, 35, 36, and #37) were evaluated by a psychiatrist weekly.

Findings include:

1.) Patient #1 was admitted to the facility on 5/1/13 with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transporation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitation was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on 06/17/13, with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsiblity of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the paitent could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disabiity. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."

The Medical Staff Bylaws dated 04/18/13, documented "...F...All pertinent medical problems will be communicated to all appropriate medical staff and incorporated into the treatment plan.."

The clinical record lacked documented evidence the physician was aware of the delay in the patient receiving the GI consultation, as the appointment for 07/23/13 was with a primary care physician. There was no clear system in place to ensure consultations were done in a timely manner.

2.) Patient #31 was admitted to the Psychiatric Observation Unit on 05/04/13, on a legal hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 05/05/13, the clinical impression was depressive disorder and polysubstance dependence.

The patient was admitted as an inpatient to Pod H on 05/07/13 at 7:33 PM. The patient was evaluated by a psychiatric advanced nurse practitioner on 5/9/13 at 12:45 PM, with a clinical impression of depressive disorder, polysubstance dependence, pathological gambling and personality disorder. The initial treatment plan included: Trazadone for insomnia, Prozac for depression, Abilify for mood, Vistaril for anxiety, Lisinopril for hypertension, Acyclovir for infection, Flexiril for muscle spasms and group attendance.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:44 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #31's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #35 was admitted to the Psychiatric Observation Unit on 05/08/13 at 9:16 PM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist on 05/09/13 at 2:46 PM, the clinical impression was bipolar disorder, mixed episode and alcohol abuse.

Tha patient was admitted as an inpatient to Pod H on 05/09/13 at 10:02 PM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:37 PM, with a clinical impression of bipolar disorder and alcholol abuse. The initial treatment plan included: Depakote for mood, Seroquel XR for mood, monitor for mood symptoms and supportive, group and milleu therapy.

A review of the clinical revealed the next entry from the psychiatrist was 05/21/13 at 1:27 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #35's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #36 was admitted to the Psychiatric Observation Unit on 05/09/13 at 3:40 PM, on a legal psychiatric hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 5/9/13 at 10:30 PM, the clinical impression was bipolar type I, most recent episode depressed.

The patient was admitted as an inpatient to Pod H on 05/10/13 at 5:47 AM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:23 PM, with a clinical impression of bipolar type I, most recent episode depressed. The initial treatment plan included: discontinue Lithium, Lamictal for mood, Cymbalta for depression, Vistaril for anxiety, Ambien for insomnia, monitor for mood symptoms, and supportive, group amd milleu therapy.

The patient was evaluated by the internal medicine physician on 05/10/13 at 4:39 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:38 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #36's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #37 was admitted to the Psychiatric Observation Unit on 05/2/13 at 5:05 AM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist and the clinical impression was major depressive disorder.

The patient was admitted as an inpatient to Pod H on 05/2/13 at 8:38 PM. The patient was evaluated by a psychiatric advanced practice nurse on 05/3/13 at 3:56 PM, with a clinical impression of major depressive disorder. The initial treatment plan included: Celexa for depression, Ambien for insomnia, Vistaril for anxiety, Risperidone for mood, the patient was to attend groups and routine observations.

The patient was evaluated by an internal medicine physician on 05/3/13 at 3:22 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/17/13 at 2:57 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #37's clinical record lacked a psychiatric progress note for the week of 05/6/13 through 05/12/13.

The Medical Staff Bylaws dated 04/18/13, documented "...I. Progress notation and treatment plan documentation shall be in compliance with...policies..."

On 06/19/13, the Psychiatric Medical Director indicated during the week of 5/8/13 through 5/16/13, one psychiatrist was moved from the H pod to the POU at assist with staffing.

Based on clinical record review, interview and document review, the facility failed to ensure the medical staff communicated pertinent medical problems to appropriate medical staff and incorporated the pertinent medial problems into the treatment plan for 1 of 47 sampled patients (Patient #1); and failed to ensure 4 of 47 sampled patients (Patient's #31, 35, 36, and #37) were evaluated by a psychiatrist weekly.

Findings include:

1.) Patient #1 was admitted to the facility on 5/1/13 with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transporation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitation was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on 06/17/13, with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsiblity of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the paitent could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disabiity. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."

The Medical Staff Bylaws dated 04/18/13, documented "...F...All pertinent medical problems will be communicated to all appropriate medical staff and incorporated into the treatment plan.."

The clinical record lacked documented evidence the physician was aware of the delay in the patient receiving the GI consultation, as the appointment for 07/23/13 was with a primary care physician. There was no clear system in place to ensure consultations were done in a timely manner.

2.) Patient #31 was admitted to the Psychiatric Observation Unit on 05/04/13, on a legal hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 05/05/13, the clinical impression was depressive disorder and polysubstance dependence.

The patient was admitted as an inpatient to Pod H on 05/07/13 at 7:33 PM. The patient was evaluated by a psychiatric advanced nurse practitioner on 5/9/13 at 12:45 PM, with a clinical impression of depressive disorder, polysubstance dependence, pathological gambling and personality disorder. The initial treatment plan included: Trazadone for insomnia, Prozac for depression, Abilify for mood, Vistaril for anxiety, Lisinopril for hypertension, Acyclovir for infection, Flexiril for muscle spasms and group attendance.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:44 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #31's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #35 was admitted to the Psychiatric Observation Unit on 05/08/13 at 9:16 PM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist on 05/09/13 at 2:46 PM, the clinical impression was bipolar disorder, mixed episode and alcohol abuse.

Tha patient was admitted as an inpatient to Pod H on 05/09/13 at 10:02 PM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:37 PM, with a clinical impression of bipolar disorder and alcholol abuse. The initial treatment plan included: Depakote for mood, Seroquel XR for mood, monitor for mood symptoms and supportive, group and milleu therapy.

A review of the clinical revealed the next entry from the psychiatrist was 05/21/13 at 1:27 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #35's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #36 was admitted to the Psychiatric Observation Unit on 05/09/13 at 3:40 PM, on a legal psychiatric hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 5/9/13 at 10:30 PM, the clinical impression was bipolar type I, most recent episode depressed.

The patient was admitted as an inpatient to Pod H on 05/10/13 at 5:47 AM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:23 PM, with a clinical impression of bipolar type I, most recent episode depressed. The initial treatment plan included: discontinue Lithium, Lamictal for mood, Cymbalta for depression, Vistaril for anxiety, Ambien for insomnia, monitor for mood symptoms, and supportive, group amd milleu therapy.

The patient was evaluated by the internal medicine physician on 05/10/13 at 4:39 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:38 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #36's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #37 was admitted to the Psychiatric Observation Unit on 05/2/13 at 5:05 AM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist and the clinical impression was major depressive disorder.

The patient was admitted as an inpatient to Pod H on 05/2/13 at 8:38 PM. The patient was evaluated by a psychiatric advanced practice nurse on 05/3/13 at 3:56 PM, with a clinical impression of major depressive disorder. The initial treatment plan included: Celexa for depression, Ambien for insomnia, Vistaril for anxiety, Risperidone for mood, the patient was to attend groups and routine observations.

The patient was evaluated by an internal medicine physician on 05/3/13 at 3:22 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/17/13 at 2:57 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #37's clinical record lacked a psychiatric progress note for the week of 05/6/13 through 05/12/13.

The Medical Staff Bylaws dated 04/18/13, documented "...I. Progress notation and treatment plan documentation shall be in compliance with...policies..."

On 06/19/13, the Psychiatric Medical Director indicated during the week of 5/8/13 through 5/16/13, one psychiatrist was moved from the H pod to the POU at assist with staffing.

Based on interview, clinical record review, personnel file review and document review, the facility failed to ensure Nursing services provided patient care with delineation of responsibilities and accountablities as evidenced by:

Nursing staff failure to follow up on request for a physician consultation (A-395)

Certified nursing assistant performance evaluations were not completed by nursing staff (A-398).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record review, interview and document review, the facility failed to ensure the nursing staff followed up on a request for a gastrointestinal consultation for 1 of 47 sampled patients (Patient #1).

Findings include:

Patient #1 was admitted to the facility on 5/1/13 with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transportation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitian was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on 06/17/13, with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsibility of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the patient could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disability. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."

Based on review of hospital personnel records and staff interview the facility failed to ensure:1) Evaluations were consistently done by a nurse for 7 of 26 agency (non-employee) Certified Nursing Assistants (CNA's); 2) Evaluations were completed for 2 of 26 agency CNA's; and 3) Evaluations were recent for 5 of 26 agency CNA's.

Findings include:

On 6/18/13 at 1:15 PM, the Director of Nursing (DON) indicated all agency CNA's used in the units work as CNA's and not mental health technicians (MHT's).

On 6/18/13 at 1:25 PM, a review of 26 personnel records for agency CNA's revealed the following:

- CNA #1 was last evaluated on 10/29/11, by a Mental Health Technician (MHT).
- CNA #2 was last evaluated on 11/9/11 by a MHT.
- CNA #3 was last evaluated on 10/31/11 by a MHT.
- CNA #4's personnel record lacked documented evidence of an evaluation.
- CNA #5's personnel record lacked documented evidence of an evaluation.

On 6/18/13 at 1:55 PM, information provided by the Staffing Coordinator revealed the following:

- CNA #1 worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #2 last worked on 4/24/13.
- CNA #3 worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #4's worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #5's worked on 6/16/13.

On 6/18/13 at 2:46 PM, an Administrative Assistant explained evaluations for agency CNA's were done at a minimum quarterly or as needed.



06395

On 6/18/13 at 1:25 PM, a review of 26 personnel records for agency CNA's revealed the following:

- Agency provided CNA #6 was last evaluated on 9/07, by a Mental Health Technician IV (MHT).
- Agency provided CNA #7 was last evaluated on 3/14/11 by a MHT.
- Agency provided CNA #8 was evaluated on 5/25/11 by a MHT III, an evaluation on 6/7/11 that was not signed by the evaluator, and last evaluated on 12/11/11 by a MHT III.

On 6/18/13 at 1:55 PM, information provided by the Staffing Coordinator revealed the following:

- CNA #6 worked on 5/22/13.
- CNA #7 last worked on 6/15/13.

Based on observation the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were properly located.

Findings include:

Alcohol-based handrub dispensers were observed to be installed over ignition sources in the following locations:

On 6/12/13 at 2:27 PM Rawson-Neal, E-Pod Nurses Station. An ABHR dispenser was installed over a public announcement, volume control switch.

On 6/13/13 at 9:40 AM Building 3A. An ABHR dispenser was installed over a duplex, electrical outlet in hallway near the Medication room.

On 6/13/13 at 11:05 AM Building 1. An ABHR dispenser was installed over a light switch in the Medication room. At 11:50 AM, ABHR installed over an electrical duplex outlet in the hallway near room 49.

On 6/13/13 at 4:30 PM at the East Las Vegas Clinic. An ABHR dispenser was installed over an electrical duplex outlet in the hallway near room 40.

On 6/14/13 at 7:20 AM in the Rawson-Neal's Section B, Conference room. An ABHR dispenser was installed over duplex light switches. The dispenser was moved during the survey.

On 6/14/13 at 9:25 AM in the Henderson Clinic. An ABHR dispenser was installed over a duplex light switch in the reception office. The dispenser was moved during the survey.

Based on observation, staff interview and review of maintenance request forms the facility failed to maintain carpet in a clean manner in one of three outpatient facilities, maintain the protective edge in one section of carpet in one of three patient units, failed to ensure walls in patient sleeping rooms were free of holes and damage in 3 of 20 patient rooms on the H unit.

Findings include:

On 6/12/13 the main entrance, patient lobby and hallways of the Outpatient Facility on East Sahara Avenue were observed. The carpet in the main entrance area and lobby of the outpatient facility was exceptionally stained and heavily soiled throughout. Staff accompanying the surveyors also observed the stains and indicated the carpets, although cleaned regularly, are continually stained.

On 6/14/13 observed the G Unit - B Side carpet area located close to the medication dispensing area of the unit. A portion of the protective strip between the carpet and non-carpeted area of flooring was missing. Observation of the male and female bathrooms revealed overhead lights were not illuminated in one of three toilet rooms and in the second shower room. The paint was observed to be scraped off the outer surface of the sheetrock. The lights were not illuminated in the female bathroom in two of three toilet rooms.

Review of the work order document revealed a submission date for repair or replacement of light bulbs was submitted in the morning on 6/13/13. Interview with the maintenance staff on 6/14/13, in the afternoon, revealed the lights were to be repaired the same day the work order is received.

On 6/18/13, observed patient rooms H118, H119, H120 in the H Unit - A side, the walls were in need of repair due to holes beneath the windows.

On 6/18/13 observed a full container of urine sitting on the bedside table in Patient Room H120A in the morning at approximately 9:00am. Staff indicated the urinal should have been emptied.

Based on observation and staff interview the facility failed to ensure that open-element space heaters were prohibited from use on the campus.


Findings include:

On 6/13/13 at 11:17 AM a space heater was found in room R30, in Rawson-Neal's "Building 1". At 1:25 PM a space heater was discovered in room R3. The Facility Supervisor indicated that it was the facility's policy to prohibit the use of space heaters on the campus.

1. Based on record review and staff interview, it was determined that the facility failed to perform and document examination for orientation and an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 12 active sample patients (D1, E1, E2) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for 5 of 12 active sample patients (G1, H1, H2, H3 and P2). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)¿¿

2. Based on record reviews and interview the facility failed to provide and document individualized and measurable short and long term goals on the Master Treatment Plans (MTPs) for 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). Specifically, the MTP's listed similarly worded short term goals for patients that were not measurable outcome behaviors, and listed no long term goals. These failures result in treatment plans that do not identify individualized expected patient outcomes in a manner that can be utilized by the treatment team to measure the effectiveness of treatment and/ or progress towards discharge. (Refer to B121)
3. Based on record reviews and interview the facility failed to provide and document individualized interventions on the Master Treatment Plans (MTP) for12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2) to address the patient's identified treatment needs. The MTPs listed interventions that were routine, generic discipline functions that lacked focus and frequency of treatment. There were no physician interventions listed for 11 of 12 active sample patients (D1, D2, E2, G1, G2, G3, H1, H2, H3, P1 and P2) and no SW interventions listed for 4 of 12 active sample patients (G2, G3, H1, P1). In 4 of 12 records (D2, G1, H2, P2), Social Work listed a summary progress note to the date of the entry, rather than planned interventions with focus and frequency. In addition, none of the plans listed any specific group modalities related to any patient's specific needs; patients were just assigned to all the groups offered by disciplines, and without any individualized focus. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal directed. (Refer to B122)
4. Based on observations, record review and interview the facility failed to provide individualized active treatment measures for 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). Patients were not assigned or scheduled for groups based on their treatment needs; instead groups were scheduled for the units and patients were encouraged to attend. Two of 12 active sample patients (E1 and P2) did not attend groups and the facility failed to provide purposeful alternative interventions. This failure may result in patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement and timely discharge. (Refer to B125)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individualized recommendations for social work services from the data gathered for 8 of 12 active sample patients (D1, E2, G1, G3, H1, H2, H3, and P2). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

1. Patient D1 was admitted on 06/29/13. The psychosocial assessment, done on 07/03/13, did not include any patient specific individualized social service recommendations. The documented recommendations were discipline specific functions and generic in nature and not based on identified psychosocial problems. They were: "to coordinate discharge planning, obtain collateral information and refer pt [Patient] for aftercare medication management and counseling" and were identical to the social services recommendations of patient H2.

2. Patient E2 was admitted on 06/25/13. The psychosocial assessment, done on 06/26/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature and not based on identified psychosocial problems. They were: "the pt [Patient] will be offered a referral to medication clinic when ready for discharge. The patient's barriers to discharge involve the social worker making contact with family or other support system if available".

3. Patient G1 was admitted on 06/26/13. The psychosocial assessment, done on 06/28/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, not based on identified psychosocial problems. They were: "Social work to include gathering of collateral information, education of community resources available and discharge planning" and were identical to the social services recommendations of patient G3.

4. Patient G3 was admitted on 07/10/13. The psychosocial assessment, done on 07/15/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, not based on identified psychosocial problems. They were: "Social work to include gathering of collateral information, education of community resources available and discharge planning" and were identical to the social service recommendations of patient G1.

5. Patient H1 was admitted on 06/22/13. The psychosocial assessment, done on 06/23/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, not based on identified psychosocial problems. They were: "referrals for outpatient services including medication management and therapy, return to home, NA meetings".

6. Patient H2 was admitted on 07/21/13. The psychosocial assessment, done on 07/22/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, not based on identified psychosocial problems. They were: "to coordinate discharge planning, obtain collateral information from pt's [Patient's] support system and refer pt. [Patient] to outpatient clinic for meds and therapy following discharge" and were identical to the social services recommendations of patient D1.

7. Patient H3 was admitted on 07/12/13. The psychosocial assessment, done on 0715/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, based on identified psychosocial problems. They were: "D/C [discharge] to catholic charities of southern Nevada... followup at West Charleston Clinic... for outpatient services including medication management and therapy".

8. Patient P2 was admitted on 07/21/13. The psychosocial assessment, done on 06/21/13, did not include individualized recommendations. The documented recommendations were discipline specific functions and generic in nature, not based on identified psychosocial problems. They were: "referrals for outpatient services including medication management and therapy, Las Vegas rescue mission for shelter".

B. Staff Interviews

1. During an interview on 07/25/13 at 2:00 p.m., the Director of Social Work stated, "I don't see it here [referring to social services recommendations] but it should be there. I will work with my staff to improve".

2. During an interview on 07/25/13 at 3:30 p.m., the Medical Director stated, "I agree social service assessments should contain recommendations but they are not here".

Based on record review, and interview, it was determined that for 1 of 12 active sample patients (G3), the facility failed to perform and document a screening neurological examination. As a result, it was not possible for the facility to determine if the patient required further examination, such as a complete comprehensive neurological examination. The absence of this patient information restricts clinicians' ability to accurately diagnose the patient's condition and to measure change in baseline function, thus affecting patient care.
Findings include:
A. Record Review:
Patient G3 was admitted on 07/10/13. The physical examination performed on 07/11/13 did not document a screening neurological examination.
B. Staff Interviews:
During an interview on 07/25/2013 at 3:30 p.m., Associate Medical Director stated, "I see the screening neuro exam is not done".

Based on record review and staff interview, it was determined that the facility failed to perform and document examination for orientation and an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 12 active sample patients (D1, E1, E2) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for 5 of 12 active sample patients (G1, H1, H2, H3 and P2). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient D1 was admitted on 06/29/13. The psychiatric evaluation, done on 06/29/13 stated, "Memory Function Intact" and "Orientation Full." There was no supportive information documented.

2. Patient E1 was admitted on 07/06/13. The psychiatric evaluation, done on 07/08/13, stated, "memory function unable to fully assess due to disorganized thought process and impaired concentration and attention" and "patient is oriented." There was no documentation of making further attempts at completing memory testing during the course of hospitalization. There was no supportive information documented for orientation testing.

3. Patient E2 was admitted on 06/25/13. The psychiatric evaluation, done on 06/25/13, stated, "memory function difficult to assess due to lack of cooperation" and "patient did not cooperate with orientation testing". There was no documentation of making further attempts at completing these testing during the course of hospitalization.

4. Patient G1 was admitted on 06/26/13. The psychiatric evaluation, done on 06/27/13 stated, "oriented times three." There was no supportive information documented.

5. Patient H1 was admitted on 06/22/13. The psychiatric evaluation, done on 06/23/13, stated, "fully...oriented." There was no supportive information documented.

6. Patient H2 was admitted on 07/21/13. The psychiatric evaluation, done on 07/22/13, stated, "A&Ox3" [alert and oriented times three]. There was no supportive information documented.

7. Patient H3 was admitted on 07/12/13. The psychiatric evaluation, done on 07/12/13, stated, "oriented times three." There was no supportive information documented.

8. Patient P2 was admitted on 06/17/13. The psychiatric evaluation, done on 06/19/13, stated, "A&Ox4" [alert and oriented times four]. There was no supportive information documented.

B. Interview

During an interview on 07/25/2013 at 3:30 p.m., Associate Medical Director stated, "I am aware of problems with mental status examinations. We are changing our format for mental status examinations and now our medical staff will be required to do more comprehensive mental status examinations. We will also have weekly audit." The Associate Medical Director also stated "I agree with your findings, our own assessment of our programs is not different than yours and we are on a track to improve".

Based on record review and staff interview, it was determined that the facility failed to document an inventory of assets in the psychiatric evaluation of 2 of 12 active sample patients (H2, and P2). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.
Findings include:
A. Record Review
1. Patient H2 was admitted on 07/21/13. The psychiatric evaluation completed on 07/22/13 did not document an inventory of assets.
2. Patient P2 was admitted on 06/17/13. The psychiatric evaluation completed on 06/19/13 did not document an inventory of assets.
B. Staff Interview
During an interview on 07/25/13 at 3:30 p.m., the Medical Director agreed with the findings and stated, "I see inventory of assets is missing."

Based on record review the facility failed to list patient strengths in the MTPs in descriptive fashion for 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). The MTPs listed strengths that were identical or similarly worded for all patients, and not individualized or tailored to each patient. This lack of information hinders the team's ability to develop treatment plans that builds on the patient's assets/strengths.
Findings include:
A. Record Review
1. Patient D1 was admitted on 06/29/2013. The MTP dated 7/21/13, in the section titled "Patient Strengths," noted the following: "able to state needs." No other descriptive information was noted.
2. Patient D2 was admitted on 07/04/2013. The MTP 07/19/13, in the section titled "Patient Strengths," noted the following: "able to state needs, alert." No other descriptive information was noted.
3. Patient E1 was admitted on 07/05/2013. The MTP 07/24/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs." No other descriptive information was noted.
4. Patient E2 was admitted on 06/24/2013. The MTP 06/24/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs known." No other descriptive information was noted.
5. Patient G1 was admitted on 06/26/2013. The MTP 07/19/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs." No other descriptive information was noted.
6. Patient G2 was admitted on 06/10/2013. The MTP 06/11/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs." No other descriptive information was noted.
7. Patient G3 was admitted on 07/11/2013. The MTP 07/11/13, in the section titled "Patient Strengths," noted the following: "able to state needs, alert cooperative." No other descriptive information was noted.
8. Patient H1 was admitted on 06/22/2013. The MTP 06/24/13, in the section titled "Patient Strengths," noted the following: "able to state needs, ambulatory." No other descriptive information was noted.
9. Patient H2 was admitted on 07/21/2013. The MTP 07/22/13, in the section titled "Patient Strengths," noted the following: "able to make needs known." No other descriptive information was noted.
10. Patient H3 was admitted on 07/12/2013. The MTP 07/21/13, in the section titled "Patient Strengths," noted the following: "Pt. is able to make needs known." No other descriptive information was noted.
11. Patient P1 was admitted on 07/21/2013. The MTP 07/21/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs." No other descriptive information was noted.
12. Patient P2 was admitted on 06/15/2013. The MTP 07/20/13, in the section titled "Patient Strengths," noted the following: "able to verbalize needs." No other descriptive information was noted.

Based on record review and interview the facility failed to provide MTPs that identified patient-related short-term and long-term goals stated in observable, measurable, behavioral terms for 12 out of 12 active sampled patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). Instead, the MTP's listed similarly worded short term goals for patients that were not measurable outcome behaviors, and listed no long term goals. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patient stays beyond the resolution of the behaviors requiring admission.
Findings include:
A. Record Review
1. Patient D1 was admitted on 06/29/2013. The MTP dated 07/21/13, in the section titled "Goals," noted the following: Short-Term Goal NSG (Nursing): "Pt will demonstrate improved thought process and orientation as evidenced by clear sentences and completion of simple tasks daily." Allied Therapy (AT): short term Goal: "Patient will increase goal-directed behaviors." No long-term goals were listed on the plan.
2. Patient D2 was admitted on 07/4/2013. The MTP dated 07/19/13, in the section titled "Goals," noted the following: Short-term goal Nursing Goal: "Patient will demonstrate improved thought process as evidenced by clear sentences with no delusional thoughts and paranoia." AT short-term goal: "Patient will increase goal-directed behaviors." There was no long term goal listed on the plan.
3. Patient E1 was admitted on 07/05/2013. The MTP dated 07/24/13, in the section titled "Goals," noted the following: Physician: "Resolution of psychosis with diminished symptoms of mania and disorganized behavior. Stabilization through medication." NSG Goal: "Will demonstrate improved thought process as evidenced by clear speech and sentences with no flight of ideas and completing simple task daily." AT Goal: "Pt. will be free of manic symptoms by time of discharge." No long term goal was listed on the plan.
4. Patient E2 was admitted on 06/24/2013. The MTP dated 06/24/13, in the section titled "Goals," noted the following: Nursing Goal: "Patient will have decreased number of violent responses as evidenced by patient's demonstration of behavioral control to eliminate physically aggressive behavior daily." No long-term goal was listed on plan.
5. Patient G1 was admitted on 06/26/2013. The MTP dated 07/19/13, in the section titled "Goals," noted the following: Nursing Goal: "Patient will be free of delusions or demonstrate the ability to function without responding to persistent delusional thoughts daily." AT Goal: "[Patient] will demonstrate improved thought processing with better insight and judgment regarding the management of [his] mental illness." No long-term goal was listed on the plan.
6. Patient G2 was admitted on 06/10/2013. The MTP dated 06/11/13, in the section titled "Goal," noted the following: Nursing Goal: "Patient will not harm self as evidenced by patient's report of no self-inflicted (non-violent or swift, injurious force) injury x 3 daily." No long-term goal was listed on the plan.
7. Patient G3 was admitted on 07/11/2013. The MTP dated 07/11/13, in the section titled "Goal," noted the following: Nursing Goal: "Patient will not harm self as evidenced by patient's report of no self-inflicted (non-violent or swift, injurious force) injury daily." No long-term goal was listed on the plan.
8. Patient H1 was admitted on 06/22/2013. The MTP 06/24/13, in the section titled "Goal" noted the following: Nursing Goal: "Patient will not harm self as evidenced by patient's report of having no self inflicted injuries daily." No long-term goal was listed on the plan.
9. Patient H2 was admitted on 07/21/2013. The MTP dated 07/22/13, in the section titled "Goal" noted the following: Nursing Goal: "Control or eliminate active psychotic symptoms so that supervised functioning is positive and medication is taken consistently." "Patient will be able to focus on reality, have decreased paranoia, improved thoughts process, less delusions, not be a danger to others, and perform simple tasks within the next two weeks." No long-term goals were listed on the plan.
10. Patient H3 was admitted on 07/12/2013. The MTP dated 07/21/13, in the section titled "Goal" noted the following: "Pt will not harm self daily through time of discharge." "Pt will develop goals to bring meaning and purpose to life to avoid future hospitalizations." "Develop social and recreational activities as a routine part of life." SW goal: "Pt will agree to work with SW regarding recommendations for discharge/aftercare, including housing, sub abuse TX, employment." No long-term goal was listed on the plan.
11. Patient P2 was admitted on 06/15/2013. The MTP 07/20/13, in the section titled "Goal," noted the following: NSG Goal: "Resolve current psychotic sx's (symptoms) through consistent use of psych meds through time of d/c." "Pt will develop realistic thought processes, become more trusting of others and learn to focus on health, constructive activities." No long-term goal was listed on the plan.
B. Interview
1. During the interview on 07/25/13 at 2:30 p.m. with the Director of Nursing (DON), the Master Treatment Plans for 10 out of 12 sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, and P2) were reviewed. She stated "base on my own findings I know the treatment plans need a lot of work; long term goals needed to be developed and short term goals are not measurable."
2. During an interview on 07/25/13 at 10:47 a.m. with the Nurse Manager and RN 4 from staff development the Master Treatment Plans for Patients D1, D2,E1,E2, G1, G2, G3, H1, H2, and P2 were reviewed. The Nurse Manager and the staff development person agreed that the short-term goals were not measurable and the long-term goals were missing from the plans.
C. Document Review:
A review of the hospital policy entitled "Treatment Plan," with an effective date of 02/13, revealed that the facility had not established instruction on how to develop individualized short and long term goals which were measurable.

Based on record review and interview, the facility failed to develop MTPs that identified nursing, allied therapy and social work interventions that were individualized and specific to the patients treatment needs for 12 of 12 sampled patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). The MTPs listed interventions that were routine, generic discipline functions that lacked focus and frequency of treatment. There were no physician interventions listed for 11 of 12 active sample patients (D1, D2, E2, G1, G2, G3, H1, H2, H3, P1 and P2) and no SW interventions listed for 4 of 12 active sample patients (G2, G3, H1, P1). In 4 of 12 records (D2, G1, H2, P2), Social Work listed a summary progress note to the date of the entry, rather than planned interventions with focus and frequency. In addition, none of the plans listed any specific group modalities related to any patient's specific needs; patients were just assigned to all the groups offered by disciplines, and without any individualized focus. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, and potentially delaying patient improvement, and discharge from the hospital.
Findings include:
A. Record Review
1. Patient D1
Master Treatment Plan dated 07/21/13, for the problem "psychosis," listed the following generic and routine discipline functions as interventions:
"Encourage the client to seek frequent reality testing to challenge his/her [sic] cognitions with the experience of trusted caregiver, friends and family."
Master Treatment Plan dated 07/21/13, for the problem "altered thought process" listed the following generic and routine discipline functions as interventions:
"Nursing staff will establish a trusting, therapeutic relationship with pt by being honest, supportive and consistent." "Nursing staff will encourage pt to verbalize feelings and thoughts openly." "Nursing staff will provide observation as ordered for safety." "Nursing staff will collaborate with the multidisciplinary team regarding pt's plan of care." "Nursing staff will reorient pt to person, place or time as needed." "Nursing staff will redirect pt as needed and promote reality orientation while providing routine care by identifying pt by name, identifying staff members by name, and identifying time of community group, meal time, activities, etc."
Allied Therapy: "AT will provide Music, Art and Recreation Therapies and Fitness/Wellness groups."
Social Work: "SW will meet pt 1:1 and with Tx (treatment) team to assist pt with psychosocial and D/C planning needs. SW will provide pt psychoeducation about psychosis and co-occurring D/O (disorder), coping with mental illness, importance of sobriety and TX and med compliance. Per pt consent, SW will speak with mother for collateral contact and D/C planning."
Physician: No treatment intervention was listed on the treatment plan.
2. Patient D2
The Master Treatment Plan, dated 07/19/13, for the problem of "disturbed thought process," listed generic and routine discipline functions as interventions:
"Monitor medication for side effects/adverse reactions." "Nursing staff will provide Q15 (every 15 minute) close observation for safety." "Nursing staff will focus on reality based thinking/orientation."
"Nursing staff will re-orient the patient to person, place and tim [sic], call the patient by name, tell the patient your name, tell the client where [s/he] is etc." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard to the patient) from the patient and room." "Nursing staff will decrease environmental stimuli whenever possible." "Respond to cues of increased agitation by removing stimuli or removing the patient from the group to a quiet room." "Nursing will promote reality orientation while providing routine care by indentifying staff members by name and identifying time of community group, meal times, activities, etc." "Nursing staff will administer medication as indicated."
Allied Therapy: "AT will provide Music, Art and Recreation Therapies and Fitness/Wellness groups."
Social Work interventions were not listed; instead there were summary progess notes: 07/13/13 to 07/19/13 SW met with pt and Tx Team (MD, SW, RN, MHT) several this week [sic] to assist pt with psychosocial and discharge planning needs." "On 7-17-13, SW and Tx Team (MD, SW, RN, MHT) met with pt to assist pt with psychosocial and discharge/aftercare planning. SW and Tx Team reviewed pt's Tx Plan with pt; pt disagreed and refused to sign." "Pt is not taking [her/his] medications as ordered and continues to be very uncooperative." "DOR [sic] for medication initiated on 7/11/13". "...on 7/17/13 pt declined to sign consent for mother, [additional source name] for collateral discharge and aftercare planning." "SW attempted to provide pt PSYCHOEDUCATION about Disturbance (Paranoid Schizophrenia), coping with mental illness and the importance of Tx and medication compliance as it relates to disturbance, ability to regulate thoughts, emotions, and actions." "Pt actively delusional; unwilling to participate." "Pt continues to isolate in [his/her] room and not participating in any on/off unit activities."
Physician: No treatment intervention was listed on the treatment plan.
3. Patient E1
The Master Treatment Plan dated 07/24/13, for the problem of "altered thought process," listed the following generic and discipline functions as interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff will focus on reality based thinking/orientation." "Nursing staff will re-orient the patient to person, place and time (call the patient by name, tell the patient your name, tell the client where she/he is etc [sic])." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard to the patient) from the patient and room." "Nursing staff will decrease environmental stimuli whenever possible. Respond to cues of increased agitation by removing stimuli or removing the patient from the group to a quiet room." "Nursing will promote reality orientation while providing routine care by indentifying staff members by name and identifying time of community group, meal times, activities, etc." "Nursing staff will re-orient the patient to person, place and time as indicated." "Nursing staff will communicate with the client using clear, direct statements." "Nursing staff will provide an environment with a low degree of stimulation." "Nursing staff will provide adequate lighting if the client is experiencing a visual hallucination." "Nursing will encourage activities that promote socialization."
Allied Therapy: "AT groups to include art, games, music, leisure, fitness and wellness activities."
Social Work: "After obtaining the proper release of information from the client, request assistance from family members, roommates, peers, or caregiver to administer the medication to the client."
4. Patient E2
The Master Treatment Plan dated 06/24/13, with the identified problem as "risk for self or other directed violence," listed the following generic discipline functions as treatment interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff will establish an environment that reduces agitation (e.g. decrease noise level, give short concise explanation." "Nursing staff will institute time out procedure (retreat to the "quiet room" to provide the opportunity to regain internal control. Teach the client that time is a positive opportunity for cooling off, not a punishment [sic]." "Nursing staff will assist client in examining alternatives to acting out behavior." "Nursing will provide a safe environment for the patient and others by removing items that can be used as potential weapons." "Nursing staff will encourage patient to engage in physical exercise or to substitute safe physical activities for aggressive behavior i.e. lifting weights." "Nursing staff will be firm and consistent in setting and maintaining limits, enforcing hospital and unit policies." "Nursing staff will protect other clients from abuse behavior by redirection." "Implement seclusion and/or restraint as needed to protect patient and others from violent behaviors." "Nursing staff will listen carefully for suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviors are critical clues regarding self harm."
Allied Therapy: "Allied Therapy will provide art, music and recreational therapy"
Social Work: "SW will contact sister...after obtaining ROI (Release of Information) at (phone number listed). SW will attempt to confirm housing." The remainder was a progress note: "SW educated pt on the importance of medication compliance and demonstrating appropriate coping skills in the community, to avoid people calling the police on [him/her] and being evicted. SW educated pt that she contacted a housing provider but they require full scope Medicaid and pt has medicaire [sic] so patient does not qualify."
Physician: No treatment intervention was listed on the treatment plan.
5. Patient G1
The Master Treatment Plan dated 07/19/13, with identified problem as "altered thought process," listed the following generic and discipline functions as treatment interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff assess for self destructive behaviors and provide needed precautions."
Allied therapy: "AT will offer daily activity groups to include music, art, exercise, dance and sport."
Social work interventions were not listed; instead there were summary progess notes: "Week of 07/15/13 - On 07/15/13 - Patient attends weekly treatment team meeting with Psychiatrist, Social Worker, established Mojave Case Manager and Mother. Patient is monitored for change, improvement and discharge readiness. Patient reports decrease in presenting symptoms, [s/he] is medication compliant and cooperative. Patient tentative discharge date is scheduled for next week 7/24/13."
Physician: No treatment intervention was on the plan.
6. Patient G2
The Master Treatment Plan dated 06/11/13, with identified the problem as "risk for harm directed towards self/others," listed the following generic and discipline functions as interventions:
"Nursing staff will provide Q 15 minutes observation for safety." "Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precautions daily. Explain suicide precaution to the patient." "Nursing staff will monitor, remove sharp and dangerous objects such as glass, plastic bags, belts, hangers and other potentially hazardous objects from the patient's room." "Nursing staff will observe, record, and report any changes in the client's mood (elation, withdrawal, sudden resignation)." "Nursing staff will administer medication as needed (specify drug name, route, dosage, frequency)." "Nursing staff will ask the patient if [s/he] has a plan for suicide. Attempt to ascertain how detailed and feasible the plans are."
Allied Therapy: No treatment intervention listed on plan.
Social Work: No treatment intervention listed on plan.
Physician: No treatment intervention listed on plan.
7. Patient G3
The Master Treatment Plan dated 07/11/13, with the identified problem as "risk for suicide," listed the following generic and disciple functions as interventions:
"Monitor medications for side effects/adverse reactions." "Nursing staff will provide Q15 close observation." "Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precaution daily. Explain suicide precaution to the patient." "Nursing staff will monitor, remove sharp and dangerous objects such as glass, plastic bags, belts, hangers and other potentially hazardous objects from the patient patient's room." "Nursing staff will monitor for cheeking of medications, check to ensure that all medications are swallowed." "Nursing staff will observe, record, and report any changes in the client's mood (elation, withdrawal, sudden resignation)." "Nursing staff will administer medication as needed."
Allied Therapy: No treatment intervention listed on plan.
Social Work: No treatment intervention listed on plan.
Physician: No Intervention on the treatment plan.
8. Patient H1
The Master Treatment Plan dated 06/24/13, with the identified problem as "risk for self-harm," listed the following generic and discipline functions as interventions:
"Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precaution daily." "Nursing staff will explain suicide precautions to the patient as needed." "Nursing staff will monitor, remove sharp and dangerous objects or contraband from the patient and patient areas daily." "Nursing staff will monitor for cheeking with each medication administration to ensure all medication are swallowed." "Nursing staff will administer scheduled medications as ordered and prn medications as needed." "Nursing staff will ask the patient if having a plan [sic] for suicide and assess how plausible the patient's plan is daily."
Allied Therapy: No treatment intervention listed on plan.
Social work: No treatment intervention listed on plan
Physician: No treatment intervention listed on plan
9. Patient H2
The Master Treatment Plan dated 07/22/13, with the identified problem as "disturbed thought process," listed the following generic and discipline functions as treatment interventions:
"Nursing staff will administer medications and evaluate effectiveness or side effects." "Nursing staff will observe pt. Q 15 minutes for safety." "Nursing staff will provide a safe, therapeutic environment." "Nursing staff will observe the pt. Q shift for s/s (signs/symptoms) of anxiety, frustration, anger, or danger to self and others and initiate immediate 1:1 assessment and prn med. if indicated." "Nursing staff will remove all hazardous items from pt. room and day area for safety." "Nursing staff will advise pt to attend support groups for improved coping skills to manage life's daily challenges safely."
Allied Therapy: No treatment intervention listed on the plan.
Social Work interventions were not listed; instead there were summary progess notes: "Initial assessment: Pt attended treatment team with psychiatrist and social worker and informed the treatment team on present physical and mental health, and on the effectiveness of medications prescribed to [him/her]." "Pt met with social worker to discuss discharge placement plan." "Pt reports that [s/he] would like to reside with [his/her] mother, Social worker will plan on contacting pt's mother to collect collateral information and confirm discharge placement there."
Physician: "Monitor the client for psychotropic medication prescription compliance, effectiveness, and side effects; redirect if the client is noncompliant."
10. Patient H3
The Master Treatment Plan dated 07/21/13, with the identified problem as "risk for violence directed towards self/poor coping skills," listed the following generic and discipline functions as interventions:
"Nursing staff will administer medications and evaluate effectiveness or side effects." "Nursing will observe pt Q15 minutes for safety." "Nursing staff will provide a safe, therapeutic environment." "Nursing staff will observe pt. Q shift for s/s of anxiety, frustration, anger or danger to self and others and initiate immediate 1:1 assment(sic) and prn. med. if indicated." "Nursing staff will remove all hazardous items from pt. room and day area for safety." "Nursing staff will advise pt to attend support groups for improved coping skills to manage life's daily challenges safely."
Allied Therapy: "Allied therapy will provide daily art, music, and recreation therapy and fitness/wellness groups."
Social work: "SW will contact (named source) for collateral info needed for discharge /aftercare planning."
Physician: No treatment intervention listed on treatment plan.
11. Patient P1
The Master Treatment Plan dated 07/21/13, with the identified problem as "risk for violence directed towards self," listed the following generic and discipline functions as interventions:
"Nursing staff will provide Q15 observation for safety." "Nursing staff will provide a safe environment for [patient] and others by removing items that can be used as potential weapons." "Nursing staff will administer medications as ordered by MD. And observe for effectiveness or any adverse reactions."
Allied Therapy: No treatment intervention listed on treatment plan
Social Work: No treatment intervention listed on treatment plan.
Physician: No treatment intervention listed on plan.
12. Patient P2
The Master Treatment Plan dated 07/20/13, with the problem of "Disturbed thought process and risk for violence/injury directed towards others," listed the following generic and discipline functions as interventions:
"Nursing staff will provide ordered observation for safety." "Nursing staff will focus on reality based thinking/orientation." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard." "Nursing staff will decrease environmental stimuli whenever possible. Respond to cues of increased anxiety or agitation by removing stimuli or removing client from the group to a quiet room." "Nursing staff will encourage client to participate in milieu groups and activities that promote socialization." "Nursing staff will administer medication as indicated. Provide med teaching regarding current med name, dose, side effects and impts [sic] of compliance RX: Geodon, Benadryl, and prn Ambien." "Staff may use seclusion and/or restraints to ensure a safe environment for [patient] and others on the unit due to pt's hx of aggression and assault."
Allied Therapy: No intervention listed on the treatment plan.
Social Work interventions were not listed; instead there were summary progess notes:
"7/15/13 - 7/19/13: SW contacted detective regarding pt self-reported crime and update on proposed warrant. Pt continues to refuse to participate in hospitalization and has been assaultive on the unit." "Pt continues to be INVOL(involuntary) w/active DOR for medication over objection."
Physician: No intervention listed on the treatment plan.
B Staff Interviews:
1. During an interview on 07/25/13 at 10:47 a.m. with the Nurse Manager and RN 4 from staff development the Master Treatment Plans for Patients G1, G2, G3, H1, H2, and H3 were reviewed. The Nurse Manager agreed that nursing interventions were generic nursing functions. He further stated that "I understand that these are nursing functions that the nurses understand they are responsible for during their shift. I agree they are job duties." The staff development person stated "we need better interventions."
2. During the interview on 07/25/13 at 2:30 p.m. with the Director of Nursing the Master Treatment Plans for Patients D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2 were reviewed. She agreed that the nursing interventions listed on the plans were generic routine nursing staff duties. She agreed that the treatment plans should reflect patient active treatment activities and each patient needed to be aware of his/her schedule. She stated "this should be addressed in the treatment team meeting and the plan should reflect the patient's individualized treatment needs." She agreed patients are not assigned to active treatment groups based on their individual needs and stated "this needs to be improved."
3. During the interview on 07/26/113 at 9:50 a.m. with Assistant Training Officer, Nurse Trainer (RN 3), and RN 4 the treatment plan interventions for Patients D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2 were reviewed. RN 3 stated "the interventions are vague; I agree they are nursing functions." "This is the way the nursing staffs are trained to write the intervention." "We will need to do some retraining." The staff develop person stated "we are using the traditional view on writing nursing interventions; this is the way we were taught in school." "Diagnoses drive needs; I agree that the interventions are staff duties." The training officer stated that "the interventions are non-specific staffing functions and they do not reflect patient needs."
4. During an interview on 07/24/2013 at 12:00 p.m., QA specialist stated, "It makes sense, treatment plans should include all modalities. They (referring to treatment plans) are not up to the speed."
C. Document Review:
A review of the hospital policy entitled "Treatment Plan," with an effective date of 02/13, revealed there was no evidence that the facility had established procedures on how to develop individualized treatment interventions.

Based on observations, record review and interview the facility failed to provide individualized active treatment measures to 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). Patients were not assigned or scheduled for groups based on their treatment needs; instead groups were scheduled for the units and patients were encouraged to attend. Two of 12 active sample patients (E1 and P2) did not attend groups and the facility failed to provide purposeful alternative interventions. These failures may result in patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement and timely discharge.
Findings include:
A. Record Review
Patient D1, MTP dated 07/21/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process." No individual schedule of activities was documented in the medical record.
Patient D2, MTP dated 07/19/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process." No individual schedule of activities was documented in the medical record.
Patient E1, MTP dated 07/24/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "altered thought process." No individual schedule of activities was documented in the medical record.
Patient E2, MTP dated 06/24/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk for self or other directed violence."
No individual schedule of activities was documented in the medical record.
Patient G1, MTP dated 07/19/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "altered thought process."
No individual schedule of activities was documented in the medical record.
Patient G2, MTP dated 06/11/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk for harm directed toward self/others."
No individual schedule of activities was documented in the medical record.
Patient G3, MTP dated 07/11/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk for suicide." No individual schedule of activities was documented in the medical record.
Patient H1, MTP dated 06/24/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk of self harm."
No individual schedule of activities was documented in the medical record.
Patient H2, MTP dated 07/22/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process."
No individual schedule of activities was documented in the medical record.
Patient H3, MTP dated 07/21/13 had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk for violence directed towards self."
No individual schedule of activities was doumented in the medical record.
Patient P1, MTP dated 7/21/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "risk for violence directed towards self."
No individual schedule of activities was documented in the medical record.
Patient P2, MTP dated 07/20/13, had no assigned treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process", or "risk for violence/injury directed towards others."
No individual schedule of activities was documented in the medical record.
B. Observations:
1. During an observation of the Nursing medication group on the Psychiatric Observation Unit (POU) on 07/25/13 at 10:30 a.m. sample patient P1 was observed sitting away from the group at a table alone, with his/her head down on the table. The group instructor provided general information on psychotropic medication. The instructor did not engage the patients in any way. Patients were talking to each other and two patients walked away from the group. Nursing staff did return them to the group. There was a total of 12 patients out of a census of 20 in the group.
2. Patient P2 was admitted to the POU on 06/15/2013 and transferred to unit H4A on 06/17/13, but then transferred back to the unit POU on 07/18/13 because of alleged aggressive and violent behaviors. During an observation on the unit POU on 07/24/2013 at 11:10 a.m., Patient P2 was not in attendance at the "Medication Group." When inquired about the Patient P2's whereabouts on 07/24/13 at 11:20 a.m., the unit charge nurse (RN 5) stated, "this patient (P2) is refusing all activities and [s/he] is in [his/her] bedroom. We cannot force patients to go to group." During another observation on the unit POU on 07/24/2013 at 2:30 p.m., Patient P2 was also not in attendance at the "Activity Group." The patient was observed fully awake, sitting in his/her bedroom during both these observations.
3. During an observation on unit E on 07/24/2013 at 2:45 p.m., Patient E2 was not in attendance at the "Psychology Group." When inquired about this patient's whereabouts on 07/24/2013 at 2:50 p.m., the UM (Unit Manager) coordinator stated, "The patient is refusing to go to group." Patient was observed awake in his/her bedroom.
C. Interview
1. During an interview on 07/24/13, at 2:35 p.m. with active sample patient H3, the patient stated s/he attended some on-unit activity, but being on restriction prevented attendance at off- unit activities. H3 stated "I don't receive a weekly schedule of activities to attend; activities are announced each morning in the unit meeting." When asked what s/he does when there is no unit program to attend, s/he stated s/he walks around talking with other patients, who would talk with him/her.
2. During an interview on 07/24/13 at 2.55 p.m. with active sample patient G1 the patient stated "I attend most of the activities" on the unit program, "they are nice but don't help me, I am feeling worse than when I was admitted to the hospital."
3. During an interview on 07/24/13 at 3:15 p.m. with RN Unit Manager, he stated "the treatment team does not assign patients to group activities, but we encourage patients to participate in the unit group activities...It is my understanding that we cannot force the patient to attend groups, we can only encourage them." He agreed that there was no individual schedule of activity in the patients' records and that groups were not developed based on the individual patient needs.
4. During an interview on 07/25/13 at 2:30 p.m. with the DON she agreed that the treatment plans should reflect patient active treatment activities and each patient needed to be aware of his/her schedule. She stated "this should be addressed in the treatment team meeting and the plan should reflect the patient's individualized treatment needs." She agreed patients are not assigned to active treatment groups based on their individual needs and stated "this needs to be improved."
5. During an interview on 07/24/2013 at 11:50 a.m., SW1 stated, "we do not include specific group modalities on to the treatment plans. Group varies from day to day. Usually patients are asked to go to groups and they can refuse to go. I agree recreational therapies should be part of treatment plans."
6. During an interview, on 07/24/2013 at 11:35 a.m., Physician 2 stated, "[S/he] (referring to patient P2) is so psychotic, [s/he] will not benefit from group."

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure that the discharge summary was dictated, transcribed and filed within 30 days of discharge in 2 of 5 (R1 and R2) discharge records reviewed. This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of labs and testing, anticipated problems, and discharge plans with outpatient providers.
Findings include:
A. Record Review:
1. Patient R1 was discharged on 03/28/13. The discharge summary was not dictated until 04/30/13.
2. Patient R2 was discharged on 06/20/13. The discharge summary was not dictated until 07/24/13.
B. Policy Review:
The facility's Medical Staff by laws stated "Discharge summary shall be completed and placed in the permanent record within thirty days from the day of discharge."
C. Staff Interview:
During an interview on 07/25/2013 at 3:30 p.m., Associate Medical Director stated, "I am aware of discharge summaries not done on time, the director of health information services gave me the report of late discharge summaries yesterday. We need to improve."

Based on record review and staff interview, it was determined that the facility failed to ensure that follow-up appointments were included in discharge summaries for 4 of 5 patients (R1, R3, R4, and R5) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do.
Findings include:
A. Record Review:
1. Patient R1 was discharged on 03/28/13. Discharge summary dictated on 04/30/13 did not include the date and time for follow-up appointments.
2. Patient R3 was discharged on 06/21/13. Discharge summary dictated on 06/21/13 did not include the date and time for follow-up appointments.
3. Patient R4 was discharged on 06/20/13. Discharge summary dictated on 06/20/13 did not include the date and time for follow-up appointments.
4. Patient R5 was discharged on 06/21/13. Discharge summary dictated on 06/21/13 did not include the date and time for follow-up appointments.
B. Staff Interview:
During an interview on 07/25/2013 at 3:30 p.m., Associate Medical Director stated, "I agree with your findings, it is important to include date and time for follow up".

Based on record review and staff interview, it was determined that the facility failed to ensure that the discharge summaries for 5 of 5 sampled discharged patients (R1, R2, R3, R4, and R5) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk were not available to the aftercare providers.

Findings include:

A. Record Review

1. Patient R1 was discharged on 03/28/13. Discharge summary dictated on 04/30/13, condition on discharge was documented only as "stable."

2. Patient R2 was discharged on 06/20/13. Discharge summary dictated on07/24/13, condition on discharge was documented only as "stable."

3. Patient R3 was discharged on 06/21/13. Discharge summary dictated on 06/21/13, condition on discharge was documented only as "stable."

4. Patient R4 was discharged on 06/20/13. Discharge summary dictated on 06/20/13, condition on discharge was documented only as "stable."

5. Patient R5 was discharged on 06/21/13. Discharge summary dictated on 06/21/13, condition on discharge was documented only as "fair."

B. Staff Interview

During an interview on 07/25/13 at 3:30 p.m., Associate Medical Director confirmed that five of five discharge records listed condition on discharge in one word, as described above.

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically the Medical Director failed to assure that:

I. The physician performed and documented a screening neurological examination for 1 of 12 sample patients (G3). As a result, it was not possible for the facility to determine if the patient required a complete comprehensive neurological examination. The absence of this patient information restricts clinicians' ability to accurately diagnose the patient's condition and to measure change in baseline function, thus affecting patient care. (Refer to B109)
II. Physicians performed and documented examination for orientation and an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 12 active sample patients (D1, E1, E2) and documented an examination of orientation with supportive information in the psychiatric evaluation for 5 of 12 active sample patients (G1, H1, H2, H3 and P2). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)

III. Physicians documented an inventory of assets in the psychiatric evaluation of 2 of 12 active sample patients (H2, and P2). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)
IV. The facility provided and documented individualized and measurable short or long term goals on the Master Treatment Plans (MTP) for 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). Specifically, the MTP's listed similarly worded short-term goals for patients that were not measurable outcome behaviors and listed no long-term goals. These failures results in treatment plans that do not identify individualized expected patient outcomes in a manner that can be utilized by the treatment team to measure the effectiveness of treatment and/ or progress towards discharge. (Refer to B121)
V. The facility provided and documented individualized interventions on the Master Treatment Plans (MTP) for12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2) to address the patient's identified treatment needs. Interventions listed were generic staff roles, and there were no interventions listed for physicians on 11 of the 12 plans. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal-directed. (Refer to B122)
VI. The facility provided active treatment measures or purposeful alternative interventions for 12 of 12 active sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2) Patients were not assigned or scheduled for groups based on their treatment needs. Instead groups were scheduled for the units and patients were encouraged to attend. In addition, for 2 of 12 active sample patients who could not or would not attend (E1, P2), no meaningful alternative treatment was provided. This failure may result in patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement and timely discharge. (Refer to B125)
VII. The discharge summary was dictated, transcribed and filed within 30 days of discharge in 2 of 5 (R1, and R2) discharge records reviewed. This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of labs and testing, anticipated problems, and discharge plans with outpatient providers. (Refer to B133)
VIII. The discharge summaries for 4 of 5 patients (R1, R3, R4, and R5) included follow-up appointments. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)
IX. The discharge summaries for 5 of 5 sampled discharged patients (R1, R2, R3, R4, and R5) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk were not available to the aftercare providers. (Refer to B135)

Staff Interview:
During an interview on 07/25/2013 at 3:30 p.m., the Associate Medical Director stated, "I agree with your findings, our own assessment of our programs is not different than yours and we are on a track to improve."

Based on record review and interview, the Director of Nursing (DON) failed to:
I. Ensure that nursing staff developed Master Treatment Plans (MTPs) that identified nursing interventions that were individualized and specific to the patients treatment needs for 12 of 12 sampled patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). The MTPs listed interventions that were routine, generic nursing functions that lacked focus for treatment. These failures hamper nursing staff's ability to provide individualized treatment that is purposeful and goal directed.
1. Patient D1
Master Treatment Plan dated 07/21/13, for the problem "psychosis," listed the following generic and routine nursing discipline functions as interventions:
"Encourage the client to seek frequent reality testing to challenge his/her [sic] cognitions with the experience of trusted caregiver, friends and family."
Master Treatment Plan dated 07/21/13, for the problem "altered thoughts process" listed the following generic and routine nursing discipline functions as interventions:
"Nursing staff will establish a trusting, therapeutic relationship with pt by being honest, supportive and consistent." "Nursing staff will encourage pt to verbalize feelings and thoughts openly." "Nursing staff will provide observation as ordered for safety." "Nursing staff will collaborate with the multidisciplinary team regarding pt's plan of care." "Nursing staff will reorient pt to person, place or time as needed." "Nursing staff will redirect pt as needed and promote reality orientation while providing routine care by identifying pt by name, identifying staff members by name, and identifying time of community group, meal time, activities, etc."
2. Patient D2
The Master Treatment Plan, dated 07/19/13, for the problem of "disturbed thought process," listed generic and routine nursing discipline functions as interventions:
"Monitor medication for side effects/adverse reactions." "Nursing staff will provide Q15 (every 15 minute) close observation for safety." "Nursing staff will focus on reality based thinking/orientation."
"Nursing staff will re-orient the patient to person, place and tim [sic], call the patient by name, tell the patient your name, tell the client where [s/he] is etc." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard to the patient) from the patient and room." "Nursing staff will decrease environmental stimuli whenever possible." "Respond to cues of increased agitation by removing stimuli or removing the patient from the group to a quiet room." "Nursing will promote reality orientation while providing routine care by indentifying staff members by name and identifying time of community group, meal times, activities, etc." "Nursing staff will administer medication as indicated."
3. Patient E1
The Master Treatment Plan dated 07/24/13, for the problem of "altered thought process," listed the following generic nursing functions as interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff will focus on reality based thinking/orientation." "Nursing staff will re-orient the patient to person, place and time (call the patient by name, tell the patient your name, tell the client where she/he [sic] is etc)." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard to the patient) from the patient and room." "Nursing staff will decrease environmental stimuli whenever possible. Respond to cues of increased agitation by removing stimuli or removing the patient from the group to a quiet room." "Nursing will promote reality orientation while providing routine care by indentifying staff members by name and identifying time of community group, meal times, activities, etc." "Nursing staff will re-orient the patient to person, place and time as indicated." "Nursing staff will communicate with the client using clear, direct statements." "Nursing staff will provide an environment with a low degree of stimulation." "Nursing staff will provide adequate lighting if the client is experiencing a visual hallucination." "Nursing will encourage activities that promote socialization."
4. Patient E2
The Master Treatment Plan dated 6/24/13, with the identified problem as "risk for self or other directed violence," listed the following generic nursing functions as treatment interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff will establish an environment that reduces agitation (e.g. decrease noise level, give short concise explanation." "Nursing staff will institute time out procedure (retreat to the "quiet room" to provide the opportunity to regain internal control. Teach the client that time is a positive opportunity for cooling off, not a punishment." [sic] "Nursing staff will assist client in examining alternatives to acting out behavior." "Nursing will provide a safe environment for the patient and others by removing items that can be used as potential weapons." "Nursing staff will encourage patient to engage in physical exercise or to substitute safe physical activities for aggressive behavior i.e. lifting weights." "Nursing staff will be firm and consistent in setting and maintaining limits, enforcing hospital and unit policies." "Nursing staff will protect other clients from abuse behavior by redirection." "Implement seclusion and/or restraint as needed to protect patient and others from violent behaviors." "Nursing staff will listen carefully for suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviors are critical clues regarding self harm."
5. Patient G1
The Master Treatment Plan dated 07/19/13, with identified problem as "altered thought process," listed the following generic nursing functions as treatment interventions:
"Nursing staff will provide Q15 close observation for safety." "Nursing staff assess for self destructive behaviors and provide needed precautions."
6. Patient G2
The Master Treatment Plan dated 06/11/13, with identified the problem as "risk for harm directed towards self/others," listed the following generic nursing functions as interventions:
"Nursing staff will provide Q 15 minutes observation for safety." "Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precautions daily. Explain suicide precaution to the patient." "Nursing staff will monitor, remove sharp and dangerous objects such as glass, plastic bags, belts, hangers and other potentially hazardous objects from the patient's room." "Nursing staff will observe, record, and report any changes in the client's mood (elation, withdrawal, sudden resignation)." "Nursing staff will administer medication as needed (specify drug name, route, dosage, frequency)." "Nursing staff will ask the patient if [s/he] has a plan for suicide. Attempt to ascertain how detailed and feasible the plans are."
7. Patient G3
The Master Treatment Plan dated 07/11/13, with the identified problem as "risk for suicide," listed the following generic nursing functions as interventions:
"Monitor medications for side effects/adverse reactions." "Nursing staff will provide Q15 close observation." "Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precaution daily. Explain suicide precaution to the patient." "Nursing staff will monitor, remove sharp and dangerous objects such as glass, plastic bags, belts, hangers and other potentially hazardous objects from the patient patient's room." "Nursing staff will monitor for cheeking of medications, check to ensure that all medications are swallowed." "Nursing staff will observe, record, and report any changes in the client's mood (elation, withdrawal, sudden resignation)." "Nursing staff will administer medication as needed."
8. Patient H1
The Master Treatment Plan dated 06/24/13, with the identified problem as "risk for self-harm," listed the following generic nursing functions as interventions:
"Nursing staff will assess the patient's suicidal potential, and evaluate the level of suicide precaution daily." "Nursing staff will explain suicide precautions to the patient as needed." "Nursing staff will monitor, remove sharp and dangerous objects or contraband from the patient and patient areas daily." "Nursing staff will monitor for cheeking with each medication administration to ensure all medication are swallowed." "Nursing staff will administer scheduled medications as ordered and prn medications as needed." "Nursing staff will ask the patient if having a plan [sic] for suicide and assess how plausible the patient's plan is daily."
9. Patient H2
The Master Treatment Plan dated 07/22/13, with the identified problem as "disturbed thought process," listed the following generic nursing functions as treatment interventions:
"Nursing staff will administer medications and evaluate effectiveness or side effects." "Nursing staff will observe pt. Q 15 minutes for safety." "Nursing staff will provide a safe, therapeutic environment." "Nursing staff will observe the pt. Q shift for s/s (signs/symptoms) of anxiety, frustration, anger, or danger to self and others and initiate immediate 1:1 assessment and prn med. if indicated." "Nursing staff will remove all hazardous items from pt. room and day area for safety." "Nursing staff will advise pt to attend support groups for improved coping skills to manage life's daily challenges safely."
10. Patient H3
The Master Treatment Plan dated 07/21/13, with the identified problem as "risk for violence directed towards self/poor coping skills," listed the following generic nursing functions as interventions:
"Nursing staff will administer medications and evaluate effectiveness or side effects." "Nursing will observe pt Q15 minutes for safety." "Nursing staff will provide a safe, therapeutic environment." "Nursing staff will observe pt. Q shift for s/s of anxiety, frustration, anger or danger to self and others and initiate immediate 1:1 assment [sic] and prn. med. if indicated." "Nursing staff will remove all hazardous items from pt. room and day area for safety." "Nursing staff will advise pt to attend support groups for improved coping skills to manage life's daily challenges safely."
11. Patient P1
The Master Treatment Plan dated 07/21/13, with the identified problem as "risk for violence directed towards self," listed the following generic nursing functions as interventions:
"Nursing staff will provide Q15 observation for safety." "Nursing staff will provide a safe environment for [patient] and others by removing items that can be used as potential weapons." "Nursing staff will administer medications as ordered by MD. And observe for effectiveness or any adverse reactions."
12. Patient P2
The Master Treatment Plan dated 07/20/13, with the problem of "Disturbed thought process and risk for violence/injury directed towards others," listed the following generic nursing functions as interventions:
"Nursing staff will provide ordered observation for safety." "Nursing staff will focus on reality based thinking/orientation." "Nursing staff will remove dangerous items (plastic bags, pens, any objects that may pose a hazard." "Nursing staff will decrease environmental stimuli whenever possible. Respond to cues of increased anxiety or agitation by removing stimuli or removing client from the group to a quiet room." "Nursing staff will encourage client to participate in milieu groups and activities that promote socialization." "Nursing staff will administer medication as indicated. Provide med teaching regarding current med name, dose, side effects and impts [sic] of compliance RX: Geodon, Benadryl, and prn Ambien." "Staff may use seclusion and/or restraints to ensure a safe environment for [patient] and others on the unit due to pt's hx of aggression and assault."
I. Ensure that patients are scheduled to attend nursing groups that are specific to their individualized treatment needs.
A. Record Review
Review of the Unit schedules revealed that on the weekly unit schedules some groups were listed as "Nursing Group" and they occurred daily Monday through Sunday. There was no specific title listed, so the subject was announced at the time that patients attended and they were given instruction of some topic that falls under nursing.
Patient D1, MTP dated 07/21/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient D2, MTP dated 07/19/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient E1, MTP dated 07/24/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "altered thought process." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient E2, MTP dated 06/24/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk for self or other directed violence." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient G1, MTP dated 07/19/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "altered thought process." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient G2, MTP dated 06/11/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk for harm directed toward self/others." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient G3, MTP dated 07/11/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk for suicide." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient H1, MTP dated 06/24/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk of self harm." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient H2, MTP dated 07/22/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient H3, MTP dated 07/21/13 had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk for violence directed towards self." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient P1, MTP dated 07/21/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "risk for violence directed towards self." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
Patient P2, MTP dated 07/20/13, had no assigned nursing treatment measures specific to the patient's treatment needs, for the primary problem "disturbed thought process," or "risk for violence/injury directed towards others." No individual schedule of activities was documented in the medical record. (Refer to B122 for listed nursing interventions)
B. Interview
1. During the interview on 07/25/13 at 2:30 p.m. with the Director of Nursing (DON) the MTPs for sample patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2) were reviewed. She agreed that the nursing interventions listed on the plans were generic routine nursing staff duties.
II. In the same interview mentioned above the DON, agreed that the treatment plans did not list the nursing groups to which the patients were assigned nor was each patient given an individualized weekly schedule. She agreed that patients should be aware of the specific title of nursing groups scheduled. She stated "this should be addressed in the treatment team meeting and the plan should reflect the patient individualized treatment needs." She agreed patients are not assigned to active treatment groups based on their individual needs and stated "this needs to be improved."

Based on record review and interviews, it was determined that the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided to patients at the facility. Specifically the Director of Social Services failed to assure that:

1. Social service assessments included individualized recommendations for social work services from the data gathered for 8 of 12 active sample patients (D1, E2, G1, G3, H1, H2, H3, and P2). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108)

2. The facility developed MTPs that identified social work interventions that were individualized and specific to the patients treatment needs for 12 of 12 sampled patients (D1, D2, E1, E2, G1, G2, G3, H1, H2, H3, P1 and P2). This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, and potentially delaying patient improvement, and discharge from the hospital. (Refer to B122)