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Based on observation, resident interview, staff interview and record review, the facility failed to implement seclusion in a safe manner for 1 of 4 patients sampled for seclusion, #2. The East wing seclusion room contained a bed with removable metal springs.

The findings include:

On 11/9/15 at approximately 2:00pm, an interview was conducted with patient #2. Patient #2 stated that he had been in seclusion several times. Patient #2 stated that the seclusion room contained a restraint bed, but he was not restrained. He was free to walk around the seclusion room. The exit door was locked.

An observation of the seclusion room was conducted with Patient #2 during the interview. The restraint bed was securely bolted to the floor. The mattress was easily removable and was laying on a metal frame composed of thick metal wires and metal connectors. The metal connectors were fairly easy to remove and could have been utilized for self-injurious behavior.

A record review for seclusion and restraint was conducted for Patient #2. Patient #2 was in seclusion on 8/20/15 for 37 minutes. Patient #2 was also observed receiving an injection in the seclusion/restraint room on 11/9/15 at approximately 9:30am.

On 11/10/15 at approximately 11:40am, the east hall restraint bed was observed with the Infection Control and Quality Assurance nurse. The Infection Control and Quality Assurance nurse stated that the metal wires and connectors were a potential hazard, and that she would address this with maintenance today.

A policy or standard for the seclusion room and restraint bed was requested from the Program Director on 11/10/15 at approximately 3:04pm. The Director was unable to locate a policy addressing a description of the restraint room and bed., but did find where room safety was addressed in the seclusion policy. The West Florida Community Care Center Policy and Procedure on the Use of Seclusion, dated, April 2014 was reviewed. Under Section B, part vii, was the statement, "prior to placing a patient in seclusion, staff shall check the seclusion room to ensure it is safe and free of unsafe items..." "Any potentially dangerous objects shall be removed...".

Based on observation of rooms and staff interview the facility failed to maintain resident rooms in a safe and sanitary manner for 5 of 12 rooms viewed ( E 139, E 140, E 150, E 144, and S 116).

The findings are:
A tour of the building was conducted with the Maintenance Director (MD) on 11/10/15 about 9:31 am. Room 139 and Room 140 has no baseboards in the room The MD says the baseboards were removed about four months ago and have not been replaced. Room E 150 is missing about 3 feet of baseboard in the far right corner facing the room from the doorway Room E 144 was found to have peeling paint above the bed closest to the door. The patient in the room says his roommate lies in bed and peels the paint. The peeling paint is about 9 inches by 9 inches showing blue paint underneath on the existing paint. . Room S 116 was found to have the baseboard coming away from the wall extending about 1 foot to the left on entry to the room closest to the window. This room also has a light brown stain on the wall to the right that covers about a foot of the wall closest to the baseboard.
The MD was asked if he had a written plan in place to replace the baseboards and or paint the rooms on 11/10/15 about 10:00 am. He stated, No we do not have a written plan in place.

Based on record review and staff interview, the hospital failed to include patient specific treatment modalities in the individualized treatment plans for 8 of 8 patients sampled for treatment plan review (#2, 3, 4, 5, 6, 9, 11 and 12). Each patient had a schedule of activities, but the individualized schedules were not identified in the treatment plans. The treatment plans did not address why each activity was selected with the specific purpose and focus for that patient.

The findings:

Patient #2:
A record review of the treatment plan and schedule of activities was conducted for patient #2. The treatment plan was established on 7/7/15. Under interventions, the treatment plan stated:

Psychosocial Instructor will provide 3 hours of classes weekly including General Therapy, Healthy Relationships and Symptoms Management.

The schedule of activities had one of these classes listed per the treatment plan, Symptoms Management, but the schedule did not include the classes of General Therapy and Healthy Relationships. Instead, the schedule showed Exercise, Basic Dual Diagnosis Program, Alcoholic / narcotics anonymous, Rehab Class, Psych Education - self esteem and Reflection.

The treatment plan only identified one of the activities to be utilized. The treatment plan did not identify why the particular treatment modalities were selected for patient #2, nor did it include the specific purpose for each activity.

Patient #3:
A record review of the treatment plan and schedule of activities was conducted for patient #3. The treatment plan was established on 9/3/15. Under interventions, the treatment plan stated:

Psychosocial Instructor will provide a schedule of groups and classes to educate regarding symptom management, relapse-prevention, adaptive coping skills, healthy relationships, substance abuse and wellness.

The schedule of activities had these client specific classes / groups identified: Exercise, Rehab Class, a medical disease specific class, Psych Ed-self esteem and Unit reflection.

The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #3.

Patient #4:
A record review of the treatment plan and schedule of activities was conducted for patient #4. The treatment plan was established on 1/3/15. Under interventions, the treatment plan stated:

Psychosocial Rehab will provide a schedule of groups and classes to educate patient regarding symptom management, medication compliance, coping skills, and mood disorder.

The schedule of activities had these client specific classes / groups identified: Exercise, Living Skills, Rehab Class, Solutions, Social Skills, Monthly trip and Unit Reflection.

The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #4.

Patient #5:
A record review of the treatment plan and schedule of activities was conducted for patient #5. The treatment plan was established on 1/7/15. Under interventions, the treatment plan stated:

Clinical Counselor will meet with patient weekly to monitor mood, behaviors, and provide treatment interventions for anger, low self-esteem, better communication and emotional regulation.

Psychosocial rehab will provide a schedule of groups and classes to educate patient regarding symptom management, medication compliance, coping skills, and mood disorder.

The schedule of activities had these client specific classes / groups identified: Exercise, Living Skills, Rehab Class, Arts and Crafts, Social Skills, Solutions, Psych Education and Unit Reflection.

The treatment plan did not identify the specific activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #5.

Patient #6:

A record review of the treatment plan and schedule of activities was conducted for patient #6. The treatment plan was established on 7/21/15. Under interventions, the treatment plan stated:

Psychoeducational Instructor will provide a schedule of groups and classes to educate patient regarding mood disorder, symptom management, healthy relationships and anger management.

Psychiatric technician will prompt patient to attend groups, comply with medications and maintain activities of daily living.

The schedule of activities had these client specific classes / groups identified: Exercise, Rehab Class, Activities of Daily Living, Healthy Relationships, Unit Reflection, Psych Education, Symptom Management, Happiness and General Therapy.

The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #6.

Patient #9:

A record review of the treatment plan and schedule of activities was conducted for patient #9. The treatment plan was established on 4/29/15. Under interventions, the treatment plan stated:

Clinical Counselor will offer individual CBT (cognitive behavioral therapy) once weekly to monitor symptoms, help to develop effective coping skills and to address and issues as needed.

Clinical Counselor will provide group therapy using CBT one hour weekly.

Psychosocial Instructor will provide supportive counseling and assistance with discharge planning.

The schedule of activities had these client specific classes / groups identified: Exercise, Rehab Class, Re-Think class, Psych education self esteem, and Unit reflection.

The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #9.

Patient #11:
A record review of the treatment plan and schedule of activities was conducted for patient #11. The treatment plan was established on 3/2/15. Under interventions, the treatment plan stated:

Psychosocial Instructor will provide a schedule of groups and classes to educate patient regarding symptom management, activities of daily living, anger management and coping skills

The schedule of activities had these client specific classes / groups identified: Activities of daily living, Exercise, Living Skills, Rehab Class, Solutions, monthly trip, and social skills. The class entitled symptom management was not on the patient's schedule.

The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #11.

Patient #12:

A record review of the treatment plan and schedule of activities was conducted for patient #12. The treatment plan was established on 9/9/15. Under interventions, the treatment plan stated:

Clinical Counselor will offer individual CBT (cognitive behavioral therapy) once weekly to monitor symptoms, develop healthy coping skills.

Clinical Counselor will provide group therapy using CBT one hour weekly.

Psychosocial Instructor will provide 3 hours of classes weekly, including Depression Management, Assertiveness and Anger Management

The schedule of activities had these client specific classes / groups identified: Exercise, Rehab Class, Arts & Crafts, General Therapy, Relaxation, and Symptom Management.

The weekly classes listed on the treatment plan did not correspond to class names on the activity schedule. The treatment plan did not identify the activities to be utilized, nor did it identify why these particular treatment modalities were selected and the specific purpose for patient #12.

On 11/10/15 at approximately 10:30am, an interview was conducted with the Program Director. The Program Director reviewed the treatment plans and compared them to the Schedule of Activities. The Program Director was unable to locate documentation within the treatment plans that identified the specific treatment modalities being utilized for each patient. The Program Director stated that the facility's current treatment plan format was under review, and she was actively looking for another more updated format.