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Based on record review and staff interviews, the Hospital failed to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by failing to identify, investigate and document a patient representative's concerns as a grievance for 1 (#3) of 2 (#1, #3) sampled patients reviewed for grievances out of a total sample of 5 (#1-#5).

Findings:

Review of the Hospital policy titled, Grievance Procedure Patient and Family Louisiana, Policy Number RTS-05 revealed in part the following: The Governing Body is responsible for the effective operation of the complaint resolution process but has designated the hospital Administrator as the responsible hospital based party....
Grievance: An allegation, however made, or a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time the complaint is made and requires further action for resolution.
Patient and/or Family member may at any time express a complaint of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility to any staff member. May at any time file a grievance allegation of violation of a patient's rights or concern regarding quality of care....If no resolution is made at the time of the complaint, the Administrator is notified and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is entered into immediately.

Review of the Complaint and Grievance Log for February 2017 revealed the following:
Patient/Family Name: Daughter of Patient #3
Date of Complaint or Grievance: 02/20/17
Nature of Complaint or Grievance: Safety/Treatment
Complaint Resolution: Resolved over the phone, explained about bump.
Date of Patient/Family Contact & Start of Investigation: 02/20/17
Date Investigation Complete: 02/20/17
Mail Date of Copy of "Grievance Report" to Patient/Family: Resolved with daughter over the phone-pleased.

Review of the Complaint and Grievance Log for March 2017 revealed the following:
Patient/Family Name: Daughter of Patient #3
Date of Complaint or Grievance: 03/08/17
Nature of Complaint or Grievance: Safety/Treatment
Complaint Resolution: Grievance completed
Date of Patient/Family Contact & Start of Investigation: 03/08/17
Date Investigation Complete: 03/10/17
Mail Date of Copy of "Grievance Report" to Patient/Family: 03/13/17.

On 04/03/17 at 2:30 p.m., the documentation of the grievance for Patient #3 was requested for review.
The following typed document was provided by S2DON:
"Time Line for Patient #3
2-20-2017
DON informed Administrator that Patient#3's daughter called her regarding her mother. She stated her mother had a bump 'hicky' on her head and a twisted finger. DON stated she would look into the incidents.

DON spoke to S3RN, S4RN, and S8NP. S3RN documented patient had bump to the right side of her head and documented as such on the 17th (found during her assessment). There was no documentation for the 16th of any incident or injury.

Interview with S4RN (via phone) with DON - S4RN stated the patient must have hit her head on the bedside table the night of the 16th. S4RN failed to notify anyone. The following day, since S3RN noted the change of condition and told S4RN about the change, S4RN called S8NP and reported the patient had bumped her head on the bedside table. S8NP gave orders for ice pack and neuro checks. Braden was updated on the 17th. S4RN was questioned by DON why orders, change of condition and documentation wasn't completed at time of incident. S4RN responded she wasn't aware patient had an incident but felt she had to 'go back and document'.

At this point - No one contacted the Admin or DON. No incident report was completed. No one contacted the family after the "bump" was found. Admin requested the DON to meet with the staff. Also asked DON to complete an incident report as a third party. Whatever incident happened, it was unwitnessed, but certainly required an investigation and incident report.

After DON spoke to S3RN, S4RN and S8NP, she called Patient #3's daughter back and explained that the bump was possibly from the patient hitting her head on the bedside table. There were no reports of falls or other injuries. The patient's daughter said she understood and was satisfied with the DON's response and explanation.

DON reported to Admin that Patient #3's daughter called her on the 27th and stated her mother didn't have a twisted finger, that it normally looks like that. No further requests or concerns.

March 8th - Patient #3's family (daughter called) and started talking about Patient #3's bump again. It appears that she isn't happy with the earlier explanation. Admin completed a grievance. Will give family a copy of records per their request."

Review of the medical record for Patient #3 revealed the patient was an 86 year old admitted to the hospital on 02/07/17 from a SNF with a diagnosis of Dementia with Behavioral Disturbances. The patient was discharged on 02/20/17 back to the SNF.

Review of the Multi-Disciplinary Progress Notes revealed there was no documented evidence of any entries from 02/15/17 at 10:00 a.m. to 02/17/17 at 7:20 a.m.

Review of the Daily Nurse Notes from 02/15/17 at 10:00 a.m. to 02/16/17 at 7:55 p.m. revealed no documented evidence of any bruises or swelling. Review of the notes revealed S9RN documented the patient's assessments on 02/16/17 from 7:00 p.m. to 7:00 a.m.

Review of the Close Observation Check Sheet dated 02/16/17 from 7:00 p.m. to 7:00 a.m. revealed the patient was in her wheelchair in the hall all night. The observations were documented by S5MHT.

Further review of the Multi-Disciplinary Progress notes revealed the following:
02/17/17 at 7:20 a.m.: Upon assessment patient noted to have a nodule approx. the size of a quarter that is raised and soft to touch to the right side of her forehead, right eye lid slightly swollen and red, upper right cheek slightly swollen, will continue to monitor. The entry was signed by S3RN.
02/17/17 at 8:20 p.m. S8NP notified of nodule to right side of temple and decreased blood pressure. See order. The entry was signed by S4RN.
02/18/17 at 9:00 a.m. S13Physician on unit given update on patient as he was informed yesterday of noted changes and assessment to right side of head and face. The entry was signed by S3RN.
02/18/17 at 9:15 a.m. The patient's daughter called for update, stated she visited last night and wants to speak to DON. The entry was signed by S3RN.
02/18/17 at 10:30 a.m. S2DON called update given along with daughter's phone number.
02/18/17 at 2:10 p.m. Daughter came to visit, update given, states she will call on Monday to speak to DON if not called prior to. The entry was signed by S3RN.

In an interview on 04/04/17 at 7:55 a.m. S9RN and confirmed she had been assigned to Patient #3 on the 7:00 p.m. to 7:00 a.m. shift on the night of 02/16/17. She confirmed she had assessed the patient and stated she made rounds every hour throughout the night. S9RN stated she did not remember any bruises or swelling on the patient's forehead. S9RN stated she did not receive any reports of incidents or injury related to Patient #3 that night. S9RN indicated if she had noticed a bruise or swelling on the patient she would have documented an incident report and notified the DON, administrator, physician, and the patient's family. S9RN confirmed she had not been asked to write a statement about the events of that night.

In an interview on 04/04/17 at 8:05 a.m., S5MHT confirmed she had worked on the 7:00 p.m. to 7:00 a.m. shift on 02/16/17 and was assigned to Patient #3. S5MHT stated she did not have any problems with the patient that night and confirmed the patient remained in her wheel chair in the hall all night. S5MHT indicated no one from the hospital had asked her about the patient's condition on 02/16/17.

In a telephone interview on 04/04/17 at 8:35 a.m., S3RN stated the MHT came and told her she saw the patient had a nodule on her head. She stated she the report from the night nurse did not indicate a bump or swelling. S3RN stated the bump was raised but she did not remember if there was discoloration. S3RN stated she did not know what happened but she reported it to the DON and physician. S3RN confirmed S1ADM and S2DON had asked her about the incidents on this day with this patient, but, but she was not asked to write a statement.

In an interview on 04/04/17 at 9:00 a.m., S1ADM was asked if this incident was considered for possible abuse, she stated S3RN told S2DON that the patient hit her head on the bedside table. After reviewing the patient's record she confirmed the record indicated the patient was in a wheelchair all night. S1ADM confirmed there was no documented evidence that the night shift staff on 02/16/17 were interviewed about the patient's injury. S1ADM confirmed the incident was not handled as a grievance until the patient's family came to the hospital on 03/08/17 to obtain medical records. She confirmed there was no investigation into how the patient was injured. S1ADM confirmed there were no written statements obtained from the employees involved. S1ADM confirmed it was the hospital's policy to obtain written statements during an investigation. She provided a form to be used for the written statements. S1ADM stated they handled the daughter's initial complaint as a complaint and not a grievance since she indicated in the return phone call that she was satisfied with the response.

In a telephone interview on 04/04/17 at 9:24 a.m., S8NP was asked about the verbal order he had given to S4RN on 02/17/17 at 8:20 p.m. for neuro checks and ice pack to right temporal area. S8NP stated he remembered the nurse had called, saying the patient had hit her head on the table. He stated the patient kept dropping her head forward and hitting the table. S8NP confirmed he was on call that evening and had never seen Patient #3. S8NP confirmed his report of the patient hitting her head on the table was from what the nurse had told him. He confirmed he did not see the patient on 02/17/17.

In an interview on 04/04/17 at 9:36 a.m., S2DON confirmed Patient #3's daughter reported to her on 02/20/17 that when she visited her mother on Saturday (02/18/17) she had a contusion on her right forehead and a black eye and when she saw her mother last, it was not there. S2DON stated she informed her she would look into her concerns and would call her back. S2DON stated after she talked to the staff she called the patient's daughter back and explained that the patient hit her head, and S8NP would be happy to call her if she wanted to speak with him. S2DON was asked how she knew the patient hit her head on bedside table, she stated S3RN told her it was the bedside table. S2DON stated it would have been likely she hit her head on the table in the dining room as the patient frequently was laying her head (side of her head) on the table. S2DON confirmed they did not handle this incident as a grievance until the family returned on March 8th. S2DON confirmed she did not ask staff to document statements regarding the injury of unknown origin.

Based on observations and staff interview, the Hospital failed to ensure that patients received care in a safe setting by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute inpatient psychiatric patients as evidenced by the presence of ligature risks and safety risks.

Findings:

Observation of the main campus patient rooms and bathrooms on 04/03/17 at 4:55 p.m. with S1ADM revealed there were 9 patient rooms with 2 beds in each room. Bathrooms were located between rooms. Observation of the toilets in all the patient bathrooms revealed a 3 inch circular opening approximately 1 foot from the floor in the base of the toilets. S1ADM confirmed the opening in the toilet base and confirmed the opening could be used as a possible ligature point.

Observation of the beds in the patient rooms revealed that 17 out of 18 beds in use had a metal bed frame with space between the springs that could be used as ligature points. The beds with the metal bed frame were also observed to have removable metal springs that could be removed and used as a weapon or to injure themselves or others. S1ADM confirmed 17 out 18 patient beds contained metal bed frames with removable metal springs and confirmed the beds could pose a ligature point or safety hazard for patients.


Observation of the off-site campus patient rooms and bathrooms on 04/04/17 at 11:45 a.m. with S1ADM revealed there were 5 patient rooms with 2 beds in each room, and 2 rooms with 1 bed. Bathrooms were located between the semi-private rooms and the private rooms each had a bathroom. Observation of the toilets in all the patient bathrooms revealed a 3 inch circular opening approximately 1 foot from the floor in the base of the toilets. S1ADM confirmed the opening in the toilet base and confirmed the opening could be used as a possible ligature point.

Observation of the beds in the patient rooms revealed that 12 out of 12 beds in use had a metal bed frame with space between the springs that could be used as ligature points. The beds with the metal bed frame were also observed to have removable metal springs that could be removed and used as a weapon or to injure themselves or others. S1ADM confirmed all 12 patient beds contained metal bed frames with removable metal springs and confirmed the beds could pose a ligature point or safety hazard for patients.

Based on record review and staff interview, the Hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to notify the physician, family, and hospital administration of an injury of unknown origin for 1 of 1 (#3) sampled patients reviewed for injury, and;
2) Failing to document an incident report for an injury of unknown origin for 1 of 1 (#3) sampled patients reviewed for injury.

Findings:

1) Failing to notify the physician, family, and hospital administration of an injury of unknown origin for 1 of 1 (#3) sampled patients reviewed for injury:

Review of the Hospital policy titled, Patient Incident & Occurrence Reporting, Policy Number EOC-13 revealed in part the following: Facility staff will report all patient occurrences through the use of the facility's incident reporting form....A patient incident or occurrence is anything that is out of the expected norm for the patient (ex: elopement, fall, medication error, altercation, psychiatric emergency)....All staff: The Administrator will be notified of any Sentinel Event or unanticipated outcome. Notify patient's family and physician.

Patient #3

Review of the medical record for Patient #3 revealed the patient was an 86 year old admitted to the hospital on 02/07/17 with a diagnosis of Dementia with Behavioral Disturbances, and was discharged on 02/20/17.

Review of the Multi-Disciplinary Note dated 02/17/17 at 7:20 a.m. documented by S3RN, revealed the following: Upon assessment patient noted to have a nodule approximately the size of a quarter that is raised and soft to touch to the right side of her forehead, right eye lid slightly swollen and red, upper right cheek slightly swollen, will continue to monitor.
Further review of the Multi-Disciplinary Notes revealed no documented evidence that the physician/LIP was notified of the swelling to the patient's face until 02/17/17 at 8:20 p.m. when S8NP was contacted by S4RN.
There was no documented evidence that the patient's family or the Hospital administration was notified of the incident.

Review of the Daily Nurse Note dated 02/17/17 for the day shift (7A-7P) revealed "right forehead nodule" was documented. There was no documented evidence that the physician, family or the Hospital administration was notified of the incident. Further review of the Daily Nurse Notes revealed no documented evidence of bruising or swelling to the patient's face prior to 02/17/17 at 7:20 a.m.

Review of the physician orders revealed the following verbal order received from S8NP on 02/17/17 at 8:20 p.m.: Start neuro checks every hour for 24 hours, apply ice pack to right temporal area as needed.

Review of the physician's progress notes dated/timed 02/17/17 at 6:25 p.m. by S13Physician revealed no documented evidence that the patient had swelling or bruising to the forehead. Review of the physician's progress notes dated 02/18/17 at 10:01 revealed the following: "She apparently had a fall about 2 days ago, but it was unwitnessed and she had a knock on her head."

In a telephone interview on 04/04/17 at 8:35 a.m., S3RN indicated that she remembered Patient #3 and stated the MHT reported to her that the patient had a bump on her forehead at the beginning of the shift (7:00 a.m.-7:00 p.m.) on 02/17/17. S3RN confirmed she went to the dining room to assess the patient. S3RN stated the patient had a bump that was raised but she was not sure if there was discoloration. S3RN confirmed she had taken care of the patient prior to 02/17/17 and this was the first time she had seen this bump/nodule on the patient. S3RN confirmed she did not document an incident report because the incident did not happen on her shift. S3RN stated she wanted to say she reported the incident to the DON but she was not sure. S3RN stated she notified the physician, but confirmed she did not document that she notified the physician. S3RN confirmed there was no documented evidence that she notified the DON, physician or the patient's family. S3RN stated she did neurological checks on the patient but did not document them. S3RN was unable to explain why S4RN notified S8NP of the swelling/bump on the patient's forehead on 02/17/17 at 8:20 p.m.

In an interview on 04/04/17 at 9:00 a.m., S1ADM who was present for the above stated S3RN told S2DON that the patient hit her head on the bedside table. After reviewing the patient's record, S1ADM confirmed the record indicated the patient was in a wheelchair all night. S1ADM stated S2DON had told her that S3RN did not notify her of the incident. S1ADM confirmed she had not been notified of the incident until the S2DON notified her on 02/20/17.

In an interview on 04/04/17 at 9:36 a.m., S2DON stated she was first notified of the incident with Patient #3 when she contacted the patient's daughter on 02/20/17. S2DON stated she had received a message on 02/20/17 from the patient's daughter requesting that she call her. S2DON stated the patient's daughter reported that when she saw the patient on Saturday (02/18/17) there was a contusion and black eye on the right side of her forehead and when she last saw her mother, it was not there. S2DON confirmed the patient's daughter had informed her that no one had notified the family of the bruising. S2DON stated neither S3RN nor S4RN notified the family and stated S3RN should have. S2DON confirmed no staff reported the incident to her or S1ADM. S2DON confirmed there was no documented evidence that the staff notified the physician until 02/17/17 at 8:20 p.m.



2) Failing to document an incident report for an injury of unknown origin for 1 of 1 sampled patients reviewed for injury:
Review of the Hospital policy titled, Patient Incident & Occurrence Reporting, Policy Number EOC-13 revealed in part the following: Facility staff will report all patient occurrences through the use of the facility's incident reporting form....A patient incident or occurrence is anything that is out of the expected norm for the patient (ex: elopement, fall, medication error, altercation, psychiatric emergency)....All staff: If one has witnessed an incident or is informed an incident has occurred, completes the incident reporting process.

Patient #3

Review of the medical record for Patient #3 revealed the patient was an 86 year old admitted to the hospital on 02/07/17 with a diagnosis of Dementia with Behavioral Disturbances, and was discharged on 02/20/17.

Review of the Multi-Disciplinary Note dated 02/17/17 at 7:20 a.m. documented by S3RN, revealed the following: Upon assessment patient noted to have a nodule approximately the size of a quarter that is raised and soft to touch to the right side of her forehead, right eye lid slightly swollen and red, upper right cheek slightly swollen, will continue to monitor.

Review of the incident log for February 2017 revealed no documented evidence of an incident for Patient #3.

Review of the Grievance/Complaint documentation for Patient #3 revealed an incident report was documented by S2DON on 02/20/17 for Patient #3. Review of the incident report revealed the following statement hand written at the top of the form, "3rd Party - DON heard thru nurses." Further review of the incident report revealed: "Per investigation: S8NP was called on 02/17/17 at 8:20 p.m. for a swollen area to right temporal area. New orders on chart. Neuro checks in chart per orders. After talking to staff this was an unwitnessed incident."

In a telephone interview on 04/04/17 at 8:35 a.m., S3RN indicated that she remembered Patient #3 and stated the MHT reported to her that the patient had a bump on her forehead at the beginning of the shift (7:00 a.m.-7:00 p.m.) on 02/17/17. S3RN confirmed she went to the dining room to assess the patient. S3RN stated the patient had a bump that was raised but she was not sure if there was discoloration. S3RN confirmed she had taken care of the patient prior to 02/17/17 and this was the first time she had seen this bump/nodule on the patient. S3RN confirmed she did not document an incident report because the incident did not happen on her shift. S3RN stated she documents an incident report when it happens on her shift. When asked if that was this hospital's policy, she indicated she had been instructed to document incident reports whenever an issue is found regardless of when it happened.

Based on a record review and staff interview, the Hospital failed to perform and document a history and physical (H&P) examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 3 of 3 (#2, #4, #5) current sampled patients. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Review of the Hospital policy titled, Assessment Process, Policy Number AS-01 revealed in part the following:
The Physician (H&P) completes the History and Physical within 24 hours of inpatient admit....Performs a comprehensive physical examination including neurological and cranial nerves I-XII.

Review of the Hospital policy titled, Medical History and Physical Examination, Policy Number AS-02 revealed in part the following: The physician or assistant conducts a physical examination within 24 hours of admission which includes a review of systems, and a neurological evaluation with view of cranial nerves I-XII.

Review of the Medical Staff Rules and Regulations, Policy Number BLA-03 revealed in part the following: A complete admission history and physical examination on each patient must be written or dictated and transcribed within twenty-four hours of admission and no more than 30 days prior to.

Patient #2
Review of the medical record for current Patient #2 revealed the patient was a 76 year old admitted to the hospital on 03/27/17 with a diagnosis of Schizophrenia.

Review of the H&P dictated by S14NP on 03/28/17 revealed the physical exam section of the H&P documented the following: "Cranial nerves: I through XII grossly intact." There was no explanation of the testing methods.

In an interview on 04/05/17 at 11:50 a.m., S1ADM reviewed the H&P for Patient #2 and confirmed H&P did not include as assessment of Cranial nerves, only "Cranial Nerves I-XII grossly intact".


Patient #4
Review of the medical record for current Patient #4 revealed the patient was a 66 year old admitted to the hospital on 3/16/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the H&P dictated by S14NP on 03/16/17 revealed the physical exam section of the H&P documented the following: "Cranial nerves: I through XII grossly intact." There was no explanation of the testing methods.

In an interview on 04/05/17 at 10:51 a.m., S1ADM reviewed the patient's medical record and confirmed S14NP documented "Cranial nerves I-XII grossly intact". S1ADM confirmed there was no documented assessment of the cranial nerves other that the above statement.


Patient #5
Review of the medical record for current Patient #5 revealed the patient was a 73 year old admitted to the hospital on 03/30/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the H&P dictated by S14NP on 03/31/17 revealed the physical exam section of the H&P documented the following: "Cranial nerves: I through XII grossly intact." There was no explanation of the testing methods.

In an interview on 04/05/17 at 11:45 a.m., S1ADM reviewed the patient's medical record and confirmed S14NP documented "Cranial nerves I-XII grossly intact". S1ADM confirmed there was no documented assessment of the cranial nerves other that the above statement.

Based on record review, observation and staff interview, the Hospital failed to ensure each patient had an individualized comprehensive treatment plan as evidence by:
1) Failing to include therapeutic activity therapy in the patient's comprehensive treatment plan for 3 of 3 (#2, #4, #5) current patients reviewed for therapeutic activities out of a total sample of 5 (#1-#5), and;
2) Failing to update the comprehensive treatment plan when the patient refused to participate or attend the psychotherapy groups for 1 (#2) of 3 (#2, #4, #5) current patients out of a total sample of 5 (#1-#5).

Findings:

1) Failing to include therapeutic activity therapy in the patient's comprehensive treatment plan:

Review of the Hospital policy titled, Therapeutic Recreation Services, Scheduling and Supervision, Policy Number CS-13 revealed in part the following: The therapeutic recreation staff will meet with each patient and develop an individualized treatment plan to meet patient's needs.

Patient #2
Review of the medical record for current Patient #2 revealed the patient was a 76 year old admitted to the hospital on 03/27/17 with a diagnosis of Schizophrenia. Review of the initial assessments revealed no documented evidence of an assessment of the patient's social/leisure/recreational needs. Review of the Comprehensive Integrated Assessment revealed the section titled, "Social/Leisure Activity Screening (RT)" was left blank.

Review of the patient's treatment plan revealed no documented evidence that therapeutic recreation therapy was included in the patient's treatment plan.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #2 was observed participating in a music activity conducted by S10LPC. Patient #2 was observed using a tambourine.

In an interview on 04/05/17 at 12:10 p.m., S2DON reviewed patient's record and confirmed there were no therapeutic activities included in the treatment plan. S2DON provided the form that should have been used.



Patient #4
Review of the medical record for current Patient #4 revealed the patient was a 66 year old admitted to the hospital on 03/16/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the Comprehensive Integrated Assessment revealed the sections for the therapeutic activity assessment were not on the record. There was no documented evidence of a therapeutic activity therapy assessment on the record.

Review of the patient's treatment plan revealed no documented evidence that therapeutic recreation therapy was included in the patient's treatment plan.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #4 was observed participating in a music activity conducted by S10LPC. Patient #4 was observed using a tambourine.


In an interview on 04/05/17 at 10:51 a.m., S1ADM confirmed S15CTRS had not worked since 03/09/17 and there were no services provided by a CTRS or trained recreation therapist since that date. S1ADM confirmed S15CTRS covered both campuses of the hospital.

In an interview on 04/05/17 at 11:50 a.m., S1ADM provided the therapeutic activity assessment documented by S10LPC on 03/17/17 and stated S10LPC had the documents and had not filed them in the patient's record. She confirmed S10 LPC did the assessment and confirmed the assessment was not signed by a CTRS/TRS.

In an interview on 04/05/17 at 12:10 p.m., S2DON reviewed patient's record and confirmed there were no therapeutic activities included in the treatment plan. S2DON provided the form that should have been used.


Patient #5
Review of the medical record for current Patient #5 revealed the patient was a 73 year admitted to the hospital on 03/30/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the Comprehensive Integrated Assessment revealed the sections for the therapeutic activity assessment were not on the record. There was no documented evidence of a therapeutic activity therapy assessment on the record.

Review of the patient's treatment plan revealed no documented evidence that therapeutic recreation therapy was included in the patient's treatment plan.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #5 was observed participating in a music activity conducted by S10LPC. Patient #5 was observed using a tambourine.

In an interview on 04/05/17 at 11:50 a.m., S1ADM provided the therapeutic activity assessment documented by S10LPC on 03/31/17 and stated S10LPC had the documents and had not filed them in the patient's record. She confirmed S10 LPC did the assessment and confirmed the assessment was not signed by a CTRS/TRS.

In an interview on 04/05/17 at 12:10 p.m., S2DON reviewed patient's record and confirmed there were no therapeutic activities included in the treatment plan. S2DON provided the form that should have been used.


2) Failing to update the comprehensive treatment plan when the patient refused to participate or attend the psychotherapy groups:

Patient #2
Review of the medical record for current Patient #2 revealed the patient was a 76 year old admitted to the hospital on 03/27/17 with a diagnosis of Schizophrenia.

Review of the treatment plan revealed the identified problem of alteration in thought processes related to psychosis. The social services interventions identified for this problem included the following:
Provide Group Psychotherapy to address issues associated with agitation and irrational thoughts.
Provide Cognitive Stimulation Therapy Groups to improve mood, mental abilities and wellbeing for 45-60 minutes 1 time a day for 1-2 weeks.
Provide 1:1 counseling to address issues associated with agitation and irrational thoughts.

Review of the Inpatient Group Documentation from 03/28/17 to 04/03/17 revealed the patient refused to attend the psychotherapy groups. Further review of the notes revealed 1:1 was documented as the plan.

Review of the Multi-Disciplinary Progress Notes dated 03/31/17 revealed the following: "1:1 on several occasions." Review of the progress note dated 03/30/17 revealed S10LPC had met with the patient.

In an interview on 04/04/17 at 12:50 p.m. S10LPC confirmed she does the psychotherapy groups and confirmed Patient #2 had refused to participate in the groups. S10LPC reviewed her group notes and confirmed 1:1 PRN was the plan documented when patient refused the groups. She indicated in her note dated 3/31/17 that she had done 1:1 with the patient on "several occasions" and documented that she met with the patient on 3/30/17. She confirmed this was the only documentation of 1:1 provided to the patient.

In an interview on 04/05/17 at 9:15 a.m., S11CD confirmed she was the Director of Social Services for the entire hospital. S11CD confirmed that S10 LPC was the counselor at the off-site campus and she was her supervisor. S11CD confirmed she had reviewed the medical record for Patient #2 and confirmed the treatment plan had not been updated with the patient's refusal to attend/participate in group therapy. She confirmed the group therapy notes and multi-disciplinary progress notes did not include documentation of patient's refusal or all 1:1s attempted. S11CD confirmed she would expect to see the treatment plan updated since the patient refused the group therapy and she would expect all attempts and patient response to 1:1 to be documented on the notes.

Based on record review, observation and staff interview, the Hospital failed to ensure therapeutic activities were provided by qualified therapists in accordance with the active treatment program for 3 of 3 (#2, #4, #5) current sampled patients reviewed for therapeutic activities out of a total sample of 5 (#1-#5). The deficient practice had the potential to affect 41 patients admitted to the hospital since 03/10/17.

Review of the Hospital policy titled, Therapeutic Recreation Service, Scheduling and Supervision, Policy Number CS-13 revealed in part the following: Purpose: to provide quality care and meet the physical, social, cultural, recreational, spiritual, health maintenance and rehabilitative needs of client. To prevent injury during activities. Therapeutic activities shall be offered to patients during program hours to provide a consistent well-structured, yet flexible, framework for daily living. The Therapeutic Recreation Department shall provide supervision for all of its activities on the grounds....Therapeutic Recreation Staff: Meet with each patient and develop an individualized treatment plan to meet the patient's needs. Encourage patients to participate in scheduled activities and in leisure planning to plan recreational activities which reflect individual's changing needs.

Review of the Hospital staff roster revealed no documented evidence of a current CTRS or other recreational therapy staff.

Review of the Hospital's Program Schedule revealed Activity Therapy by the Activity Therapist was scheduled for 9:30 a.m. Monday through Friday.


Patient #2
Review of the medical record for current Patient #2 revealed the patient was a 76 year old admitted to the hospital on 03/27/17 with a diagnosis of Schizophrenia. Review of the initial assessments revealed no documented evidence of an assessment of the patient's social/leisure/recreational needs. Review of the Comprehensive Integrated Assessment revealed the section titled, "Social/Leisure Activity Screening (RT)" was left blank.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #2 was observed participating in a music activity conducted by S10LPC. Patient #2 was observed using a tambourine.

In an interview on 04/04/17 at 1:20 p.m., S1ADM stated S15CTRS was the CTRS until 2 weeks ago when she resigned. S1ADM confirmed there was no current CTRS employed at either campus. S1ADM reviewed the patient's record and confirmed the patient did not have a therapeutic activity assessment done. Review of the Comprehensive Integrated Assessment revealed the section titled, "Social/Leisure Activity Screening (RT)" was documented by S10LPC. The section for the CTRS/TRS or TRA Designee Signature was left blank.



Patient #4
Review of the medical record for current Patient #4 revealed the patient was a 66 year old admitted to the hospital on 03/16/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the Comprehensive Integrated Assessment revealed the sections for the therapeutic activity assessment were not on the record. There was no documented evidence of a therapeutic activity therapy assessment on the record.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #4 was observed participating in a music activity conducted by S10LPC. Patient #4 was observed using a tambourine.


In an interview on 04/05/17 at 10:51 a.m., S1ADM reviewed patient's medical record and confirmed there was no therapeutic activity therapy assessment on the record. S1ADM stated S10LPC may have pulled the assessment to confer with S11CD on if she could do the assessment. S1ADM confirmed S15CTRS had not worked since 03/09/17 and there were no services provided by a CTRS or trained recreation therapist since that date. S1ADM confirmed S15CTRS covered both campuses of the hospital.

In an interview on 04/05/17 at 11:50 a.m., S1ADM provided the therapeutic activity assessment documented by S10LPC on 03/17/17 and stated S10LPC had the documents and had not filed them in the patient's record. She confirmed S10 LPC did the assessment and confirmed the assessment was not signed by a CTRS/TRS.


Patient #5
Review of the medical record for current Patient #5 revealed the patient was a 73 year admitted to the hospital on 03/30/17 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the Comprehensive Integrated Assessment revealed the sections for the therapeutic activity assessment were not on the record. There was no documented evidence of a therapeutic activity therapy assessment on the record.

On 04/05/17 at 9:50 a.m., an observation was made of the Activity Therapy group. Patient #5 was observed participating in a music activity conducted by S10LPC. Patient #5 was observed using a tambourine.

In an interview on 04/05/17 at 11:50 a.m., S1ADM provided the therapeutic activity assessment documented by S10LPC on 03/31/17 and stated S10LPC had the documents and had not filed them in the patient's record. She confirmed S10 LPC did the assessment and confirmed the assessment was not signed by a CTRS/TRS. S1ADM confirmed none of the hospital's patients admitted after 03/09/17 had therapeutic activities provided by a CTRS or trained recreational therapist.

Review of the resume' and application for S10LPC revealed no documented evidence of any training or experience in providing therapeutic recreation.