HospitalInspections.org

Based on policy review, medical record review and staff interviews, the nursing staff failed to document injection sites per hospital policy for 3 of 32 sampled medical records (#15, #31 and #32).
The findings include:
Review of policy, "Medication Administration" with revision date of April 2013, revealed ".......For all medications, appropriate documentation on the Medication Adminstration Record (MAR) is required." Review of policy revealed no instructions for documenting injection sites.
1. Open medical record review of Patient #15 revealed a 18 year old female admitted on 06/18/2016 for SI (suicidal ideations). Further review revealed a history of IDDM (insulin dependent diabetes). Review of Physician admission orders written on 06/18/2016 revealed Lantus (insulin) 10 units sq (subcutaneous) q (every) HS (hour of sleep). Review of MAR (medication administration record) revealed nurses initials on 06/19/2016 (no time) and 06/20/2016 (no time) indicating administration of insulin. No documentation was found indicating the location of the injection site.
Interview on 06/21/2016 at 1130 with RN #1 revealed "I was not taught to write injection sites".
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."
2. Closed medical record review of Patient #31 revealed a 12 year old male admitted on 04/04/2016 for DMDD (dysphoric mood dysregulation disorder), intermittent explosive disorder, conduct disorder childhood onset, and attention deficit hyperactivity disorder. Review of the MAR dated 04/06/2016 through 04/11/2016 revealed administration of Diphenhydramine (Benadryl-medication for calming) 50 mg (milligrams) IM (intramuscular) on 04/06/2016 at 0810 and 04/11/2016 at 1456. No documentation was found indicating the location of the injection sites. Further review revealed administration on 04/06/2016 at 0810 and 04/11/2016 at 1456 of Ziprasidone (Geodon-medication used for sedation) 20 mg IM. No documentation was found indicating the location of the injections sites.
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."
3. Closed medical record review of Patient #32 revealed a 21 year old male admitted on 05/13/2016 for schizophrenia paranoid with acute exacerbation (mental disorder characterized by abnormal social behavior and failure to understand what is real). Review of MAR revealed orders on 05/13/2016 for Ziprasidone 20 mg IM every 6 hours if needed for agitation. Further review revealed adminstration of Ziprasidone 20 mg IM on 05/21/2016 at 2330 and 05/22/2016 at 0950. No documentation was found indicating the location of the injection sites. Further review of Patient #32's MAR revealed Ativan 2 mg IM ordered on 05/13/2016 for agitation. Review revealed documentation of adminstration of Ativan on 05/21/2016 at 2330 and 05/22/2016 at 0950. No documentation was found indicating the location of the injection sites.
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."

Based on hospital policy and procedure reviews, observations during dietary tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure: hand hygiene and glove changes were performed between clean and dirty tasks; frozen foods with excessive ice formation were discarded and were covered to prevent exposure to air and contaminants; kitchen surfaces and food preparation/cooking equipment surfaces were kept clean of excessive grease/grim/dust buildup; cookware and serving utensils were cleaned and stored in a sanitary condition; and potentially hazardous foods were not available for consumption in 1 of 1 Dietary Departments toured.

The findings include:

Review on 06/22/2016 of hospital policy, "Dinning Room Maintenance" revised 04/2016 revealed, "POLICY: Every dietary services employee is responsible for providing the residents and his/her peers with a clean, sanitary and well maintained dining environment. PROCEDURE: ...The sanitation schedule is a guideline for detailed cleaning..."

Review on 06/22/2016 of hospital policy, "Housekeeping and Sanitation: Infection Control Sanitation Recommendations" revised 04/2016 revealed, "POLICY: Due to the seriousness of infection transmitted from people to food in preparation, the kitchen itself must be of good cleanliness and the dietary service staff must work in a sanitary manner. PROCEDURE: ...F. Dishwasher Procedures ...3. The dish area should be clean. ...9. Dishes sent through machine are removed, allowed a few minutes to drain and dry before storage. ...11. Utensil may be run through the dishwasher only after thorough cleaning in the three compartment sink. G. Cleaning Equipment ...Ovens a) Remove shelves (if present) b) Use wire brush to remove burnt particles c) Spray with commercial oven cleaner. d) Washed with detergent solution ... f) Wipe exterior with detergent solution ...L. Personal Hygiene... 7. Gloves must be changed and hands must be washed when starting a new task."

1. Observations during tour of the hospital's main kitchen on 06/20/2016 at 1230 and 1405 onward, revealed the following:

In the main kitchen service line area:
a. Observation on 06/20/2016 at 1230 of the hospital's main kitchen service line revealed, Dietary Staff #1 serving meals with gloves on. Observation revealed Dietary Staff #1 walked to the push-through warmer, opened the door with gloved hands, removed a tray of rolls, returned to the food service line steam bar, removed a roll with the same gloved hand used to obtain the tray of rolls, and placed it on the patient tray without performing hand hygiene or changing gloves.

Interview on 06/20/2016 at 1450 with the Administrative Dietary Manager #1 revealed dietary staff wear gloves when serving food. Interview revealed it is not uncommon for staff to move between the service line and the push-through cabinets, hot or cold, to replenish the line. Interview revealed staff use the same gloved hands to continue to serving, handling the service end of the serving utensils only. Interview revealed concerns of possible cross contamination from the push-through cabinet to hand food had not historically been an issue. Interview revealed barriers for use when obtaining food such as rolls, garlic bread, cornbread, etc. had not been used; however, it would be a consideration going forward. Interview confirmed observation findings.

In refrigeration storage area:
b. Observation inside the Freezer unit located beside the Fresh Vegetable preparation station revealed two (2), partially full boxes of individually packaged frozen slices of toast bread and three (3) loaves of bread. Observation revealed excessive (thick layer) build up of ice crystals inside each of the individually packaged slices of toast bread and the three (3) loaves of bread.

Interview during tour with the Administrative Dietary Manager #1 at 1410 revealed there should not be excessive ice crystals on food stored in the freezer. Interview revealed food with excessive ice crystals should not be available for patient use and should be discarded. Interview verified the observation findings.

In the walk-in freezer area:
c. Observation of the walk-in freezer revealed an open box of frozen peas. Observation revealed the box lid flaps were bent down, exposing the plastic packaging inside the box. Observation revealed a large hole in the plastic packaging, leaving the frozen peas exposed to open air.

Interview with the Administrative Dietary Manager #1 revealed food stored in the walk-in freezer or any other food storage area should be covered once opened. Interview revealed staff should obtain the required food, close the bag, and close the lids down on the box. Interview revealed peas, or any other foods with the exception of fruits and some vegetables, should not be left uncovered in any storage area in the kitchen. Interview verified observation findings.

In the food preparation area:
d. Observation of the food preparation area revealed a food preparation table across from the food storage area. Observation revealed dehumidifier stationed at the end of the table, with the same height as the top of the preparation site. Observation revealed the top and front panel of the humidifier were covered in a sticky substance with excessive (thick layer) dust accumulation. Observation revealed a large, uncovered tote stored on a shelf underneath the food preparation table with a commercial mixer, food scales, and other undefined kitchen aide equipment inside. Observation revealed a sticky substance covering the outside of the tote and all items inside the tote with an excessive (thick layer) of dust present. Observation revealed three (3) metal brackets where shelving once hung, along the wall behind the food preparation table, covered in a sticky substance with excessive (thick layer) dust accumulation.

Interview with the Administrative Dietary Manager at 1405 revealed the humidifier was just recently provided to the kitchen sometime during the week prior to survey (week of 06/13/2016). Interview revealed the dehumidifier was not cleaned prior to being placed into use in the food preparation area. Interview revealed the unit should have been cleaned prior to being delivered for use and should not be in the food preparation area as it was. Interview revealed the tote beneath the food preparation table appeared to be covered in "grease" and should not be stored in the manner it was. Interview revealed kitchen aides inside the tote were no longer used and should not be located in the food preparation area. Interview revealed the tote would be removed from the area. Interview revealed the brackets along the back wall of the food preparation table were used as support for the shelving and were no longer needed. Interview revealed the brackets would be removed. Interview verified observation findings.

In the cooking areas:
e. Observation of the fried food preparation area revealed a tilt skillet. Observation revealed a red regulator knob located on the side. Observation revealed sticky substance with an excessive (thick layer) of dust covering it. Observation revealed a double oven with excessive (thick layer) grease splattered on interior door and thick burnt particles in oven bottom. Observation revealed excessive (thick layer) grease dripped down front side of oven doors. Observation revealed a floor grade drain located in front of the tile skillet and double oven with excessive (thick layer) of sticky substance covered with dirt and dust. Observation revealed one commercial dough proofer cabinet (used too aid yeast bread fermentation process). Observation revealed a water pan located in the base of the cabinet with a layer of blackened substance in the bottom of the pan. Observation revealed the substance was easily wiped clean with a paper towel. Observation revealed two adjustable temperature knobs located at the bottom of the cabinet, near the floor, with a sticky substance and excessive (thick layer) of grit and dust on both temperature knobs. Observation revealed a microwave oven located on a shelf just before entering the dish washing area, plugged in a wall receptacle. Observation revealed a excessive (thick layer) of a sticky substance with dust along the top portion of the wall plate.

Interview during tour with Administrative Dietary Manager #1 at 1450 revealed the kitchen staff follow the hospital's "Dining Room Maintenance" guidelines for scheduled cleaning. Interview revealed the policy's "Sanitation Schedule" is completed by the Director of Dietary Services and posted in the kitchen on a weekly basis for staff to follow. Interview revealed the schedule for the week of 06/19/2016 - 06/25/2016 was not posted for review. Interview revealed the "Kitchen Weekly Task Cleaning Schedule" was last performed the week of 06/12/2016 - 06/18/2016. Interview observations during the tour did not appear to indicate the scheduled cleaning duties had been performed within the past week, some in previous weeks. Interview revealed observations of the sticky substance appeared to be "grease" and "grim" build up. Interview verified the observation findings.

In dish machine area:
f. Observation of the dish machine area revealed a drying tray with pitchers, plastic lids, and measuring cups. Observation revealed 3 of 3 measuring cups and 1 of 1 measuring spoons were stored face up with water standing in each. Observation revealed a double sink with excessive (thick layer) of a brownish-tan substance around fixtures and a white substance across the top of the back portion of the sink and on the back splash. Observation revealed substances were easily removed with paper towel. Observation revealed chunks of potato in the floor drain beneath the dish machine. Follow-up observation on 06/22/2016 at 1330 revealed potato chunks in the floor drain beneath the dish machine.

Interview during tour with Administrative Dietary Manager #1 at on 06/20/2016 at 1450 revealed the draining pitchers and measuring cups had been sanitized and were drying for storage and use. Interview revealed measuring cups and spoons should not be stored face up. Interview revealed food should not be in the floor drain and that if food were to inadvertently fall into the drain, it should be removed at least during the evening kitchen clean and moping. Interview on 6/22/2016 at 1330 revealed potato chunks were present in the floor drain and should have been removed immediately upon discovery. Interview verified observation findings.

In cookware/dishware dry storage area:
g. Observation revealed solid portion serving spoons, ice cream scoops, and perforated portion serving spoons stored face up. Observation revealed 2 of 5 sampled serving spoons had dried food particles noted on interior surfaces and 1 of 5 had a circular film with a scant amount of water present on the interior surface. Observation revealed 1 of 2 sampled ice cream scoops had standing water with a translucent white cloudy appearance in the interior surface. Observation revealed 3 of 4 metal pans sampled were stacked face down with clear liquid on the exterior surfaces. Observation revealed sticky brown residue build-up on cart holding, ready-for-use dishware.

Interview during tour with Administrative Dietary Manager #1 at 1450, revealed the stored cookware and dishware was clean and available for use by staff. Interview revealed cleaned items should not have residual dried food particles stuck on their surfaces after being cleaned and sanitized. Interview revealed cookware and dishware should not be stored face up or stacked wet. Interview revealed there should be no sticky residue. Interview verified the observation findings.

In the dining room service-line area:
h. Observation revealed a steam/ice table used to for food preparation during meals. Observation during the kitchen tour revealed four bowls, partially covered with paper towels on the steam table in the serving area at 1615. Observation revealed pasta salad, sliced cucumbers, tomatoes, and mixed greens were separately placed in the bowls. Observation revealed the bowls were not sitting in ice or being cooled. Observation revealed a metal serving spoon remained inside the bowl of pasta salad. Observation revealed the mixed greens appeared wilted and discolored.

Interview during the tour with the Administrative Dietary Manager #1 revealed the food should not be in the steam table without ice or some way of keeping it cool. Interview revealed the food was not covered appropriately for future use, if it were to be reused. Interview revealed the pasta salad was a mayonnaise based dish and should be refrigerated following use. Interview revealed the mixed greens were not acceptable for reuse and should be disposed of. Interview verified the observation findings.

Based on observations as referenced in the Life Safety Report of Survey completed June 21, 2016 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01

1. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The loss of normal power to generator automatic transfer switch required greater than ten seconds to restore power to the facility.

b. There is no generator annunciator panel to monitor emergency power supply system in the Adams Building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144

Building 02

2. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The emergency power system generator located on the exterior of the building does not have a remote manual stop switch located outside the generator housing unit. All level 1 and level 2 generator instillation's shall have a remote manual stop station located other than where the prime generator is located.
b. The facility has exposed electrical wiring inside the generator housing unit that were not enclosed in an electrical junction box.
~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144

Building 04

3. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The EPS supplying load indicator did not function with test of the emergency power supply system. The generator annunciator panel failed to function properly with automatic transfer switch "ES" in emergency mode.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144

Based on observations as referenced in the Life Safety Report of Survey completed June 21, 2016, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

The findings include:

Building 02

1. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There are holes in the cross corridor smoke barrier between room 109 and therapist office.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025

Building 02

2. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There is dust and debris accumulation on duct smoke detector sampling tubes - located above corridor ceiling between room 109 and therapist office.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 054

Building 02

3. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The sprinkler tamper switch supervisory signal fails to sound with main control valve in the closed position. The audible signal could be silenced with the valve in the closed position.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061

Building 04

4. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The ceiling of the gas fired hot water heater room.

b. The ceiling and corridor wall of the maintenance / main electrical room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029

Building 04

5. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The front entrance exit door utilizes an electromagnetic lock, without a key switch adjacent to door release hardware for rapid removal of occupants in the event of an emergency.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032


Building 04

6. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. Main sprinkler control valves in outside valve pit are monitored by non-listed supervisory switches. Existing switches use cord and plug arrangement not permitted for NFPA 13 Sprinkler system supervision.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061

Building 04

7. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. Blow-off caps are missing from range hood fire suppression nozzles located above cooking equipment in kitchen area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 069

Building 04

8. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The facility has unsecured carbon dioxide cylinders in the dry storage room across from the dietary department. Gas cylinders should be properly and individually chained or supported in a proper cylinder stand or cart.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076

Based on review of policy, observations during tours, and staff interviews, the nursing staff failed to maintain the facility in a manner to ensure an acceptable level of safey and quality as evidenced by improper storage of oxygen cyliners by storing empty and full containers of oxygen (one empty and five full) in same storage container for 1 out of 5 patient care floors.
The findings include:
Review of policy "Storage of Compressed Gas", with revision date of 02/16 revealed "...4. Cylinders shall be marked empty or full and shall be kept separate."
Observations on 06/21/2016 at 1130 on patient care floor #1 revealed a metal storage container which held a total of 6 oxygen cylinders. Observation revealed five green oxygen tanks labeled "full" and one green oxygen tank labeled "empty" stored together.
Interview with AS #2 on 06/21/2016 at 1530 revealed the storage of full and empty oxygen cylinders together needed to be corrected immediately.
Interview with RN #1 on 06/21/2016 revealed the maintenance personnel is usually called to take the empty O2 tanks downstairs. Further interview revealed RN #1 was unsure of the amount of time the empty oxygen tank had been sitting in metal container with the full oxygen tanks.
Interview with RN #2, a nurse covering for the floor manager, revealed RN #2 was unsure where the empty oxygen tanks should be stored while waiting for maintenance to remove them.
Interview with Nurse Manager on 06/22/2016 at 0915 revealed he was unaware of the requirement for the oxygen tanks to be separated.

Based on medical record review and staff interview it was determined that the facility failed to ensure--
1. Psychosocial Assessments contained a description of the role of the social work staff in discharge planning. (See B108)
2. Psychiatric Assessments contained information concerning memory function. (See B116)
3 Psychiatric Assessments contained an assessment of patient assets. (See B117)
4. Treatment Plans contained problems expressed behaviorally. (See B119)
5. Treatment Plans contained goals expressed in measurable format. (See B121)
6 Treatment Plans were individualized and interventions were more than generic discipline functions. (See B122)
7. Progress notes by nursing staff disclosed the results of the interventions selected on the Master Treatment Plan. (See B127)

Based on medical record review and staff interview it was determined that for six (6) of eight (8) patients their Psychosocial Assessments failed to include a description of the role of the social service staff in discharge planning. This failure results in neither the patient nor the comprehensive treatment team members knowing what efforts the social service staff will tentatively be pursing. (Patients A3, B3, B13, C5, E12 and F2).

The findings include:

I. Medical Records:

1. Patient A3: The Psychosocial Assessment dated 6/07/2016 stated as the role of the social service staff "The therapist will recommend the patient to {sic} discharge and follow up with OVBHS (Old Vineyard Behavioral Health Services) PHP (Partial Hospital Program) for continued treatment following discharge."

2. Patient B3: The Psychosocial Assessment dated 6/17/2016 had no role for social service staff described.

3. Patient B13: The Psychosocial Assessment dated 6/17/2016 had no role for the social service staff described.

4. Patient C5: The Psychosocial Assessment dated 6/16/2016 stated "Clinician recommends gathering collateral information from mother, possible family session prior to discharge."

5. Patient E 12: The Psychosocial Assessment dated 6/09/2016 stated "The clinician recommends gathering collateral information from pts {sic} best friend prior to discharge."

6. Patient F2: The Psychosocial Assessment dated 5/05/2016 had no role for social service staff described.


II. Staff Interview:

On 6/21/2016 at 1:00 PM the Director of Social Services was interviewed. She acknowledged that the role of the social service staff should be described in the Psychosocial Assessment of the patient. She stated that she was working on providing an area on the assessment form to alert the social work staff to provide information about their anticipated role in discharge planning.

Based on medical record review and staff interview it was determined that the Psychiatric Evaluations of eight (8) of eight (8) patients failed to disclose any information about memory functioning and how stated impressions were made. Instead, there was only "intact" or "impaired" stated for immediate, recent and remote memory functioning. This failure results in no data base available to compare or contrast memory functioning in future assessments. (Patients A3, B3, B13, C5, D1, D13, E12 and F2)

The findings include:

I. Medical Record Review:

The Psychiatric Evaluations (dates in parenthesis) all had only a check mark on the preprinted form that stated either "intact" or "impaired" as the evaluation of immediate, recent and remote recall. Patients: A3 (6/15/2016), B3 (6/16/2016), B13 (6/17/2016), C5 (6/15/2016), D1 (6/14/2016), D13 (6/11/2016), E12 (6/08/2016) and F2 (6/04/2016).

II. Staff Interview:

On 6/22/2016 at 11:30 AM the clinical director was interviewed. He was shown the findings described in Section I, above. He agreed that they were uninformative.

Based on medical record review and staff interview it was determined that the Psychiatric Evaluations for eight (8) of eight (8) patients failed to describe assets in descriptive not interpretive fashion. This failure results in the treatment team not being aware of what personal factors might be utilized for achieving the Treatment Plan or possibly useful in therapeutic endeavors. (Patients A3, B3, B13, C5, D1, D13, E12 and F2)

The findings include:

I. Medical Record Review:

1. Patient A3: The Psychiatric Evaluation dated 6/15/2016 had only for patient assets a check mark on the preprinted form by "average or above intelligence".

2. Patient B3: The Psychiatric Evaluation dated 6/16/2016 had no assets described on the preprinted form.

3. Patient B13: The Psychiatric Evaluation dated 6/17/2016 had no assets described on the preprinted form.

4. Patient C5: The Psychiatric Evaluation dated 6/15/2016 had only "ability for insight" check marked on the preprinted form.

5. Patient D1: The Psychiatric Evaluation dated 6/14/2016 had only for patient assets a check mark on the preprinted form by "average or above intelligence".

6. Patient D13: The Psychiatric Evaluation date d6/11/2016 had only for patient assets a check mark on the preprinted form by "average or above intelligence".

7. Patient E12: The Psychiatric Evaluation dated 6/08/2016 had only "ability for insight" check marked on the preprinted form.

8. Patient F2: The Psychiatric Evaluation dated 6/04/2016 had only for patient assets a check mark on the preprinted form by "average or above intelligence".

II. Staff Interview:

On 6/22/2016 at 11:30 AM the clinical director was interviewed. He was shown the findings described in Section I, above. He agreed that there was not present a description of patient assets in descriptive not interpretive fashion.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that described patient strengths and disabilities (problems) in behavioral terms for eight (8) of eight (8) active sample patients (A3, B3, B13, C5, D1, D13, E12 and F2). The problems on the treatment plans were selected from a preprinted list that included generalized statements, rather than identifying specific problem behaviors to be reduced or resolved. This failure results in a fragmented, confusing Master Treatment Plan that fails to identify specific disabilities (problems) to be treated during the hospitalization and results in poorly defined goals and interventions. This failure can adversely affect clinical decision making and can prevent the patient from receiving necessary treatment in a timely manner.

Findings include:

A. Medical Records

1. Facility policy #ID.290.00, titled "Inter-disciplinary Treatment "Planning", last reviewed 9/2013, stated: "[Name of facility] strives to provide therapeutic services to patients in a planned, coordinated, multi-disciplinary manner"---"[The MTP] includes the following: Identification of admission diagnosis, patient's assets, patient stressors, initial problems."

2. Active sample patient A3, MTP dated 6/17/16, had the following patient strengths: "Ability to verbalize feelings, capable of independent living, and communication skills." The patient's limitations (disabilities) were: "Poor insight, lack of healthy supports, and medication non-compliance." The problem was "Depression." "Neither the strengths, disabilities or identified problems" included specific patient's behaviors that could be used in developing individualized goals and interventions for this patient.

3. Active sample patient B3, MTP dated 6/17/16, had the following patient strength: "Ability to verbalize feelings." No disabilities were identified from the list of choices provided. One identified problem was "Depression with suicidal ideation." The specific suicidal thoughts were not listed. Second problem listed was "Psychotic behaviors evidenced by odd bizarre behaviors." Neither the strength nor problems included specific patient behaviors that could be used in developing individualized goals and interventions.

4. Active sample patient B13, MTP dated 6/17/16, had the following patient's strengths: "Ability to verbalize feelings, supportive family/friends and capable of independent living." The disabilities were "poor insight, medication non-compliance" and "health problems." The identified problem was "psychotic behaviors" evidenced by "irrational statements." Neither the strengths, disabilities nor identified problems included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

5. Active sample patient C5, MTP dated 6/17/16, had the following patient strength: "Ability to verbalize feelings." The disabilities were "poor insight, lack of healthy supports" and "access to medications." The identified problem was "psychotic behavior evidenced by: irrational statements." Neither the strengths, disabilities nor identified problems included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

6. Active sample patient D1, MTP dated 6/15/16, had the following patient strengths: "Ability to verbalize feelings, average or above intelligence, supportive family/friends, and physical health." The disability was "poor insight." The identified problem was "Depression/SUA [Suicide Attempt]." The strengths and disabilities did not include specific patient's behaviors that could be used in developing individualized goals and interventions. The problem (Depression/SUA) did not include helpful information of ways patient either tried or thought of using to commit suicide which would have provided staff with specific behavior(s) to be on alert when monitoring. Neither the strengths, disabilities nor identified problems included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

7. Active sample patient D13, MTP dated 6/13/16, had the following patient strengths: "Ability to verbalize feelings, average or above intelligence" and "religious affiliation." The disabilities were: "poor insight" and "cognitive impairment." The identified problem was "Depression without suicidal ideation evidenced by: recent attempt." Neither the strengths, disabilities nor identified problems included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

8. Active sample patient E12, MTP dated 6/10/16, had the following patient strengths: "Ability to verbalize feelings, capable of independent living" and "communication skills." The disabilities were: "poor insight, lack of healthy supports" and "access to medication." The identified problem was "Depression with suicidal ideation evidenced by specific ideation - jumping off bridge." Neither the strengths, disabilities nor identified problem included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

9. Active sample patient F2, MTP dated 6/6/16, had the following strength: "Ability to verbalize feelings." The disabilities were: "Health problems" and "Access to medications." The identified problem was "Depression with suicidal ideation." Neither the strengths, disabilities or identified problems included specific patient behaviors that could be used in developing individualized goals and interventions for this patient.

B. Interviews

1. In an interview on 6/21/16 at 12:10 p.m., the pre-printed Master Treatment Plan forms that were selected by diagnosis, with a list of strengths and disabilities to be chosen from by staff, was discussed with LPC1. She agreed that the choices did not include a description of specific patient behaviors that staff could use in individualizing the plans.

2. In an interview on 6/22/16 at 8:20 a.m. with the Nursing Director, the problem of patient's strengths and disabilities not being stated in behavioral terms for clarity was discussed. She agreed with the findings.

Based on record review and interview, the facility failed to formulate Master Treatment Plan (MTP) goals that were relevant to the patient's condition for eight (8) of eight (8) active sample patients (A3, B3, B13, C5, D1, D13, E12 and F2). Many goals on the treatment plans were either obvious basic functions of a psychiatric hospital ward, such as "will identify family/support problem to obtain collateral information" or consisted of adherence to treatment ("will participate in medication evaluation") rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in case of lack of progress.

Findings include:

A. Record Review

1. Facility policy #ID.290.00, title "Inter-disciplinary Treatment Planning", last revised 9/2013, and stated: "[Name of hospital] strives to provide therapeutic services to patients in a planned, coordinated, multi-disciplinary manner. In order to provide effective interventions, the treatment team must be person-center"...It includes the following: "Measureable short-term goals based on the goals [sic] of treatment." The policy did not include a specific description of how the goals should be worded.

2. Active sample patient A3: MTP dated 6/17/16, had as a problem "Depression evidenced by 'blank space' ." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, will verbalize no suicidal thoughts or exhibit self-destructive behaviors for 2 consecutive days, will report any suicidal thoughts/impulses to staff prior to acting on them, will identify two participating factors (triggers) which increase thoughts of suicide or self-harm", and "will identify 2 warning signs of depression which lead to suicidal thoughts of self-harm."
An example of obvious function of a psychiatric hospital was "[name of patient] will identify family/support to obtain collateral information, engage in developing a safety plan for discharge, including a plan to remove lethal means of self-harm."

3. Active sample patient B3: MTP dated 6/17/16, had as a problem "Depression with suicidal ideation." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, will verbalize no suicidal thoughts or exhibit self-destructive behaviors for 2 consecutive days, will report any suicidal thoughts/impulses to staff prior to acting on them, will identify two participating factors (triggers) which increase thoughts of suicide or self-harm", and "will identify 2 warning signs of depression which lead to suicidal thoughts of self-harm."
An example of obvious function of a psychiatric hospital was "[name of patient] will identify family/support to obtain collateral information, engage in developing a safety plan for discharge, including a plan to remove lethal means of self-harm."

4. Active sample patient B13, MTP dated 6/17/16, had as a problem "Psychotic behaviors evidenced by odd or bizarre behaviors." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation," and "[name of patient] will take (antipsychotic medication) willingly." The following is an example of obvious functions of a psychiatric hospital: "[Name of patient] will identify family/support person to obtain collateral information, engage in developing a safety plan for discharge, including a plan to remove lethal means of self-harm."

5. Active sample patient C5: MTP dated 6/17/16, had as a problem "Psychotic behaviors evidenced by: irrational statements." The following short-term goals were all examples of adherence to treatment: "Will participate in medication evaluation, [name of patient] will demonstrate the ability to differentiate between what is real and what is not real, [name of patient] will verbalize 2 early warning signs of relapse, [name of patient] will identify post discharge aftercare needs and safety plan."

6. Active sample patient D1: MTP dated 6/15/16, had as a problem "Depression evidenced by recent attempt." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, will verbalize no suicidal thoughts or exhibit self-destructive behaviors for 2 consecutive days, will report any suicidal thoughts/impulses to staff prior to acting on them, will identify two participating factors (triggers) which increase thoughts of suicide or self-harm", and "will identify 2 warning signs of depression which lead to suicidal thoughts of self-harm."
An example of obvious function of a psychiatric hospital was "[name of patient] will identify family/support to obtain collateral information, engage in developing a safety plan for discharge, including a plan to remove lethal means of self-harm."

7. Active sample patient D13, MTP dated 6/13/16, had as a problem "Depression with suicidal ideation evidenced by recent attempt." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, will verbalize no suicidal thoughts or exhibit self-destructive behaviors for 3 consecutive days, will report any suicidal thoughts/impulses to staff prior to acting on them, will identify two participating factors (triggers) which increase thoughts of suicide or self-harm" and "will identify 3 warning signs of depression which lead to suicidal thoughts of self-harm."
An example of obvious function of a psychiatric hospital was "[name of patient] will identify family/support to obtain collateral information, engage in developing a safety plan for discharge, including a plan to remove lethal means of self-harm."

8. Active sample patient E12: MTP dated 6/16/16, had as a problem "Depression with suicidal ideation evidenced by specific ideation- jump off bridge." The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, will verbalize no suicidal thoughts or exhibit self-destructive behaviors for 3 consecutive days, will report any suicidal thoughts/impulses to staff prior to acting on them, will identify two participating factors (triggers) which increase thoughts of suicide or self-harm" and "will identify 3 warning signs of depression which lead to suicidal thoughts of self-harm."
An example of obvious function of a psychiatric hospital was "[name of patient] will identify family/support to obtain collateral information, engage in developing a safety plan for discharge including a plan to remove lethal means of self-harm."

9. Active sample patient F2: MTP dated 6/16/16, had as a problem "Depression with suicidal ideation evidenced by (blank space. No choices selected.) The following short-term goals were all examples of adherence to treatment: "[Name of patient] will participate in medication evaluation, [name of patient] will report any suicidal thoughts/impulses to staff prior to acting on them, [name of patient] will identify two participating factors [triggers] which increase thoughts of suicide or self-harm, [name of patient] will demonstrate use of coping strategies identified in safety plan in milieu and groups, [name of patient] will demonstrate use of 2 therapeutic activities to decrease depressive suicidal thinking and sad feeling.

B. Interview

In an interview on 6/22/16 at 8:20 a.m., the problem of treatment plan goals not being relevant to the patients' conditions was discussed with the Nursing Director. She agreed that this was a problem.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) interventions addressed specific treatment needs eight (8) of eight (8) active sample patients (A3, B3, B13, C5, D1, D13, E12 and F2). The staff interventions on the MTPs were stated as generic discipline functions. The facility used pre-printed treatment plans based on identified problems, such as "Depression" and "Psychosis." The pre-printed interventions for an identified problem like "Depression", listed the same interventions for that category. Staff only had to check off which interventions listed they wanted to use for individual patients. The same choices for identified problem prevented a difference of approach regardless of each patient's individual needs. Failure to document specific treatment approaches interferes with the assurance of staff consistency in approaching each patient's problems and may result in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. Facility policy #ID.290.00, titled "Inter-disciplinary Treatment Planning," last reviewed 9/2013, stated: "[Name of facility] strives to provide therapeutic services to patients in a planned coordinated, multi-disciplinary manner. In order to provide effective interventions, the treatment team must be person-centered"---"It includes the following: Therapeutic interventions to be used with the patients". The policy failed to include a description or examples of the types of interventions to be included.

2. Active sample patient A3: MTP dated 6/17/16, for the problem of "Depression", some generic discipline functions were:

- Physician intervention: "Educate patient regarding purpose, actions, risks & [and] side effects of [blank space]."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, conduct suicide measurements, implement staff observations & [and] safety measures including level II [two] observations, room checks."

- Unit clinician (social worker) interventions: "Help the patient to identify stressors & circumstances that trigger thoughts of suicide or self-harm, assist patient to identify early signs of depressive thoughts and behaviors."

3. Active sample patient B3: MTP dated 6/17/16 for the problem of "Depression without suicidal ideation evidenced by: [blank space]," some generic discipline functions were:

- Physician intervention: "Educate patient regarding purpose/actions, risks & side effects of Lexapro 10 mg [milligrams]."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, conduct suicidal measurements. Implement staff observation & safety measures including standard 15 minute observations."

- Unit clinician interventions: "Help the patient to identify stressors & circumstances that trigger thoughts of suicide or self-harm, assist patient to identify early signs of depressive thoughts and behaviors. Help patient identify coping strategies from safety plan and practice use of them with peers and staff."

4. Active sample patient B13: MTP dated 6/17/16 for the problem of "Psychotic behaviors evidenced by: [blank space]," some generic discipline functions were:

- Physician intervention: "Assess patient's response and any side effects to prescribes medications: Wellbutrin x [times] 2"

- Nursing interventions: "Educate patient on the benefits of taking (antipsychotic medication), their side effects, and the importance of medication compliance."

- Unit clinician interventions: "Educate the patient/family about the early warning signs of relapse, including: social isolation, decline in self-care, work or school, depressed mood, decreased motivation, sleep disturbance, develop discharge and safety plan with pt. and review with patient."

5. Active sample patient C5: MTP dated 6/17/16 for the problem of "Psychotic behaviors evidenced by irrational statements," some generic discipline interventions were:

- Physician intervention: "Assist patient's response and side effect to prescribed medications."

- Nursing interventions: "Educate patient/family about the early warning signs of relapse, including social isolation, decline in self-care, work or school, depressed mood, decreased motivation, sleep disturbance." This intervention is also performed by unit clinicians (social work staff).

- Unit clinician interventions: "Assist identified support person(s) in development of a crisis safety plan to include: confirming access or removal of weapons (lethal means of self-harm) by family or support person, and assist patient in identifying positive support persons to help define onset of depression and/or suicidal thoughts, triggers, warning signs and needs in a crisis from the support persons in their life." "Develop discharge and safety plan with pt. and review with: [choice of patient, family, others]." No choices were checked.

- Recreation therapy intervention: "[Name of patient] will demonstrate use of 2 therapeutic activities to decrease psychotic behaviors."

6. Active sample patient D1: MTP dated 6/15/16 for the problem of "Depression evidenced by recent attempt," some generic interventions were:

- Physician intervention: "Educate patient regarding purpose, actions, risks & side effects of any prescribed meds [medications]."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-ins with patient regarding mood, negative and suicidal thought and significant behavioral changes in condition, conduct suicidal reassessment, implement staff observation & safety measures including level II observations, 1:1 observation."

- Unit clinician interventions: "Assist identified support person(s) in development of a crisis safety plan to include: confirming access or removal of weapons (lethal means of self-harm) by family or support person, and assist patient in identifying positive support persons to help define onset of depression and/or suicidal thoughts, triggers, warning signs and needs in a crisis from the support persons in their life." "Develop discharge and safety plan with pt. and review with: [choice of patient, family, others]." No choices were checked.

"Help the patient to identify stressors & circumstances that trigger thoughts of suicide or self-harm. Develop discharge and safety plan with pt. and review with patient."

- Recreation therapy intervention: "Teach emotional expression and regulation through use of therapeutic activities including physical outlets, leisure activities, expressive activities and meditation/relaxation."

7. Active sample patient D13: MTP dated 6/13/16 for the problem of "Depression without suicidal ideation evidenced by recent attempt," some generic discipline interventions were:

- Physician intervention: "Educate patient regarding purpose, actions, risks & side effects of Prozac, Depakote."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments, implement staff observation & safety measures including [ There were no checks from six (6) choices listed]."

- Unit clinician interventions: "Help the patient to identify stressors & circumstances that trigger thoughts of suicide or self-harm, help patient identify coping strategies from safety plan and practice use of them with peers and staff."

"Assist identified support person(s) in development of a crisis safety plan to include: confirming access or removal of weapons (lethal means of self-harm) by family or support person, and assist patient in identifying positive support persons to help define onset of depression and/or suicidal thoughts, triggers, warning signs and needs in a crisis from the support persons in their life." "Develop discharge and safety plan with pt. and review with: [choice of patient, family, others]." No choices were checked.

- Recreation therapy intervention: "Teach emotional expression and regulation through use of therapeutic activities including physical outlets, leisure activities, expressive activities and meditation/relaxation."

8. Active sample patient E12: MTP dated 6/10/16 for the problem "Depression with suicidal ideation evidenced by: specific ideation- jumping off bridge," some generic discipline interventions were:

- Physician intervention: "Educate patient regarding purpose, actions, risks & side effects of all prescribed [sic]."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments, implement staff observation & safety measures including level II observations, room checks."

- Unit clinician interventions: "Assist patient to identify early signs of depressive thoughts and behaviors, develop discharge and safety plan with pt. and review with patient."

- Recreation therapy intervention: "Teach emotional expression and regulation through use of therapeutic activities including physical outlets, leisure activities, expressive activities and meditation/relaxation."

9. Active sample patient F2: MTP dated 6/6/16, for the problem "depression with suicidal ideation," some generic discipline interventions were:

- Physician intervention: "Educate patient regarding purpose, actions, risks & side effects of all prescribed [sic]."

- Nursing interventions: "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments."

- Unit clinician interventions: "Assist patient to identify early warning signs of depressive thoughts and behaviors, help patient identify coping strategies from safety plan and practice use of them with peers and staff, develop discharge and safety plan with pt. and review with patient."

- Recreation therapy intervention: "Teach emotional expression and regulation through use of therapeutic activities including physical outlets, leisure activities, expressive activities and meditation/relaxation."

B. Interviews

1. In an interview on 6/21/16 at 12:10 p.m. with the Director of Social Work, the generic discipline interventions were discussed. She agreed with the findings.

2. In an interview on 6/22/16 at 11:30 a.m., the problems with the treatment plan interventions not addressing the specific needs of individual patients was discussed with the Medical Director. He agreed with the findings.

Based on record review and interview, the facility failed to ensure that nursing staff documented the progress of patients in achieving nursing interventions in progress notes for five (5) of eight (8) active sample patients (A3, B3, B13, C5 and E12). This failure results in the treatment team being unable to determine if there are any measureable changes in the patients' condition and to make necessary changes to the treatment plan when needed.

Findings include:

A. Medical Records

1. Active sample patient A3: MTP dated 6/17/16, had for the problem of "Depression," a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment." Nursing progress notes were reviewed between admission date of 6/15/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

2. Active sample patient B3: MTP dated 6/17/16 had for the problem "Depression with suicidal ideation," a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment."
For the problem "psychiatric behaviors evidenced by odd or bizarre behaviors," the nursing intervention was "educate patient on the benefits of taking (antipsychotic medication), their side effects, and the importance of medication compliance."
Nursing progress notes were reviewed between admission date of 6/15/16 and 6/20/16 for any documentation related to the interventions being carried out and the patient ' s progress. None were found.

3. Active sample patientB13: MTP dated 6/17/16, had as a problem "Psychotic behaviors as evidenced by [blank space]," a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment."
Nursing progress notes were reviewed between admission date of 6/16/16 and 6/20/16 for any documentation related to the interventions being carried out and the patient's progress. None were found.

4. Active sample patient C5: MTP dated 6/17/16, had as a problem "Psychotic behaviors evidenced by irrational statements." Nursing progress notes were reviewed between admission date of 6/19/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

5. Active sample patient E12: MTP dated 6/10/16, had as a problem "Depression with suicidal ideation." Nursing progress notes were reviewed between admission date of 6/7/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

B. Interview

In an interview on 6/21/16 at 12:00 p.m. the lack of nursing progress notes for nursing interventions found on the MTPs was discussed with LPC1 who assisted in the chart review. She stated, "I understand. There are none there."

Based on medical record review and staff interview it was determined that the clinical director failed to ensure:

1. Psychiatric Evaluations contained descriptions of memory functioning. (See B116 for details)

2. Psychiatric Evaluations contained a description of personal assets in descriptive not interpretative fashion. (See B117 for details)

3. Treatment Plans contained Problems behaviorally stated. (See B119 for details)

4. Treatment Plans had goals for patients that were measurable. (See B121 for details)

5. Treatment Plans were (a) not a listing of generic discipline functions and (b) were individualized. (See B122 for details)

Based on record review and interview, it was determined that the Nursing Director failed to monitor the quality of the nursing care provided to patients. Specifically, the Nursing Director failed to:

I. Ensure that the nursing interventions on the Master Treatment plans (MTPs) for eight (8) of eight (8) active sample patients (A3, B3, B13, C5, D1, D13, E12 and F2) addressed their specific treatment needs. Many nursing interventions on the MTPs were stated as generic discipline functions. The facility used pre-printed treatment plans based on identified problems, such as "Depression" and "Psychosis." The pre-printed interventions for an identified problem, like "depression", listed the same interventions for that category. Staff only had to check off which of the interventions listed they wanted to use for individual patients. The same choices on each identified problem prevented a difference of approach regardless of each patient's individual needs. Failure to document specific treatment approaches interferes with the assurance of consistency approach to each patient's problems and may result in prolonged hospitalization for patients.

II. Ensure that nursing staff documented the progress of patients in achieving nursing interventions in progress notes for five (5) of eight (8) active sample patients (A3, B3, B13, C5 and E12). This failure results in the treatment team being unable to determine if there are any measureable changes in the patients' condition and to make necessary changes to the treatment plan when needed.

Findings include:

A. Medical Records

I. Failed to ensure that the nursing interventions addressed specific treatment needs:

1. Facility policy #ID.290.00, titled "Inter-disciplinary Treatment Planning," last reviewed 9/2013, stated: "[Name of facility] strives to provide therapeutic services to patients in a planned coordinated, multi-disciplinary manner. In order to provide effective interventions, the treatment team must be person-centered"---"It includes the following: Therapeutic interventions to be used with the patients". The policy failed to include a description of example of the types of interventions to be included.

2. Active sample patient A3: MTP dated 6/17/16, for the problem of "Depression", some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, conduct suicide measurements. Implement staff observations & [and] safety measures including level II [two] observations, room checks."

3. Active sample patient B3, MTP dated 6/17/16, for the problem of "Depression with suicidal ideation evidenced by: [blank space]," some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, conduct suicidal measurements. Implement staff observation & safety measures including standard 15 minute observations."

4. Active sample patient B13: MTP dated 6/17/16, for the problem of "Psychotic behaviors evidenced by: [blank space]," a generic nursing discipline intervention was:

- "Educate patient on the benefits of taking (antipsychotic medication), their side effects, and the importance of medication compliance."

5. Active sample patient C5: MTP dated 6/17/16, for the problem of "Psychotic behaviors evidenced by irrational statements," a generic nursing discipline intervention was:

- "Educate patient/family about the early warning signs of relapse, including social isolation, decline in self-care, work or school, depressed mood, decreased motivation, sleep disturbance."

6. Active sample patient D1: MTP dated 6/15/16, for the problem of "Depression evidenced by recent attempt," some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-ins with patient regarding mood, negative and suicidal thought and significant behavioral changes in condition, conduct suicidal reassessment, implement staff observation & safety measures including level II observations, 1:1 observation."

7. Active sample patient D13: MTP dated 6/13/16, for the problem of "Depression without suicidal ideation evidenced by recent attempt," some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments, implement staff observation & safety measures including [no checks for any of the six (6) choices listed]."

8. Active sample patient E12: MTP dated 6/10/16, for the problem of "Depression with suicidal ideation evidenced by: specific ideation- jumping off bridge," some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments, implement staff observation & safety measures including level II observations, room checks."

9. Active sample patient F2: MTP dated 6/6/16, for the problem of "Depression with suicidal ideation evidenced by specific ideation jump off bridge," some generic nursing discipline interventions were:

- "Educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments."

B. Interview

In an interview on 6/22/16 at 8:20 a.m., the problem of treatment plan goals being generic nursing discipline interventions on the MTPs were discussed with the Nursing Director. She agreed that this was a problem.

II. Ensure that nursing staff documented the progress of patients in achieving nursing interventions in progress notes for five (5) of eight (8) active sample patients (A3, B3, B13, C5 and E12). This failure results in the treatment team being unable to determine if there are any measureable changes in the patients' condition and to make necessary changes to the treatment plan when needed.


A. Medical Records

1. Active sample patient A3: MTP dated 6/17/16, had for the problem of "Depression" a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment", a nursing progress notes were reviewed between admission date of 6/15/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

2. Active sample patient B3: MTP dated 6/17/16, had for the problem of "Depression with suicidal ideation" a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment."

For the problem of "psychiatric behaviors evidenced by odd or bizarre behaviors," the nursing intervention was "educate patient on the benefits of taking (antipsychotic medication), their side effects, and the importance of medication compliance."

Nursing progress notes for both interventions were reviewed between admission date of 6/15/16 and 6/20/16 for any documentation related to the interventions being carried out and the patient's progress. None were found.

3. Active sample patientB13: MTP dated 6/17/16, had for the problem "Psychotic behaviors as evidenced by [blank space]" a nursing intervention of "educate patient regarding symptoms of depression and importance of compliance with treatment."

Nursing progress notes were reviewed between admission date of 6/16/16 and 6/20/16 for any documentation related to the interventions being carried out and the patient's progress. None were found.

4. Active sample patient C5: MTP dated 6/17/16, had for the problem "Psychotic behaviors evidenced by irrational statements." A nursing intervention was "Educate patient/family about the early signs of relapse, including social isolation, decline in self-care, work or school, depressed mood, decreased motivation, sleep disturbance. Nursing progress notes were reviewed between admission date of 6/19/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

5. Active sample patient E12: MTP dated 6/10/16, had for the problem "Depression with suicidal ideation" nursing interventions of "educate patient regarding symptoms of depression and importance of compliance with treatment, provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition, conduct suicidal assessments, implement staff observation & safety measures including level II observations, room checks." Nursing progress notes were reviewed between admission date of 6/7/16 and 6/20/16 for any documentation related to this intervention being carried out and the patient's progress. None were found.

B. Interview

In an interview on 6/22/16 at 8:20 a.m., the lack of nursing progress notes for nursing interventions found on the MTPs was discussed with the Nursing Director. She stated "I'm aware of this problem. I've been monitoring nurses' progress notes and pointing out this deficiency to them."

Based on medical record review and staff interview it was determined that the Director of Social Work failed to ensure that Psychosocial Assessments contained a description of what the role of the social service staff would be in discharge planning. (Patients A3, B3, B13, C5, E12 and F2).

The findings include:

I. Medical Records:

1. Patient A3: The Psychosocial Assessment dated 6/07/2016 stated as the role of the social service staff "The therapist will recommend the patient to {sic} discharge and follow up with OVBHS (Old Vineyard Behavioral Health Services) PHP (Partial Hospital Program) for continued treatment following discharge."

2. Patient B3: The Psychosocial Assessment dated 6/17/2016 had no role for social service staff described.

3. Patient B13: The Psychosocial Assessment dated 6/17/2016 had no role for the social service staff described.

4. Patient C5: The Psychosocial Assessment dated 6/16/2016 stated "Clinician recommends gathering collateral information from mother, possible family session prior to discharge."

5. Patient E 12: The Psychosocial Assessment dated 6/09/2016 stated "The clinician recommends gathering collateral information from pts {sic} best friend prior to discharge."

6. Patient F2: The Psychosocial Assessment dated 5/05/2016 had no role for social service staff described.

II. Staff Interview:

On 6/21/2016 at 1:00 PM the Director of Social Services was interviewed. She acknowledged that the role of the social service staff should be described in the Psychosocial Assessment of the patient. She stated that she was working on providing an area on the assessment form to alert the social work staff to provide information about their anticipated role in discharge planning.