HospitalInspections.org

18044

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

I. Ensure that the Master Treatment Plans (MTPs) for five (5) of eight (8) active sample patients (A1, A28, B19, C9, and C16) were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 I)

II. Develop and document MTPs based on the individual needs of eight (8) of eight (8) active sample patients (A1, A28, B7, B19, C9, C16, D1, and D14). This failure resulted in the absence of specific plans to direct staff in the implementation, evaluation, and revision of care based on individual patient findings. (Refer to B118 II)

III. Provide active psychiatric treatment for seven (7) of eight (8) active sample patients (A1, A28, B19, C9, C16, D1 and D14) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125 I)

IV. Ensure that patients in the facility received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evening hours and on weekends. On evenings and weekends, no treatment groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning, thereby potentially delaying a timely discharge. (Refer to B125 II)

V. Assess and treat the medical problems of one (1) of one (1) active sample patients (Patient C16). Failure to address and respond to medical issues results in a potential risk to the health and lives of patients. (Refer to B125 III)

VI. Ensure privacy for patients during the hospitalization admission process. All patients were "patted down" during the contraband search by a Public Safety Officer. These searches were often conducted by a Public Safety Officer of the opposite sex. This results in failure to ensure that all patients are provided privacy and respect during the admission process. (Refer to B125 IV)

VII. Appropriately use and document seclusion/restraint as an external control of violence toward self and others for three (3) of three (3) active non-sample patients (A22, B13, and B18) and one (1) of one (1) discharged patient (E1) reviewed for the use of seclusion. These patients were secluded without documented justification based on changing behaviors. The use of seclusion/restraints without documented justification that these external control procedures were used only in emergency situations resulted is a violation of the patients' right to be free from restraints. (Refer to B125 V)

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

I. Ensure that the Master Treatment Plans (MTPs) for five (5) of eight (8) active sample patients (A1, A28, B19, C9, and C16) were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

II. Develop and document MTPs based on the individual needs of eight (8) of eight (8) active sample patients (A1, A28, B7, B19, C9, C16, D1, and D14). This failure resulted in the absence of specific plans to direct staff in the implementation, evaluation, and revision of care based on individual patient findings.

Findings include:

I. Failure to revise treatment plans

A. Record Review

1. Patient A1

a. Patient A1 was admitted on 10/11/11. The annual "Psychiatric History & Mental Status Exam Reassessment" dated 11/3/15 included the diagnoses of "Schizoaffective Disorder" and "Polysubstance Abuse."

b. Patient A1's treatment schedule attached to the treatment plan assigned this patient to attend 10 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the weekend.

c. The social work progress notes dated 1/29/16 at 4:20 p.m. and 2/18/16 at 2:55 p.m. both stated "Pt seen at least 1 x [time] every week...SW [social work] focus is reassurance, liaison [with] mother." A review of the medical record and documentation provided by administration revealed that Patient A1 attended no group activities and no other individual treatment was documented from 1/21/16 to 2/22/16.

c. The Master Treatment Plan for Patient A1, last reviewed 1/28/16, indicated no revision to the interventions to address the needs of Patient A1 despite not participating in group therapy and failed to include alternative treatments (1:1 and/or groups).

2. Patient A28

a. Patient A28 was admitted on 2/12/16. The "Psychiatric History & Mental Status Exam" dated 2/12/16 included the diagnoses of "Schizophrenia, multiple episodes, currently in acute episode; alcohol use disorder, cannabis use disorder."

b. Patient A28's treatment schedule attached to the treatment plan assigned this patient to attend 13 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the weekend.

c. A review of the medical record and documentation provided by administration revealed that Patient A28 attended only 2 on-unit activity groups, including groups "in which pts [patients] listen to music" and "educated on the date, weather and quote of the day..." from 2/12/16 to 2/22/16. The only other documentation provided was that Patient A28 received 9 psychoeducational handouts as part of a "Patient Education Group" on 2/12/16 8:00 p.m.

d. The Master Treatment Plan for Patient A28, last reviewed 2/17/16, indicated no revision to the interventions to address the needs of Patient A1 despite not participating in group therapy and failed to include alternative treatments (1:1 and/or groups).

3. Patient B19

a. Patient B19 was admitted on 11/10/15. The "Psychiatric History & Mental Status Exam Reassessment" dated 11/10/15 included the diagnoses of "Schizoaffective Disorder bipolar type."

b. Patient B19's treatment schedule attached to the treatment plan assigned this patient to attend 1-3 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the week-end.

c. An Activity Therapy note (1/21/16) documented, " Pt. (Patient) has been to 0/7 to (sic) groups. (Refused)"

d. An Activity Therapy note (1/28/16) documented, "Pt. (Patient) has been to 0/8 groups."

e. The "Treatment Team Update" note dated 2/4/16 for Patient B19 stated "Patient refused most AT (Activity Therapy) groups, did come 1x (time) yesterday so [s/he] could go to special event next week. Pt. (Patient) usually stays in bed, room smells bad."

f. A review of the medical record and documentation provided by administration revealed that Patient B19 attended only a total of three (3) groups/activities (1 formal 1:1 session with a Clinical Counselor (assistant to nursing) and two (2) of 10 assigned activity therapy groups) from 1/21/16-2/22/16.

g. The Master Treatment Plan for Patient B19 with most recent date of 12/1/15 indicated no revision to the interventions to address the needs of Patient B19 despite not participating in group therapy/activities.

4. Patient C9

a. Patient C9 was admitted on 5/28/09. The "Psychiatric History & Mental Status Exam Reassessment" dated 6/16/15 included the diagnoses of "Schizophrenia, Cognitive Disorder Not Otherwise Specified."

b. Patient C9's treatment schedule attached to the treatment plan assigned this patient to attend one (1) leisure and/or psychoeducational group Monday-Friday and leisure activities when offered on the weekend.

c. The Group Therapy Note dated 2/16/16 at 4:40 p.m. stated "Pt has attended 0/1 on lodge AT [activities therapy] group, refused x 1."

d. A review of documentation in the medical record (provided by administration) revealed that Patient C9 attended approximately only five (5) on-unit activity groups, including "putting puzzles together with peers" and "painting nails with peers," from 1/21/16 to 2/22/16.

e. The Master Treatment Plan for Patient C9, last reviewed 2/22/16, indicated no revision to the interventions to address the needs of Patient C9 despite not participating in group therapy and failed to include alternative treatments (1:1 and/or groups).

5. Patient C16

a. Patient C16 was admitted on 2/1/06. The "Psychiatric History & Mental Status Exam Reassessment" dated 8/14/15 included the diagnoses of "Schizoaffective Disorder, Bipolar Type. Neurocognitive Disorder, Unspecified."

b. Patient C16's treatment schedule attached to the treatment plan assigned this patient to attend one (1) leisure and/or psychoeducational group Monday-Friday and leisure activities when offered on the weekend.

c. The Group Therapy Note dated 2/16/16 at 4:30 p.m. stated "Pt has attended 0/1 on lodge AT [activities therapy] group, refused x 1."

d. A review of documentation in the medical record (provided by administration) revealed that Patient C16 attended only approximately nine (9) on-unit activity groups, such as "Bingo group," "coloring group," and "nail group," from 1/21/16 to 2/22/16.

e. The Master Treatment Plan for Patient C16, last reviewed 2/3/16, indicated no revision to the interventions to address the needs of Patient C16 despite not participating in group therapy and failed to include alternative treatments (1:1 and/or groups).

B. Staff Interviews

1. During an interview with the Director of Nursing, including a review of treatment plans, on 2/23/16 at 3:00 p.m., he acknowledged that treatment plans for patients who did not attend group or other types of therapies had not been revised.

2. During an interview with the Medical Director, including a review of treatment plans, on 2/23/16 at 11:15 a.m., she acknowledged that treatment plans for patients who did not attend group or other types of therapies had not been revised.

II. Provide individualized master treatment plans

A. Record Review

Findings include:

A. Review of the treatment plans for eight (8) of eight (8) active sample patients (A1-dated 1/28/16; Patient A28-dated 2/17/16; Patient B7-2/17/16; Patient B19-2/4/16; Patient C9-dated 2/22/16; Patient C16-dated 2/3/16; Patient D1-dated 2/22/16 and Patient D14-2/16/16) revealed that the master treatment plans were preprinted forms. These forms were based on selected problems (e.g. altered thought process, mood instability, and violence) and included a list of patient goals and a list of staff interventions that consisted of generic interventions, discipline role functions and guides to be considered for the patient's care. Selected goals and interventions were identified by a date and the initials of the responsible staff member. None of the selected goals and interventions was modified based on the specific needs of the patients, nor were the majority of these altered based on patient changes. One patient (D1) had a behavior management plan (not dated); the Medical Director reported on 2/23/16 at 1:00 p.m. that this behavioral management plan had not proved "useful" and was being revised.

B. Staff Interviews

1. During an interview with the Director of Activities, including a review of treatment plans, on 2/23/16 at 10:00 a.m., she acknowledged that the interventions listed for Activities Therapy staff were generic and nonspecific.

2. During an interview with the Director of Social Work, including a review of treatment plans, on 2/23/16 at 2:00 p.m., she acknowledged that treatment plan goals and interventions for social work were not individualized to the specific patients.

3. During an interview with the Director of Nursing, including a review of treatment plans, on 2/23/16 at 3:00 p.m., he acknowledged that the treatment plans for the sample patients had not been significantly changed since the previous survey and were generic and not individualized to specific patients.

4. During an interview with the Medical Director, including a review of treatment plans, on 2/23/16 at 11:15 a.m., she stated that based on her reviews, the majority of treatment plans did not contain specific, individualized interventions and that short-term goals were not measurable. She acknowledged that the treatment plans for the sample patients had not been significantly changed since the previous survey.







25353

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

I. Provide active psychiatric treatment for seven (7) of eight (8) active sample patients (A1, A28, B19, C9, C16, D1, and D14) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement.

II. Ensure that patients in the facility received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evening hours and on weekends. On evenings and weekends, no treatment groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge.

III. Assess and treat the medical problems of one (1) of one (1) active sample patients (Patient C16). Failure to address and respond to medical issues results in a potential risk to the health and lives of patients.

IV. Ensure privacy for patients during the hospitalization admission process. All patients were "patted down" during the contraband search by a Public Safety Officer. These searches were often conducted by a Public Safety Officer of the opposite sex. This results in failure to ensure that all patients are provided privacy and respect during the admission process

V. Appropriately use and document seclusion/restraint as an external control of violence toward self and others for three(3) of three (3) active non-sample patients (A22, B13, and B18) and one (1) of one (1) discharged patient (E1) reviewed for the use of seclusion. These patients were secluded without documented justification based on changing behaviors. The use of seclusion/restraints without documented justification that these external control procedures were used only in emergency situations resulted is a violation of the patients' right to be free from restraints.

Findings include:

I. Provide active psychiatric treatment

A. Observations

1. During an observation on 2/22/16 at 2:25 p.m., at the time of the scheduled activities therapy groups, Patient C9 was observed lying on a sofa in a secondary dayroom and Patient C16 was observed asleep in a bed.

2. During an observation on 2/22/16 at 3:20 p.m., at the time of the scheduled activities therapy groups, Patient C9 was observed continuing to lie on the same sofa in a secondary dayroom as earlier in the day and Patient C16 was observed sitting alone in the large dayroom.

3. During an observation on 2/22/16 at 2:00 p.m., at the time of the scheduled activities therapy groups, Patient A1 and A8 were observed sitting in a dayroom with five (5) other unit patients.

4. During an observation on 2/22/16 at 3:30 p.m., at the time of the scheduled activities therapy groups, Patient A1 was observed sitting the dayroom with other patients and A8 were observed in his/her bedroom.

5. During an observation on 2/22/16 at 2:20 p.m., Patient D14 was covered up with a coat on asleep in his assigned room. He reported that because s/he was always "tired," s/he stayed in bed a lot. The patient reported that s/he only goes to the dayroom some and then returns to the bed.

B. Record Review

1. Patient A1

a. Patient A1 was admitted on 10/21/11. The "Psychiatric History & Mental Status Exam Reassessment" dated 11/3/15 included the diagnoses of "Schizoaffective Disorder; Polysubstance Abuse (per history)."

b. Patient A1's treatment schedule attached to the treatment plan assigned this patient to attend 10 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the weekend.

c. The social work progress notes dated 1/29/16 at 4:20 p.m. and 2/18/16 at 2:55 p.m. both stated "Pt seen at least 1 x [time] every week...SW [social work] focus is reassurance, liaison [with] mother."

d. A review of the medical record and documentation provided by administration revealed that Patient A1 attended no group activities and no other individual treatment was documented from 1/21/16 to 2/22/16.

2. Patient A28

a. Patient A28 was admitted on 2/12/16. The "Psychiatric History & Mental Status Exam" dated 2/12/16 included the diagnoses of "Schizophrenia, multiple episodes, currently in acute episode; alcohol use disorder, cannabis use disorder."

b. Patient A28's treatment schedule attached to the treatment plan assigned this patient to attend 13 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the weekend. The only other documentation provided was that Patient A28 received nine (9) psychoeducational handouts as part of a "Patient Education Group" on 2/12/16 8:00 p.m.

d. A review of the medical record and documentation provided by administration revealed that Patient A28 attended only two (2) on-unit activity groups, including groups "in which pts [patients] listen to music" and "educated on the date, weather and quote of the day..." from 2/12/16 to 2/22/16.

3. Patient B19

a. Patient B19 was admitted on 11/10/15. The "Psychiatric History & Mental Status Exam Reassessment" dated 11/10/15 included the diagnoses of "Schizoaffective Disorder bipolar type."

b. Patient B19's treatment schedule attached to the treatment plan assigned this patient to attend 1-3 leisure and/or psychoeducational groups Monday-Friday and leisure activities when offered on the weekend.

c. An Activity therapy note (1/21/16) documented, "Pt. (Patient) has been to 0/7 to (sic) groups. (Refused)."

d. An Activity therapy note (1/28/16) documented, "Pt. (Patient) has been to 0/8 groups."

e. The "Treatment Team Update" note dated 2/4/16 for Patient B19 stated "Patient refused most AT (Activity Therapy) groups, did come 1x (time) yesterday so [s/he] could go to special event next week. Pt. (Patient) usually stays in bed, room smells bad."

f. A review of the medical record and documentation provided by administration revealed that Patient B19 attended only a total of three (3) activities/groups (1 formal 1:1 session with a Clinical Counselor (assistant to nursing) and two (2) of 10 assigned activity therapy groups) from 1/21/16-2/22/16.

g. Even though this patient was not non-compliant with his/her treatment, the Master Treatment Plan for Patient B19 with most recent date of 12/1/15, failed to include alternative treatment (1:1 and/or groups) based on his/her current needs.

4. Patient C9

a. Patient C9 was admitted on 5/28/09. The "Psychiatric History & Mental Status Exam Reassessment" dated 6/16/15 included the diagnoses of "Schizophrenia, Cognitive Disorder Not Otherwise Specified."

b. Patient C9's treatment schedule attached to the treatment plan assigned this patient to attend 1 leisure and/or psychoeducational group Monday-Friday and leisure activities when offered on the weekend.

c. The Group Therapy Note dated 2/16/16 at 4:40 p.m. stated "Pt has attended 0/1 on lodge AT [activities therapy] group, refused x 1."

d. A review of the medical record and documentation provided by administration revealed that Patient C9 attended approximately only five (5) on-unit activity groups, including "putting puzzles together with peers" and "painting nails with peers," from 1/21/16 to 2/22/16.

5. Patient C16

a. Patient C16 was admitted on 2/1/06. The "Psychiatric History & Mental Status Exam Reassessment" dated 8/14/15 included the diagnoses of "Schizoaffective Disorder, Bipolar Type. Neurocognitive Disorder, Unspecified."

b. Patient C16's treatment schedule attached to the treatment plan assigned this patient to attend 1 leisure and/or psychoeducational group Monday-Friday and leisure activities when offered on the weekend.

c. The Group Therapy Note dated 2/16/16 at 4:30 p.m. stated "Pt has attended 0/1 on lodge AT [activities therapy] group, refused x 1."

d. A review of the medical record and documentation provided by administration revealed that Patient C16 attended only approximately nine (9) on-unit activity groups, such as "Bingo group," "coloring group," and "nail group," from 1/21/16 to 2/22/16.

6. Patient D1

a. Patient D1 was admitted on 9/24/04. The "Psychiatric History & Mental Status Exam Reassessment" dated 3/3/15 included the diagnoses of "Schizoaffective Disorder, Bipolar Type."

b. Patient D1's treatment schedule attached to the treatment plan assigned this patient to attend 1 Activity Therapy group on Fridays. On 2/3/16 the assignment of a "DPT group (frequency was not identified)" was added to (his/her) treatment plan. On 2/11/16 an intervention was added to (his/her) plan written as "Staff will interact with pt [patient] 1:1 and encourage pt to express feelings when (s/he) feels like harming (himself/herself)" Frequency was not identified.

c. A treatment plan update note (2/3/16) stated, "Pt [Patient] has decline (sic) on-lodge AT [Activity Therapy groups for past month, has attended none."

d. A review of the medical record and documentation provided by administration revealed that Patient D1 attended a total of 10 activities, including three (3) DBT groups, two (2) Activity Therapy groups and five (5) on-lodge groups (leisure and psychoeducational led by a Clinical Counselor (assistant to nursing) from 1/21/16-2/22/16. The only social work note provided as proof of treatment was a monthly progress note (2/11/16).

7. Patient D14

a. Patient D14 was admitted on 6/15/15. The "Psychiatric History & Mental Status Exam" dated 6/16/15 included the diagnoses of "Schizoaffective Disorder, Bipolar Type."

b. Patient D14's treatment schedule attached to the treatment plan assigned this patient to attend 1 Activity Therapy group on Fridays. The only additions to the treatment plan related to 1:1 or treatment groups were: On 2/16/16 an intervention stating "AT [Activity Therapy] groups will be designed & implemented..." and on 2/18/16 "Social Work will meet c/ pt [with patient] weekly to discuss how to (illegible word) + [positive] goals for the future."

c. A review of the medical record and documentation provided by administration revealed that Patient D14 attended a total of 26 activities/groups (an average of less than one a day), including 18 Activity Therapy groups, and eight (8) on-lodge groups (leisure and psychoeducational led by a Clinical Counselor (assistant to nursing) from 1/21/16-2/22/16.

B. Staff Interviews

1. During an interview with the Director of Activities on 2/23/16 at 10:00 a.m., she acknowledged that no documentation of active treatment was available for these patients other than episodic groups.

2. During an interview with the Director of Social Work on 2/23/16 at 2:00 p.m., she acknowledged that no documentation of active treatment was available for these patients other than episodic groups.

3. During an interview with the Director of Nursing on 2/23/16 at 3:00 p.m., he acknowledged that no documentation of active treatment was available for these patients other than episodic groups.

4. During an interview with the Medical Director on 2/23/16 at 11:15 a.m., she acknowledged that no documentation was available that active treatment was being provided for these patients.

II. Failure to provide sufficient individualized therapeutic modalities including evenings and weekends.

A. Document Review

A review of the "Patient Group Schedule" for each unit presented by the facility as the current programming schedules indicated no active treatment groups were provided Monday through Friday and on weekends. The only groups/activities were leisure activities every other weekend offered by an activity staff member. On 2 of the 4 lodges (G and K), 1-2 groups were offered by a Clinical Counselor (assistants to nursing); these groups were focused on leisure or psycho-education.

B. Staff Interviews

1. During interview with the Medical Director on 2/23/16 at 11:10 a.m. she stated, "Our treatment programming has room for improvement."

2. During an interview with the Director of Nursing on 2/23/16 at 3:00 p.m., he acknowledged that no treatment groups were provided on evenings or weekends.

III. Assess and treat the medical problems

Based on interview and record review, the facility failed to assess and treat the medical problems of one (1) of eight (8) sample patients (C16) in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health.

Findings include:

A. Record Review

1. Patient C16 was a 64 year-old admitted 2/1/06 with diagnoses of "Schizoaffective Disorder, Bipolar Type" and "Neurocognitive Disorder, Unspecified."

2. The "Physician Progress Note" written by FNP 2 on 1/26/16 at 1:05 p.m. stated "Staff reported pt [patient] hasn't been out of bed today and has temp [temperature] of 101.7. Pt. sleeping in bed through most of exam. Rhonchi throughout (pt not awake to cough), bases clear with good air movement. Pt with much nasal congestion. Flu swab negative. Pt spoke at times, but tried to remain sleeping. Pt's only c/o [complaint] is mid back pain. Recent UA [urinalysis] negative." "Diagnosis: URI [upper respiratory illness]."

3. The nursing note dated 1/26/16 at 1:20 p.m. stated that Patient C16 "...Felt warm to touch, T [temperature] 101.7. [FNP 2] notified & assessed. Lung sounds are coarse, rhonchi, tried to get pt [patient] to cough & clear. Pt tired and somnolent..."

4. The nursing note dated 1/26/16 at 9:30 p.m. stated "Temp [temperature] checked, 102.2 [degrees] F [Fahrenheit]." The nursing note dated 1/26/16 at 10:10 p.m. stated "Temp rechecked, Temp 101.5 [degrees] F." The nursing note on 1/27/1 at 4:33 p.m. stated "oral temp 102/100.3 axillary. Reported to [nurse manager] and [FNP 2]. Instructed to give ordered prn [as needed] Motrin and recheck & report [with] continued fever." The nursing note dated 1/27/16 at 6:30 p.m. stated "VS [vital signs] re [check]: 99.8 (oral), 99.6 (aux [axillary]), BP [blood pressure] 85/61 manual, pulse 99, respirations 22..." Continues to be vague about symptoms stating "I told you I just don't feel good." The nursing note on 1/28/16 at 11:00 a.m. stated "Pt is lethargic, lying in bed al shift, difficult to arouse." The nursing note dated 1/28/16 at 11:30 a.m. stated "VS: 99.7, P [pulse] 111, BP 105/58, O2 Sat [oxygen saturation] 88%...Pt warm to touch & lethargic. Drooling present. [decreased] appetite...assistant director of nursing services notified. Pt to be transported to [outside medical facility] via ambulance."

5. The Discharge Summary for Patient C16, dated 2/2/16, from the outside medical facility stated that Patient C16 was "noted to have a right upper lobe pneumonia" and presented with "cough and confusion" and "a temperature of 101.3 Fahrenheit."

6. No assessments of Patient C16's condition were documented by facility medical staff after 1/26/16 at 1:05 p.m. prior to Patient C16's transfer to the outside medical facility on 1/28/16 at 12:05 p.m. despite continued deterioration in the Patient C16's condition.

B. Staff Interviews

1. During an interview with the Director of Nursing on 2/23/16 at 3:00 p.m., he acknowledged that no documentation was available that indicated Patient C16 was assessed by a medical provider between 1/26/16 and the transfer of the patient to the outside facility on 1/28/16.

2. During an interview with the Medical Director on 2/23/16 at 11:15 a.m., she acknowledged that no documentation was available that indicated Patient C16 was assessed by a medical provider between 1/26/16 and the transfer of the patient to the outside facility on 1/28/16.

IV. Privacy for Patients

A. During review of documentation of the role of the Public Safety Officers and their care in the treatment of patients, reports of their specific functions carried out from January 21, 2016 through February 22, 2016 were reviewed. These reports revealed that during this period of time 19 of 24 female patients, including active sample Patient B7, were "patted down" by male Public Safety Officers during the contraband search at the time of admission.

B. Staff Interview:

1. During interview, with review of police reports, on 2/2316 at 9:10 a.m., Public Safety Officer 1 stated, "The male officers 'pat down' female patients for contraband as knives, guns." He described this procedure as "I run my hands down your back, run my hands around your waist and rub my hands down legs. It is observed on a camera. The nurse will watch through the window. This is a law enforcement procedure. We have been trained-it doesn't matter if it is a male or a female. I look at this from a law enforcement perspective. If a female officer is present, she does it (pats down)." He acknowledged that he was more comfortable if a female safety officer was available to "pat down" a female patient.

2. During interview with the Public Safety Officer Lieutenant on 2/23/16 at 9:35 a.m., she acknowledged that male police officers do "pat down" female patients and female officers do "pat down" male patients as a part of a search for weapons and contraband. She stated that the extent of the body search varied, "depending on the officer."

3. During interview on 2/23/16 at 3:05 p.m. the Director of Nursing acknowledged that "patting down" of patients by Public Safety Officers of the opposite sex could be a privacy issue. He reported, "I can see that based on the need to separate the role of law enforcement from clinical care, this (procedure) may not be appropriate."

V. Proper Use and Documentation of Seclusion/Restraints:

A. Patient A22

1. Patient A22 was secluded on 2/6/16 at 4:15 p.m. According to the physician's order, the patient was secluded for "threatening, aggressive behavior toward staff." Even though the RN progress notes at 7:00 p.m., 7:10 p.m. and failed to document behaviors supporting continued seclusion, the patient was retained in seclusion until 7:30 p.m. The 15-minute monitoring sheets documented that Patient A22 was asleep from 6:15 p.m. to 7:15 p.m.

In addition, the physician's order for the use of seclusion for Patient A22 listed "able to be verbally redirected" as a criteria for release from seclusion. This is not a behavior that reflects absence of an immediate treat of violence to self or others

2. Patient A22 was again secluded on 2/8/16 at 3:51 p.m. According an RN progress note, the patient was "assaultive/threatening." The 15-minute monitoring sheet failed to document behaviors indicating an immediate threat to self or others from 5:15 p.m. until the patient was removed from seclusion at 7:50 p.m.

B. Non-sample Patient B13 was secluded on 2/18/16 from 5:00 p.m. to 7:45 p.m. As documented in the physician's order, the patient was secluded for "aggressive/combative behavior: hitting staff." This order included "Severe disruption of the therapeutic milieu" as one of the reasons for the use of seclusion for this patient. This is not a behavior that justified use of this procedure.

In addition, this order listed "able to be verbally redirected" as a criteria for release from seclusion. This is not a behavior that reflects absence of an immediate treat of violence to self or others.

C. Non-sample Patient B18 was secluded on 2/4/16 at 4:15 p.m. Based on an RN progress note (4:10 p.m.) the patient swung fists at another patient and tried to kick this patient, and kicked a staff member. The last RN assessment note (7:20 p.m.) for this seclusion event stated, "At 7:00 p.m. pt. [patient] sitting on seclusion mattress talking to herself. (S/he) ate supper, drinking liquids and has been escorted to bathroom. Pt. [Patient] has no insight into why (s/he) is in seclusion." Even though this note failed to document behavior indicating immediate risk of violence, Patient B18 was retained in seclusion until 8:15 p.m.

In addition, review of the 15 minute monitoring sheets during this seclusion period failed to document any behavioral concern was documented as "yelling or screaming" at 6:45 p.m. The documentation on this form failed to support justification for continued seclusion of Patient B18.

D. Patient E1 was secluded on 2/16/16 at 9:50 a.m. As documented in the physician's order and the nursing note (9:50 a.m.) the patient was disruptive and disturbing the milieu. Neither of these reasons reflected an immediate risk of violence to self or others. The criteria for release included that the patient be "cooperative + [and] able to accept redirection." These behaviors do not reflect the absence of behaviors that are an immediate risk of violence to self/others. Even though Patient E1 was not removed from seclusion until 11:35 a.m. there were no behaviors documented in the nursing assessments, nor on the 15-minute monitoring sheet to justify the use of seclusion to prevent violence to self or others.

B. Staff Interviews

1. During an interview with review of seclusion documentation on 2/23/16 at 12:30 p.m., the Medical Director stated "We need to look at the justification for use of seclusion."

2. During an interview with review of seclusion documentation on 2/23/16 at 3:00 p.m., the Director of Nursing agreed that the monitoring sheets did not always document behaviors supporting the continued use of seclusion. He acknowledged that disruption of the milieu by the patient and the patient's inability to follow staff directions does not reflect an immediate risk of violence to self or others.

Based on observation, interview and document review, the facility failed to provide adequate clinical leadership in medical and nursing to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in B144 and lack of supervision of active nursing care delivered as documented in B148.

Based on observation, interview and record review, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Ensure that the Master Treatment Plans (MTPs) for five (5) of eight (8) active sample patients (A1, A28, B19, C9 and C16) were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 I)

II. Develop and document MTPs based on the individual needs of eight (8) of eight (8) active sample patients (A1, A28, B7, B19, C9, C16, D1 and D14). This failure resulted in the absence of specific plans to direct staff in the implementation, evaluation, and revision of care based on individual patient findings. (Refer to B118 II)

III. Provide active psychiatric treatment for seven (7) of eight (8) active sample patients (A1, A28, B19, C9, C16, D1 and D14) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125 I)

IV. Ensure that patients in the facility received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evening hours and on weekends. On evenings and weekends, no treatment groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge. (Refer to B125 II)

V. Assess and treat the medical problems of one (1) of one (1) active sample patients (Patient C16). Failure to address and respond to medical issues results in a potential risk to the health and lives of patients. (Refer to B125 III)

VI. Ensure privacy for patients during the hospitalization admission process. All patients were "patted down" during the contraband search by a Public Safety Officer. These searches were often conducted by a Public Safety Officer of the opposite sex. This results in failure to ensure that all patients are provided privacy and respect during the admission process (Refer to B125 IV)

VII. Appropriately use and document seclusion/restraint as an external control of violence toward self and others for 3 of 3 active non-sample patients (A22, B13, and B18) and one (1) of one (1) discharged patient (E1) reviewed for the use of seclusion. These patients were secluded without documented justification based on changing behaviors. The use of seclusion/restraints without documented justification that these external control procedures were used only in emergency situations resulted is a violation of the patients' right to be free from restraints. (Refer to B125 V)





25353

Based on observation, interview and document review, the Director of Nursing failed to:

I. Ensure nursing interventions were included in MTPs based on the individual needs of eight (8) of eight (8) sample patients (A1, A28, B7, B19, C9, C16, D1 and D14). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118 II)

II. Provide active psychiatric treatment for seven (7) of eight (8) active sample patients (A1, A28, B19, C9, C16, D1 and D14) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125 I)

III. Ensure privacy for patients during the hospitalization admission process. All patients were "patted down" during the contraband search by a Public Safety Officer. These searches were often conducted by a Public Safety Officer of the opposite sex. This results in failure to ensure that all patients are provided privacy and respect during the admission process. (Refer to B125 IV)

IV. Appropriately use and document seclusion/restraint as an external control of violence toward self and others for three (3) of three (3) active non-sample patients (A22, B13, and B18) and one (1) of one (1) discharged patient (E1) reviewed for the use of seclusion. Registered Nurses secluded patients without documented justification based on changing behaviors. The use of seclusion/restraints without documented justification that these external control procedures were used only in emergency situations resulted is a violation of the patients' right to be free from restraints. (Refer to 125 V)