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Based on facility policy and procedure review, medical record reviews and staff interviews the facility's staff failed to ensure the physician, LIP (licensed independent practioner) or trained registered nurse documented the one hour face-to-face evaluation within 1 hour after initiation of restraint or seclusion in 2 of 2 patients (Patient #10 and #12) requiring intervention of violent or self-destructive behaviors.

The findings include:

Review of the facility's "Restraint and Seclusion" policy reviewed/revised August 2018 revealed "... Behavioral Health Restraint and Seclusion (Violent or self-destructive behavior) A. Requirements for all Settings ... 7. One hour face-to-face assessment: The physician, LIP (licensed independent practitioner), or a registered nurse or nurse practitioner/physician assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint. The face-to-face assessment is performed even in those situations where the person is released early (prior to the hour). This assessment shall include and be documented in the medical record: The patient's immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition; The need to continue or terminate the restraint or seclusion. ..."

1. Closed medical record review of Patient #12 revealed a 34 year-old female admitted under involuntary commitment petition on 06/11/2019 with suicide ideation. Review of the record revealed the patient was placed in a therapeutic hold, seclusion and four point limb restraints on 06/11/2019 at 1650 due to combative behaviors. Review reveled the patient remained in restraints through 06/11/2019 at 1900 (two hours ten minutes). Review of the one hours face-to-face assessment revealed the date and time of the one hour face-to-face assessment was blank.

Interview on 08/29/2019 at 1445 with the Director of Nursing (DON) revealed nursing staff must have one year experience with psychiatric patients and complete a training module and test prior to being able to conduct one hour face-to-face assessments during restraint or seclusion use. Upon review of the one hour face-to-face assessment documentation for Patient #11, the DON reported she was unable to verify the date or time that the one hour face-to-face assessment was conducted. Interview revealed the date and time of the assessment was not documented and should have been recorded.


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2. Closed medical record review of Patient #10 revealed a 30 year-old male admitted under involuntary commitment petition on 05/08/2019 with substance abuse withdrawal and suicide ideation. Review of the record revealed the patient was placed in four point limb restraints on 05/10/2019 at 2300 due to combative and threatening behaviors. Review reveled the patient remained in restraints through 05/11/2019 at 0800 (nine hours). Review of the record revealed the patient was administered Thorazine (antipsychotic medication) 50 mg (milligrams) IM (intramuscular) at 2300. Review of the one hours face-to-face assessment revealed the date and time of the one hour face-to-face assessment was blank.

Interview on 08/29/2019 at 1445 with the Director of Nursing (DON) revealed nursing staff must have one year experience with psychiatric patients and complete a training module and test prior to being able to conduct one hour face-to-face assessments during restraint or seclusion use. Upon review of the one hour face-to-face assessment documentation for Patient #10, the DON reported she was unable to verify the date or time that the one hour face-to-face assessment was conducted. Interview revealed the date and time of the assessment was not documented and should have been recorded.

Based on review of policies, observations, review of medical records, and interviews with staff, the nursing staff failed to supervise and evaluate the care of patients by failing to provide nursing assessments for a diabetic patient with elevated blood sugar in 1 of 1 patients (#11); failed to provide safe medication administration in 1 of 2 medication observations (#13); failed to provide reassessments of PRN medications in 4 of 4 patients (#1, #6 , #8, and #3); and failed to follow orders for CIWA patients in 1 of 1 patients with orders for CIWA (#3).

The findings include:

A. Review of policy titled "Continued Stay Criteria" with revision date of 03/18, revealed "...1. RN reassessment is completed each shift not to exceed every 8 hours and more frequent if the patient's condition changes...."

Review of the closed medical record on 08/29/2019 of Patient #11 revealed a 52 year old female admitted on 06/27/2019 for Suicide Ideations (thoughts of suicide) with past medical history of Insulin Dependent Diabetes. Review of the physician orders dated 06/28/2019 at 1000 revealed "Accuchecks TID (three times daily) AC (before meals) and HS (bedtime) with Humalog (short acting insulin). <60 (less than 60) call MD, 150-200 one unit; 201-250 two units; 251-300 three units; 301-350 four units; 351-400 five units; > 400 (Greater than 400) six units and call MD." Review of MAR (Medication Administration Record) dated 06/28/2019 at 9 pm revealed a circled blood glucose result of "307". Review revealed no insulin given as documented and zero with line striked through. Review revealed "see back." Review of handwritten nurses note on back written by RN #1 dated 06/28/2019 at 2155 revealed "Needs 4 units but no Humalog available. Called provider on call. LVM (left voice message) requesting call back." Review of MAR dated 06/29/2019 at 0700 revealed blood glucose result of 339. Review revealed "no insulin available." Review of MAR dated 06/29/2019 at 1130 revealed glucose of 395 with 5 units of insulin given at 1200, 15 hours after initial blood sugar result. Review of physician's orders revealed no orders received during 06/28/2019 at 2100 through 06/29/2019 at 1130.

An interview was requested on 08/29/2019 for RN #1. RN #1 was not available for interview.

Interview on 08/29/2019 at 1400 with CNO revealed Humalog insulin was not in refrigerator as supposed to be. RN #1 called the CNO to inform of the inability to locate insulin. Interview confirmed the insulin was not found during the night shift. The insulin was found the next day around lunch time. Interview confirmed the patient did not receive Humalog insulin on 06/28/2019 at 2100 fingerstick. Interview revealed patient did not receive insulin until noon the next day.

Interview on 08/29/2019 at 1135 with the Medical Director revealed no recollection of the nurses calling the Medical Director regarding the inability to locate the humalog insulin or elevated blood sugar of Patient #11. Interview revealed the patient #11 should have been transferred out to the hospital for diabetic care for best practice of care. Interview revealed patient's safety should always be priority.

B. Review of policy titled "Medication Ordering, Dispensing & Administration" with reviewed date of 02/19, revealed "...3. All patients shall be properly identified prior to drug administration. Use at least two patient identifiers. (Name and Birthdate). A visual check should be made in the patient's chart or MAR to compare the picture taken during the admission process matches the patient receiving the medication and arm band must be present...."

Review of closed medical record of patient #13 revealed a 58 year old male admitted on 07/31/2019 under involuntary committment for Auditory hallucinations (hearing voices) to harm himself. Review of the physician's orders dated 08/02/2019 at 2100 revealed "Voltaren 1% (topical used to treat pain of osteoarthritis of joints) Apply 2 grams QID (four times daily) to knees." Review of MAR dated 08/27/2019 at 1300 revealed RN #3's initials as documentation of administration of Voltaren.

Observation on 08/27/2019 at 1300 of RN #3 squeezed the ordered amount of Voltaren cream into the medicine cup. RN #3 walked to Patient's #13's room with the medicine cup in hand. Observation revealed Patient #13 was lying in the bed. RN #3 did not check patient's arm band, ask date of birth, or ask patient's name. Observation revealed RN #3 did not take the patient's MAR bedside of patient #13.

Interview on 08/27/2019 at 1305 with RN #3 revealed the patient's two identifiers should have been verified. "I should have taken the MAR to patient's bedside." Interview of RN #3 revealed she "knew the patient."

Interview on 08/27/2019 at 1615 with Nurse manager revealed RN #3 should have verified the patient with the two identifers and should have taken the patient's MAR to the bedside for safety. Interview revealed the RN #3 did not demonstrate best nursing practice.

C. Review of policy titled "PRN ORDERS" with revision date of 03/18 revealed "...4. All PRN (as needed) medications must be documented addressing effectiveness of medication within one hour of receiving medication. 5. Documentation is written by medication nurse on back of the MAR including medication given and patient response to the medication....."

1. Review of closed medical record of patient #1 revealed a 26 year old male admitted on 08/20/2019 for being a danger to himself with suicidal ideations. Review of physician's orders dated 08/24/2019 revealed "Vistaril 50 mg po every 8 hours PRN (as needed) for anxiety...." Review of MAR dated 08/24/2019 at 1410 revealed documentation of administration of Vistaril. Review of documentation of reassessment failed to reveal a reassessment of effectiveness.

Interview on 08/27/2019 at 1615 with Nurse Manager revealed medication effectiveness should be documented on back of MAR within the hour after administration. Interview confirmed no documentation was available for effectiveness of Vistaril. Interview revealed best practice was not followed.

2. Review of open medical record of Patient #6 revealed a 27 year old male admitted on 08/22/2019 for Suicidal thoughts. Review of physician's orders dated 08/25/2019 revealed "Imitrex (Medication to treat migraine headaches) 50 mg by mouth daily PRN (as needed) migraine." Review of MAR revealed documentation of administration on 08/25/2019 at 1900 and on 08/27/2019 at 0810. Review of MAR failed to reveal a response of effectiveness to the medication. Review of nurses notes failed to reveal documentation of pain medication response.

Interview on 08/27/2019 at 1615 with Nurse Manager revealed medication effectiveness should be documentted on back of MAR within the hour after administration. Interview confirmed no documentation was available for effectiveness of either administration of the Imitrex. Interview revealed best practice was not followed.

3.Review of closed medical record of Patient #8 revealed a 25 year old male admitted on 08/02/2019 with major depressive disorder with suicide attempt. Review of physician's orders dated 08/03/2019 revealed orders for "Motrin 600 mg po (milligrams by mouth) every 6 hours as needed for pain." Review of MAR revealed documentation of administration of Motrin on 08/04/2019 at 1110 and 1700; 08/05/2019 at 0800 and 2100; 08/06/2019 at 1600; 08/07/2019 at 0800 and 2030; 08/08/2019 at 0800; 08/09/2019 at 0440 and 1810; 08/10/2019 at 0745 and 1430; 08/11/2019 at 0800; 08/12/2019 at 0930 and 2100; and 08/13/2019 at 0813. Review of MAR for effectiveness revealed no documentation of effectiveness for any of the administered Motrin. Review of nurses notes failed to review documentation of pain medication response. Review of nurses notes failed to reveal documentation of pain medication response.

Interview on 08/27/2019 at 1615 with Nurse Manager revealed medication effectiveness should be documented on back of MAR within the hour after administration. Interview confirmed no documentation was available for effectiveness of any administration of Motrin. Interview revealed best practice was not followed.

4. Review of closed medical record of Patient #3 revealed a 34 year old male admitted on 07/02/2019 for Suicide Ideations. Review of physician's orders dated 07/02/2019 revealed "Acetaminophen 650 mg PO every 6 hours PRN pain..." Review of MAR revealed documentation of administration of Acetaminophen 650 mg on 07/03/2019 at 0900. Review of MAR for effectiveness revealed no documentation of effectiveness. Review of physician orders dated 07/06/2019 for "Tramadol 50 mg po q (every) 8 hours PRN pain x (for) 3 days." Review of MAR revealed documentation of administration of Tramadol on 07/06/2019 at 1300 and 2200; On 07/07/2019 at 0600 and 1400; On 07/08/2019 at 0625; and 07/09/2019 at 0430. Review of MAR for effectiveness revealed no documentation of effectiveness. Review of nurses notes failed to reveal documentation of pain medication response.

Interview on 08/27/2019 at 1615 with Nurse Manager revealed medication effectiveness should be documented on back of MAR within the hour after administration. Interview confirmed no documentation was available for effectiveness of administration of Acetaminophen or Tramadol. Interview revealed best practice was not followed.

D. Review of Learning Module titled "CIWA" with revision date of 05/08/2019 revealed "The Clinical Institute Withdrawal Assessment for Alcohol" commonly abbreviated as CIWA...is a ten-item scale used in the assessment and management of alcohol withdrawal....The goal of CIWA is to provide an efficient and effective means of assessing alcohol withdrawal....Scoring: The maximum score is 67; Mild alcohol withdrawal is defined with a score less than or equal to 15; Moderate with scores 16-20; and Severe any score greater than 20. The ten items evaluated on the scale are common signs and symptoms of alcohol withdrawal, listed as follows: Nausea and vomiting; Tremor; Paroxysmal tremors; Anxiety; Agitation; Tactile disturbances; Auditory disturbances; Visual disturbances; Headache; and Orientation and clouded sensorium."

Review of closed medical record of Patient #3 revealed a 33 year old male admitted on 07/02/2019 with suicide ideations. Review of History and Physical dated 07/03/2019 revealed "increased alcohol use over the last week....ETOH 187 in ER...Patient reports coming into hospital 'because I drank a little bit...." Review of NP #1's orders dated 07/03/2019 at 1045 revealed "...Alcohol withdrawal protocol c (with) PRN (as needed) Librium only..CIWA q (every) 4 hours...." Review of CIWA evaluation forms revealed 07/04/2019 at 0000 as first assessment completed for CIWA. Review of completed nurses assessments dated 07/04/2019 through 07/09/2019 revealed CIWA assessments were completed every 6 hours (midnight, 0600, 1200 and 1800) instead of ordered 4 hours.

Interview on 08/28/2019 at 1410 with NP #1 revealed CIWA orders were written to begin on 07/03/2019 at 1045. Interview revealed no documentation of CIWA assessments until midnight on the day of the order and every 6 hours instead of the ordered 4 hours. Interview revealed orders were written for every 4 hours due to alcohol intake prior to admission.

Interview on 08/29/2019 at 1400 with CNO revealed orders were written for every 4 hours instead of every 6 hours as documented. Interview revealed assessments should have been documented every 4 hours as ordered.

Based on observations during tour, and staff interviews, the hospital's staff failed to prevent expired and non-operational emergency supplies to be available for emergency use in 1 of 1 emergency supplies container.

The findings include:

Review of policies revealed no policy for checking emergency supplies.

Observation on 08/27/2019 at 1110 during tour of patient's clothes bin closet revealed a large black wheeled luggage with a yellow zip tie. Observation of the contents of the luggage, opened by request, revealed emergency supplies: Suction machine with packaged tubing and pulse oximetry. Observation revealed the pulse oximetry did not work when placed on staff's finger. Observation of the packaged suction tubing revealed a manufacturer's date of 07/16/16 with printed package instructions: "Expire in 3 years". Observation revealed the tubing was out of date on 07/16/2019, 42 days ago.

Interview on 08/27/2019 at 1112 with Nurse Manager revealed luggage contained emergency supplies. Interview revealed the emergency supplies were available for patient use during emergency. Interview revealed pulse oximetry did not work. Interview revealed the suction tubing was out of date for 42 days and should have been replaced prior to expiration. Interview revealed the facility did not have a crash cart with other emergency supplies.

Based on review of the facility's policy, medical record review and staff interview, the facility failed to ensure that a complete neurological screening examination was performed by a physician on admission for 6 of 6 sampled patients (#1, #4, #9, #2, #5, and #7).

The findings include:

Review of the facility's "Treatment Planning Process" policy revised 03/2018 revealed "....C. The following assessments are completed by the time of the initial team meeting: Type of Assessment Medical History and Physical Examination To Be Completed By Physician, Psychiatric Evaluation To Be Completed By Physician..."


1. Review on 08/27/2019 of an open medical record for Patient #1 revealed a 26 year-old male admitted on 08/20/2019 with Bipolar Disorder, current episode depressed. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Nurse Practitioner on 08/20/2019 at 1603 and co-signed by a physician on 08/20/2019 at 1623. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.

2. Review on 08/27/2019 of an open medical record for Patient #4 revealed a 30 year-old male admitted on 08/18/2019 with Major depressive disorder, recurrent severe without psychotic features. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Nurse Practitioner on 08/19/2019 at 1232 and co-signed by a physician on 08/19/2019 at 1311. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.

3. Review on 08/27/2019 of an open medical record for Patient #9 revealed a 39 year-old male admitted on 08/09/2019 with Schizophrenia. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Physician Assistant on 08/10/2019 at 1423 and co-signed by a physician on 08/10/2019 at 1425. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.


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4. Review on 08/27/2019 of an open medical record for Patient #2 revealed a 46 year-old male admitted on 08/20/2019 with major depressive disorder, severe. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Nurse Practitioner on 08/21/2019 at 1303 and co-signed by a physician on 08/21/2019 at 1753. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.

5. Review on 08/27/2019 of an open medical record for Patient #5 revealed a 22 year-old male admitted on 08/18/2019 with schizophrenia. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Nurse Practitioner on 08/19/2019 at 1240 and co-signed by a physician on 08/19/2019 at 1304. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.

6. Review on 08/27/2019 of an open medical record for Patient #7 revealed a 52 year-old female admitted on 08/13/2019 with bipolar disorder and substance abuse. Record review revealed a History and Physical Examination had been conducted and electronically signed by a Nurse Practitioner on 08/14/2019 at 1259 and co-signed by a physician on 08/14/2019 at 1310. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 08/29/2019 at 1055 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.

Based on policy review, medical record review and staff interview, the facility staff failed to ensure treatment modalities selected were consistent with a patient's request to decline family involvement for 2 of 6 sampled patients (#2, #9).

The findings include:

Review of the facility's "Treatment Planning Process" policy reviewed/revised March 2018 revealed "... Treatment planning is the structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions. ... The Patient/Family/Significant Other Involvement in Treatment Plan is completed by the assigned staff member and is based on the patient's consent for others to be involved in the treatment. ... Interventions are the actions each discipline will take to assist the patient in meeting the short-term goals. ..."

1. Review on 08/27/2019 of an open medical record for Patient #2 revealed a 46 year-old male admitted on 08/20/2019 with major depressive disorder, severe. Review of the "Patient/Family/Significant Other Involvement in Treatment Plan" signed by a social worker staff member (SW #4) on 08/23/2019 revealed "Patient does not wish Family/SO (significant other) involvement." Further review of this form revealed "Patient declines to allow family contact at present" and patient's goals for treatment (in their own words) recorded "Refused family involvement."
Review of the "Interdisciplinary Master Treatment Plan" revealed an initial problem identified on 08/20/2019 of "Suicide Ideation." Review of the treatment plan revealed long-term and short-term goals identified related to the problem of suicide behaviors. Review of "Social Work Interventions" dated 08/23/2019 included "Family contact 1 time per week for education related to suicide, identification of stressors, support and discharge planning." Review of the treatment modalities revealed the intervention to have family contact one time per week was not consistent with the patient's request to not include family in the patient's treatment.

Interview on 08/28/2019 at 1325 with SW #4 revealed Patient #2 had refused family involvement with treatment. The staff member reviewed treatment plan interventions for suicide behaviors and stated "I got happy with the check marks." The staff member stated the treatment team hoped to include family involvement with treatment, but would honor a patient's right to decline family inclusion. SW #2 stated, "This was an error."



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2. Review on 08/27/2019 of an open medical record for Patient #9 revealed a 39 year-old male admitted on 08/09/2019 with Schizophrenia. Review of the "Patient/Family/Significant Other Involvement in Treatment Plan" signed by a social worker staff member (SW #4) on 08/09/2019 revealed "Patient does not wish Family/SO (significant other) involvement." Further review of this form revealed "Patient declines to allow family contact at present" and patient's goals for treatment (in their own words) recorded "Refused family involvement."
Review of the "Interdisciplinary Master Treatment Plan" revealed an initial problem identified on 08/09/2019 of "Hallucinations." Review of the treatment plan revealed long-term and short-term goals identified related to the problem of hallucinations. Review of "Social Work Interventions" dated 08/12/2019 included "Family contact 1 time per week for education, support and discharge planning." Review of the treatment modalities revealed the intervention to have family contact one time per week was not consistent with the patient's request to not include family in the patient's treatment.

Interview on 08/28/2019 at 1325 with SW #4 revealed Patient #2 had refused family involvement with treatment. The staff member reviewed treatment plan interventions for suicide behaviors and stated "I got happy with the check marks." The staff member stated the treatment team hoped to include family involvement with treatment, but would honor a patient's right to decline family inclusion. SW #2 stated, "This was an error."

Based on policy review, medical record review and staff interview, the facility staff failed to include responsibilities of each member of the treatment team for 1 of 6 sampled patients (#2).

The findings include:

Review of the facility's "Treatment Planning Process" policy reviewed/revised March 2018 revealed "... Treatment planning is the structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions. ... Define specific interventions which comprise the treatment that will be utilized to help patient achieve short- and long-term goals on the Individual Treatment Plans. Include the frequency of each activity, which discipline will be responsible for implementation, focus on intervention, and when possible the name of the person responsible.... Interventions are the actions each discipline will take to assist the patient in meeting the short-term goals. Each discipline lists interventions related to the problem and the short-term goals. ..."

1. Review on 08/27/2019 of an open medical record for Patient #2 revealed a 46 year-old male admitted on 08/20/2019 with major depressive disorder, severe. Review of the patient's Interdisciplinary Master Treatment Plan revealed a problem of "Aggression" identified on 08/22/2019. Review revealed a long-term goal of "Report being able to maintain self control with no aggressive behaviors." Review of short-term goals revealed "Identify 2 negative consequences associated with acts of aggression, violence and/or physical threats" with a target date documented as 09/04/2019. Review revealed social work interventions documented on 08/22/2019; recreational therapy interventions documented on 08/22/2019 at provider interventions documented on 08/25/2019. Review of the "Nursing interventions" section included seven pre-printed interventions with boxes to check the interventions that applied. Review of the "Nursing Interventions" section revealed it was blank with no interventions documented. Review revealed the signature line, date and time in this section was blank.

Interview on 08/28/2019 at 1030 with RN #5 revealed treatment team meeting occurred on Monday, Wednesday and Friday. Interview revealed nursing staff attended the treatment team meetings. Interview revealed nursing interventions should be included on all patient problem areas. The staff member reviewed Patient #2's nursing interventions for the problem area of aggression and confirmed no nursing interventions were documented. Interview revealed nursing interventions should have been added once the problem was identified.

Interview on 08/28/2019 at 1325 with SW #4 revealed when a new problem is added to the treatment plan, the social worker places the paperwork in a box at the nursing station. The staff member stated "Nursing staff is expected to check the box and update the nursing interventions. We have a problem with that and need to look at our process."

Based on the facility's policy, medical record review and staff interview, the facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 1 of 6 sampled patients (#9).

The findings include:

Review of the facility's "Treatment Planning Process" policy revised 03/2018 revealed "....TREATMENT PLAN REVIEW PROCEDURE A. Each patient is reassessed to determine current clinical problems, needs and responses to treatment. Reviews occur when major changes occur and at least every 7 days minimally or more often if clincally indicated. B Record progress or lasck of progress for each short term goal..."

1. Review on 08/27/2019 of an open medical record for Patient #9 revealed a 39 year-old male admitted on 08/09/2019 with Schizophrenia. Review of the "Interdisciplinary Master Treatment Plan" revealed an initial problem identified on 08/09/2019 of "Hallucinations." Review of the "Interdisciplinary treatment plan review" on 08/26/2019 at 1415 revealed short-term goals identified related to the problem of hallucinations. Review revealed the "Progress Toward Short-Term Goals are blank. Review revealed signatures of the treatment team members dated 08/26/2019.

Interview on 08/28/2019 at 1325 with SW #4 revealed the treatment team met and the goal progress should have been updated. Interview revealed the patient was progressing and the information should have been documented during the meeting.

Based on review of Medical Staff Bylaws, Rules and Regulations, facility policy review, observation, medical record review and staff, patient and physician interview, the facility failed to ensure adequate availability of a physician to participate in treatment planning for 6 of 6 sampled patients (#5; #2; #7; #1, #4 and #9).

The findings include:

Review of the facility's "Medical Staff Rules and Regulations Clinical Privileges and Medical Staff Bylaws" Signed 09/25/2018 revealed "....3.4 The attending physician shall be present at treatment team meetings on all of his patients and shall participate in, review, and approve all treatment plans formulated by the treatment team..."

Review of the facility's "Treatment Planning Process" policy reviewed/revised March 2018 revealed "... Treatment planning is the structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions. ... The Prioritized Problem List determines the focus of treatment based on the active problems which have been determined through the interdisciplinary assessments. ... Interdisciplinary Team Meetings. The initial treatment team meeting is held no later than three (3) days after admission at which time the Interdisciplinary Treatment Plan is reviewed and revised. Each team member is responsible for having completed their assessment and to present a summary in the team meeting. The treatment team meetings are directed by the Attending Psychiatrist. ... A treatment team review meeting is held at least every 7 days and more frequently, if clinically indicated. ... All treatment team staff should attend, signing the updated treatment plan review."

Observation on 08/28/2019 at 1130 revealed a Treatment Team meeting that included four staff members consisting of social workers and nursing staff. Observation revelaed three different patients were reviewed during the treatment team meeting including Patients #1, #4 and #5. Each individual patient was present during the treatment team review of the identified patient. Observation revealed there was not a physician present during the treatment plan meeting.

1. Open medical record review on 08/27/2019 of Patient #5 revealed a 22 year-old male admitted on 08/18/2019 for schizophrenia. Review of the patient's Interdisciplinary Master Treatment Plan revealed a problem of "Hallucinations" identified on 08/18/2019 and "Elopement" identified on 08/19/2019. Review revealed long-term and short-term goals and interventions were identified on 08/20/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/21/2019); social worker (signed 08/21/2019); recreational therapist (signed 08/23/2019; and nurse practitioner (signed 08/24/2019). Review revealed no signature of the attending psychiatrist. Review of a "Treatment Care Plan and Reviews Signature Sheet" revealed a signature by the attending psychiatrist dated 08/21/2019 with a pre-printed statement "I have reviewed and agree with the current Master Treatment Plan."

Interview on 08/28/2019 at 1035 with Patient #5 revealed he was aware of his treatment goals and felt he was making progress toward goals. The patient reported that nursing and social worker staff talked with him about his treatment. Interview revealed the patient had talked with a physician remotely over a screen (telepsychiatry). The patient reported he was not sure if he had seen a physician in person. Interview revealed the patient had not been present in any treatment team meetings.

Interview on 08/28/2019 at 1003 with RN #5 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The nurse reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed patients have not attended treatment team meetings when the interviewed nurse has been there. Interview revealed the attending psychiatrist does not attend treatment team meetings. The nurse reported that the psychiatrist comes to the facility once a week on Thursdays.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.

2. Review on 08/27/2019 of an open medical record for Patient #2 revealed a 46 year-old male admitted on 08/20/2019 with major depressive disorder, severe. Review of the patient's Interdisciplinary Master Treatment Plan revealed problems of "Suicidal Ideation" and "Substance Abuse" identified on 08/20/2019 and "Pain" identified on 08/22/2019. Review revealed long-term and short-term goals and interventions were identified on 08/20/2019; 08/22/2019 and 08/23/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/23/2019); social worker (signed 08/23/2019); recreational therapist (signed 08/26/2019); and nurse practitioner (signed 08/25/2019). Review revealed no signature of the attending psychiatrist. Review of a "Treatment Care Plan and Reviews Signature Sheet" revealed a signature by the attending psychiatrist dated 08/23/2019 with a pre-printed statement "I have reviewed and agree with the current Master Treatment Plan."

Interview on 08/28/2019 at 1035 with Patient #2 revealed he had not attended treatment team meetings. Interview revealed the patient had met with the psychiatrist twice since he was admitted.

Interview on 08/28/2019 at 1325 with SW #4 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The social worker reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed the attending psychiatrist does not attend treatment team meetings. The social worker reported that the psychiatrist comes to the facility once a week on Thursdays. Interview revealed the social worker sends the "Treatment Care Plan and Reviews Signature Sheet" electronically to the psychiatrist for him to sign attesting to review and agreement to the master treatment plan. Interview revealed the master treatment plan was not sent to the psychiatrist for review.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.

3. Open medical record review on 08/27/2019 of Patient #7 revealed a 52 year-old female admitted on 08/13/2019 with bipolar disorder and substance abuse. Review of the patient's Interdisciplinary Master Treatment Plan revealed problems of "Suicidal Ideations; Substance Abuse; Hallucinations; Delusions" identified on 08/13/2019 and "Hypertension" identified on 08/26/2019. Review revealed long-term and short-term goals and interventions were identified on 08/13/2019; 08/15/2019 and 08/26/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/15/2019); social worker (signed 08/15/2019); recreational therapist (signed 08/16/2019; and nurse practitioner (signed 08/16/2019). Review revealed no signature of the attending psychiatrist. Review revealed an Interdisciplinary Treatment Plan Review occurred on 08/21/2019 with participation of staff that included a registered nurse (signed 08/21/2019); SW (signed 08/21/2019); recreational therapist (signed 08/22/2019) and nurse practitioner (signed 08/23/2019). Review revealed no signature of the attending psychiatrist for the treatment plan review meeting on 08/21/2019. Review revealed an Interdisciplinary Treatment Plan Review occurred on 08/26/2019 with participation of staff that included a registered nurse (signed 08/26/2019); SW (signed 08/26/2019); recreational therapist (signed 08/26/2019) and nurse practitioner (signed 08/73/2019). Review of the problem areas revealed all problems were resolved. Review revealed no signature of the attending psychiatrist for the treatment plan review meeting on 08/26/2019. Review of the medical record failed to have a "Treatment Care Plan and Reviews Signature Sheet" showing evidence that the attending psychiatrist had "reviewed and agree(d) with the current Master Treatment Plan (s)."

Interview on 08/28/2019 at 1325 with SW #4 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The social worker reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed the attending psychiatrist does not attend treatment team meetings. The social worker reported that the psychiatrist comes to the facility once a week on Thursdays. Interview revealed the social worker sends the "Treatment Care Plan and Reviews Signature Sheet" electronically to the psychiatrist for him to sign attesting to review and agreement to the master treatment plan. Interview revealed the master treatment plan was not sent to the psychiatrist for review. Interview revealed there was no "Treatment Care Plan and Reviews Signature Sheet" found for Patient #7.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.



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4. Open medical record review on 08/27/2019 of Patient #1 revealed a 26 year-old male admitted on 08/20/2019 for Bipolar Disorder, current episode depressed. Review of the patient's Interdisciplinary Master Treatment Plan revealed a problem of "Suicidal Behaviors" and "Substance Abuse Witdrawl" identified on 08/20/2019. Review revealed long-term and short-term goals and interventions were identified on 08/20/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/20/2019); social worker (signed 08/22/2019); recreational therapist (signed 08/22/2019); and nurse practitioner (signed 08/20/2019). Review revealed no signature of the attending psychiatrist. Review of a "Treatment Care Plan and Reviews Signature Sheet" revealed a signature by the attending psychiatrist dated 08/23/2019 with a pre-printed statement "I have reviewed and agree with the current Master Treatment Plan."

Interview on 08/28/2019 at 0945 with Patient #1 revealed he was aware of his goals that he set for himself. Interview revealed staff has helped in learn coping skills and felt lilke he was ready for discharge. The patient reported he did not participate in treatment team but staff mad him aware of his goals. Interview revealed the patient had talked with a physician remotely over a screen (telepsychiatry). The patient reported he has not seen a physician in person.

Interview on 08/28/2019 at 1003 with RN #5 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The nurse reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed patients have not attended treatment team meetings when the interviewed nurse has been there. Interview revealed the attending psychiatrist does not attend treatment team meetings. The nurse reported that the psychiatrist comes to the facility once a week on Thursdays.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.

5. Open medical record review on 08/27/2019 of Patient #4 revealed a 30 year-old male admitted on 08/18/2019 for Major Depressive Disorder. Review of the patient's Interdisciplinary Master Treatment Plan revealed a problem of "Suicidal " and "Incapacitating Depression" identified on 08/18/2019 and "Pain" identified on 08/20/2019. Review revealed long-term and short-term goals and interventions were identified on 08/18/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/18/2019); social worker (signed 08/21/2019); recreational therapist (signed 08/21/2019); and nurse practitioner (signed 08/27/2019). Review revealed no signature of the attending psychiatrist. Review of a "Treatment Care Plan and Reviews Signature Sheet" revealed a signature by the attending psychiatrist dated 08/21/2019 with a pre-printed statement "I have reviewed and agree with the current Master Treatment Plan."

Interview on 08/28/2019 at 1003 with RN #5 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The nurse reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed patients have not attended treatment team meetings when the interviewed nurse has been there. Interview revealed the attending psychiatrist does not attend treatment team meetings. The nurse reported that the psychiatrist comes to the facility once a week on Thursdays.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.

6. Open medical record review on 08/27/2019 of Patient #9 revealed a 39 year-old male admitted on 08/08/2019 for Schizophrenia. Review of the patient's Interdisciplinary Master Treatment Plan revealed a problem of "Hallucinations" identified on 08/09/2019 and
"Substance Abuse Withdrawl" identified on 08/12/2019. Review revealed long-term and short-term goals and interventions were identified on 08/09/2019. Review revealed signatures of treatment team members that participated included a registered nurse (signed 08/09/2019); social worker (signed 08/12/2019); recreational therapist (signed 08/12/2019); and nurse practitioner (signed 08/12/2019). Review revealed no signature of the attending psychiatrist. Review of a "Treatment Care Plan and Reviews Signature Sheet" revealed signatures by the attending psychiatrist dated 08/12/2019, 08/19/2019 and 08/26/2019 with a pre-printed statement "I have reviewed and agree with the current Master Treatment Plan."

Interview on 08/28/2019 at 1003 with RN #5 revealed treatment team meeting occurred on Mondays, Wednesdays and Fridays each week. The nurse reported that treatment team meetings are lead by the social worker, with nursing staff attending. Interview revealed the nurse practitioner sometimes attends treatment team meetings. Interview revealed patients have not attended treatment team meetings when the interviewed nurse has been there. Interview revealed the attending psychiatrist does not attend treatment team meetings. The nurse reported that the psychiatrist comes to the facility once a week on Thursdays.

Interview on 08/29/2019 at 1055 with MD #6 revealed he is the attending psychiatrist and Medical Director. Interview revealed MD #6 sees all new admissions via telepsychiatry or in person when he is at the facility on Thursdays. Interview revealed the physician gets updates on any "significant events" from the nurse practitioner that is at the facility Monday through Wednesday and every fourth weekend. Interview revealed MD #6 did not attend treatment team meetings. The physician stated that the nurse practitioner participates in treatment team meetings and she reports changes with the treatment plans to MD #6. Interview revealed MD #6 signs the "Treatment Care Plan and Reviews Signature Sheet" attesting that he has reviewed and agreed with the master treatment plan. The physician stated "not every treatment plan is sent to me. They may tell me the changes." Interview with MD #6 revealed he was not aware of the medical staff bylaws, rules and regulations that require a physician to be present at all treatment team meetings and stated "That's not happening. We need to change the bylaws." Interview revealed the attending psychiatrist does not participate in treatment team meetings.