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

I. Ensure that the Master Treatment Plans for 2 of 8 active sample patients (D and G) were revised when the patients failed to participate in the prescribed treatment. Master Treatment Plans 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. Provide individualized treatment based on the presenting needs of 2 of 8 sample patients (D and G). These patients did not participate in most of the group modalities listed on their Master Treatment Plans and were observed in their bedrooms during the time groups were taking place on the unit. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion. This potentially delays their improvement. (Refer to B125-I)

III. Adequately follow restraint procedure, including needed documentations, for the use of restraint (physical holds) for the external control of violence toward self and others for 2 of 8 sample patients (A and H). These patients had physical holds for medication administration without physician orders for restraint or documentations of appropriate nursing and physician assessments. The use of seclusion/restraints without appropriate physician orders and documentation of required assessment of their use can potentially be a danger to patients, and a violation of patient rights. (Refer to B125-II)

Based on record review and staff interview, the facility failed to document a complete descriptive neurological examination for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) including a description of what tests were performed to assess neurological functions. Failure to document the neurological status of patients compromises accurate diagnosis, the relationship of neurologic conditions to the current mental illness, and the ability to perform future comparative reexaminations to measure changes from baseline functioning.

Findings include:

A. Record Review

For the following History and Physical examinations (dates in parentheses), the neurologic examination was in a checkbox format consisting of "within normal limits," "not within normal limits," or "refused." The examinations for Patients A (2/9/11), B (2/4/11), C (2/24/11), D (3/3/11), E (3/1/11), F (1/4/11), and G (2/25/11) were all checked "within normal limits." The examination for Patient H (3/10/11) was checked "not within normal limits" without further elaboration of specific tests or findings of abnormality.

B. Staff Interview

During a review of neurological examinations on 3/15/11 at 3:00p.m., the Medical Director acknowledged that the examinations for the sample patients did not include complete neurological examinations that documented an accurate diagnosis, the possible relationship of neurologic conditions to the current mental illness, and data for comparative reexamination to measure future changes in function.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an estimate of intellectual functioning and memory functioning in measurable, behavioral terms for 7 of 8 sample patients (A, C, D, E, F, G and H). This deficiency results in the absence of data on cognitive functioning to use for diagnosis and treatment, and does not allow assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations.

Findings include:

A. Record Review

The psychiatric evaluations (dates in parentheses) did not contain descriptive data regarding the degree of impairment in insight, judgment, ability to abstract, memory, concentration, or intelligence estimate for the following patients:

1. Patient A (2/9/11): "Insight and judgment seemed poor. Memory seems intact."

2. Patient C (2/23/11): "Insight and judgment seem impaired at this time..."

3. Patient D (3/3/11): "Cognitively seems grossly intact. His insight and judgment however seem poor."

4. Patient E (3/1/11): "His concentration and attention are fair. His memory for recent and remote is fair. He has poor insight, poor impulse control and poor judgment. His overall fund of knowledge is satisfactory and his language is satisfactory."

5. Patient F (1/4/11): "Her attention and concentration is poor. Her memory for recent and remote is poor. She has poor insight, poor impulse control and poor judgment. Her overall fund of knowledge is poor."

6. Patient G (2/25/11): "His concentration and attention are poor. His memory for recent and remote cannot be done as the patient is agitated. He has poor insight, poor impulse control and poor judgment. His overall fund of knowledge is fair and his language is fair."

7. Patient H (3/10/11): "He is oriented to person only...His insight is nil and his judgment is greatly impaired."

B. Staff Interview

During a review of the psychiatric evaluations on 3/15/11 at 3:00p.m., the Medical Director acknowledged that the above psychiatric assessments did not contain estimates of intellectual and memory functioning in measurable, behavioral terms for these patients.

Based on record review and staff interview, the facility failed to ensure that Psychiatric Evaluations included an inventory of specific patient assets for 8 of 8 sample patients (A, B, C, D, E, F, G and H). Failure to identify patient assets impairs the ability of the treatment team to choose treatment modalities that best utilize the attributes of the patient in their treatment.

Findings include:

A. Record Review

The Psychiatric Evaluations (dates in parentheses) did not contain specific patient assets for the following patients:

1. Patient A (2/9/11): "The patient seems verbal, health. On the other hand, she is non-compliant with treatment at the moment and still seems to be in a psychotic frame of mind."

2. Patient B (2/4/11): "1. The patient is verbal. 2. She seems in good spirits..."

3. Patient C (2/23/11): none documented.

4. Patient D (3/3/11): none documented.

5. Patient E (3/1/11): "1. The patient is verbal. 2. He is cognitively intact. 3. The patient can go home."

6. Patient F (1/4/11): "1. The patient is confused, but she can go back to (another facility)."

7. Patient G (2/25/11): "1. The patient is verbal. 2. He is cognitively intact. 3. We will discuss about his placement."

8. Patient H (3/10/11): "He has a supportive family, and he is already referred to (another facility) and is awaiting an Alzheimer's bed."

B. Staff Interview

During an interview on 3/14/11 at 3:00p.m., the Medical Director acknowledged that the psychiatric assessments did not contain specific patient assets that could be utilized for treatment planning.

Based on interview and record review the facility failed to ensure that the Master Treatment Plans for 2 of 8 active sample patients (D and G) were revised when the patients failed to participate in the prescribed treatment. The Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Patient D:

1. Based on a review of the initial psychiatric evaluation dated 3/3/11, Patient D was admitted to the facility on 3/3/11 with the diagnosis of "Schizophrenia, chronic paranoid type."

2. The Master Treatment Plan for Patient D, dated 3/3/11, listed the following modalities to be used as treatment interventions: "Psychotherapy group," "Patient Education Group," "Individual Therapy," "Goal Group," and "Medication Group." The only other modalities documented were "Patient Education - individual" and "Medication Therapy." A review of the "Group/Education Group" notes from 3/3/11 through 3/14/11 revealed that Patient D attended only 7 of his 101 assigned group sessions during this time period. A review of the medical record revealed no documented individual therapy sessions.

3. A review of the medical record revealed that, as of 3/15/11, there was a failure to address Patient D's lack of attendance in group therapy and other programming activities, and no revisions had been made in the plan.

4. During an interview with MD B1, SW B1, and RN B2 on 3/15/11 at 9:40a.m., they all acknowledged that the Master Treatment Plan had not been revised, despite Patient D's failure to attend his assigned therapeutic groups. They all acknowledged that Patient D was not provided individual therapy. They also acknowledged that medication management was the only active psychiatric treatment provided for Patient D, although he had failed to attend or participate in other modalities since admission.

B. Patient G:

1. Based on a review of the initial psychiatric evaluation dated 2/25/11, Patient G was admitted to the facility on 2/25/11 with the diagnosis of "Psychosis, NOS. Consider schizoaffective disorder."

2. The Master Treatment Plan for Patient G, dated 2/25/11, listed that the following modalities were to be used as treatment interventions: "Patient Education - individual" "Adjunct Therapy," and "Individual Therapy." No other modalities were identified on the Master Treatment Plan. A review of the "Group/Education Group" notes revealed that Patient did not regularly attend group sessions during this time period. A review of the medical record revealed no documented individual therapy sessions.

3. A review of the medical record revealed that as of 3/15/11, there was a failure to address Patient G's lack of attendance at group therapy or other programming activities and no revisions were made in the plan.

4. Interview

During an interview with SW B2 on 3/16/11 at 9:35a.m., s/he stated that Patient G "was not comfortable in the group setting" and that group therapy was "too stimulating for him." SW B2 stated that Patient G had not received individual therapy specified in the Master Treatment Plan. S/he also acknowledged that the Master Treatment Plan had not been revised to address Patient G's lack of participation in group therapy or to provide alternative treatments.

Based on record review and interview, the facility failed to develop Master Treatment Plans that clearly delineated individualized interventions to address the specific treatment needs of 8 of 8 sample patients (A, B, C, D, E, F, G and H). The Master Treatment Plans included a list of interventions for problems that lacked a specific focus for treatment. None of the 8 active sample patient's Master Treatment Plans included psychiatrist interventions. This failure results in Master Treatment Plans that fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Patient A

1. For the problem of "Alteration in thought process (dementia)," the following "Interventions" were checked: "Provide the patient with brief, simple tasks through group or individual activities as needed," "Play soothing music when appropriate; especially during sun-downing times (dim the lights if appropriate," "Allow the patient to wander in a safe, secured designated environment daily," "Utilize therapeutic communication to increase participation in and acceptance of care," "Provide small frequent meals and finger foods when possible," "Engage the patient in short routine social interactions throughout the day," and "Monitor percent of nutritional intake." These interventions were identical for the problem of "Alteration in thought process (dementia)" for Patient H (see H. below). There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Anxiety," the following "Interventions" were checked: "Assess the patient's level of functioning daily," "to identify events or situation that preceded the symptoms of anxiety." "Educate the patient on relaxation techniques, as needed," and "Assist the patient to identify alternative adaptive coping techniques, as needed." There were no additional interventions to address the role of the physician in patient treatment.

3. For the problem of "Potential for violence directed at self and or others," the following "Interventions" were checked: "Monitor compliance with safety agreement," "Educate patient regarding contacting staff to discuss feelings of agitation," "Verbally de-escalate the patient when patient displays signs and symptoms of increased agitation," "Educate patient about relaxation techniques," "Reduce environmental stimuli if indicated," and "Monitor and document response to medications." There were no additional interventions to address the role of the physician in patient treatment.

4. For the problem of "Altered Thought Process," the following "Interventions" were checked: "Assess the patient's ability to think logically and to utilize realistic judgment and problem solving abilities," "Provide support and praise for appropriate social interactions on the unit," and "Educate the patient on the disease process and the need to comply with treatment." There were no additional interventions to address the role of the physician in patient treatment.

5. For the problem of "Non-adherence to treatment," the following "Interventions" were checked: "Provide patient to written information regarding medications (sic)" and "Have patient participate in planning aftercare." There were no additional interventions to address the role of the physician in patient treatment.

6. For the problem of "Alteration in mood," the following "Interventions" were checked: "Encourage the patient to identify positive aspects of self daily" and "Educate the patient regarding psychosocial stressors and how to recognize, manage and prevent symptoms." There were no additional interventions to address the role of the physician in patient treatment.

B. Patient B

1. For the problem of "Altered Thought Process," the following "Interventions" were checked: "Refocus conversations to realistic topics," "Assess the patient's ability to think logically and to utilize realistic judgment and problem solving abilities," "Educate the patient on the disease process and the need to comply with treatment," and "Offer task and education gps (groups)." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Self-care deficit," the following "Interventions" were checked: "Assist with personal hygiene, appropriate dress, grooming and laundering until the patient can function independently," "Make available only those items needed for grooming/dressing," "Encourage patient to complete as much self-care as possible," and "Provide privacy in accordance with safety protocols." There were no additional interventions to address the role of the physician in patient treatment.

C. Patient C

1. For the problem of "Non-adherence to treatment" and "Non-adherence to aftercare referrals and appointments," the following "Interventions" were checked: "Orient orient (sic) patient to program schedules and level of privilege system," "Provide patient to written information regarding medications (sic)," and "Have patient participate in planning aftercare." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Substance abuse," the following "Interventions" were checked: "Medication education," "Educate about disease process of addiction including medical aspects," "Offer praise for even the slightest progress," and "Encourage and teach proper nutrition and fluid intake daily." There were no additional interventions to address the role of the physician in patient treatment.

3. For the problem of "Anxiety," the following "Interventions" were checked: "Assess the patient's level of functioning daily," "Assess the patient's anxiety level to prevent escalation daily," "Educate the patient on relaxation techniques, as needed," and "Assist the patient to identify alternative adaptive coping techniques, as needed." There were no additional interventions to address the role of the physician in patient treatment.

4. For the problem of "Potential for self-directed violence," the following "Interventions" were checked: "Orient patient to suicide precautions upon implementation and as requested," "Ongoing monitoring for compliance with Patient Safety Agreement at all times," and "Level of observation? - Therapeutic documentation care plan (Intervention sheet)." There were no additional interventions to address the role of the physician in patient treatment.

5. For the problem of "Alteration in mood," the following "Interventions" were checked: "Educate the patient on the need to stay compliant daily," "Provide activities suitable to the patient's level of tolerance/capability that are noncompetitive daily," and "Educate patient daily regarding importance of daily schedule including sleep/rest." There were no additional interventions to address the role of the physician in patient treatment.

D. Patient D

1. For the problem of "Altered Thought Process," the following "Interventions" were checked: "Educate patient on medication regime including dose, frequency and side effects," "Refocus conversations to realistic topics," "Assess the patient's ability to think logically and to utilize realistic judgment and problem solving abilities," "Provide support and praise for appropriate social interactions on the unit," "Educate the patient on the disease process and the need to comply with treatment," and "Offer task and education gps (groups)." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Non-adherence to medication intake," the following "Interventions" were checked: "Orient orient (sic) patient to program schedules and level of privilege system," "Provide patient to written information regarding medications (sic)," "Provide liquid medications if needed," and "Have patient participate in planning aftercare." There were no additional interventions to address the role of the physician in patient treatment.

E. Patient E

1. For the problem of "Depression," the following "Interventions" were checked: "Assist the patient in formulating attainable goals daily," "Educate the patient regarding adaptive coping mechanisms and problem solving techniques daily," and "Educate the patient regarding psychosocial stressors and how to recognize, manage and prevent symptoms." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Potential for self-directed violence," the following "Interventions" were checked: "Orient patient to suicide precautions upon implementation and as requested," "Ongoing monitoring for compliance with Patient Safety Agreement at all times," and "Discuss (with) pt (patient) his thoughts on surgery." There were no additional interventions to address the role of the physician in patient treatment.

F. Patient F

1. For the problem of "Alteration in thought process (dementia)," the following "Interventions" were checked: "Provide the patient with brief, simple tasks through group or individual activities as needed," "Play soothing music when appropriate; especially during sun-downing times (dim the lights if appropriate)," "Allow the patient to wander in a safe, secured designated environment daily," "Utilize therapeutic communication to increase participation in and acceptance of care," "Provide small frequent meals and finger foods when possible," "Engage the patient in short routine social interactions throughout the day," and "Monitor percent of nutritional intake." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Anxiety," the following "Interventions" were checked: "Assess the patient's level of functioning daily," "Assess the patient's anxiety level to prevent escalation daily," "Assist the patient to identify events or situation that preceded the symptoms of anxiety." "Educate the patient on relaxation techniques, as needed," and "Assist the patient to identify alternative adaptive coping techniques, as needed." There were no additional interventions to address the role of the physician in patient treatment.

3. For the problem of "Potential for violence directed at self," the following "Interventions" were checked: "Monitor compliance with safety agreement," "Educate patient regarding contacting staff to discuss feelings of agitation," "Verbally de-escalate the patient when patient displays signs and symptoms of increased agitation," "Educate patient about relaxation techniques," "Reduce environmental stimuli as indicated," and "Monitor and document response to medications." There were no additional interventions to address the role of the physician in patient treatment.

4. For the problem of "Altered Thought Process," the following "Interventions" were checked: "Educate patient on medication regime including dose, frequency and side effects," "Refocus conversations to realistic topics," "Assess the patient's ability to think logically and to utilize realistic judgment and problem solving abilities," "Provide support and praise for appropriate social interactions on the unit," and "Educate the patient on the disease process and the need to comply with treatment." There were no additional interventions to address the role of the physician in patient treatment.

G. Patient G

For the problem of "Potential for self-directed violence," the following "Interventions" were checked: "Orient patient to suicide precautions upon implementation and as requested," "Ongoing monitoring for compliance with Patient Safety Agreement at all times," "Instruct family about suicide precautions within 24 hours and as required," and "Level of observation? - Therapeutic documentation care plan (Intervention sheet)." There were no additional interventions to address the role of the physician in patient treatment.

H. Patient H

1. For the problem of "Potential for violence directed at self," the following "Interventions" were checked: "Monitor compliance with safety agreement," "Educate patient regarding contacting staff to discuss feelings of agitation," "Verbally de-escalate the patient when patient displays signs and symptoms of increased agitation," "Educate patient about relaxation techniques," "Reduce environmental stimuli as indicated," and "Monitor and document response to medications." There were no additional interventions to address the role of the physician in patient treatment.

2. For the problem of "Alteration in thought process (dementia)," the following "Interventions" were checked: "Provide the patient with brief, simple tasks through group or individual activities as needed," "Play soothing music when appropriate; especially during sun-downing times (dim the lights if appropriate," "Allow the patient to wander in a safe, secured designated environment daily," "Utilize therapeutic communication to increase participation in and acceptance of care," "Provide small frequent meals and finger foods when possible," "Engage the patient in short routine social interactions throughout the day," and "Monitor percent of nutritional intake." There were no additional interventions to address the role of the physician in patient treatment.

I. Staff Interviews

1. During an interview with the Director of Nursing (DON) on 3/14/11 at 1:30p.m., she acknowledged that the Master Treatment Plan interventions were generic and not specific to the patient needs.

2. During an interview with the Medical Director on 3/14/11 at 3:00p.m., he acknowledged that the Master Treatment Plan interventions were generic and not specific to the patient needs.

Based on record review, observations and interviews with staff, the hospital failed to provide individualized treatment based on the presenting needs of 2 of 8 sample patients (D and G). These patients did not participate in most of the group modalities listed on their Master Treatment Plans, and they were observed in their bedrooms during the time groups were taking place on the unit. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement.

Findings include:

I. Record Review

A. Patient D

1. Patient D was admitted on 3/3/11 with a diagnosis of "Schizophrenia, chronic paranoid type with acute exacerbation."

2. From 3/3/11 through 3/14/11 there were a total of 101 groups to which Patient D was assigned. Of these groups, Patient D attended 7 groups. Documentation did not indicate active participation during the 7 groups attended. Examples of Patient D's participation notes showed that during the "Arts and Crafts" group on 3/4/11, Patient D was in a geri chair with a sheet pulled over his head. On 3/6/11, in the "Goal Evaluation and Wrap-Up Group," Patient D's response to group was documented as "observed." On 3/10/11 in "Music Group" Patient D's response to group was also documented as "observed."

3. During an observation on 3/14/11 at 11:11a.m., which was the time of the scheduled "Sharpen Your Feelings" group in the dayroom, Patient D was observed lying in his bed. Based on a review of the medical record, no alternative treatment was documented.

4. During an observation on 3/14/11 at 3:30p.m., which was the time of the scheduled "Adjunct Therapy" group in the dayroom, Patient D was observed lying in his bed. When asked about attending the group, he replied "I don't go to groups." Based on a review of the medical record, no alternative treatment was documented.

5. During an interview with MHT B1 on 3/14/11 at 4:30p.m., when asked about patient D's attendance at groups, the response was "he sits in his room constantly."

6. During observations on 3/15/11 at 9:10a.m. and at 9:25a.m., during the time of the scheduled "Community Meeting Adjunct," Patient D was observed lying in bed. When asked about attending the group, he replied "I don't feel good." He stated that he attended "a couple" of groups earlier in his hospitalization but they were "boring" and he did not like them. Based on a review of the medical record, no alternative treatment was documented.

7. During an interview with MD B1, SW B1, and RN B2 on 3/15/11 at 9:40a.m., MD B1 stated that he believed Patient D was "hopeless and helpless" and was "depressed." SW B1 stated that the intervention of "encouraging" Patient D to attend groups was "not working." MD B1 acknowledged that no alternative treatment for depression had been provided other than medication and that no behavioral treatment (rewards for appropriate behaviors) was provided to address Patient D's refusal to attend groups. SW B1 stated that individual therapy was "probably not going to happen" while in the hospital. MD B1, SW B1, and RN B2 all agreed that no alternative therapy was being provided, despite Patient D's prolonged refusal of group therapies. MD B1 stated that the team planned to address Patient D's depression and "getting him out of the room to the dayroom" but that, as of the time of this interview, no new interventions had been developed or implemented.

8. During an interview on 3/15/11 at 1:30p.m., the DON acknowledged that Patient D should have received alternative treatments, and that the Master Treatment Plan should have been revised if the patient was not participating in the prescribed modalities.

9. During an interview on 3/15/11 at 2:30p.m., the Director of Adjunctive Therapy acknowledged that Patient D had not received alternative treatments from Adjunct Therapy when he did not participate in group treatments.

10. During an interview on 3/15/11 at 4:00p.m., AT B1 stated that Patient D did not generally participate in group therapies and no individual activities were provided for the patient by Adjunctive Therapy.

11. During an interview on 3/15/11 at 3:00p.m., the Medical Director acknowledged that Patient D should have received alternative treatments, and that the Master Treatment Plan should have been reviewed and revised if the patient was not participating in the prescribed modalities. He stated that the treatment team should have been "more proactive" in addressing Patient D's refusal to leave his bedroom. He stated that the treatment team should have "done something" and "not let him sit" in his bedroom.

B. Patient G

1. Patient G was admitted on 2/25/11 with a diagnosis of "Psychosis NOS." During an observation on 3/14/2011 at 1:15p.m., Patient G was in his room asleep during the time of the scheduled "Orientation" group. Based on a review of the medical record, no alternative treatment was documented.

2. Patient G attended no scheduled groups on 2/26/11. On 2/27/11, the patient only attended two groups. On 2/27/11, he did not attend any groups. On 3/2/11, he attended two groups. On 3/7/11 and 3/8/11, he attended one group. On 3/8/11, Patient G only attended "Art" group. There was no documentation of staff encouraging the patient to attend the scheduled groups.

3. During an observation on 3/14/11 at 1:15p.m. at the time of the scheduled "Orientation" group, Patient G was observed asleep in his bedroom. Based on a review of the medical record, no alternative treatment was documented.

4. During an interview with AT B1 on 3/15/11 at 4:00p.m., s/he stated that Patient G did not generally participate in group therapies and no individual activities were provided for the patient by Adjunctive Therapy.

II. Based on record review and interviews, the facility failed to carry out proper restraint procedures, including needed documentations, for the use of restraint (physical holds) for the external control of violence toward self and others for 2 of 8 sample patients (A and H). These patients had physical holds for medication administration without physician orders for restraint or documentations of appropriate nursing and physician assessments. The use of seclusion/restraints without appropriate physician orders and documentation of required assessment of their use is a potential danger to patients and a violation of patients' rights.

Findings include:

A. Patient Findings

1. Patient A

a. During interviews on 3/14/11 at 1:35p.m. and on 3/15/11 at 11:30a.m., Patient A stated that she had received medications against her consent on 2/12/11. She stated that "three or four men held me down" to administer medication intramuscularly (IM) because of her resistance.

b. The nursing progress note for Patient A for dated 2/12/11 at 11:30a.m. stated "Patient refused medications today and had prn (as needed) Zyprexa IM."

c. A review of the medical record for Patient A revealed no physician order or other documentation for the physical hold utilized by staff on 2/12/11.

2. Patient H

a. The nursing progress note for Patient H for dated 3/12/11 at 4:30p.m. stated "Patient earlier had an angry, violent outburst at 15:00pm. Patient punched this writer, pinned another staff member against a wall and attempted to pull over a gerichair with a patient still in the chair. Patient was yelling and threatening...Administered Haldol, Benadryl and Ativan via intramuscular injection..."

b. During an interview with MHT B1 on 3/15/11 at 11:25a.m., s/he stated that s/he was on duty during this time period. S/he stated that Patient H was "combative and very aggressive." S/he stated that Patient H was physically held by facility staff during this time period including the time required for administering medication.

c. A review of the medical record for Patient H revealed no physician order or other documentation for the physical hold utilized by staff on 3/12/11.

3. Other Staff Interviews

a. During an interview with RN B1 on 3/14/11 at 2:50p.m., s/he stated that physical holds were not considered a type of restraint by the facility and did not require a physician's order, assessments, or other documentation as required by the facility for seclusion or mechanical restraints. She stated that the authority for a physical hold was implied whenever medications were ordered to be administered by force without consent of a patient.

b. During an interview on 3/14/11 at 1:30p.m., the DON stated that holding a patient physically has not been considered a restraint. She acknowledged that patients were restrained for "forced medications" and at other times without documented justification and appropriate nursing and physician assessment.

c. During an interview on 3/14/11 at 3:00p.m., the Medical Director stated that the hospital did not require physician orders for the use of physical holds. He acknowledged that patients were restrained for forced medications and at other times without documented justification and appropriate nursing and physician assessment

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

I. Ensure the documentation of a complete descriptive neurological examination for 8 of 8 active sample patients (A, B, C, D, E, F, G and H), including the description of what tests were performed to assess neurological functions. Failure to document a patient's neurological status compromises accurate diagnosis, the relationship of neurologic conditions to the current mental illness, and the ability to perform future comparative reexaminations to measure changes from baseline functioning. (Refer to B109)

II. Ensure that Psychiatric Evaluations included an estimate of intellectual functioning and memory functioning in measurable, behavioral terms for 7 of 8 sample patients (A, C, D, E, F, G and H). This deficiency results in the absence of cognitive data to use for diagnosis and treatment, and does not allow assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations. (Refer to B116)

III. Ensure that Psychiatric Evaluations included an inventory of specific patient assets for 8 of 8 sample patients (A, B, C, D, E, F, G and H). Failure to identify patient assets impairs the ability of the treatment team to choose treatment modalities that best utilizes the attributes of the patient in their treatment. (Refer to B117)

IV. Ensure that the Master Treatment Plans for 2 of 8 active sample patients (D and G) were revised when the patients failed to participate in the prescribed treatment. The Master Treatment Plans 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)

V. Develop Master Treatment Plans that clearly delineated interventions to address the specific treatment needs of 8 of 8 sample patients (A, B, C, D, E, F, G and H). The Master Treatment Plans included a list of interventions for the listed problems which lacked a focus for treatment. There were no specific psychiatrist interventions. This failed practice results in Master Treatment Plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

VI. Provide individualized treatment based on the presenting needs of 2 out of 8 sample patients (D and G). These patients did not participate in most of the group modalities listed on their Master Treatment Plans, and they were observed in their bedrooms during the time groups were taking place on the unit. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, thus potentially delaying their improvement. (Refer to B125-I)

VII. Carry out proper restraint procedure, including needed documentations, for the use of restraint (physical holds) for the external control of violence toward self and others for 2 of 8 sample patients (A and H). These patients had physical holds for medication administration without physician orders for restraint or documentations of appropriate nursing and physician assessments. The use of seclusion/restraints without appropriate physician orders and documentation of required assessment of their use can potentially be a danger to patients, and violates patients' rights. (Refer to B125-II)

Based on observations, interviews, and record review the Director of Nursing failed to:

I. Ensure that patients attended groups as scheduled or provide alternative treatment interventions for patients on the Adult Psychiatric and the Geriatric Unit. This failure resulted in patients spending many hours without structured activities and occupied their time by sleeping and staying in their rooms. There was also a lack of suitable alternative activities for patients. In addition, there was no monitoring of the documentation of the patient's response to groups. The patient responses were general statement such as "observed" or "participated." (Refer to B125-I)

II. Ensure that nursing staff carried out proper restraint procedures, including the documentation for the use of restraints (physical holds) for external control of violence toward self and others for 2 out of 8 patients (A and B). These patients had physical holds for medication administration without physician orders for restraint or documentations of appropriate nursing assessments. The use of seclusion/restraints without appropriate physician orders and documentation of required assessment of their use can potentially be a danger to patients, and is a violation of patients' rights. (Refer to B125- II)