HospitalInspections.org

Based on observation, interview, document review, and record review this facility failed to:

I. Provide Medical/Psychiatrist attendance at treatment planning meetings for six (6) of eight (8) active sampled patients. The Master Treatment Plan (MTP) failed to have signatures on the MTP document confirming physician attention to the document. (Patients G2, G4, G5, G6, G7 and G8). In addition there is a failure to follow Facility Policy "Protocol for Multidisciplinary Treatment Plan #NUR " dated11/14/2011. This practice has the potential to have patient care provided without the direction of a physician and potentially compromise a patient ' s medical and psychiatric care. (See B118)

II. Provide active treatment including alternative interventions for two (2) of eight (8) active sample patients (G6 and G8) who were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B 125.1)

III. Provide active treatment to address the needs of one (1) of eight (8) active sample patients (Patient G5). The treatment groups scheduled for Patient G5 were not appropriate to his/her understanding resulting in his/her non-participation in the assigned groups. Failure to address the treatment needs of patients can lead to difficulty in assessing patient progress and delays in improvement of the patient's condition. (See B 125.2)

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G 6, G7 and G8) This 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:

MEDICAL RECORD REVIEW:

1. Patient G1's psychiatric evaluation dated 12/10/14 did not list the patient's assets.
2. Patient G2's psychiatric evaluation dated 1/22/15 did not list the patient's assets.
3. Patient G3's psychiatric evaluation dated 1/05/15 did not list the patient's assets
4. Patient G4's psychiatric evaluation dated 2/01/15 did not list the patient's assets.
5. Patient G5's psychiatric evaluation dated 2/04/15 did not list the patient's assets.
6. Patient G6's psychiatric evaluation dated 1/12/15 did not list the patient's assets
7. Patient G7's psychiatric evaluation dated 1/29/15 did not list the patient's assets.
8. Patient G8's psychiatric evaluation dated 1/28/15 did not list the patient's assets.

INTERVIEWS:

1. In an interview on 2/10/15at 3:30 PM the Chief Operating Officer and the Compliance Officer confirmed that patient assets were not listed on the psychiatric evaluations.

2. In an interview on 2/10/15 at 10:40 AM the Medical Director concurred that patient assets were not listed on the psychiatric evaluation.

Based on observation, interview, document review, and record review this facility failed to consistently provide Medical/Psychiatrist attendance at treatment planning meetings for six (6) of eight (8) active sample patients. The MTP's failed to have signatures on the MTP document confirming physician attention to the document. (Patients G2, G4, G5, G6, G7 and G8). In addition there is a failure to follow Facility Policy "Protocol for Multidisciplinary Treatment Plan #NUR" dated11/14/2011. The absence of physician signatures on MTP resulted in an inability to confirm physician presence/direction at treatment team planning meetings. This practice has the potential to have patient care provided without the direction of a physician and potentially compromise a patient's medical and psychiatric care.

Findings include:

A. OBSERVATION:

1. During Treatment Team meeting for Patient G6 on 2/10/15 at 10:30 AM, it was observed that only a Social Worker (SW1) and a Registered Nurse (RN3) were in attendance. When asked if this was representative of the attendance at Treatment Team meetings, SW1 stated "Yes".

B. INTERVIEWS:

1. In interview on 2/10/15 at 8:45 AM, SW1 and RN4 both acknowledged that the physician and/or nurse practitioner were not always present for the Treatment Team meetings, including the initial Master Treatment Planning meeting. SW1 stated "We always have a nurse and a social worker."

2. In an interview 2/10/2015 at 9:45 AM Social Worker 2 indicated that physicians rarely attended treatment planning meetings. Usually treatment plans were completed by the RN with SW adding their part. Treatment team meetings were not consistently scheduled and plans were usually completed whenever the RN and SW could meet.

3. In an interview on 2/10/15 at 10:40 AM the Medical Director indicated that he did not attend treatment team planning meetings. He indicated that there was a morning meeting that had the format of morning report but did not directly address treatment planning. He further indicated that in the past such meetings had occurred but the meeting schedule had stopped.

4. In an interview on 2/10/15 at 11:30 AM the Director of Social Work indicated there were no formalized treatment meetings. These meetings were scheduled as staff had time and that physicians were not usually in attendance at these meetings.

5. In an interview on 2/10/15 3:00 PM the Nurse Practitioner indicated that she did not have time to attend treatment planning meetings and that there had not been regularly scheduled times for this to occur

6. In an interview on 2/10/15 at 3:30 PM the Director of Nursing and the Chief Operating Officer met with both federal surveyors. They concurred that formal treatment planning meetings were not being scheduled nor were they being held on a regular basis.

C. DOCUMENT REVIEW

1. Facility Policy and Procedures document "Protocol for Multidisciplinary Treatment Plan" dated 11/14/2011 and numbered NUR states the following: "The initial multidisciplinary plan of care session shall be scheduled within 72 hours of the patient's admission to the Behavioral Health Unit. Plan of care meetings will be attended by the primary physician or designee, the DON or designee, the unit RN, the Charge Nurse, Social Worker, and Recreational Therapist."

D. MEDICAL RECORD REVIEW

1. Patient G2's MTP dated 1/22/15 did not have a physician signature on the document
2. Patient G4's MTP dated 1/31/15 did not have a physician signature on the document.
3. Patient G5's MTP dated 2/04/15 did not have a physician signature on the document.
4. Patient G6's MTP dated 1/11/15 did not have a physician signature on the document.
5. Patient G7's MTP dated 1/29/15 did not have a physician signature on the document.
6. Patient G8's MTP dated 1/28/15 did not have a physician signature on the document.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for eight (8) of eight (8) active patients. (G1, G2, G3, G4, G5, G6, G7 and G8). Lack of patient specific goals hampers the treatment team ' s ability to assess changes in patients' condition as a result of treatment.

Findings include:

A. RECORD REVIEW

1. Patient G1 admitted 12/09/14 with a diagnosis of "Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD) and Alcohol (ETOH) Dependence" had listed on the Master Treatment Plan (MTP) dated 12/12/14 for the problem, "Victim of violence or Trauma (motor vehicle accident), the following Short-Term Goals [STG] which fail to list goals noting behavioral changes that reflect problem resolution: "Identify ways to reduce anxiety" and "Report lowered anxiety."

2. Patient G2 admitted 1/21/15 with a diagnosis of "Schizoaffective Disorder" had listed on the MTP dated 1/22/15 for the problem, "Hallucinations", the following STG which fail to list goals noting specific behavioral changes that reflect problem resolution: "Increase goal directed behaviors."

3. Patient G3 admitted 2/4/15 with a diagnosis of "Bipolar Disorder, MDD, and Polysubstance Abuse" had listed on the MTP dated 2/4/15 for the problem, "Mood/Behavior-Depressed", the following STG which fail to list goals noting behavioral changes that reflect problem resolution: "Demonstrate decreased fear, anxiety and/or agitation" and "Identify coping strategies that stabilize moods."

4. Patient G4 admitted 1/31/15 with a diagnosis of "MDD with Suicidal Ideation, Polysubstance Abuse and Traumatic Brain Injury" had listed on the MTP dated 2/3/15 for the problem, "Thought Processes-Flight of Ideas", the following STGs which fail to list goals noting behavioral changes that reflect problem resolution: "Demonstrate decreased anxiety level" and "Respond to reality based orientation as prompted by others."

5. Patient G5 admitted 2/4/15 with a diagnosis of "Autism, Anxiety Disorder, Explosive Disorder, Depression and Psychosis" had listed on the MTP dated 2/5/15 for the problem, "Mood Behavior-Angry", the following STGs which fail to list goals noting behavioral changes that reflect problem resolution: "Demonstrate decreased fear, anxiety and/or agitation" and "Identify coping strategies that stabilize mood."

6. Patient G6 admitted 1/11/15 with a diagnosis of "Schizophrenia" had listed on the MTP dated 1/13/15 for the problem, "Mood/Behavior-Paranoid", the following STGs which fail to list goals noting behavioral changes that reflect problem resolution: "Demonstrate decreased fear, anxiety and/or agitation" and "Identify coping strategies that stabilize mood."

7. Patient G7 admitted 1/29/15 with a diagnosis of "Psychotic Disorder Not Otherwise Specified (NOS) and Major Depressive Disorder Recurrent Severe with Psychotic Features", had listed on the MTP dated 2/5/15 for the problem, "Hallucinations", the following STG which fail to list specific goals noting behavioral changes that reflect problem resolution: "Increase goal directed behaviors."

8. Patient G8 admitted 1/28/15 with a diagnosis of "Dementia with Confusion and Behaviors with Hallucinations", has listed on the MTP dated 1/29/15 for the problem, "Mood/Behavior-Depression", the following STGS which fail to list goals noting behavioral changes that reflect problem resolution: "Demonstrate decreased fear, anxiety and/or agitation" and "Identify coping strategies that stabilize mood."

B. DOCUMENT REVIEW
1. Facility policy " Protocol for Multidisciplinary Treatment Plan " dated 11/14/11 Phase II " Plan of Care Development: Formulating the Multidisciplinary Plan of Care (Initial Session) lists the following requirement for patient goals: " goals or goals [sic] stated as behavioral changes which reflect problem resolution. "


C. INTERVIEW

In interview on 2/9/15 at 4:30 PM, the Chief Operating Officer and the Compliance Officer agreed that many of the short-term goals were not behavioral, observable or measureable.

Based on record review and interview, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7 and G8). All interventions listed on treatment plans were preprinted. In addition, all treatment plans reviewed (G1, G2, G3, G4, G5, G6, G7 and G8) listed no physician interventions for the patients. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings Include:

A. MEDICAL RECORD REVIEW:

1. Patient G1 admitted on 12/09/14 with a diagnosis of "MDD [Major Depressive Disorder] recurrent, PTSD [Post Traumatic Stress Disorder], and ETOH [Ethanol] Dependency" had listed of the MTP [Master Treatment Plan] dated 12/12/14 for the problem "Alcohol and Substance Abuse" had listed the following preprinted generic interventions: "Monitor VS [Vital Signs] Q [each] shift PRN [as needed] per OWLS [sic] and CIWA [sic] protocol, monitor signs and symptoms of withdrawal." There were no physician interventions listed on the MTP.

2. Patient G2 admitted on 1/21/15 with a diagnosis of "Schizoaffective/Bipolar Disorder" had listed of the MTP dated 1/22/15 for the problem "Psychosis" had listed the following preprinted generic interventions: "Offer 1:1 time to assist patient to select aides to manage negative thought process; Administer medications as ordered and note response; Evaluate need for PRN medications." There were no physician interventions listed on the MTP.

3. Patient G3 admitted on 2/04/15 with a diagnosis of "Bipolar Disorder, Major Depressive Disorder, Polysubstance Dependence" had listed of the MTP dated 2/04/15 for the problem "Hallucinations" the following preprinted generic interventions: "Assess patient's mental status and re-orient, as needed, and q shift; Discuss strategies with patient regarding way to cope with hallucinations; Provide medications Education; Encourage group activity." There were no physician interventions listed on the MTP.

4. Patient G4 admitted on 1/31/15 with a diagnosis of "MDD c[with] SI [suicidal ideation], Polysubstance, TBI [Traumatic Brain Injury]" had listed of the MTP dated 1/31/15 for the problem "Thought Processes described as Short term/Long Term memory loss" had listed the following preprinted generic interventions:
"Observe patient for escalation of behavior intervene to set limits and provide comfort/support before behavior escalates; Administer medications as ordered and note response; Evaluate need for PRN medications." There were no physician interventions listed on the MTP.

5. Patient G5 admitted on 2/4/15 with a diagnosis of "Autism, Anxiety Disorder; Explosive DisorderDepressive Psychosis" had listed of the MTP dated 2/04/15 for the problem "MH [Mental Health] as evidenced by lack of knowledge concerning the following: Mental Health Diagnosis; Medical Regime" had listed the following preprinted generic interventions: "Medication Education; Mental Health Dx [Diagnosis]; Positive Coping Skills" [this patient is largely non-communicative]. There were no physician interventions listed on the MTP.

6. Patient G6 admitted on 1/11/15 with a diagnosis of "Schizophrenia" had listed on the MTP dated 1/11/15 for the problem "Thought Processes Described believes family puts thing in food" had listed the following preprinted generic interventions: "Observe patient for Escalation of behavior; Intervene to set limits and provide comfort/support before behavior escalates; Administer medications as ordered and note response; Evaluate need for PRN medications". There were no physician interventions listed on the MTP.

7. Patient G7 admitted on 1/29/15 with a diagnosis of "Psychotic Disorder NOS [Not Otherwise Specified]; Major Depressive Disorder; Recurrent Severe c [with] Psychotic features" had listed of the MTP dated 1/29/15 for the problem "Suicidal Ideation (No Plan)" had listed the following preprinted generic interventions:
"Assess patient for safety and implement special precautions as needed; Assist with safety plan; Monitor for change in Affect/behavior; Administer meds as ordered". There were no physician interventions listed on the MTP.

8. Patient G8 admitted on 1/28/15 with a diagnosis of "Dementia c [with] Confusion and Behaviors c [with] hallucinations" had listed of the MTP dated 1/28/15 for the problem "Knowledge deficit/MH [Mental Health] as evidence by lack of knowledge concerning the following: Mental Health Diagnosis" had listed the following preprinted generic interventions:
"Assess learning needs patient/family Facilitate Groups Related to Mental Health Dx [Diagnosis]; Encourage patient participation in group activity according to patient need". There were no physician interventions listed on the MTP.

INTERVIEW:

In an interview on 2/9/15 at 4:30 PM, the Chief Operating Officer and the Director of Nursing concurred that the preprinted treatment interventions on treatment plans were largely generic nursing interventions which are usually part of nursing job descriptions and lacked patient individuality.

[Prior surveyor training has in the past recommended not directly quoting hospital staff secondary to surveyor potential to accidentally misquote or hospital employees denying the quote; therefore the use of the terms concurred, indicated, etc]

Based on record review and interview, the hospital failed to identify by name and discipline the team member responsible for the modalities/interventions selected for eight (8) of eight (8) active patients. (G1, G2, G3, G4, G5, G6, G7 and G8) The treatment plans listed only staff initials and did not identify the specific names and disciplines of those staff members responsible for treatment modalities/interventions. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment.

Findings Include:

MEDICAL RECORD REVIEW:

1. Patient G1's MTP dated 12/12/14 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
2. Patient G2's MTP dated 1/22/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
3. Patient G3's MTP dated 2/04/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
4. Patient G4's MTP dated 1/31//15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
5. Patient G5's MTP dated 2/04/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
6. Patient G6's MTP dated 1/11/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
7. Patient G7's MTP dated 1/29/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.
8. Patient G8's MTP dated 1/28/15 listed only staff initials for those staff responsible for providing this patient his/her designated treatment modalities/interventions.

INTERVIEWS:

1. In an interview on 2/10/15 SW2 (Social Worker) concurred that only initials were listed for the staff responsible for treatment interventions/modalities and it was difficult to always determine from the initials the identity of the specific staff and discipline.

2. In an interview on 2/10/15 at 3:30 pm the Chief Operating Officer and the Director of Nursing concurred that staff were not listed by name and discipline and that primarily only initials were noted on the plans

Based on record review, observation and interview, the facility failed to provide:

l. Active treatment including alternative interventions for two (2) of eight (8) active sample patients (G6 and G8) who were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

2. Active treatment to address the needs of one (1) of eight (8) active sample patients (Patient G5). The treatment groups scheduled for Patient G5 were not appropriate to his/her understanding resulting in his/her non-participation in the assigned groups. Failure to address the treatment needs of patients can lead to difficulty in assessing patient progress and delays in improvement of the patient's condition. Findings include:

I. Treatment Interventions

A. Patient Findings

1. Patient G6 was admitted on 1/11/15 with a diagnosis of Schizophrenia. Review of the Group Progress Notes from 1/13/15 to 2/9/15 revealed that the patient attended only 22 of the 71 assigned groups (31%). Review of the Multidisciplinary Progress Notes for Patient G6 revealed the following:

1/24/14 at 5:00 PM - "Pt [patient] refuses to go to groups."
1/26/15 at 2:00 PM - "Pt remains isolative and paranoid, not interacting with staff or other pts."
1/29/15 at 2:00 PM - "Pt observed pacing briskly around unit previously during shift. Pt currently resting in bed with eyes closed."
1/31/15 at 1:00 PM - "Pt continues to isolate."

Review of the MTP Update dated 1/19/15 acknowledged that Patient G6 "Refuse [sic] to attend group." The MTP was not modified to address non-attendance of groups or alternative treatment options.

Observations

Observation on 2/9/15 at 11:20 AM on Unit 52 revealed that Patient G6 was in room sitting on bed. There was a scheduled Music Group occurring on the unit during this time.

Observation on 2/9/15 at 1:40 PM on Unit 52 revealed that Patient G6 was lying in bed. There was a scheduled Nutrition Group on the unit during this time.

Observation on 2/9/15 at 3:10 PM on Unit 52 revealed that Patient G6 was sitting on the bed with the door closed. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 1:50 PM on Unit 52 revealed that Patient G6 was sitting on the bed with the door closed. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 3:30 PM on Unit 52 revealed that Patient G6 was on the phone. There was a scheduled Music Group on the unit during this time.

Interviews

In interview on 2/9/15 at 11:15 AM, the Chief Operating Officer (COO) stated that all the patients were expected to go to all the scheduled groups on the units unless they were excused or refused to go. When asked what an excuse would be for not going to group, the COO stated that some patients might want to sleep.

In interview on 2/9/15 at 1:40 PM, Patient G6 stated that he/she went to some groups but never to the Music or Recreation Groups.

2. Patient G8 was admitted on 1/28/15 with a diagnosis of Dementia with Confusion and Behaviors with Hallucinations. Review of the Group Progress Notes from 1/29/15 revealed that the patient attended only five (5) of the 20 assigned groups (20%). Review of the Multidisciplinary Progress Notes for Patient G8 revealed the following:

2/4/15 at 3:00 PM - "Patient spent most of morning in bed, refusing to get up when prompted."

2/7/15 at 11:15 AM - "Isolative to self when on unit, but mostly stays in room."

Review of the MTP Update dated 2/4/15, was not modified to address the non-attendance at groups or alternative treatment options.

Observation

Observation on 2/9/15 at 11:15 AM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Music Group on the unit during this time.

Observation on 2/9/15 at 2:00 AM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Nutrition Group on the unit during this time.

Observation on 2/10/15 from 11:00 AM - 12:00 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Current Events Group on the unit during this time.

Observation on 2/10/15 at 2:15 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 3:45 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Music Group on the unit during this time.

Interviews

In interview on 2/9/15 at 11:15 AM, Mental Health Technician 1 (MHT1) when asked why Patient G8 was not participating in the Music Group stated that the patient had eaten breakfast, taken his/her medicine and gone back to bed. MHT1 further stated that Patient G8 was often in bed and not in groups. MHT1 further stated that the staff tried to get the patients to go to group but could not force patients to go.

In interview on 2/9/15 at 2:15 PM, MHT1 reported that Patient G8 attended the Nutrition Group for 10-15 minutes and was "put back to bed" because of back pain.

In interview on 2/10/15 at 10:45 AM, Patient G8 stated that he/she did not go to groups because his/her legs hurt and he/she needed to stay in bed.

ll. Failure to Address Patient Needs

Patient G5 was admitted on 2/4/15 with the diagnoses of Autism, Anxiety Disorder, Explosive Disorder, Depression and Psychosis. The Initial Psychiatric Evaluation dated 2/4/15 described Patient G5 as "Pt is able to hear but unable to speak." The Psychosocial Assessment dated 2/5/15 listed the Patient Problems as "aggressive behavior" toward the staff at the Extended Living Facility. The MTP dated 2/4/15 did not identify patient's "strengths" or "barriers" and instead recorded "UTA" (Unable to Assess). Short-term goals listed on Patient G5's MTP dated 2/4/15 included: "Attend scheduled groups and therapy daily to enhance healthy expression of emotions", "Attend Anger Mgmt. (Management) Group" and "Verbalize importance of medication compliance." These goals did not address Patient G5's functional level and were not attainable by the patient as written. Review of the Multidisciplinary Progress Notes revealed the following:

2/5/15 at 11:20 PM - "Pt communicates mostly by body language."

2/6/15 at 4:00 PM - "Pt gets up and walks around periodically around unit rocking back and forth laughing."

2/7/15 at 4:00 PM - "Pt holding 3 Mario stuffed animals and tapes and sits on the couch in the lobby."

2/7/15 at 11:30 PM - "Pt has not been observed interacting with other patients."

2/8/15 at 5:45 PM - "Pt remains calm and pleasant holding his teddy bears."

Observation

Observation on Unit 52 at 11:15 AM revealed that Patient G5 was sitting in the dayroom at a table away from the Music Group activities. Patient G5 had stuffed Mario figures that he/she was holding and placing in a straight line on the table. He/she was not looking toward the group activities. Patient G5 laughed at intervals and rocked back and forth. .

Observation on Unit 52 at 1:15 PM revealed that Patient G5 was sitting in the dayroom at a table away from the Nutrition Group being held. Patient G5 was holding stuffed Mario figures and had several Mario pages from a coloring book on the table. He/she did not look at the group being held.

Observation in the recreation room (during Recreation Group) on 2/9/15 at 3:05 PM revealed that Patient G5 was sitting at a table with his/her stuffed Mario figures lined up on the table. He/she did not participate in any of the activities and instead rocked back and forth, stared at another patient sitting at the same table and at times waved his/her arms.

Observation on Unit 52 on 2/10/15 from 8:30 AM - 12:00 PM revealed that Patient G5 was lying on the sofa near the nurses' station with his/her eyes closed.

Observation in the recreation room on 2/10/15 at 2:20 PM revealed that Patient G5 was sitting at a table. He/she was wrapped in a blanket and not participating in any of the activities being offered.

Interviews

In interview on 2/9/15 at 2:25 PM, RN3 stated that Patient G5 walks around the unit laughing at times and holding his/her Mario stuffed animals. RN3 stated that the patient was given Mario coloring sheets to "keep [him/her] busy" and further stated that Patient G5 sat near groups but did not participate at all.

In interview on 2/10/15 at 9:40 AM, RN3 stated that Patient G5 sat in the dayroom when groups were being held but agreed that he/she didn't know what was going on in the group.

Based on observation, interview, policy review, and medical record review, the Medical Director failed to ensure:

I. The provision of psychiatric evaluations that included an assessment of patient assets in descriptive fashion for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7 and G8) This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (See B117)

Findings Include:

MEDICAL RECORD REVIEW:

1. Patient G1's psychiatric evaluation dated 12/10/14 did not list the patient's assets.

2. Patient G2's psychiatric evaluation dated 1/22/15 did not list the patient's assets.

3. Patient G3's psychiatric evaluation dated 1/05//15 did not list the patient's assets.

4. Patient G4's psychiatric evaluation dated 2/01//15 did not list the patient's assets.

5. Patient G5's psychiatric evaluation dated 2/4/15 did not list the patient's assets.

6. Patient G6's psychiatric evaluation dated 1/12/15 did not list the patient's assets

7. Patient G7's psychiatric evaluation dated 1/29/15 did not list the patient's assets.

8. Patient G8's psychiatric evaluation dated 1/28/15 did not list the patient's assets.

INTERVIEWS:

1. In an interview on 2/10/15at 3:30 PM the Chief Operating Officer and the Compliance Officer confirmed that patient assets were not listed on the psychiatric evaluations.

2. In an interview on 2/10/15 at 10:40 AM the Medical Director concurred that patient assets were not listed on the psychiatric evaluation.

II. The provision for Medical/Psychiatrist attendance at treatment planning meetings. Six (6) of eight (8) active sampled patients MTP's failed to have signatures on the MTP document confirming physician attention to the document. (G2, G4, G5, G6, G7 and G8). In addition there is a failure to follow Facility Policy "Protocol for Multidisciplinary Treatment Plan #NUR" dated11/14/2011. This practice has the potential to have patient care provided without the direction of a physician and potentially compromise a patient's medical and psychiatric care. (See B118)

Findings include:

A. OBSERVATION:

1. During Treatment Team meeting for Patient G6 on 2/10/15 at 10:30AM, it was observed that only a Social Worker (SW1) and a Registered Nurse (RN3) were in attendance. When asked if this was representative of the attendance at Treatment Team meetings, SW1 stated "Yes".

B. INTERVIEWS:

1. In interview on 2/10/15 at 8:45 AM, SW1 and RN4 both acknowledged that the physician and/or nurse practitioner were not always present for the Treatment Team meetings, including the initial Master Treatment Planning meeting. SW1 stated "We always have a nurse and a social worker."

2. In an interview 2/10/2015 at 9:45 AM Social Worker 2 indicated that physicians rarely attended treatment planning meetings. Usually treatment plans were completed by the RN with SW adding their part. Treatment team meetings were not consistently scheduled and plans were usually completed whenever the RN and SW could meet.

3. In an interview on 2/10/15 at 10:40 AM the Medical Director indicated that he did not attend treatment team planning meetings. He indicated that there was a morning meeting that had the format of morning report but did not directly address treatment planning. He further indicated that in the past such meetings had occurred but the meeting schedule had stopped.

4. In an interview on 2/10/15 at 11:30 AM the Director of Social Work indicated there were no formalized treatment meetings. These meetings were scheduled as staff had time and that physicians were not usually in attendance at these meetings.

5. In an interview on 2/10/15 3:00 PM the Nurse Practitioner indicated that she did not have time to attend treatment planning meetings and that there had not been regularly scheduled times for this to occur

6. In an interview on 2/10/15 at 3:30 PM the Director of Nursing and the Chief Operating Officer met with both federal surveyors. They concurred that formal treatment planning meetings were not being scheduled nor were they being held on a regular basis.

C. DOCUMENT REVIEW

1. Facility Policy and Procedures document "Protocol for Multidisciplinary Treatment Plan" dated 11/14/2011 and numbered NUR states the following: 'The initial multidisciplinary plan of care session shall be scheduled within 72 hours of the patient's admission to the Behavioral Health Unit. Plan of care meetings will be attended by the primary physician or designee, the DON or designee, the unit RN, the Charge Nurse, Social Worker, and Recreational Therapist."

D. MEDICAL RECORD REVIEW

1. Patient G2's MTP dated 1/22/15 did not have a physician signature on the document

2. Patient G4's MTP dated 1/31/15 did not have a physician signature on the document.

3. Patient G5's MTP dated 2/04/15 did not have a physician signature on the document.

4. Patient G6's MTP dated 1/11/15 did not have a physician signature on the document.

5. Patient G7's MTP dated 1/29/15 did not have a physician signature on the document.

6. Patient G8's MTP dated 1/28/15 did not have a physician signature on the document.


III. The provision of active treatment including alternative interventions for two (2) of eight (8) active sample patients (G6 and G8) who were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125.1)

A. Patient Findings

1. Patient G6 was admitted on 1/11/15 with a diagnosis of Schizophrenia. Review of the Group Progress Notes from 1/13/15 to 2/9/15 revealed that the patient attended only 22 of the 71 assigned groups (31%). Review of the Multidisciplinary Progress Notes for Patient G6 revealed the following:

1/24/14 at 5:00 PM - "Pt [patient] refuses to go to groups."

1/26/15 at 2:00 PM - "Pt remains isolative and paranoid, not interacting with staff or other pts."

1/29/15 at 2:00 PM- " Pt observed pacing briskly around unit previously during shift. Pt currently resting in bed with eyes closed."

1/31/15 at 1:00 PM - " Pt continues to isolate."

Review of the MTP Update dated 1/19/15 acknowledged that Patient G6 "Refuse [sic] to attend group." The MTP was not modified to address non-attendance of groups or alternative treatment options.

Observations

Observation on 2/9/15 at 11:20 AM on Unit 52 revealed that Patient G6 was in room sitting on bed. There was a scheduled Music Group occurring on the unit during this time.

Observation on 2/9/15 at 1:40 PM on Unit 52 revealed that Patient G6 was lying in bed. There was a scheduled Nutrition Group on the unit during this time.

Observation on 2/9/15 at 3:10 PM on Unit 52 revealed that Patient G6 was sitting on the bed with the door closed. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 1:50 PM on Unit 52 revealed that Patient G6 was sitting on the bed with the door closed. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 3:30 PM on Unit 52 revealed that Patient G6 was on the phone. There was a scheduled Music Group on the unit during this time.

Interview

In interview on 2/9/15 at 11:15 AM, the Chief Operating Officer (COO) stated that all the patients were expected to go to all the scheduled groups on the units unless they were excused or refused to go. When asked what an excuse would be for not going to group, the COO stated that some patients might want to sleep.

In interview on 2/9/15 at 1:40 PM, Patient G6 stated that he/she went to some groups but never to the Music or Recreation Groups.

2. Patient G8 was admitted on 1/28/15 with a diagnosis of Dementia with Confusion and Behaviors with Hallucinations. Review of the Group Progress Notes from 1/29/15 revealed that the patient attended only 5 of the 20 assigned groups (20%). Review of the Multidisciplinary Progress Notes for Patient G8 revealed the following:

2/4/15 at 3:00 PM - "Patient spent most of morning in bed, refusing to get up when prompted."

2/7/15 at 11:15 AM - "Isolative to self when on unit, but mostly stays in room."

Review of the MTP Update dated 2/4/15, was not modified to address the non-attendance at groups or alternative treatment options.

Observation

Observation on 2/9/15 at 11:15AM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Music Group on the unit during this time.

Observation on 2/9/15 at 2:00 AM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Nutrition Group on the unit during this time.

Observation on 2/10/15 from 11:00 AM-12:00 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Current Events Group on the unit during this time.

Observation on 2/10/15 at 2:15 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Recreation Group off the unit during this time.

Observation on 2/10/15 at 3:45 PM on Unit 52 revealed that Patient G8 was in bed under the covers. There was a scheduled Music Group on the unit during this time.

Interviews

In interview on 2/9/15 at 11:15 AM, Mental Health Technician 1 (MHT1) when asked why Patient G8 was not participating in the Music Group stated that the patient had eaten breakfast, taken his/her medicine and gone back to bed. MHT1 further stated that Patient G8 was often in bed and not in groups. MHT1 further stated that the staff tried to get the patients to go to group but could not force patients to go.

In interview on 2/9/15 at 2:15 PM, MHT1 reported that Patient G8 attended the Nutrition Group for 10-15 minutes and was "put back to bed" because of back pain.

In interview on 2/10/15 at 10:45 AM, Patient G8 stated that he/she did not go to groups because his/her legs hurt and he/she needed to stay in bed.

IV. The provision of active treatment to address the needs of one (1) of eight (8) active sample patients (Patient G5). The treatment groups scheduled for Patient G5 were not appropriate to his/her understanding resulting in his/her non-participation in the assigned groups. Failure to address the treatment needs of patients can lead to difficulty in assessing patient progress and delays in improvement of the patient's condition. (See B125.2)

Findings Include:

Patient G5 was admitted on 2/4/15 with the diagnoses of Autism, Anxiety Disorder, Explosive Disorder, Depression and Psychosis. The Initial Psychiatric Evaluation dated 2/4/15 described Patient G5 as "Pt is able to hear but unable to speak." The Psychosocial Assessment dated 2/5/15 listed the Patient Problems as "aggressive behavior" toward the staff at the Extended Living Facility. The MTP dated 2/4/15 did not identify patient's "strengths" or "barriers" and instead recorded "UTA" (Unable to Assess). Short-term goals listed on Patient G5's MTP dated 2/4/15 included: "Attend scheduled groups and therapy daily to enhance healthy expression of emotions", "Attend Anger Mgmt. (Management) Group" and "Verbalize importance of medication compliance." These goals did not address Patient G5's functional level and were not attainable by the patient as written. Review of the Multidisciplinary Progress Notes revealed the following:

2/5/15 at 11:20 PM - "Pt communicates mostly by body language."

2/6/15 at 4:00 PM - "Pt gets up and walks around periodically around unit rocking back and forth laughing."

2/7/15 at 4:00 PM - "Pt holding 3 Mario stuffed animals and tapes and sits on the couch in the lobby."

2/7/15 at 11:30 PM - "Pt has not been observed interacting with other patients."

2/8/15 at 5:45 PM - "Pt remains calm and pleasant holding his teddy bears."

Observation

Observation on Unit 52 at 11:15 AM revealed that Patient G5 was sitting in the dayroom at a table away from the Music Group activities. Patient G5 had stuffed Mario figures that he/she was holding and placing in a straight line on the table. He/she was not looking toward the group activities. Patient G5 laughed at intervals and rocked back and forth.

Observation on Unit 52 at 1:15PM revealed that Patient G5 was sitting in the dayroom at a table away from the Nutrition Group being held. Patient G5 was holding stuffed Mario figures and had several Mario pages from a coloring book on the table. He/she did not look at the group being held.

Observation in the recreation room (during Recreation Group) on 2/9/15 at 3:05 PM revealed that Patient G5 was sitting at a table with his/her stuffed Mario figures lined up on the table. He/she did not participate in any of the activities and instead rocked back and forth, stared at another patient sitting at the same table and at times waved his/her arms.

Observation on Unit 52 on 2/10/15 from 8:30 AM-12:00 PM revealed that Patient G5 was lying on the sofa near the nurses' station with his/her eyes closed.

Observation in the recreation room on 2/10/15 at 2:20 PM revealed that Patient G5 was sitting at a table. He/she was wrapped in a blanket and not participating in any of the activities being offered.

Interviews

In interview on 2/9/15 at 2:25 PM, RN3 stated that Patient G5 walks around the unit laughing at times and holding his/her Mario stuffed animals. RN3 stated that the patient was given Mario coloring sheets to "keep [him/her] busy" and further stated that Patient G5 sat near groups but did not participate at all.

In interview on 2/10/15 at 9:40AM, RN3 stated that Patient G5 sat in the dayroom when groups were being held but agreed that he/she didn't know what was going on in the group.

V. That discharge summaries for four (4) of the five (5) selected discharge records (D1, D2, D3 and D4) documented medical conditions of patients upon discharge. These omissions have the potential to prevent outpatient providers from having the necessary information for providing a seamless transition to outpatient care and risks (without medical information in the final diagnosis) less than optimal outpatient care.

MEDICAL RECORD REVIEW:

1. Patient D1's discharge summary dated 1/17/15 indicated the patient has "DMII [Diabetes Mellitus 2), Anemia, malnutrition, Chronic Pancreatitis". The Diagnosis at Discharge listed Axis III as "N/A."

2. Patient D2's discharge summary dated 1/24/15 indicated the patient has HTN [Hypertension}, Hep C+ [Hepatitis C]. The Diagnosis at Discharge listed Axis III as "N/A."

3. Patient D3's discharge summary dated 1/24/15 indicated the patient has "Chronic Foot Pain". The Diagnosis at Discharge listed Axis III as "N/A."

4. Patient D5's discharge summary dated 1/10/15 indicated the patient has "ADHD [Attention Deficit Hyperactivity Disorder] Seizure D/O [Disorder], Anemia. The Diagnosis at Discharge listed Axis III as "deferred."

B. Discharge Summaries for four (4) of five (5) discharge records listed above (D1,D2,D3 and D5) had Axis IV statements that were of identical content as follows:

"Psychosocial/environmental; Problems with primary support group; Problems related to the social environment; Problems related to the lost [sic] of a loved one."

INTERVIEWS:

1. In an interview on 2/10/15 at 10:40 AM the Medical Director concurred that the discharge summaries did not document final medical Axis III diagnoses. He also agreed that the Axis IV statements were identical in content and not individualized.

2. In the interview on 2/10/15 at 3:00 PM the Nurse Practitioner indicated that the medical diagnoses for patients were not listed on the Axis III discharge section of the discharge summaries. In addition she concurred with the findings that the Axis IV statements were identical and lacked individualizations.

Based on record review and interview, the facility failed to:

l. Identify in the MTP specific nursing interventions/modalities to address the identified patient problems eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8). The interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

II. Ensure active treatment participation including alternative interventions for two (2) of eight (8) active sample patients (G6 and G8). The patients were unwilling to attend many of their assigned groups. Failure to ensure participation in active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125 l.)

Findings include:

l. Nursing Interventions

A. Medical Record Review

1. Patient G1 admitted on 12/09/14 with a diagnosis of "MDD [Major Depressive Disorder] recurrent, PTSD [Post Traumatic Stress Disorder], and ETOH [Ethanol] Dependency" had listed of the MTP [Master Treatment Plan] dated 12/12/14 for the problem "Alcohol and Substance Abuse" had listed the following preprinted generic nursing interventions: "Monitor VS [Vital Signs] Q [each] shift PRN [as needed]."

2. Patient G2 admitted on 1/21/15 with a diagnosis of "Schizoaffective/Bipolar Disorder" had listed of the MTP dated 1/22/15 for the problem "Psychosis" had listed the following preprinted generic nursing interventions: "Administer medications as ordered and note response; Evaluate need for PRN medications."

3. Patient G3 admitted on 2/04/15 with a diagnosis of "Bipolar Disorder, Major Depressive Disorder, Polysubstance Dependence" had listed of the MTP dated 2/04/15 for the problem "Hallucinations" the following preprinted generic nursing interventions:
"Assess patient's mental status and re-orient, as needed, and q shift; Encourage group activity."

4. Patient G4 admitted on 1/31/15 with a diagnosis of "MDD c[with] SI [suicidal ideation], Polysubstance, TBI [Traumatic Brain Injury]" had listed of the MTP dated 1/31/15 for the problem "Thought Processes described as Short term/Long Term memory loss" had listed the following preprinted generic nursing interventions:
"Observe patient for escalation of behavior intervene to set limits and provide comfort/support before behavior escalates; Administer medications as ordered and note response; Evaluate need for PRN medications."

5. Patient G5 admitted on 2/4/15 with a diagnosis of "Autism, Anxiety Disorder; Explosive Disorder Depressive Psychosis" had listed of the MTP dated 2/04/15 for the problem "MH [Mental Health] as evidenced by lack of knowledge concerning the following: Mental Health Diagnosis; Medical Regime" had listed the following preprinted generic nursing intervention: "Encourage patient participation in group activity according to patient need."

6. Patient G6 admitted on 1/11/15 with a diagnosis of "Schizophrenia" had listed of the MTP dated 1/11/15 for the problem "Thought Processes Described believes family puts thing in food" had listed the following preprinted generic nursing interventions:
"Observe patient for Escalation of behavior; Intervene to set limits and provide comfort/support before behavior escalates; Administer medications as ordered and note response; Evaluate need for PRN medications."

7. Patient G7 admitted on 1/29/15 with a diagnosis of "Psychotic Disorder NOS [Not Otherwise Specified]; Major Depressive Disorder; Recurrent Severe c [with] Psychotic features" had listed of the MTP dated 1/29/15 for the problem "Suicidal Ideation (No Plan)" had listed the following preprinted generic nursing interventions:
"Assess patient for safety and implement special precautions as needed; Administer meds as ordered."

8. Patient G8 admitted on 1/28/15 with a diagnosis of "Dementia c [with] Confusion and Behaviors c [with] hallucinations" had listed of the MTP dated 1/28/15 for the problem "Knowledge deficit/MH [Mental Health] as evidence by lack of knowledge concerning the following: Mental Health Diagnosis" had listed the following preprinted generic nursing interventions: "Encourage patient participation in group activity according to patient need."

INTERVIEW:

In an interview on 2/9/15 at 4:30 PM, the Chief Operating Officer and the Director of Nursing acknowledged that the preprinted treatment interventions on treatment plans were interventions that the nurse would apply to any patient (such as " assess for safety " , " encourage participation in group " ) and were not specific to the patients ' individualized needs requiring hospitalization.

Based on interview the director of Social Work failed to provide documentation and the establishment of a system to evaluate the quality and appropriateness of social work services provided by the hospital social workers. This lack of evaluation of social work services has the potential to limit the assurance that patients will receive all the services required for a timely discharge risking a longer length of stay than necessary.

1. In an interview on 2/10/15 at 11:30 AM the Director of Social Work indicated there was currently no system in place to evaluate the current quality of social services being provided by the facility. He/she stated the facility was recruiting additional social workers at which point he/she would have the time to develop the needed evaluation system.

Based on observation and interview it was determined that the facility failed to provide professional therapeutic staff who would design and implement structured therapeutic activities. This failure resulted in a lack of structured therapeutic groups/activities to assist the patient in meeting their treatment goals.

Findings include:

A. Interviews

In interview on 2/19/15 at 9:25 AM, the Director of Social Work stated that CDCA2, although a counselor, was "pretty much the recreational therapist on Unit 52." The Director further stated that a RT position was currently being advertised.

In interview on 2/20/15 at 1:00 PM, CDCA1stated that there had not been an Activity Therapy (AT) Director at the hospital for 8-9 months when the former Director was "let go." CDCA1 further stated that Counselors were filling in as leaders of recreation therapy groups. She/he stated "There is not a licensed recreation therapist here."

B. Observation

Observation on 2/9/15 at 11:15 AM on Unit 52 revealed that CDCA2 was leading a scheduled Music Group.

Observation on 2/10/15 at 1:50 PM in the Recreation Room revealed that CDCA2 was leading a scheduled Recreation Group.

Observation on 2/10/15 at 3:30 PM on Unit 52 revealed that CDCA2 was leading a scheduled Music Group.