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Based on record review, interview and review of Hospital policy, it was determined that the Hospital failed to ensure that patients were involved in the development of treatment plan goals for 1 patient (Pt. #13) of 14 patient clinical records reviewed during the unit tours.
Findings include:

1. On 6/26/12, a review of Pt. #13's clinical record was conducted. This review revealed that Pt. #13 was admitted on 6/22/12 with a diagnosis of Depression. Review of the document titled, "Treatment Plan" revealed that the initial treatment plan was developed on 6/23/12. The treatment plan was signed by a registered nurse (RN). No other staff signed the treatment plan. Review of the entire record revealed no further updates or revisions to the treatment plan. The plan was not signed by Pt. #13 and there was no documentation that indicated that Pt. #13 was unable or unwilling to review the treatment plan.

2. In an interview on 6/26/12 at 11:20am, E#4 confirmed that the treatment plan in the record was the current treatment plan for Pt #13. E#4 confirmed that Pt. #13 had been admitted for more than 48 hours at this time.

3. In an interview on 6/28/12 at 9:30am, E# 5 stated that the RN on duty will complete the initial treatment plan upon admission. E#5 stated that the treatment team will develop an updated treatment plan that will involve the patient within 48 hours. E#5 stated that the patient is given the treatment plan for review and will offer input or suggestions that will be incorporated into the treatment plan if possible. E#5 stated that patients are asked to sign the treatment plan after review and that staff will document on the treatment plan if a patient refuses to review the plan. E#5 confirmed that Pt. #13 was capable of participating in the development of her treatment plan.

4. In an interview on 6/28/12 at 9:40am, Pt #13 stated that the Hospital provided her a copy of her treatment plan and asked for her involvement in developing treatment goals on 6/26/12 (the date of survey).

5. Review of the Hospital policy titled, "Interdisciplinary Treatment Plan" with a revision date of 4/26/12, revealed that the "treatment team will possibly consist of the following but not limited to: patient..." The policy specifies that the "Treatment plan will be completed within 48 hours after the patient is admitted to acute units..." and "Whenever appropriate, the patient shall participate in the development of his or her treatment plan, and such participation will be documented."

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Based on review of Hospital policy, clinical records and staff interview, it was determined that for 3 of 14 (Pt. #s 4, 7 and 8) clinical records reviewed during unit tours, the Hospital failed to ensure consent was obtained for psychotropic medications prior to initiating treatment.

Findings include:

1. Hospital policy titled, "Informed Consent for Psychotropic Medication" (revised 5/17/12) required, "all psychotropic medications are administered after informed consent has been obtained from patient/parent/patients authorized representative".

2. The clinical record of Pt. #4 included that the Pt. was a 16 year old female admitted on 6/23/12 with the diagnoses of Major Depression with Psychosis. The clinical record included a physicians' order dated 6/24/12 for Xanax (antianxiety medication) 1 milligram (mg) by mouth twice a day, " give dose now." The Medication Administration Record (MAR) noted the Xanax was administered 6/24/12 at 2:00 PM. The consent form was not signed by Pt. #4's parent. The physician obtained consent on 6/25/12, after administration of the medication.

3. The clinical record of Pt. #7 included that the Pt. was an 85 year old female admitted on 6/13/12 with the diagnosis of Agitation. The clinical record included a physicians' order dated 6/16/12 at 11:25 PM and 6/17/12 at 4:32 PM for," Geodon (antianxiety medication) 10 mg Intramuscular (IM) now." The MAR noted that Geodon was administered on 6/16/12 at 11:45 PM and 6/17/12 at 5:00 PM. The clinical record lacked a signed consent from the patient. The physician obtained consent on 6/18/12, after administration of the medication.

4. The Charge Nurse (E#7) was interviewed on 6/26/12 at 1:30 PM and stated, "I am unable to find a signed consent for the medication".

5. The clinical record of Pt. #8 included that the Pt. was a 62 year old female admitted on 6/18/12 with the diagnosis of Major Depression. The clinical record included a physicians' order dated 6/23/12 at 9:10 AM for Pamelor 25 mg by mouth every night for depression. The MAR noted the Pamelor was administered on 6/23/12 at 9:00 PM. The clinical record lacked a signed consent from the patient.

6. The Registered Nurse(E#6) who administered the Pamelor was interviewed on 6/26/12 at 2:00 PM and stated that, "I must have forgotten to have Pt. #8 sign the consent form".

A. Based on review of event occurrence reports and staff interview, it was determined that the Hospital failed to put a system in place to ensure the safety and well being of patients seeking assessment while in the Emergency Department (Referral Resource Center). This potentially affects all patients who present to the Referral Resource Center (RCC).

Findings include:

1. On 6/27/12 the event occurrence reports were reviewed for 2011-2012. One event occurrence report dated 9/10/11 included "pt walked in crying stating she was feeling suicidal. Brought her to room and while I was getting her registered she took half bottle of pills. contacted house supervisor and called 911... Supplemental Data... Mgr Action (s) Taken... Communication Process Enhanced". The report lacked documentation of any "Risk Management Activities".

2. On 6/27/12 at approximately 1:15 P.M. an interview was conducted with the RCC Nurse Manager. The Manager stated that they have the lockers in the waiting room, and the staff have been instructed to request that patients empty their pockets and surrender anything that might cause harm. "We don't do a search... We hope they give us everything". The Nurse Manager also stated that there have been no policies changed or implemented as a result of this occurrence.

3. An interview was conducted with the Safety Risk Manager on 6/27/12 at approximately 2:20 P.M. When asked about the above occurrence the Risk Manager stated that believes the lockers were installed because of this occurrence, and that the staff are requested to ask the patients to empty their pockets. "... because of respect and dignity, patients are not asked to remove their clothes."


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B. Based on review of Hospital policy, clinical records, and interview it was determined that for 2 of 4 (Pt. #9, Pt. #11) clinical records reviewed on the Adult Unit, and 1 of 8 (Pt. #29)Precaution Records on the Eating Disorder Program Unit (EDP) the Hospital failed to ensure the patient was monitored as ordered.

1. On 6/26/12 the Facility's policy titled "LOH-CLIN 078 Safety Precautions (revised 6/21/12)" was reviewed, and contained, "E. Document safety precautions on the following: 1. Precautions Record...J. Close Observation...1. Every 15 minutes."

2. On 6/26/12 the clinical record of Pt#9 was reviewed. Pt. #9 was a 45 year old female admitted on 6/4/12 with a diagnosis of Anorexia Nervosa and was placed on close observation. The precaution record lacked documentation of monitoring for safety on 6/21/12 at 11:30 PM, and 11:45 PM, and 6/26/12 at 11:30 AM, and 11:45 PM.

3. On 6/26/12 the clinical record of Pt. #11 was reviewed. Pt. #11 was a 47 year old female admitted on 6/12/12 with a diagnosis of Depressive Disorder NOS, and was placed on suicide precaution. The clinical record lacked documentation of monitoring for safety on 6/12/12 at 11:30 PM, and 11:45 PM.

4. On 6/26/12 the Precaution Record of Pt. #29 was reviewed. Pt. #29 was a female admitted on 6/20/12 with a diagnosis of Impaired Thought Process and was placed on suicide precaution. The precaution record lacked documentation of monitoring for safety on 6/26/12 at 11:45 AM.

5. On 6/26/12 at approximately 11:00AM, the Director of Quality and Risk, Chief Nursing Officer was interviewed. The Director stated that the observation sheets should have been completed.

Based on record review, interview, observation and policy review, it was determined that the Hospital failed to ensure that physical restraint orders were not written as "standing" or "as needed" basis for 1 patient (Pt.#12) of 14 patient clinical records reviewed during unit tours.

Findings include:

1. On 6/26/12, a review of Pt. #12's clinical record was conducted. This review revealed that Pt. #12 was admitted on 6/21/12 with the diagnosis of Eating Disorder. The physician's order sheet dated 6/22/12 for Pt #12 revealed the following order: "wear mittens if self [injury] [with] nails again." The order included no time limits, monitoring or specific parameters for use. Review of Pt. 12's treatment plan dated 6/26/12, revealed that mitts were not identified as an intervention on the treatment plan. The treatment plan did not include indications for the use of the mitts or interventions to guide staff actions prior to the use of the mitts.

2. In an interview on 6/26/12 at 12:50pm, E#1 (registered nurse, [RN])confirmed that the mitts were a current order and that staff could apply the mitts if necessary. E#1 stated that the mitts were ordered to address Pt.#12's self-scratching behaviors. E#1 stated that the mitts were not a restraint because the patient could continue to move around. E#1 was asked to identify the less restrictive interventions included in the patient care plan that guide staff actions prior to the use of the mitts and identified the inclusion of an intervention dated 6/25/12 for 1:1 observation. E#1 could not identify any further guidance related to the use of the mitts in Pt.#12's treatment plan. E#1 could not identify any additional interventions added to the care plan before the order for mitts was obtained on 6/22/12. E#1 stated that the mitts were never used because staff told her that they were going to put them on her if she continued to scratch and Pt.#12 stated that she did not want them and would comply with staff expectation that she cease to scratch herself.

3. In an interview on 6/26/12 at 1:55pm, E#2 (clinical therapist) stated that he did not know what the Hospital protocol was for use of the mitts and that he did not know that the Hospital used mitts. E#2 stated that the mitts have never been used on Pt. #12 and that he is not aware of the mitts ever being used on any patient on the unit. E#2 was asked if the mitts were used to coerce or intimidate Pt.# 12 and stated that Pt.# 12 "saw [them] as a threat."

4. On 6/26/12 at 2:10pm, Hospital staff were asked to produce the mitts. Observation of the mitts revealed them to be large white, bulky mitts that would completely envelope a patient's hands and fingers if used and would prevent a patient from using his or her hands or fingers to write, eat, bathe, or operate a device such as a phone.

5. In an interview on 6/28/12 at 9:20am, E#3 confirmed that the mitts would prevent a patient from using his or her hands.
6. Review of the Hospital policy titled "Protective and Supportive Devices" with a most recent revision date of 6/21/12, revealed the Hospital defined "supportive devices as including "hand mitts (to prevent self-mutilation)..." Further review of the policy revealed that mitts were to be used "after less restrictive measures have been attempted" and "If the device is used for limiting and restricting movement for behavioral reasons, refer to Restraint policy."

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Based on review of Hospital policy, clinical records and staff interview, it was determined that for 2 of 12 (Pt. #s 7 and 11) clinical records reviewed during unit tours, the Hospital failed to ensure verbal/telephone orders were signed within 48 hours per policy.

Findings include:

1. Hospital policy titled, "Physicians' Orders" revised 9/15/1 required, " Verbal/telephone orders are signed, dated and timed by the physician, APN, or PA as soon as possible and no later that 48 hours after the order is given".

2. The clinical record of Pt. #7 included that the Pt. was an 85 year old female admitted on 6/13/12 with the diagnosis of Agitation. A physician's telephone order was written on 6/15/12 at 1:55 PM for Metoprolol. The order was unsigned as of survey date of 6/26/12.


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3. On 6/26/12 the clinical record of Pt #11 was reviewed. Pt#11 was a 47 year old female admitted to the Adult Unit on 6/21/12 with a diagnosis of Depressive Disorder NOS. The physician's admitting orders, and the admission medication reconciliation/orders lacked a physician's signature.

4. On 6/26/12 the Director of Quality and Risk Chief Nursing Officer agreed that all orders require a physician's signature.

Based on review of Hospital Medical Staff Bylaws, clinical records and staff interview, it was determined that for 1 of 3 (Pt. #26) clinical records reviewed of discharged patients, the Hospital failed to ensure a discharge summary was completed.

Findings include:

1. The Hospital Medical Staff Bylaws (approved 6/11) required, "completion of the discharge summary within 30 days of discharge".

2. The clinical record of Pt. #26 included that the Pt. was a 92 year old male admitted on 12/1/09 with the diagnosis of Dementia. Pt. #26 expired on 12/7/09. The clinical record lacked a discharge summary.

3. The Director of Special Services was interviewed on 6/28/12 at approximately 9:30 AM and stated, "I was unable to locate a discharge summary, but one should have been completed."

Based on review of medical record documentation and staff interview, it was determined that the Hospital failed to ensure the completion of medical records within 30 days after the patients' discharge.

Findings include:

1. On 6/26/12 at approximately 3:30 P.M., the Medical Records Coordinator presented a written document which included that as of 6/26/12, there were 10 delinquent medical records that were greater than 30 days post discharge.

2. During an interview on with the Medical Records Coordinator on 6/26/12 at approximately 3:30 P.M., the Coordinator stated that the 10 medical records were delinquent for the discharge summary.

Based on observation and staff interview, it was determined that in 7 of 13 (Rooms-822, 823, 824, 826, 828, 829, 833) in-patient rooms on the Adult unit, and 1 of 6 (in-patient rooms on the Eating Disorder Program (EDP) unit, the Hospital failed to ensure the patient's rooms were safe, and free of potentials for patient injury, or harm. This had the potential to effect all patients admitted to these rooms.

1. On 6/26/12 an observational tour was conducted on the Adult Unit, and the Eating Disorder Program unit and the following potential hazards were observed:

- In 7 of 13 (822,823,824,826,828,and 829) patient bathrooms, on the Adult unit, the patient's toilet had mounting studs that were missing the protective covers.

- In 1 inpatient room (833) on the Adult unit, the night light's metal cover was not securely mounted to the wall.

-In 1 inpatient room (613) on the EDP unit, the night light lacked a Plexiglas cover.

2. The Nurse Manager was interviewed on 6/26/12 on at approximately 1:00PM. The Nurse Manager acknowledged the above findings.

3. On 6/28/12 at approximately 3:00PM, the Director of Quality and Risk Management was interviewed during the exit conference. The Manager stated the toilets required protective caps and that the caps have been ordered and will be glued in place.

Based on record review and interviews, the facility failed to ensure that psychiatric assessments contained a structured assessment of memory and intellectual function for 5 of 8 active sample patients (H1, H2, H4, P2 and P3). Failure to provide complete psychiatric assessments for patients results in lack of baseline data for treatment planning and future comparisons.

Findings include:

A. Record Review

1. Patient H1 had a Psychiatric Evaluation completed on 6/13/2012. Under "Past Psychiatric History," the following was noted, "[Patient H1] also had six ECT treatments and [s/he] got disoriented and lost [his/her] memory because of that so they stopped doing the ECT." The Mental Status Examination contained no information regarding current memory or intellectual functioning.

2. Patient H2 had a Psychiatric Evaluation completed on 4/24/2012. Memory testing was documented as "Attention, concentration, and recall are all grossly intact." There was no report of the patient's intellectual functioning.

3. Patient H4 was an older patient who had a Psychiatric Evaluation completed on 6/24/2012. In the section "History of Present Illness," the following was noted: "[Patient H4] was diagnosed with acute agitation, dementia, multiple medical issues and UTI." The Mental Status Examination noted that the patient claimed "the age of [his/her] parents are both 45." There was no other assessment of memory or intellectual functioning noted in the record. The patient's Axis I diagnosis was listed as "Dementia with behavioral changes."

4. Patient P2 had a Psychiatric Evaluation completed on 6/23/2012. The Mental Status Examination contained no mention of memory or intellectual functioning, although it was noted in the "Educational History" section "[Patient] is in Special Education classes."

5. Patient P3 had a Psychiatric Evaluation completed on 6/23/2012. In the section "Past Medical History," the following was noted: "Significant for chronic headaches." The Mental Status Examination contained no mention of memory or intellectual functioning.

B. Staff Interview

On 6/27/2012 at 9:40AM, the Medical Director was interviewed regarding the above deficiencies. The Medical Director acknowledged the missing assessments of memory and intellectual functioning. He acknowledged that with medical co-morbidities, this information was important, and he stated, "There's no excuse for omitting this information in an [elderly person]"

Based on record review and staff interview, the facility failed to assure that an inventory of assets and strengths relevant to the patient's plan of care were documented on the Psychiatric Evaluations of 4 of 8 active sample patients (H2, H3, H4 and P4). Incomplete assessments result in the multidisciplinary treatment team not having relevant information on strengths/assets which can be used in the care of the patient.

Findings include:

A. Record Review

1. Patient H2 had a Psychiatric Evaluation completed on 4/24/2012. The document listed medication refusal and threatening to kill the spouse as the basis for hospitalization. The patient was also noted as: "mostly declines to answer questions, frequently stating no comment." Strengths were listed as: "Polite, pleasant in conversation."

2. Patient H3 had a Psychiatric Evaluation completed on 6/24/2012. The document listed suicidal ideation as the basis for admission and noted that the patient had engaged in frequent, self-harming promiscuous behavior prior to admission. The evaluation also said, "[Patient] denies any worry about this and does not feel like it has created any concern for [him/her] whatsoever." The patient's strength was listed as "Educational abilities."

3. Patient H4 had a Psychiatric Evaluation completed on 6/24/2012. The document listed aggressive behavior toward staff which had required multiple episodes of restraint at the pre-admission placement. "Strengths and Descriptive Assets" were listed as "[Patient] was capable of feeding...self. [S/he] was medically stable despite [his/her] obesity and hypertension. [S/he] could be redirected."

4. Patient P4 had a Psychiatric Evaluation completed on 6/23/2012. The document noted the patient had just been discharged one week before, after which [s/he] resumed [his/her] substance abuse and became suicidal, with a plan to cut [his/her] arm with "an X-Acto knife." The patient also acknowledged, per the Psychiatric Evaluation: "'I lied to you before,' elaborating that [s/he] really did not feel any better when [s/he] left the hospital, but [s/he] was just reporting that so [s/he] could be discharged." The patient's "Strength" was listed as: "Easily engages socially."

B. Staff Interview

On 6/27/2012 at 9:40AM, the Medical Director was interviewed regarding the deficiencies. The facility's CEO joined the meeting at 10 AM. The Medical Director acknowledged that the strengths listed above were not relevant to the patients' plans of care.

Based on observation, policy review, record review and interview, the facility failed to ensure participation of the medical staff in the development and implementation of patient treatment plans. For 4 of 8 active sample patients (H3, H4, P1 and P2), the Interdisciplinary Treatment Plans were not signed by the physician. For 1 of 8 active sample patients (H2), the Interdisciplinary Treatment Plan was signed by the physician more than 1 week after the plan was developed and implemented. Medical staff often was not involved in development of patients' treatment plans nor present for treatment planning meetings. Additionally, there were no physician interventions for 8 of 8 sampled patients (H1, H2, H3, H4, P1, P2, P3 and P4) on the treatment plans, and no nursing interventions for the problems listed on the plans of 6 of 8 sampled patients (H1, H2, H3, P1, P2 and P3).(See B 122). These failures result in treatment plans which lack a physician's direction, and which contain no therapeutic interventions assigned to the medical staff.

Findings include:

A. Observation

Patient H1 had an Interdisciplinary Treatment Plan review at 1 PM on 6/26/2012 in the Staffing Room on Unit A3. The patient's psychiatrist was not present for this meeting.

B. Policy Review

The Interdisciplinary Treatment Plan policy (LOH-Clinical 044) dated 4/26/12 states, "The treatment team will possibly consist of the following but not limited to: patient, patient's identified family member, POA (power of attorney) guardian, attending physicians, medical director, clinical therapist, nurses, behavioral health associates, dieticians, recreational therapists, expressive therapists, teachers, psychologists, and community therapist." This policy further states, "Each treatment plan shall be developed and implemented under the direction of the attending psychiatrist."

C. Record Review

1. Patient H1 had an Interdisciplinary Treatment Plan Completed on 6/26/2012. The Treatment Plan contained no interventions for the psychiatrist.

2. Patient H2 had an Interdisciplinary Treatment Plan completed on 4/24/2012. The document was not signed by the Attending Psychiatrist until 5/2/2012, eight days after it was completed. The treatment plan contained no interventions for the psychiatrist.

3. Patient H3 had an Interdisciplinary Treatment Plan completed on 6/25/2012. The space for Psychiatrist signature was unsigned. The Treatment Plan contained no interventions for the psychiatrist.

4. Patient H4 had an Interdisciplinary Treatment Plan completed on 6/25/2012. The space for Psychiatrist signature was unsigned. The Treatment Plan contained no interventions for the psychiatrist.

5. Patient P1 had an Interdisciplinary Treatment Plan completed on 6/26/2012. The space for Psychiatrist signature was unsigned. The Treatment Plan contained no interventions for the psychiatrist.

6. Patient P2 had an Interdisciplinary Treatment Plan completed on 6/26/2012. The space for Psychiatrist signature was unsigned. The Treatment Plan contained no interventions for the psychiatrist.

7. Patient P3 had an Interdisciplinary Treatment Plan completed on 6/24/2012. The treatment plan contained no interventions for the psychiatrist.

8. Patient P4 had an Interdisciplinary Treatment Plan completed on 6/26/2012. The treatment plan contained no interventions for the psychiatrist.

D. Staff Interviews

1. In an interview on 6/27/12 at 9:15AM, the Director of Special Services stated, "When the MD is not in the treatment team, the clinical therapist develops the treatment plan based on the Psychiatric Evaluation and it is reviewed by the MD afterwards."

2. In an interview at 1PM on 6/26/2012, when asked how often the patient's Attending Psychiatrist is present for a patient's Master Treatment Plan meeting or subsequent updates, Social Worker 1 stated, "Not very often. We usually write it for them and then call the doctor on the phone." Social Worker 2 also stated that the plan and subsequent revisions are signed during the treatment team meetings for all members present.

3. In an interview at 9:40AM on 6/27/2012 the hospital's Medical Director affirmed the missing psychiatrist signatures on the patients' treatment plans and acknowledged the facility's difficulties in getting medical staff participation in Interdisciplinary Treatment Planning meetings. The Medical Director noted that the medical staff all had outside practices and could not routinely be present for these meetings. He acknowledged that the plans were often created by the unit staff and were supposed to be signed by the Attending Psychiatrist "within a couple of days."

4. In an interview on 6/28/2012at 1PM, the CEO confirmed that for 8 of 8 active sample patients (H1, H2, H3, H4, P1, P2, P3 and P4), there were no therapeutic interventions assigned to the patient's psychiatrist. (See details at B122)

Based on record review and interview, the facility failed to provide Interdisciplinary Treatment Plans that identified individualized patient-related short-term goals stated in observable, measurable and behavioral terms for 8 of 8 active sample patients (H1, H2, H3, H4, P1, P2, P3 and P4). This failure hinders the treatment team's ability to measure change in the patient's condition as a result of treatment interventions, and it can result in inadequate treatment for patients.

Findings include:

A. Record Review

1. Patient H1

a. The first problem on the Interdisciplinary Treatment Plan dated 6/26/12 was "Suicidal Ideation/Intent." The short term goals were: "...Talk about how Dialectical Behavior Therapy can help manage symptoms"; "Cooperate with a psychiatric evaluation to assess level of risk and determine need for psychotropic medication; comply with recommendations. Understand the importance of taking medication as prescribed"; "Develop a safety plan that identifies useful coping strategies and community support that is vital for sustained recovery..and "Identify and list strengths, interests, or positive attributes." These short term goals are not measurable.

b. The second problem was identified as "Chronic Pain." There were no short term goals for this problem.

2. Patient H2

a. The first problem on the Interdisciplinary Treatment Plan dated 4/24/12 was "Inability to Care for Self." The short term goals were: "Cooperate with a psychiatric evaluation to assess level of impairment and determine need for psychotropic medication; comply with recommendations. Understand the importance of taking medications as prescribed by psychiatrist"; "Increase level of functioning and accept responsibility of caring for own basic needs, including medication regimen. Accept the need for psychiatric care and increase the ability to independently care for self" and "Report changes in the presence of hallucinations and/or delusions, the speed in which thoughts occur, and/or other cognitive symptoms related to present illness." These short term goals were not measurable.

b. The second problem was "Suicidal Ideation/Intent." The short term goals were: "...Cooperate with a psychiatric evaluation to assess level of risk and determine need for psychotropic medication; comply with recommendations." These short term goals were not measurable.

c. The third problem was "Homicidal Ideation/Intent." The short term goals were: "Decrease verbal and physical manifestations of anger, aggression, or violence while increasing awareness and acceptance of feelings" and "Identify and reorganize any irrational beliefs or maladaptive thoughts that contribute to the emergence of destructive or assaultive/aggressive behavior...." These short term goals were not measurable.

d. The fourth problem was "Psychoticism." The short term goals were: "Describe the type and history of the psychotic symptoms. Recognize that delusions and hallucinations are not part of reality. Decrease paranoid delusional thinking about white supremacist, and decrease distrust of staff"; "Accept and understand that distressing symptoms are due to mental illness. Understand the importance of taking medication as prescribed, and increase awareness of diagnosis and how it contributes to symptoms" and "Describe recent perceived severe stressors that may have precipitated the acute psychotic break." These short term goals were not measurable or individualized.

3. Patient H3

a. The first problem on the Interdisciplinary Treatment Plan dated 6/25/12 was "Suicidal Ideation/Intent." The short term goals were: "Increase communication with significant others, resulting in a feeling of understanding, empathy, and being attended to"; "Verbally report an increased sense of hope and a reduction in thoughts and impulses to take own life" and "Identify and list strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

b. The second problem was "Anxiety." The short term goals were: "Verbalize a willingness to prepare for change"; "Understand the importance of contact with the present moment and be willing to engage in increasing present moment awareness" and "Verbalize an understanding of how the principles of acceptance can effectively reduce suffering and increase value-laden behavior." These short term goals were not measurable or individualized.

c. The third problem was "Self Injury." The short term goals were: "Verbalize an agreement to make contact with staff if urge to arises before acting on it" and "Utilize cognitive methods to control trigger thoughts and reduce impulsive reactions to those trigger thoughts." These short term goals were not measurable or individualized.

4. Patient H4

a. The first problem on the Interdisciplinary Treatment Plan dated 6/25/12 was "Aggression/Threat Towards Others." The short term goals were: "Cooperate with necessary safety precautions to protect self and others from harm"; "Patient's mood and behavior will be stabilized to the point where he will be able to move back to his previous level of care"; "Complete treatment for confounding or coexisting depression, anxiety, medical conditions, and/or adverse drug reactions" and "Patient and/or patient's family to identify and list patient's strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

b. The second problem was "Risk for Falls/ Dehydration." The short term goal was: "Comply with the dietary recommendations regarding diet modifications, dietary supplements, food preparation and presentation, timing of meals, and so forth. Patient to comply with safety precautions." This short term goal was not measurable or individualized.

c. The third problem was "Hypertension." The short term goal was: "Maintain blood pressure within normal limits." This short term goal was not measurable or individualized.

d. The fourth problem was identified as "Osteoarthritis." The short term goal was: "Identify the losses or limitations that have been experienced due to the medical condition." This short term goal was not measurable or individualized.

e. The fifth problem was "Urinary Tract Infection." The short term goal was: "Comply with the medication regimen and necessary medical procedures, reporting any side effects or problems to physicians or therapists." This short term goal was not measurable or individualized.

f. The sixth problem was "Potential for Skin Breakdown." The short term goal was: "Describe history, symptoms, and treatment of the medical condition." This short term goal was not measurable or individualized.

5. Patient P1

a. The first problem on the Interdisciplinary Treatment Plan dated 6/26/12 was "Suicidal Ideation/Intent." The short term goals were: "...Increase awareness and acceptance of negative thinking patterns that mediate feelings of hopelessness and helplessness" and "Develop a safety plan that identifies useful coping strategies and community support that is vital for sustained recovery." These short term goals were not measurable or individualized.

b. The second problem was "Self Injury." The short term goals were: "Identify 4 different coping skills to use when having urges to injure" and "Utilize cognitive methods to control trigger thoughts and reduce impulsive reactions to those trigger thoughts." These short term goals were not measurable or individualized.

c. The third problem was "Eating Disorder." The short term goals were: "Eat at regular intervals, consuming at least the minimum daily calories"; "Identify and replace irrational beliefs about eating behavior and practice defusing from the thoughts"; "Understand and verbalize the connection between too restrictive dieting and binge episodes" and "Identify and list strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

d. The fourth problem was "Vitamin D Deficiency." There were no short term goals listed for this problem.

6. Patient P2

a. The first problem on the Interdisciplinary Treatment Plan dated 6/26/12 was "Suicide Ideation/Intent." The short term goals were: "Explore life factors that preceded and contributed to suicidal ideation"; and "...Identify and list strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

b. The second problem was "Self Injury." The short term goal was: "Identify distress tolerance skills and self-soothing strategies that can be used to help manage self-harm urges." This short term goal was not measurable or individualized.

7. Patient P3

a. The first problem on the Interdisciplinary Treatment Plan dated 6/24/12 was "Suicidal Ideation/Intent." The short term goals were: "Cooperate with a psychiatric evaluation to assess level of risk and determine need for psychotropic medication; comply with recommendations"; "Increase communication with family, resulting in a feeling of understanding, empathy, and being attended to"; "Family members/caregivers verbalize an understanding of the patient's distress and feelings of hopelessness" and "Verbally report an increased sense of hope in her life and a reduction in thoughts and impulses to take own life," These short term goals were not measurable or individualized.

b. The second problem was "Homicidal Ideation/Intent." The short term goals were: "Cooperate with a psychiatric evaluation to assess risk and need for psychotropic medication: comply with recommendations"; "Defuse from unhelpful cognitions, particularly from cognitions related to aggression, violence, and self destruction"; "Parents/Caregivers will increase their awareness of factors that contribute to patient hostility; and interact with patient in a manner that supports positive reinforcement of assertive behaviors and demonstrates respect and consistency." These short term goals were not measurable or individualized.

8. Patient P4

a. The first problem on the Interdisciplinary Treatment Plan dated 6/26/12 was "Substance Dependence." The short term goals were: "Cooperate with a medical assessment and an evaluation of the necessity for pharmacological intervention"; "Take prescribed medications as directed by the physician, and report as to compliance, side effects, and effectiveness"; "Report acute withdrawal symptoms"; "Provide honest and complete information for a substance dependence biopsychosocial history"; "Attend didactic sessions and read assigned material in order to increase knowledge of addiction and the process of recovery"; "Attend group therapy sessions to share thoughts and feelings that are associated with reasons for, consequences of, feelings about, and alternatives to addiction" and "Identify and list strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

b. The second problem was "Depressed Mood/Symptoms." The short term goals were: "Verbalize the powerlessness and unmanageability that result from using addictive behavior to cope with depression" and "Verbalize an understanding of how depression leads to addictive behavior and how addictive behavior leads to depression." These short term goals were not measurable or individualized.

c. The third problem was "Anxiety." The short term goals were: "Acknowledge the powerlessness and unmanageability caused by excessive anxiety and addiction"; "Implement positive self-talk to reduce or eliminate the anxiety" and "Comply with a physician's evaluation to determine if psychopharmacological intervention is warranted. Take any medications as directed." These short term goals were not measurable or individualized.

d. The fourth problem was "Suicidal Ideation." The short term goals were: "...Verbalize an understanding of how suicide risk is magnified by addiction"; "Meet the physician for an assessment for the need for psychotropic medication"; "Take all medications as directed" and "Identify and list strengths, interests, or positive attributes." These short term goals were not measurable or individualized.

e. The fifth problem was "Self Injury." The short term goals were: "...Utilize cognitive methods to control trigger thoughts and reduce impulsive reactions to those trigger thoughts." These short term goals were not measurable or individualized.

B. Staff Interview

On 6/27/12 at 2:40PM, the DON stated, "I see what you mean, the short term goals cannot be measured."

Based on record review and interview, the facility failed to develop Interdisciplinary Treatment Plans that clearly delineated medical interventions to address specific patient problems for 8 of 8 active sample patients (H1,H2, H3, H4, P1,P2, P3 and P4) and nursing interventions for 6 of 8 sampled patients (H1, H2, H3, P1, P2 and P3). These failures result in the treatment team being unable to provide and evaluate treatment, based on the patient's presenting needs and behaviors.

Findings include:

A. Record Review (Interdisciplinary Treatment Plan dates in parentheses)

1. Patient H1 (6/26/12) had no medical or nursing interventions for the identified problems, "Suicide Ideation/Intent" and "Chronic Pain."

2. Patient H2 (4/24/12 had no medical or nursing interventions for the identified problems "Inability to Care for Self", "Suicidal Ideation/Intent", "Homicidal Ideation/Intent," and "Psychoticism."

3. Patient H3 (6/25/12) had no medical interventions or nursing interventions for the identified problems "Suicidal Ideation/Intent", "Anxiety" and "Self Injury."

4. Patient H4 (6/25/12) had no medical interventions for the identified problems "Aggression/Threat Towards Others", "Risk for Falls/Dehydration", "Hypertension", "Osteoarthritis", "Urinary Tract Infection," and "Potential for Skin Breakdown."

5. Patient P1 (6/26/12) had no medical or nursing interventions for the identified problems "Suicidal Ideation/Intent," "Self Injury," "Eating Disorder," and "Vitamin D Deficiency."

6. Patient P2 (6/26/12) had no medical or nursing interventions for the identified problems "Suicidal Ideation/Intent" and "Self Injury."

7. Patient P3 (6/24/12) had no medical or nursing interventions for the identified problems, "Suicidal Ideation/Intent" and "Homicidal Ideation/Intent."

8. Patient P4 (6/26/12) had no medical interventions for the identified problems, "Substance Dependence," "Depressed Mood/Symptoms," "Anxiety," "Suicidal Ideation," and "Self Injury."

B. Interview

1. In an interview on 6/27/12 at 2:40PM, the Director of Nursing stated, "No, there are no nursing interventions in the plans, I am embarrassed to say."

2. In an interview on 6/28/2012 at 1PM, the CEO confirmed that for 8 of 8 active sample patients' treatment plans (H1, H2, H3, H4, P1, P2, P3 P4), there were no therapeutic interventions assigned to the patient's psychiatrist.

Based on record review, policy review and staff interviews, the Medical Director failed to monitor the quality and appropriateness of care provided. Specifically, the Medical Director failed to:

I. Assure that Psychiatric Assessments contained a structured assessment if memory and intellectual functioning for 5 of 8 patients sampled. (H1, H2, H4, P2, P3. Failure to provide complete psychiatric assessments for patients results in lack of baseline data for treatment planning and future comparisons (Refer to B116).

II. Assure that Psychiatric Evaluations listed strengths relevant to the patient's plan of care for 4 of 8 patients sampled (H2, H3, H4 and P4). This failure results in the multidisciplinary treatment team not having relevant information on strengths/assets which can be used in the care of the patient (Refer to B117).

III. Assure that there was adequate physician participation in the development and implementation of the Interdisciplinary Treatment Plan for 5 of 8 patients sampled (H2, H3, H4, P1 and P2). Additionally, there were no therapeutic interventions assigned to the medical staff for 8 of 8 patients sampled (H1, H2, H3, H4, P1, P2, P3 and P4). These failures result in treatment plans which lack a psychiatrist ' s direction, and which contain no therapeutic interventions assigned to the psychiatry staff (Refer to B118 and B122).

Based on record review and interview, the Director of Nursing failed to ensure that there were nursing interventions on the Interdisciplinary Treatment Plans of 6 of 8 active sample patients (H1, H2, H3, P1, P2 and P3). This failure results in nursing staff being unable to provide and implement care, based on the nursing needs of the patient.

Findings include:

A. Record Review (Interdisciplinary Treatment Plan dates in parentheses)

1. The treatment plan (6/26/12) for Patient H1 had no nursing interventions for the identified problems "Suicidal Ideation/Intent" and "Chronic Pain."

2. The treatment plan for Patient H2 (4/24/12) had no nursing interventions for the identified problems "Inability to Care for Self," "Suicidal Ideation/Intent," "Homicidal Ideation/Intent," and "Psychoticism."

3. The treatment plan for Patient H3 (6/25/12) had no nursing interventions for the identified problems "Suicidal Ideation/Intent," "Anxiety," and "Self Injury."

4. The treatment plan for Patient P1 (6/26/12) had no nursing interventions for the identified problems "Suicidal Ideation/Intent," "Self Injury," "Eating Disorder," and "Vitamin D Deficiency."

5. The treatment plan for Patient P2 (6/26/12) had no nursing interventions for the identified problems "Suicidal Ideation/Intent," and "Self Injury."

6. The treatment plan for Patient P3 (6/24/12) had no nursing interventions for the identified problems "Suicidal Ideation/Intent" and "Homicidal Ideation/Intent."

B. Interviews

1. In an interview on 6/26/12 at 2:00PM, RN3 stated, "We do not have interventions for nursing in the plans."

2. In an interview on 6/27/12 at 2:40PM, the Director of Nursing stated, "No, there are no nursing interventions in the plans, I am embarrassed to say."