HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure problems identified in the Infection Control program were addressed in the hospital's Quality Assurance Performance Improvement program.

Findings include:

Review on April 9, 2015, of the facility's "Performance Improvement/Risk Management Program," last reviewed May 2012, revealed "Purpose: To ensure all Hospital employees are aware of, understand, and support the Hospital's Performance Improvement/Risk Management efforts. Policy: It is the goal of this Hospital to provide treatment and services at the highest possible level of excellence and that each employee be [sic] aware of, and strive to achieve this goal. To assist in accomplishing this objective, a Performance Improvement/Risk Management Program has been established. Policies and procedures governing the administration of the Performance Improvement/Risk Management Program are contained in the attached Performance Improvement/Risk management Program Plan."

Review on April 9, 2015, of the facility's "Performance Improvement/Risk Management Program Plan," last reviewed May 2012, revealed "... 3. Organization and Responsibilities ... C. The following standing committees are an integral part of the hospital's Performance Improvement/Risk Management Program in that they report to the Executive Staff. Problems or potential problems, which are the concern of their respective committees, the actions taken for correction, and the outcome of the action; 1. Collaborative Practice Committee 2. Functional Safety and Management Committee 3. Human Rights Committee 4. Infection Control Committee 5. Information Management Committee 6. Pharmacy and Therapeutics Committee 7. Policy/Procedure Committee 8. Therapeutic Environment Committee 9. Treatment Planning Committee 10. Utilization Review Committee. ..."

Review on April 9, 2015, of the facility's Quality Committee Meeting Minutes for January 16, 2014, February 10, 2014, April 14, 2014, June 9, 2014, July 14, 2014, August 11, 2014, September 8, 2014, November 10, 2014, December 8, 2014, January 12, 2015, and March 9, 2015, revealed no documentation infection control was represented at the Quality Committee Meetings. There was no documentation the problems identified in the Infection Control program were addressed in the hospital's Quality Committee meetings.

Interview with EMP8 on April 9, 2015, at approximately 2:15 PM revealed the Infection Control officer did not attend the Quality Committee meetings or provide information for the Quality Committee meeting agenda.

Interview with EMP7, EMP8 and EMP9 on April 10, 2015, at approximately 10:45 AM confirmed there was no Infection Control representation at the Quality Committee meetings on the above dates and that Infection Control was not part of the agenda.

Based on review of facility documents, observation and staff interview (EMP) it was determined the dietary director failed to store food in a manner to protect it from contamination in the walk-in freezer.

Findings include:

Review on April 8, 2015, of facility policy "Receiving of Perishable Food," last reviewed March 20, 2015, revealed "1.0 Receiving of Frozen Food ... 1.5 Food packaging shall be inspected to ensure the box is sealed and was not tampered with. No damaged cases will be accepted. ... Policy/Procedure-Chilling, Storage, Reheating of Leftover Food Items 1.1 Leftover food items that are to be kept will be placed in the refrigerator immediately, covered and labeled with contents and the use by date. ..."

Observation at 12:00 PM on April 7, 2015, of the walk-in freezer revealed open packages of chicken breast filets, chicken nuggets, fish filets and breaded fish patties. These packages of food were not re-sealed to prevent contamination.

Interview of EMP5 and EMP6 at 12:00 PM on April 7, 2015, confirmed there were open packages of chicken breast filets, chicken nuggets, fish filets and breaded fish patties that were not re-sealed to prevent contamination.

Further interview of EMP5 and EMP6 at 1:30 PM on April 8, 2015, revealed the facility had no policy regarding re-sealing frozen bags of food after opening them.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure two physicians attended the Utilization Review Committee meetings for 10 of 10 meetings.

Findings Include:

Review on April 9, 2015, of the facility "Utilization Review Plan," last reviewed May 18, 2014, revealed "... 3. Organization The Utilization Review Committee is a multidisciplinary standing committee. The committee shall consist of at least two (2) physician representatives from the hospital, one of whom is knowledgeable or skilled in the diagnosis and treatment of psychiatric disorders. The Chief Executive Officer shall appoint physician members who have no financial interest in any hospital, and he/she shall designate one of these members as chairperson. The chairperson shall be a psychiatrist. ..."

Review on April 9, 2015, of the facility's Utilization Review Committee meeting minutes revealed one physician attended the following meetings: March 17, 2015, February 17, 2015, January 20, 2015, December 16, 2014, October 21, 2014, September 16, 2014, August 19, 2014, July 15, 2014, June 17, 2014 and May 2, 2014.

Interview of EMP3 and EMP4 at approximately 1:30 PM on April 9, 2015, confirmed that one physician attended the Utilization Review Committee meetings. EMP3 stated a second physician reviewed the information and provided a report. The second physician did not attend the meetings.

Based on review of facility documents, it was determined the facility failed to have a written agreement with an Organ Procurement Organization (OPO).

Findings include:

Review on March 10, 2015, of the facility's "Organ and Tissue Donations" policy, last reviewed May 2013, revealed "Purpose: To provide a procedure to staff on the methodologies to be instituted when a consumer has expressed the desire to be an organ and/or tissue donor upon death and for the procurement of organs and tissues for consumer deaths that occur at Danville State Hospital. ... Policy: It is the policy of Danville State Hospital to maintain compliance with all current accreditation/certification agency standards and conditions of participation. ... The Gift of Life Donor Program is the Organ Procurement Organization (OPO) designated and certified, pursuant to Federal Law, to serve as our regional procurement organization. The Gift of Life Program shall serve as the designated requester for organ and tissue procurement. A Memorandum of Agreement (MOA) with the OPO shall be kept on file in the Chief Executive Officer's (CEO) office at the hospital.

A request was made of EMP1 on April 7, 2015, and of EMP2 on April 10, 2015, for the facility's written agreement with an Organ Procurement Organization. No agreement was provided.

Cross reference
482.45(a)(5) Death Record Review

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to complete a periodic review between the Organ Procurement Organization (OPO) and the hospital death records.

Findings include:

Review on March 10, 2015, of the facility's "Organ and Tissue Donations" policy, last reviewed May 2013, revealed "Purpose: To provide a procedure to staff on the methodologies to be instituted when a consumer has expressed the desire to be an organ and/or tissue donor upon death and for the procurement of organs and tissues for consumer deaths that occur at Danville State Hospital. ... Policy: It is the policy of Danville State Hospital to maintain compliance with all current accreditation/certification agency standards and conditions of participation. Identification of consumer donors and review of consumer deaths (that occur within the hospital) for potential organ and tissue donation shall be completed to meet the needs of the individual and existing regulation. Procedure: ... Consumer Deaths That Occur at Danville State Hospital: 1. All consumer deaths that occur at Danville State Hospital shall be reported to the Gift of Life Donor Program. The Gift of Life Donor Program is the Organ Procurement Organization (OPO) designated and certified, pursuant to Federal Law, to serve as our regional procurement organization. The Gift of Life Program shall serve as the designated requester for organ and tissue procurement. A Memorandum of Agreement (MOA) with the OPO shall be kept on file in the Chief Executive Officer's (CEO) office at the hospital. ..."

Further review of this facility policy revealed no documentation of the frequency of periodic reviews of death records between the OPO and the hospital.

Interview with EMP2 on March 10, 2015, at approximately 12:00 PM confirmed the facility did not obtain reports from the OPO for periodic review of death records between the OPO and the hospital to improve identification of potential donors.

Cross reference
482.45(a)(1) OPO Agreement

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

I. Ensure that the Master Treatment Plans (MTPs) for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) 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 II)

II. Provide active psychiatric treatment for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients frequently failed to include alternative modalities such as 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)

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations included specific patient assets for eight (8) of eight (8) sample patients (A22, A24, B6, B16, E13, E28, F1 and F12). The failure to identify patient strengths impairs the treatment team's ability to choose treatment modalities that best utilize the patient's attributes in therapy.

Findings include:

A. Record Review

1. The Psychiatric Assessments presented by the facility for the following patients (dates in parentheses) did not document specific patient strengths:

a. Patient A22 (3/20/15), Patient A24 (6/9/15), and Patient E28 (9/23/15) documented no patient assets.

b. Patient B6 (6/23/15) documented only the non-specific assets, "[S/he] is able to express [his/her] needs. [S/he] is physically stable and [s/he] had responded to the treatment in the past."

c. Patient B16 (8/17/15) documented only the non-specific assets, "[S/he] is capable of providing advance directives, but [s/he] is unable to manage [his/her] financial affairs at this point."

d. Patient E13 (8/14/15) documented only the non-specific assets, "[S/he] gets SSI [social security income], $700 a month, does [his/her] own ADL's [activities of daily living], walks unassisted."

e. Patient F1 (3/17/15) documented only the non-specific assets, "[h/she] is physically healthy, has tenth grade school education. [His/her] mother is interested in [his/her] treatment and recovery. [S/he] is partially able to communicate meaningfully and has an ambition to become a park ranger."

f. Patient F12 (7/2/14) documented only the non-specific assets, "[His/her] communication is mostly goal-directed. Health situation seems to be in good status. [S/he] is mostly cooperative during the interview."

B. Staff Interview

During a review of the Psychiatric Assessments with the Medical Director on 11/17/15 at 3:00 p.m., he acknowledged that these Psychiatric Assessments did not contain specific patient assets that could be utilized for treatment planning.

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

I. Provide comprehensive Master Treatment Plans (MTPs) that documented individualized treatment interventions for eight (8) of eight (8) active sample patients. Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met. (See B122)

II. Ensure that the Master Treatment Plans (MTPs) for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities when patients refused or were unable to participate in the group therapies. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient A24

a. Patient A24 was admitted on 8/30/89. The annual Psychiatric Assessment dated 6/9/15 included the diagnosis of "Schizophrenia, Undifferentiated Type, Chronic." The Master Treatment Plan dated 4/29/15, revised 10/14/15 identified the psychiatric problems as: "Paranoid Ideation" and "ADL [activities of daily living] Deficits," and "Medication Education."

b. The groups listed on patient A24's updated Master Treatment plan, dated 10/14/15, for Paranoid Ideations were as follows: "Remember When, What Should I Do, Women's Health, Living Spaces Maintenance, Lifestyle Changes for Healthy Weight, and Health/Safety," "Social Skills, Remotivation, Life skills, Stress Management Skills and Dayroom Diversion," "Leisure Skills group and Music As Self Expression."
For the problem of ADL [Activities of Daily Living], the groups were as follows: "Personal Hygiene, Foot Care, Dining Skills, Oral Care, and Personal Enhancement group."

c. A review of the Consumer Services Record from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient A24, showed the following information on Patient A24's attendance from 10/1/15 through 10/30/15:

Occupational Services program - Remotivation group - Zero attendance for four (4) of four (4) groups held that month. Social skills group - zero attendance of 4 held, and Dayroom Diversion - zero attendance of four (4) groups held, and Stress Management Skills - zero attendance of three (3) groups held that month. For the month of November from 1-16/1, Stress Management Skills group-zero attendance for three (3) of three (3) groups held to date, Remotivation group - zero of two (2) groups held to date, Social Skills group - zero of two (2) groups held to date, and Dayroom Diversion - zero attendance of three (3) group held so far this for the month.

Nursing groups - For the month of October/2015, patient A25 attended zero of four (4) groups held on Health/Safety Issues, zero of four (4) groups of lifestyle Changes for Healthy Weight, zero of 28 groups of Oral Healthcare, zero of four (4) groups of Remember When and zero of four (4) groups on "What Should I Do." The Psychology Progress Note, dated 11/13/15 at 11:43 a.m., stated, "[Name of patient] attended 0 out of 4 scheduled individual psychotherapy sessions this report period." No documentation regarding attendance or participation in other groups was available.

c. The Master Treatment Plan for Patient A24 indicated no revision to the interventions to address the needs of Patient A24 despite not participating in group therapy.

2. Patient E13

a. Patient E13 was admitted on 8/12/15. The Psychiatric Assessment dated 8/14/15 included the diagnosis of "Schizophrenia, Paranoid Type." The Master Treatment Plan dated 8/21/15, revised 11/13/15 identified the psychiatric problems as: "Psychosis" and "Medication Education."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 19 assigned groups and one (1) individual session per week. No therapeutic activities were listed for evenings or Sundays. Active treatment groups to be provided by occupational therapy included the following: "Dayroom Diversion," "Walk & Talk," "Exercise I," and "Leisure Skills." Groups to be provided by nursing included the following: "Remember When," "Health Safety Issues," "Interaction Group," "Resource Skills," "Personal Hygiene," "Relationships Group."
Groups to be provided by therapeutic recreation included the following: "Video Group" and "Rhythm and Motion." A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient E13, revealed that Patient E13 attended only 10 out of 16 occupational therapy groups during this period. A review of the psychology progress note dated 11/6/15 at 1:00 p.m. indicated that Patient E13 attended only 2 individual therapy sessions during this period. No documentation regarding attendance or participation in other groups was available.

c. The Master Treatment Plan for Patient E13 indicated no revision to the interventions to address the needs of Patient E13 despite not participating in group therapy.

3. Patient E28

a. Patient E28 was admitted on 3/12/84. The annual Psychiatric Assessment dated 9/23/15 included the diagnoses of "Schizophrenia, Disorganized Type" and "Pica." The annual Master Treatment Plan dated 10/27/15 identified the psychiatric problems as: "Psychosis" and "Activities of Daily Living (ADL)."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 33 assigned groups. Active treatment groups to be provided by occupational therapy included the following: "Dayroom Diversion," "Remotivation," and "Individual OT Session." Groups to be provided by nursing included the following: "Remember When," "Health Safety Issues," "Personal Hygiene," "Oral Health Care," "Lifestyle Changes for a Health Weight," "Unit Based Leisure Group," "Laundry Program," "What Should I Do," "Nutrition/Dining Skills," "Remember When,"
and "Living Space Maintenance." A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient E28, revealed that Patient E28 attended only 10 out of 13 occupational therapy groups during this period. The summary of group attendance provided by therapeutic recreation staff stated that Patient E28's attendance and participation in therapeutic recreation groups from 10/16/15 to 11/15/15 was as follows: "October 20, 21, 22 - refused/did not attend," "October 24 - participating not at treatment level, i.e. did not meet goal," "Oct 27, 28 - refused/did not attend," "Oct 29 - participating at treatment level, met treatment goal," "Oct 31 - refused/did not attend." No documentation regarding attendance or participation in other groups was available.

c. The Master Treatment Plan for Patient E28 indicated no revision to the interventions to address the needs of Patient E28 despite Patient E28's inability to participate in group therapy.

4. Patient F1

a. Patient F1 was admitted on 3/5/13. The Psychiatric Assessment dated 3/17/15 included the diagnoses of "Bipolar Disorder, Type I," "Polysubstance Dependence," "ADHD [attention deficit hyperactive disorder]," "Learning Disorder," and "Personality Disorder, Not Otherwise Specified." The Master Treatment Plan dated 2/27/15, revised 11/5/15, identified the psychiatric problems as: "Aggression" and "Social Skills Deficit."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 23 assigned groups per week. No therapeutic activities were listed for evenings or Sundays. Active treatment groups to be provided by occupational therapy included the following: "What's Happening to Me," "Chit-Chat," "Life Skills," "Anything Goes," and "Stress Management." Groups to be provided by nursing included the following: " Remember When," "Health Safety Issues," "Lifestyle Changes for Healthy Weigh," "Laundry Program," "Men's Health," "What Should I Do," "Personal Hygiene," "Medication Management." Groups to be provided by therapeutic recreation included the following: "Video Technology" and "Rhythm and Motion Clinic." A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient F1, revealed that Patient F1 attended only 11 out of 17 occupational therapy groups during this period. The summary of group attendance provided by therapeutic recreation staff stated that Patient F1's attendance and participation in therapeutic recreation groups from 10/16/15 to 11/15/15 was as follows: "October 16, 23, and 30 - excused due to unit restriction," "November 6 - refused to attend 'not feeling well,' " and "November 13 - attended, pro-social behavior, appropriate interactions with peers and staff. Left 10 minutes early due to 'tooth hurts."
No documentation regarding attendance or participation in other groups was available.

B. Staff Interviews

During an interview with the Medical Director on 11/17/15 at 3:00 p.m., he acknowledged that these Master Treatment Plans were not revised despite the inability or refusal of these patients to participate in group therapies.

Based on record review and interview, the facility failed to ensure that the treatment plan interventions for eight (8) of eight (8) active sample patients (A16, A24, B6, B22, E13, E28, F1 and F12) consistently addressed their specific treatment needs. The listed interventions on the Master Treatment plans [MTPs] were stated as generic, discipline functions. Many of the interventions were the same or similar, regardless of the specific problems of each patient. In addition, three (3) of eight (8) active sample patients (B22, E13 and F1) had an intervention for a physical hold if the patient displayed an aggressive type behavior. The planned use of restraints is a violation of patient rights and should not be considered a routine part of care. These failures result in a lack of staff coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Facility policy, # 100.115N, titled "Treatment Planning Process," dated 12/13, stated: "The treatment planning process is designed to aid in the provision of quality psychiatric care for consumer at [name of facility]. The development of an Individual Treatment Plan [ITP] will be in compliance with the standards as set forth by all regulatory bodies."..."Each assigned consumer [patient] receives treatment in accordance with regulations, policies, practices, standards and privileges that are relevant to consumer treatment." The policy did not address specific components of the MTP, such as goals and interventions.

2. Patient A16

The MTP, dated 8/19/15, listed the following generic and routine discipline functions for the problem "Borderline - SIB [self-injurious behavior]" (The "Behavioral Definition" was- "Continues to engage in SIB such as swallowing objects [i.e. batteries, eyeglasses], cutting [inserting bra underwire into self], and re-aggravating existing injuries [pulling suture while prying open the wound and inserting objects into wounds]"): "SW [social worker] will meet individually with [name of patient] at least monthly or as concerns arise. SW will focus on assisting [name of patient] in utilizing coping skills to lessen SIB towards self and aggression toward others. SW will maintain contact with family & [and] BSU [Basic Service Unit- a state agency] to discuss status & dc [discharge] planning."

"NSG [nursing] will include [name of patient] in activities to promote stable mood & positive use of coping skills. These groups include the following: laundry, personal hygiene, Women & Health Issues, Nutrition/Dining skills, Health & Safety, Living Space Maintenance and Medication Management."

"TR [Therapeutic Recreation] will include [name of patient] in Leisure Group & Unit Based Leisure as per program schedule to assist him/her in exploring positive outlets for day to day stressors."

"Chapliancy [sic] will include [name of patient] in Spirituality group as per program schedule to promote spiritual exploration."
"Psych staff will meet with [name of patient] for coaching and support as per program schedule."
"Psychiatrist will provide individual supportive therapy, medication education, and order special levels of observation as needed to provide for the safety of patient and others."
"Psychologist will include [name of patient] in individual psychotherapy to promote emotion and mood regulation through CBT/DBT [Cognitive Behavioral Therapy/Dialectical Behavioral Therapy] approaches."
The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

3. Patient A24

The MTP, dated 10/14/15, listed the following generic and routine discipline functions for the problem "Paranoid Ideation" (The "Behavioral Definition" was - "[Name of patient] refused to cooperate with routine physical examinations, medications, treatment programs based on his/her paranoid beliefs. S/he believes that there is a radio that broadcast thoughts and waves into his/her room. [Name of patient] has withdrawn from social interaction and does not attend groups or other activities. S/he can be verbally hostile and get loud on the unit preventing social intervention"):

"Nursing will include [name of patient] in Remember When, What Should I Do, Women's Health, Living Space Maintenance, Lifestyle Changes for Healthy Weight, and Health/Safety Issues groups as per program schedule to improve interventions with others."

"Nursing staff will sit and talk 1:1[one to one] with [name of patient] when s/he refuses to attend scheduled programs to encourage him/her participation in unit routine."

"SW will meet with [name of patient] individually once per month to encourage the discussion of needs in a really clear manner. SW will also meet with [name of patient] individually to review and discuss his/her financial statements that the guardian officer sends him/her once a month. This worker will assist [name of patient] with his/her discharge which involves filling out housing applications, financial applications and identifying services that s/he could utilize when in the community."

"OT will include [name of patient] in Social Skills, Remotivation, life Skills, Stress Management Skills, and Dayroom Diversion groups, as per program schedule, to increase socialization."

"TR will include [name of patient] in Leisure Skills group, as per program schedule, to assist in creating positive interactions with others."

There was no psychiatrist intervention for this problem.

For the problem of "Medication Education," the "Behavioral Definition" was "[name of patient] does not acknowledge the need for medication and has little interest in learning his/her medication or their uses." The interventions were:

"Nursing will encourage [name of patient] to accept medication as per dr's [doctor's] order to stress the importance of compliance."

"The psychiatric provider [psychiatrist] will monitor medications for mental health symptoms to promote improved thinking and behavior."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

4. Patient B6

The MTP, dated 10/23/15, listed the following generic and routine discipline functions for the problem "Self-Injurious Behavior" (The "Behavioral Definition" was - "[Name of patient] makes frequent suicidal attempts and threats of SIB is [sic] his/her needs are not met or acknowledged quickly. [Name of patient] has engaged in a variety of self-destructive behaviors: deep cuts on his/her arms, tied scrubs around his/her neck, put a pillow over his/her head, and bangs his/her head"):

"SW will meet individually with [name of patient] at least monthly or as concerns arise. SW will focus using skills to become free of SIB. The SW will maintain contact with family and BSU and provide all placements regarding [sic] status and discharge plans. SW will arrange LOAs [Leave Of Absence] and trial visits and assist with all legal and financial matters."

"TR will include [name of patient] in the following groups: Interaction, Creative Arts, Exercise I, and Rhythm and Motion and Newsmakers, per program schedule, in order to increase his/her use of constructive coping skills."

"OT will include [name of patient] in the following groups: Media, Exercise I, and Pet Companion, per program schedule, to provide him/her with new methods for coping through functional tasks."

Psychiatrist - "[Name of patient] medications will be prescribed, monitored, and adjusted to promote behavior stability and eliminate SIB."

"Nursing will follow the SLO [Special Levels of Observation] order as per physician order to maintain safety and stability."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

5. Patient B22

The MTP, dated 9/28/15, listed the following generic and routine discipline functions for the problem "Psychosis" (The "Behavioral Definition" was - "[Name of patient] has a long history of paranoid thinking and reactions and a general distrust of others that has resulted in aggressive behaviors. S/he has harmed his/her mother and punched him/herself in the genitals. S/he ripped papers off the bulletin board at the [name of facility] and set fire to it as well. [Name of patient] has a history of religious preoccupation. In the last year, [name of patient] continues to cognitively decline. S/he has had several AWOL [Absent Without Leave] attempts. S/he follows people out the door. S/he does not consistently follow verbal prompts to ensure the safety of him/herself and others. Becomes hostile and aggressive when his/her requests are not met immediately"):

"Nursing will include [name of patient] in Personal Hygiene, Living Space Maintenance groups, as per program schedule to help him/her focus on reality and engage in safe behaviors. Nursing will provide one (1) to one (1) supervision for safety any time AWOL is attempted."

"TR will include [name of patient] in Swimming/Bowling as per program schedule to promote focus on reality and safe behavior choices."

"OT will include [name of patient] in Problem Solving, Remotivation, Environmental Awareness, Sense of Group, as per program schedule, to promote positive interactions in a safe environment."

Psychiatrist - "At times of redirection agitation / mood instability, verbal redirection will be attempted. If verbal redirection is unsuccessful, a physical hold or stat medication may be given for safety & special levels of observation may also be ordered safety."

The interventions on using physical holds as a mode of treatment cannot be used as it prevents patient's rights of patients for freedom of motion per State and federal regulations.

For the problem of "Medication Education" the "Behavioral Definition" was - "[name of patient] has a history of not acknowledging the need for medication and has been non-adherent with treatment and medication in the past," The generic and routine discipline functions for the problem of medication education were:

Nursing - "Will review [name of patient] medications with him/her at medication pass to help him/her learn their names, uses and importance."

Psychiatrist - "Will monitor medications for mental health symptoms to promote improved thinking and behavior."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

6. Patient E13

The MTP, dated 11/13/15, listed the following generic and routine discipline functions for the problem "Psychosis" (The Behavioral Definition "was - [name of patient] voices bizarre content of thought (my name is not [name of patient], asked if/ stated others were going to kill him/her), perceptual disturbance, visual and auditory hallucinations, saw his/her dead sister, reported hearing television speaking to him/her. Extreme agitation, including a high degree of irritability, anger, unpredictability or impulsive physical acting out. [Name of patient] destroyed his/her father's television and threatened his/her father, pushed a peer at [name of facility]. Has a history of AWOL from [name of facility]. [Name of patient] hid medication and stated s/he took an overdose of Thorazine 'to die' but now does not want to":
"TR will offer interaction, Video, Resource Skills, Relationships, Sing-A-Long, & Rhythm & Motion groups per program schedule to promote reality based interactions."
"SW will meet with [name of patient] on a 1:1 regular basis for the first 8 weeks to discuss his/her progress and concerns. The social worker will meet with [name of patient] every month thereafter to engage in reality based discussion to promote reality based thinking. In addition, social worker will encourage [name of patient] to discuss his/her interests and positive plans for discharge. BSU and family communications will be maintained."
Nursing - "At times of increased mood instability, agitation, verbal redirection will be attempted. If verbal redirection is unsuccessful a physical hold may be initiated or stat medication may be given for safety. Special levels of observation may also be ordered for safety." This intervention on using physical holds as a mode of treatment is prohibited by state and federal regulations.

"Nursing will include [name of patient] in Personal Hygiene, Laundry individually [sic], as per program schedule, to promote focus on daily living skills."

Psychiatrist - "At times of increased instability, agitation, self-harm statements, verbal redirection will be attempted. If verbal redirection is unsuccessful a physical hold may be initiated or stat medication may be given for safety. Special levels of observation may be ordered for safety." This intervention on using physical holds is not permitted under state and federal regulations.
"OT will offer Exercise, Dayroom Diversion, Walk & Talk, and Leisure Skills group, as per program schedule to promote reality based interactions."
"Psychology will offer individual sessions, as per program schedule to promote understanding of the effects of treatment and promote reality based interactions."
The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

7. Patient E28

The MTP, dated 10/27/15, listed the following generic and routine discipline functions for the problem "Psychosis" (The Behavioral Definition "was - [name of patient] can experience [sic] agitation with staff and peers. S/he will often growl and place him/herself onto the floor. S/he is also known to act impulsively by physically acting out toward staff and consuming inedible objects around him/her. [Name of patient] will over drink fluids without staff prompting. Redirection from staff is inconsistently effective to manage [name of patient's] behavior and his/her safety"):

"Nursing will include [name of patient] in Living Space Maintenance, Personal Enhancement, What Should I Do, Nutrition and Dining Skills, Personal Hygiene, Laundry Program, Oral Health Care, Remember When, Health Safety Issues and Issues and Lifestyle Changes for a Healthy Weight, as per program's schedule to encourage interaction with his/her environment and improved personal skills."

"Psychiatrist will order SLO as needed to promote safety of consumer and others." "Social worker will meet with [name of patient] on 1:1 basis at least once a month to encourage improved behavior choices and maintain family BSU contacts to assist in discharge planning when recommended."

"OT will include [name of patient] in Individual OT session, Remotivation, and Dayroom Diversion, as per program schedule to increase appropriate social behavior."
"Nursing will provide q [every] 15 minute checks x24 hours, per physician orders, and 1:1 when in the bathroom for safety."
"TR will include [name of patient] in Unit Based Leisure Skills per program schedule to promote appropriate behavior through the use of structured leisure activities."
The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

8. Patient F1

The MTP, dated 11/5/15, listed the following generic and routine discipline functions for the problem "Aggression" (The Behavior Definition "was - [name of patient] has numerous episodes of aggression [one-arm choke holds on peer and staff], SIB [burning self with cigarette], as well as destruction of property [CD players, radios, headphones]. [Name of patient] has pending legal charges for seriously injuring staff at [name of facility] with choke hold"):
"Social work will meet with [name of patient] on 1:1 basis at least one time per month to discuss the use of coping skills when agitated. SW will act as a liaison to the BSU and family and provide updates on treatment status and readiness for discharge."
Psychiatrist - "When [name of patient] becomes angry and/or agitated, staff will use verbal redirection. If this is ineffective, the MD [doctor] will write an order and [name of patient] will be held for safety. If necessary, [name of patient] will be put on SLO per MD's orders. When at risk for assaultive behavior, [name of patient] will be on 15 minute checks to maintain safety." This intervention on using physical holds is not permitted under state and federal regulations

Psychiatrist - "[Name of patient] will have a locked door order from 0630 - 1500, Monday through Sunday, for safety."

Nursing - "[Name of patient] may not enter the hallway to bathroom without 2:1[two staff to 1 patient] staff and may not go past the fire doors when in bathroom to ensure the safety of him/herself and others."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

9. Patient F12

The MTP, dated 10/27/15, listed the following generic and discipline functions for the problem "Psychosis" (The "Behavioral Definition" was - "bizarre content of thought, expressed paranoid delusions believes s/he is being persecuted by neighbors & the FBI [Federal Bureau of Investigation]. S/he was also making phone calls to the police & FBI. S/he claimed the Jewish mafia implanted a devise in his/her throat to control him/her. S/he has a history of claims that s/he sends & receives messages & is religiously preoccupied"):
Nursing - "As per program schedule NSG [nursing] will include [name of patient] in the following groups to promote reality based functioning. These groups include Help, Personal Hygiene, Laundry & Living & Living Space Maintenance."
"As per program schedule OT will include [name of patient] in the following groups to promote reality based focus. These groups include: Recycling, Chit Chat, What's Happening to Me, Walk & Talk, Stress Management & Communication Skills."
"As per program TR will include [name of patient] at the following groups to promote relevant involvements while pursuing leisure pursuits. These groups include: Newspapers & Walk &Talk."
"SW will meet with [name of patient] 1 time weekly and then monthly to engage [name of patient] in reality based conversation & contact BSU regarding progress and potential for discharge as needed."

For the problem of "Medication Education" (The "Behavioral Definition" was - "Does not acknowledge s/he has a mental health diagnosis & has reported an overdose in the past on his/her medication."), the generic and routine discipline functions were:
"Nursing will encourage consumer to accept medications as per DR ' s order and stress the importance of adherence."
"The unit psychiatrist will prescribe medication and monitor mental health symptoms to promote improved thinking."
The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

B. Interviews

1. During an interview with MD 3 on 11/17/15 at 12:20 p.m., she acknowledged that interventions on the treatment plans to be provided by the psychiatrists were generic and not specific to patients.

2. During an interview with MD 2 on 11/17/15 at 12:40 p.m., she acknowledged that interventions on the treatment plans to be provided by the psychiatrists were generic and not specific to patients.

3. During an interview on 11/17/15 at 1:10 p.m., the generic and routine discipline interventions on the MTPs was discussed with the Director of Psychology, who was heading a committee to work on creating more individualized treatment plans. She stated, "We know interventions have to be specific and we know ours aren't."

4. During an interview with the Director of Social Work on 11/17/15 at 2:40 p.m., she acknowledged that interventions to be performed by social workers were generic and not specific to the individual patient.

5. During an interview with the Medical Director on 11/17/15 at 3:00 p.m., he acknowledged that interventions to be performed by psychiatrists were generic and not specific to the individual patient.

Based on observation, interview, and document review, the facility failed to provide active psychiatric treatment for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients frequently failed to include alternative modalities such as 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.

Findings include:

A. Patient A24

1. Observation

Patient A24 was observed sitting in a chair in the hallway of unit 311 on 11/16/15 at 10:45 a.m. with eyes closed. When asked if patient A24 had any groups scheduled at this time, RN 1 stated, "No. Most of the patients are at an off unit group and A24 is not assigned to that one."

2. Record Review

a. Patient A24 was admitted on 8/30/89. The annual Psychiatric Assessment, dated 5/11/15, stated that Patient A24 was admitted from a group home on an involuntary petition. "[Name of patient] remains on unit 311 on a 305 involuntary commitment."... "[Name of patient] has a long history of schizophrenia, undifferentiated type and also struggles with medical problems to include severe kyphosis of his/her cervical and thoracic spine, as well as scoliosis. This causes him/her significant difficulty with ambulating and s/he walks in a bent-over position with his/her head nearing the floor. This is his/her sixth admission to [name of facility] and this stay has been quite lengthy. S/he has had psychiatric issues since the age of 41 and has been institutionalized in psychiatric units most of his/her life. When not hospitalized psychiatrically, s/he has been in structured settings such as mental health group homes with exception of a few years of time. In 1987, s/he was admitted from [name of county] where s/he resided in a group home. Symptoms at that time included looseness of associations, bizarre behavior, yelling, agitation, paranoid ideation, medication noncompliance and lack of attendance to personal hygiene." ..." Review of his/her medical record reveals that s/he continues with intermittent irritability, verbal abuse and hostility, especially during times of transition such as returning to the unit from meals or when s/he is forced to shower, bathe, which s/he dislikes. Most of the time, s/he is sitting in a lounge chair in the hallway commenting to passerby. S/he refuses to participate in groups."

b. The groups listed on patient A24's updated Master Treatment plan, dated 10/14/15, for the problem of "Paranoid Ideations" were as follows: "Remember When, What Should I Do, Women's Health, Living Spaces Maintenance, Lifestyle Changes for Healthy Weight, and Health/Safety," "Social Skills, Remotivation, Life skills, Stress Management Skills," "Dayroom Diversion," "Leisure Skills group" and "Music As Self Expression." For the problem of "ADL [Activities of Daily Living]," the groups were as follows: "Personal Hygiene, Foot Care, Dining Skills, Oral Care," and "Personal Enhancement group."

c. A review of the Consumer Services Record from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient A24, showed the following information on Patient A24's attendance from 10/1/15 through 10/30/15:
Occupational Services program - Remotivation group - Zero attendance for four (4) of four (4) groups held that month. Social skills group - zero attendance of 4 held, Dayroom Diversion - zero attendance of 4 groups held, and Stress Management Skills - zero attendance of three (3) groups held that month. For the month of November from 1-16/15, Stress Management Skills group-zero attendance for three (3) of three (3) groups held to date, Remotivation group - zero of two (2) groups held to date, Social Skills group - zero of two (2) groups held to date, and Dayroom Diversion - zero attendance of 3 group held so far this month.

Nursing groups - For the month of October/2015, patient A25 attended zero of four (4) groups held on Health/Safety Issues, zero of four (4) groups of lifestyle Changes for Healthy Weight, zero of 28 groups of Oral Healthcare, zero of 4 groups of Remember When and zero of four (4) groups of "What Should I Do." The Psychology Progress Note, dated 11/13/15 at 11:43 a.m., stated, "[Name of patient] attended 0 out of four (4) scheduled individual psychotherapy sessions this report period." No documentation regarding attendance or participation in other groups or alternative treatments was available.

B. Patient E13

1. Observation

a. During observation of the scheduled "Lifestyle Changes for a Healthy Weight" on 11/17/15 at 10:30 a.m., Patient E13 was observed reading a book during the group. Patient E3 was not participating in the group process.

b. During observation of the scheduled "Remembering When" group on 11/17/15 at 1:15 p.m., Patient E13 was observed reading a book during the group. Patient E13 was not participating in the group process.

2. Patient Interview

During an interview with Patient E13 on 11/16/15 at 11:20 a.m., Patient E13 stated "basically therapy time is over at 3 p.m." Patient E13 stated "at night I read books, the Bible...and walk around and talk to other patients." Patient E13 stated that "I sleep in" and "take smoke breaks" on weekends. Patient E13 stated that activities staff conducted leisure activities every night at 7:00 p.m., but stated "I haven't been [to the leisure groups] in a while." Patient E13 stated that s/he only met with his/her social worker "when she has something" for Patient E13. S/he stated "if she has something, she stops me in the hall."

3. Record Review

a. Patient E13 was admitted on 8/12/15. The Psychiatric Assessment dated 8/14/15 included the diagnosis of "Schizophrenia, Paranoid Type." The Master Treatment Plan dated 8/21/15, revised 11/13/15 identified the psychiatric problems as: "Psychosis" and "Medication Education."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 19 assigned groups and 1 individual session per week. No therapeutic activities were listed for evenings or Sundays. Active treatment groups to be provided by occupational therapy included the following: "Dayroom Diversion," "Walk & Talk," "Exercise I," and "Leisure Skills." Groups to be provided by nursing included the following: "Remember When," "Health Safety Issues," "Interaction Group," "Resource Skills," "Personal Hygiene," "Relationships Group." Groups to be provided by therapeutic recreation included the following: "Video Group" and "Rhythm and Motion."

c. A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient E13, revealed that Patient E13 attended only 10 out of 16 occupational therapy groups during this period. A review of the psychology progress note dated 11/6/15 at 1 p.m. indicated that Patient E13 attended 2 individual therapy sessions during this period. No documentation regarding attendance or participation in other groups or alternative treatments was available.

C. Patient E28

1. Observation

During observation of the scheduled "Lifestyle Changes for a Healthy Weight" on 11/17/15 at 10:30 a.m., Patient E28 was observed sitting in the group, making grunting and mumbling noises and eating pudding. Patient E28 did not participate in the group process.

2. Patient Interview

During an attempted interview on 11/16/15 at 10:20 a.m., Patient E28 did not appear to be able to communicate verbally in an intelligible manner. Patient E28 mumbled unintelligibly when asked questions and made frequent grunting sounds. Patient E28 did not follow simple verbal commands.

3. Record Review

a. Patient E28 was admitted on 3/12/84. The annual psychiatric Reassessment dated 9/23/15 included the diagnoses of "Schizophrenia, Disorganized Type" and "Pica." The Annual Master Treatment Plan dated 10/27/15 identified the psychiatric problems as: "Psychosis" and "Activities of Daily Living (ADL)."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 33 assigned groups. Active treatment groups to be provided by occupational therapy included the following: "Dayroom Diversion," "Remotivation," and "Individual OT Session." Groups to be provided by nursing included the following: "Remember When," "Health Safety Issues," "Personal Hygiene," "Oral Health Care," "Lifestyle Changes for a Health Weight," "Unit Based Leisure Group," "Laundry Program," "What Should I Do," "Nutrition/Dining Skills," "Remember When," and "Living Space Maintenance."

c. A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient E28, revealed that Patient E28 attended only 10 out of 13 occupational therapy groups during this period. No documentation regarding Patient E28's ability to participate in groups was available. The summary of group attendance provided by therapeutic recreation staff stated that Patient E28's attendance and participation in therapeutic recreation groups from 10/16/15 to 11/15/15 was as follows: "October 20, 21, 22 - refused/did not attend," "October 24 - participating not at treatment level, i.e. did not meet goal," "Oct 27, 28 - refused/did not attend," "Oct 29 - participating at treatment level, met treatment goal," "Oct 31 - refused/did not attend." No documentation regarding attendance or participation in other groups or alternative treatments was available.

D. Patient F1

1. Observations

a. During observation on 11/16/15 at 2:10 p.m., Patient F1 was scheduled for the "Video Technique" Group. Patient F1 was observed sitting the unit hallway with a pillow and a coat over his/her head at the time of this group.

b. During observation on 11/17/15 at 10:40 a.m., Patient F1 was scheduled for the "What's Happening to Me" group. Patient F1 was observed sitting the unit hallway with a coat over his/her head at the time of this group.

c. During observation on 11/17/15 at 1:20 p.m., Patient F1 was scheduled for the "Remembering When" group. Patient F1 was observed sitting the unit hallway with a coat over his/her head at the time of this group.

2. Record Review

a. Patient F1 was admitted on 3/5/13. The Psychiatric Assessment dated 3/17/15 included the diagnoses of "Bipolar Disorder, Type I," "Polysubstance Dependence," "ADHD [attention deficit hyperactive disorder]," "Learning Disorder," and "Personality Disorder, Not Otherwise Specified." The Master Treatment Plan dated 2/27/15, revised 11/5/15 identified the psychiatric problems as: "Aggression" and "Social Skills Deficit."

b. The "Therapeutic Activity Schedule" dated 10/30/15 listed 23 assigned groups per week. No therapeutic activities were listed for evenings or Sundays. Active treatment groups to be provided by occupational therapy included the following: "What's Happening to Me," "Chit-Chat," "Life Skills," "Anything Goes," and "Stress Management." Groups to be provided by nursing included the following: "Remember When," "Health Safety Issues," "Lifestyle Changes for Healthy Weigh," "Laundry Program," "Men's Health," "What Should I Do," "Personal Hygiene," and "Medication Management." Groups to be provided by therapeutic recreation included the following: "Video Technology" and "Rhythm and Motion Clinic."

c. A review of the "Consumer Services Record" from 10/16/15 to 11/15/15, presented by the facility as the record of active treatment groups for Patient F1, revealed that Patient F1 attended only 11 out of 17 occupational therapy groups during this period. The summary of group attendance provided by therapeutic recreation staff stated that Patient F1's attendance and participation in therapeutic recreation groups from 10/16/15 to 11/15/15 was as follows: "October 16, 23, and 30 - excused due to unit restriction," "November 6 - refused to attend 'not feeling well," and "November 13 - attended, pro-social behavior, appropriate interactions with peers and staff. Left 10 minutes early due to 'tooth hurts." No documentation regarding attendance or participation in other groups or alternative treatments was available.

E. Staff Interviews

1. During an interview on 11/17/15 around 11:15 a.m., the lack of active treatment measures and failure to attend assigned groups for patient A24 was discussed with MD 1. Her reply was, "S/he's very tough. S/he's been this way a long time."

2. During an interview with MD 2 on 11/17/15 at 12:40 p.m., he stated that group therapy would not be useful for Patient E28. He stated that Patient E28 required "total ADL's by staff" and required "one staff to take care of him."

3. During an interview with the Chief Social Services Executive on 11/17/15 at 8:40 a.m., she stated that staff "approach and request [patients] to go [to groups] but that's about as far as it goes" to ensure patients attend treatment groups. She stated that Patient E28 was "functioning at an ID [intellectual disability] level" and had "a lot of ADL [activities of daily living] issues."

4. During an interview with the Director of Nursing on 11/17/15 at 9:30 a.m., she acknowledged that no alternative treatments were offered to patients when they refused to attend assigned groups. She stated that the only intervention to address refusal to attend groups was "encouragement." The Director of Nursing acknowledged that Patient E28 was unlikely to benefit from the assigned group therapies due to Patient E28's cognitive abilities.

5. During an interview with the Medical Director on 11/17/15 at 3:00 p.m., he acknowledged that no alternative treatments were offered to patients when they refused to attend assigned groups. The Medical Director acknowledged that Patient E28 was unlikely to benefit from verbally-based groups due to Patient E28's level of functioning and difficulty with verbal communication.

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 psychiatric evaluations included specific patient assets for eight (8) of eight (8) sample patients (A22, A24, B6, B16, E13, E28, F1 and F12). The failure to identify patient strengths impairs the treatment team's ability to choose treatment modalities that best utilize the patient's attributes in therapy. (Refer to B117)

II Ensure that the Master Treatment Plans (MTPs) for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities when patients refused or were unable to participate in the group therapies. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 II)

III. Ensure that treatment plan interventions by psychiatrists were specific to patient treatment needs for eight (8) of eight (8) active sample patients (A16, A24, B6, B22, E13, E28, F1 and F12). The listed interventions for psychiatrists on the Master Treatment plans [MTPs] were stated as generic, discipline functions. This failure results in a lack of safe coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient A16

The MTP, dated 8/19/15, listed the following generic and routine psychiatrist functions for the problem of "Borderline - SIB [self-injurious behavior]:" "Psychiatrist will provide individual supportive therapy, medication education, and order special levels of observation as needed to provide for the safety of patient and others." This intervention did not focus on the specific behavior problems of the patient. Also missing were frequency and duration.

2. Patient A24

The MTP, dated 10/14/15, listed no interventions for the psychiatrist for the problem of "Paranoid Ideation." For the problem of "Medication Education," the psychiatrist intervention was "The psychiatric provider [psychiatrist] will monitor medications for mental health symptoms to promote improved thinking and behavior." This intervention did not focus on the specific behavior problems of the patient. Also missing was frequency and duration.

3. Patient B6

The MTP, dated 10/23/15, listed the following generic and routine psychiatrist function for the problem of "Self-Injurious Behavior:" Psychiatrist - "[Name of patient] medications will be prescribed, monitored, and adjusted to promote behavior stability and eliminate SIB." This intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

4. Patient B22

The MTP, dated 9/28/15, listed the following generic and routine psychiatrist functions for the problem of "Psychosis:" Psychiatrist - "At times of redirection agitation / mood instability, verbal redirection will be attempted. If verbal redirection is unsuccessful, a physical hold or stat medication may be given for safety & special levels of observation may also be ordered safety." For the problem of "Medication Education," the following generic and routine psychiatrist functions was: Psychiatrist - "Will monitor medications for mental health symptoms to promote improved thinking and behavior." The planned use of restraints is a violation of patient rights and should not be considered a routine part of care. These interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

5. Patient E13

The MTP, dated 11/13/15, listed the following generic and routine psychiatrist functions for the problem of "Psychosis:" Psychiatrist - "At times of increased instability, agitation, self-harm statements, verbal redirection will be attempted. If verbal redirection is unsuccessful a physical hold may be initiated or stat medication may be given for safety. Special levels of observation may be ordered for safety." This intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

6. Patient E28

The MTP, dated 10/27/15, listed the following generic and routine psychiatrist function for the problem of "Psychosis:" "Psychiatrist will order SLO as needed to promote safety of consumer and others." This intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

7. Patient F1

The MTP, dated 11/5/15, listed the following generic and routine psychiatrist function for the problem of "Aggression:" Psychiatrist - "[Name of patient] will have a locked door order from 0630 - 1500, Monday through Sunday, for safety." This intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

8. Patient F12

The MTP, dated 10/27/15, listed no interventions for the psychiatrist for the problem of "Psychosis." For the problem of "Medication Education," the generic and routine psychiatrist function was: "The unit psychiatrist will prescribe medication and monitor mental health symptoms to promote improved thinking."

This intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

B. Interview

During an interview with the Medical Director on 11/17/15 at 3:00 p.m., he acknowledged that interventions to be performed by psychiatrists were generic and not specific to the individual patient.

IV. Ensure active psychiatric treatment for four (4) of eight (8) active sample patients (A24, E13, E28 and F1) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities such as 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)

Based on record review and interview, the Nursing Director failed to ensure that treatment plan interventions by nursing staff were specific to patient treatment needs for eight (8) of eight (8) active sample patients (A16, A24, B6, B22, E13, E28, F1 and F12). The listed interventions on the Master Treatment plans [MTPs] were stated as generic, discipline functions. This failure results in a lack of safe coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient A16

The MTP, dated 8/19/15, listed the following generic and routine nursing discipline function for the problem "Borderline - SIB [self-injurious behavior]" ( the "Behavioral Definition" was- continues to engage in SIB such as swallowing objects [i.e. batteries, eyeglasses], cutting [inserting bra underwire into self], and re-aggravating existing injuries [pulling suture while praying open the wound and inserting objects into wounds)":

"NSG [nursing] will include [name of patient] in activities to promote stable mood & positive use of coping skills. These groups include the following: Laundry, Personal Hygiene, Women & Health Issues, Nutrition, Dining Skills, Health & Safety, Living Space Maintenance and Medication Management."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

2. Patient A24

The MTP, dated 10/14/15, listed the following generic and routine nursing discipline functions for the problem "Paranoid Ideation" (The "Behavior Definition" was - "[Name of patient] refused to cooperate with routine physical examinations, medications, treatment programs based on his/her paranoid beliefs. S/he beliefs that there is a radio that broadcast thoughts and waves into his/her room. [Name of patient] has withdrawn from social interaction and does not attend groups or other activities. S/he can be verbally hostile and get loud on the unit preventing social interventions " ):

"Nursing will include [name of patient] in "Remember When, What Should I Do, Women's Health, Living Space Maintenance, Lifestyle Changes for Healthy Weight, and Health/Safety Issues groups as per program schedule to improve interventions with others."

"Nursing will sit and talk 1:1 with [name of patient] when s/he refuses to attend scheduled programs to encourage him/her participation in unit routine."

For the problem of "Medication Education" (The Behavioral Definition was "[name of patient] does not acknowledge the need for medication and has little interest in learning his/her medication or their uses."), the Nursing intervention was - "Nursing will encourage [name of patient] to accept medication as per dr's [doctor's] order to stress the importance of compliance."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

3. Patient B6

The MTP, dated 10/23/15, listed the following generic and routine nursing discipline function for the problem "Self-Injurious Behavior" (The " Behavioral definition" was - "[Name of patient] makes frequent suicidal attempts and threats of SIB are [sic] his/her not met or acknowledged quickly. [Name of patient] has engaged in a variety of self-destructive behaviors: deep cuts on his/her arms, tied scares around his/her neck, put a pillow over his/her head, and bangs his/her head."):

"Nursing will follow the SLO [Special Level Observation] order as per physician order to maintain safety and stability."

The above intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

4. Patient B22

The MTP, dated 9/28/15, listed the following generic and nursing routine discipline functions for the problem "Psychosis" (The "Behavioral Definition" was - [Name of patient] has a long history of paranoid thinking and a general distrust of others that has resulted in aggressive behaviors. S/he has harmed his/her mother and punched him/herself in the genitals. S/he ripped papers off the bulletin board at the [name of facility] and set fire to it as well. [Name of patient] has a history of religious preoccupation. In the last year, [name of patient] continues to cognitively decline. S/he has had several AWOL [Absent Without Leave] attempts. S/he follows people out the door. S/he does not consistently follow verbal prompts to ensure the safety of him/herself an others, becomes hostile and aggressive when his/her requests are not met immediately.):

"Nursing will include [name of patient] in Personal Hygiene, Living Space Maintenance groups, as per program schedule to help him/her focus on reality and engage in safe behaviors. Nursing will provide 1 to 1 supervision for safety any time AWOL is attempted."

For the problem of "Medication Education" (The "Behavioral Definition" was - [name of patient] has a history of not acknowledging the need for medication and has been non-adherent with treatment and medication in the past), the generic and routine nursing discipline functions for the problem of medication education was:

"Nursing will review [name of patient] medications with him/her at medication pass to help him/her learn their names, uses and importance."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

5. Patient E13

The MTP, dated 11/13/15, listed the following generic and routine discipline functions for the problem "Psychosis" (The "Behavioral Definition" was- [name of patient] voices bizarre content of thought (my name is no [patient's name], asked if stated others were going to kill him/her. Perceptual disturbance, visual and auditory hallucinations, saw his/her dead sister, reported hearing television speaking to him/her. Extreme agitation, including a high degree of irritability, anger, unpredictability or impulsive physical acting out. [Name of patient] destroyed his/her father's television and threatened his/her father, pushed a peer at [name of facility]. Has a history of AWOL from [name of facility]. [Name of patient] hid medication and stated s/he took an overdose of Thorazine "to die" but now does not want to."):

Nursing - "At times of increased mood instability, agitation, verbal redirection will be attempted. If verbal redirection is unsuccessful a physical hold may be initiated or stat medication may be given for safety. Special levels of observation may also be ordered for safety." This intervention was probably meant for the psychiatrist. At any rate the intervention on using physical holds as a mode of treatment is prohibited in CMS regulations.
"Nursing will include [name of patient] in Personal Hygiene, Laundry Individually [sic], as per program schedule, to promote focus on daily living skills."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.


6. Patient E28

The MTP, dated 10/27/15, listed the following generic and routine discipline functions for the problem "Psychosis" (The "Behavioral Definition" was - "[name of patient] can experience [sic] agitation with staff and peers. S/he will often growl and place him/herself on to the floor. S/he is also known to act impulsively by physically acting out toward staff and consuming inedible objects around him/her. [Name of patient] will over drink fluids without staff prompting, redirection from staff is inconsistently effective to manage [name of patient's] behavior and his/her safety."):

"Nursing will include [name of patient] in Living Space Maintenance, Personal Enhancement, What Should I Do, Nutrition and Dining Skills, Personal Hygiene, Laundry Program, Oral Health Care, Remember When, Health Safety Issues and Lifestyle Changes for a Healthy Weight, as per program's schedule to encourage interaction with his/her environment and improved personal skills."

"Nursing will provide q [every] 15 minute checks x24 hours, per physician orders, and 1:1 when in the bathroom for safety."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

7. Patient F1

The MTP, dated 11/5/15, listed the following generic and routine nursing discipline function for the problem "Aggression" (The "Behavioral Definition" was - "[name of patient] has numerous episodes of aggression [one-arm choke holds on peer and staff], SIB [burning self with cigarette], as well as destruction of property [CD players, radios, headphones]. [Name of patient] has pending legal charges for seriously injuring staff at [name of facility] with choke hold."

Nursing - "[Name of patient] may not enter the hallway to bathroom without 2:1[two staff to 1 patient] staff and may not go past the fire doors when in bathroom to ensure the safety of him/herself and others."

The above intervention did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

8. Patient F12

The MTP, dated 10/27/15, listed the following generic and discipline functions for the problem "Psychosis" (The "Behavioral Definition" was - "bizarre content of thought, expressed paranoid delusions believes s/he is being persecuted by neighbors & the FBI [Federal Bureau of Investigation]. S/he was also making phone calls to the police & FBI. S/he claimed the Jewish mafia implanted a devise in his/her throat to control him/her. S/he has a history of claims that s/he sends & receives messages & is religiously preoccupied."):
Nursing - "As per program schedule NSG [nursing] will include [name of patient] in the following groups to promote reality based functioning. These groups include Help, Personal Hygiene, Laundry & Living & Living Space Maintenance."

For the problem of "Medication Education" (The "Behavioral Definition" was - "Does not acknowledge s/he has a mental health diagnosis & has reported an overdose in the past on his/her medication."), the generic and routine nursing discipline functions were:
"Nursing will encourage consumer to accept medications as per DR ' s order and stress the importance of adherence."

The above interventions did not focus on the specific behavior problems of the patient. Also missing in most interventions were frequency and duration.

B. Interview

During an interview on 11/17/51 at 9:30 a.m., the generic nursing interventions on the MTPs was discussed with the Nursing Director. She stated, "I see your point. We were having groups that were basic."

Based on record review and interview, the Director of Social Work failed to ensure that treatment plan interventions by social work staff were specific to patient treatment needs for eight (8) of eight (8) active sample patients (A16, A24, B6, B22, E13, E28, F1 and F12). The listed interventions on the Master Treatment plans [MTPs] were stated as generic, discipline functions. This failure results in a lack of safe coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient A16

The MTP, dated 8/19/15, listed the following generic and routine social work functions for the problem "Borderline - SIB [self-injurious behavior]:" "SW [social worker] will meet individually with [name of patient] at least monthly or as concerns arise. SW will focus on assisting [name of patient] in utilizing coping skills to lessen SIB towards self and aggression toward others. SW will maintain contact with family & [and] BSU [Basic Service Unit- a state agency] to discuss status & dc [discharge] planning." These interventions did not focus on the specific behavior problems of the patient.

2. Patient A24

The MTP, dated 10/14/15, listed the following generic and routine social work functions for the problem "Paranoid Ideation:" "SW will meet with [name of patient] individually once per month to encourage the discussion of needs in a really clear manner. SW will also meet with [name of patient] individually to review and discuss his/her financial statements that the guardian officer sends him/her once a month. This worker will assist [name of patient] with his/her discharge which involves filling out housing applications, financial applications and identifying services that s/he could utilize when in the community." These interventions did not focus on the specific behavior problems of the patient. For the problem of "Medication Education," there were no interventions for the social worker.

3. Patient B6

The MTP, dated 10/23/15, listed the following generic and routine social work functions for the problem "Self-Injurious Behavior:" "SW will meet individually with [name of patient] at least monthly or as concerns arise. SW will focus using skills to become free of SIB. The SW will maintain contact with family and BSU and provide all placements regarding [sic] status and discharge plans. SW will arrange LOAs [Leave Of Absence] and trial visits and assist with all legal and financial matters." These interventions did not focus on the specific behavior problems of the patient.

4. Patient B22

The MTP, dated 9/28/15, there was no social work interventions listed for the problem "Psychosis." For the problem of "Medication Education," there were no interventions listed for the social worker.

5. Patient E13

The MTP, dated 11/13/15, listed the following generic and routine social work functions for the problem "Psychosis:" "SW will meet with [name of patient] on a 1:1 regular basis for the first 8 weeks to discuss his/her progress and concerns. The social worker will meet with [name of patient] every month thereafter to engage in reality based discussion to promote reality based thinking. In addition, social worker will encourage [name of patient] to discuss his/her interests and positive plans for discharge. BSU and family communications will be maintained." These interventions did not focus on the specific behavior problems of the patient.

6. Patient E28

The MTP, dated 10/27/15, listed the following generic and routine social work functions for the problem "Psychosis:" "Social worker will meet with [name of patient] on 1:1 basis at least once a month to encourage improved behavior choices and maintain family BSU contacts to assist in discharge planning when recommended." These interventions did not focus on the specific behavior problems of the patient.

7. Patient F1

The MTP, dated 11/5/15, listed the following generic and routine social work functions for the problem "Aggression:" "Social work will meet with [name of patient] on 1:1 basis at least one time per month to discuss the use of coping skills when agitated. SW will act as a liaison to the BSU and family and provide updates on treatment status and readiness for discharge." These interventions did not focus on the specific behavior problems of the patient.

8. Patient F12

The MTP, dated 10/27/15, listed the following generic and routine social work functions for the problem "Psychosis:" "SW will meet with [name of patient] 1 time weekly and then monthly to engage [name of patient] in reality based conversation & contact BSU regarding progress and potential for discharge as needed." These interventions did not focus on the specific behavior problems of the patient. For the problem of "Medication Education," there was no intervention for the social worker for this problem.

B. Interview

During an interview with the Director of Social Work on 11/17/15 at 2:40 p.m., she acknowledged that interventions to be performed by social workers were generic and not specific to the individual patient.