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Based on observation, interview, review of medical records, documents, and policies, the facility failed to review, analyze and evaluate patient incidents and take steps to ensure that all patients were not exposed to excessive risk of harm for all patient's served by the facility, and failed to provide an environment safe from all forms of abuse, neglect and harassment for 1 of 3 patient's (MR#1)

Findings include:

The facility failed to analyze repeated incidents of safety issues regarding patient smoking, fires on the units, patient contraband, and missing incident reports along with a failure to ensure all staff attended in-service training relative to facility expectations for incident reporting. Refer to findings at A-0144.

An incident of neglect was reported relative to a patient with poor hygiene resulting in infestation of maggots in clothing and bed linens. Refer to findings at A-145.


The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment potentially affecting all 220 patients at this facility.

Based on interview and policy review, the facility failed to ensure that the submission and lack of submission of a patient's grievance was conducted according to the facility's policy for 1 of 4 patients (patient #10).

Upon admission, every patient is provided with a copy of "Your Rights When Receiving Mental Health Services in Michigan." In "The Complaint and Appeals Process" section, it states: "If you believe that any right listed in this booklet has been violated, you or someone on your behalf should file a recipient rights complaint...Within five (5) business days after receiving your complaint, the Rights Office will provide you with a letter which tells you that your complaint was received..." Under dignity and respect, it states: "The law requires all mental health service providers to assure that you are treated with dignity and respect."

Policy 10.3.1 states, dated 8/11/08, states:
E.2. "Each rights complaint shall be date stamped and logged upon receipt by ORR (Office of Recipient Rights)."
9. At a minimum, each investigation by ORR shall consist of:
a. An interview with the complainant..."

On 12/10/12 at approximately 1140, patient #10 was randomly interviewed regarding, "A couple of incidents" that happened to the patient. Patient #10 stated he made nursing aware of the incidents that happened during hospitalization. Patient #10 stated he complained three (3) times about treatment that he had received at the facility. "No one has gotten back to me and they continue to treat me bad".

On 12/10/12 at approximately 1230 during an interview with Staff #22, it was noted that Staff #22 responded that she was unaware of any problems with the patient (patient#10).

On 12/10/12 at approximately 1500 patient #10's chart was reviewed and no documentation could be found in regards to any complaints. Patient #10 stated "they act like they are going to do something and the paperwork just disappears. No one does anything to help us".

On 12/11/12 at approximately 1000 during review of the document titled, "grievance log" it was determined that no grievances had been filed by the patient or on behalf of the patient. Staff #22 was informed and stated she will follow up on the patient's grievances.

Based on document, and policy review, and interview, the facility failed to ensure that interventions and responses to grievances were conducted in the specified time frames for 2 of 11 grievances reviewed (patients #2, #3).

Findings include:

Policy
State of Michigan Department of Community Health. Number 10.3.1 Complaint Investigation, Reports and Remediation (effective date 8/11/08) states, "2. Each rights complaint shall be date stamped and logged upon receipt by ORR...3. Interventions shall be completed no later than 30 calendar days following receipt of the complaint with written notice of the results of the intervention provided to the complainant...5. ORR shall initiate investigation of apparent or suspected rights violations in a timely and efficient manner. Investigation shall be initiated immediately in cases involving alleged abuse, neglect, serious injury, or death of a recipient involving an apparent or suspected rights violation. Subject to delays involving pending action by external agencies...the office shall complete the investigation not later than 90 calendar days after it receives the rights complaint."


Document Review and accompanying Interviews
During document review on 12/12/12 for patient #3, a progress note dated 11/11/12 at 4:21 pm states, "I was called to evaluate pt 'for maggots', per RN. Pt was seen & examined in treatment room. Extremely poor hygiene. Fibers from socks are imbedded in patients feet at the plantar surfaces. Feet have putrid odor. No wound. Five larvae crawling on patient's sock, not being worn by patient. Flies on curtain in pt's room & at nurses station, & on peers' windows in other room..." A review of patient grievances indicated that a grievance regarding patient neglect had not been filed by the patient or on behalf of the patient. On 12/12/12 at approximately 9:45 am, Recipient Rights Officer (Staff #9) was interviewed regarding the above incident. Staff #9 stated he was made aware of the incident and provided an e-mail from the facility administrator dated 11/19/12, reporting the incident and states, "I am reporting it because I believe it reflects neglect." Staff #9 was then queried regarding whether a rights investigation had been conducted. Staff #9 states, "I heard from infection control that maggots were found on the mattress. So I was looking into that. So on the 10th (December 10th, the day the surveyors arrived) I opened an investigation. I don't have a file yet. I'm trying to determine if the maggots were on the mattress or on the patients clothes." Staff #9 was informed on 11/19/12 and began an investigation on 12/10/12 thus failing to "immediately initiate" an investigation of an allegation of apparent or suspected patient neglect.

During review of a complaint written by patient #2, it was noted that the complaint was received on 11/14/11 and the report of "Investigative Findings" was dated 8/16/12, more than nine months after the complaint was logged in as received. On 12-10-12 at approximately 2:45 pm, Recipient Rights Officer (Staff #9) was queried regarding the extended length of time for this investigation that involved no external agencies (such as law enforcement or the Department of Human Services). Staff #9 replied that when typing up reports he, "..... uses a shell and forgot to change the date." Staff #9 then provided a report with an amended date indicating the report date as 1-15-2012. It was unclear as to how a date seven months in the future would have been incorporated into the "shell" for this report.

Also, three additional complaints by patient #2 that were dated as received on 11/14/11, 11/14/11, and 11/18/11 then received "Intervention Response" letters all dated 1/17/12. The intervention responses were completed greater than 30 days after the complaints were received by the Office of Recipient Rights, in clear contrast to the policy and procedure utilized at the facility.

Based on document review, policy review, and interview, the facility failed to ensure in its resolution of patient grievances, to include the steps taken on behalf of the patient to investigate the grievance in 3 of 11 (patients #1,#2,#23)grievances reviewed and failed to indicate the results of the grievance intervention in 1 of 11(patient #2) grievances reviewed. Findings include:

Policy
State of Michigan Department of Community Health. Number 10.3.1 Complaint Investigation, Reports and Remediation (effective date 8/11/08) states, "14. a. Upon completion of the process...The report shall include all of the following:..(4) Investigative findings (5) Conclusions..."

Document Review
On 12/10/12 at approximately 9:30 am, the facility was asked to provide a listing of all incident/grievance/complaint reports from 9/1/11 through 12/10/12. A list of specific and random complaints were then requested and reviewed.

During review of the grievances it was noted that the following grievances failed to indicate any steps taken (interviews, written statements, medical record reviews, etc.) on behalf of the patient to investigate the grievance and no indication of what "evidence" was reviewed:

Allegation #1-C/O#1 (utilizing the facility's identification system): The Intervention Response letter dated 1/17/12 states, "The following action has been taken: ORR has reviewed your complaint and found insufficient evidence to substantiate a rights violation."

Allegation #1-C/O#2: The Intervention Response letter dated 1/17/12 states, "The following action has been taken: ORR has reviewed your complaint that your property was stolen."

Allegation #1-C/O#3: The Intervention Response letter dated 1/17/12 states, "The following action has been taken: ORR has reviewed your complaint and found no evidence to determine that a rights violation occurred."

Also, Allegation #1-C/O#2 fails to indicate the results of the intervention. The Intervention Response letter dated 1/17/12 states, "Your complaint received on 11/18/2011 alleging that 'they' stole your property has been reviewed by this office. The following action has been taken: ORR has reviewed your complaint that your property was stolen. If you are not satisfied with the results of this intervention you may contact me within 10 working days to request additional information or to initiate an investigation at the number below."(sic). The letter to the patient fails to include a conclusion or result of the grievance intervention.

Interview
On 12/12/12 at approximately 9:35 am, recipient rights officers Staff #8 and Staff #9 were queried regarding the failure to include the investigative steps taken and results of the investigation in the Intervention Response letters to the complainants. Staff #8 responded, "The investigation (response letter) doesn't always reflect what we do, like our interviews and stuff."

The facility failed to ensure in its resolution of patient grievances that the complainant was informed of the steps taken to intervene on their behalf and of the final results or conclusion of the intervention.

Based on observation, interview, policy, document and medical record review, the facility failed to review, analyze and evaluate patient incidents of smoking and take actions specified in policies to reduce the risk of harm for all the patient's served by the facility. Findings include:

Policy/Document Review:

On 12/17/12 review of the "Patient Property & Searches" policy (SOP 249) effective 6/12/12, defined tobacco products as contraband and states:
1. RN: "authorizes area search when there is reasonable cause to believe that there is contraband and documents the reason in the chart."
2. Nursing staff: "Conduct a systematic search of the designated area. A patient will be provided the opportunity to be present when his/her living area, locker or drawers are searched."
3. Nursing staff: "Confiscates any contraband found and completes an incident report per SOP 201."
5. "Documents the search results and the patient's responses to the search in the progress notes."

On 12/17/12 review of the "Incident Reporting" policy (SOP 201) revised 2/1/12, revealed:
B "All unusual incidents shall be reported on Incident Report form (DCH-0044)."
"Unusual Incident(s)" is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual."
21. The Treatment Team ".... reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
N. "The Hospital Director /Designee and Chief of Clinical Affairs shall review Incident reports as schedules and assure that: (4) Actions required to prevent recurrence were taken and documents on the Incident Report form, as necessary."

Document review:

1. A Safety Department report dated 1/6/12 noted a trash can fire in patient room #425.
2. On 1/9/12 the Risk Manager sent a memo to the Director of Nursing noting that no Incident Report had been sent for treatment team review, per policy, regarding the above incident.
3. A Safety Department report dated 10/7/12 noted a trash can fire in room 407. On 12/17/12 the Risk Manager stated that an Incident Report (SOP 201) was not submitted for review by the Treatment Team, per policy, by the Nursing Department.
4. On 12/17/12 the Risk Manager's quarterly report for January-March 2012 noted 45 missing Incident Reports. For April-June 2012, 75 Incident Reports were not submitted per policy, according to the Risk Manager. Third quarter data had not been complied yet.
5. This information was verified with the Risk Manager on 12/17/12.

Observations/Interviews:

1. On 12/11/12 at approximately 4 pm staff #27 stated that patient room #622 frequently smells of cigarette smoke and that staff fail to report it or take action to search for smoking materials.
2. On 12/11/12 at 5 pm, patient room #622 was visited with the Performance Improvement Coordinator (PIC). Patient #25 was in the bathroom and a strong odor of cigarette smoke was present. The PIC and Unit Nurse (staff #28) verified these observations.
3. On 12/12/12 at 5:05 pm, a very strong odor of cigarette smoke was noted when a unit nurse (staff #28) opened the bathroom door in room #622.
4. On 12/17/12 the Risk Manager was asked for a copy of all Incident Reports involving patient smoking on the 6 th floor on 12/11/12. No Incident Reports were filed by the Nursing Department. A progress note in patient #25's record, dated 12/11/12 at 5:05 pm, states: "Patient noted in bathroom with strong smell of cigarette smoke and smoke in the air." The nurse documented that the patient was patted down and the room was searched but no contraband was found.
5. On 12/17/12 at 12:30 pm the 6th floor Unit Manager (staff #19) was asked why Incident Reports were not completed for the two episodes of smokey rooms observed by nurse #28 on 12/11/12. Staff #19 stated: "Strong smoke smell doesn't trigger any activity or documentation."
6. On 12/17/12 at approximately 12:35 pm Unit Manager #18 stated that it was her understanding that Incident Reports should be completed for observations of strong smoke odor or smoke in patient rooms.

Required staff Training on Revised Incident Report policy (SOP 201):

1. On 12/17/12 review of "SOP Update Memo," for implementing training on revisions to SOP 201 (revised 2/1/12) states: "Training Coordinator to coordinate In-Service."
2. On 12/17/12 at approximately 11:00 am the Director of Nursing (DON) was asked if all nurses were required to complete re-training on SOP 201, revised 2/1/12. The DON responded in the affirmative
3. On 12/17/12 a list provided by the DON revealed that 96 currently employed nurses were employed since March 2012. Of that number, only 49 were documented as completing training on the revised policies, based on documentation provided by the Training Coordinator, Director or Nursing and lists collected from units on 12/17/12.
4. On 12/17/12 at 10:20 am the Training Coordinator (staff #30) and Nursing Training Coordinator (staff #31) stated that their department was not responsible for ensuring that all staff complete required training. Both stated that it was up to the Director of Nursing (DON) to ensure that all nurses completed required training. Neither knew where a complete list of staff trained on the 2/12 revision to SOP 201 was stored.
5. On 12/17/12 at approximately 11:00 am the DON stated: "We don't have a complete list in our Department...Some (lists) may be on the individual floors and some are on a list in the Training Department." The DON stated that she was not sure who verified that all nurses completed required training.


30988


During medical record review for patient #5 it was noted documentation of frequent smoke in his bathroom and contraband found in vent grill of bathroom. On 11/30/12 at 7:55 pm, The"smell of burned up paper, wet ashes in toilet", room search ordered and documented but "no contraband found." On 12/2/12 12:17 pm "strong smell of burned paper", room search ordered and documented but "no contraband found". On 12/4/12 7:37 pm "smelled burned paper", room search ordered and documented "found contraband/cigarette in bathroom vent"

Review of patients Individual Plan of Service does not address the problem of smoking in the bathroom or the possession of contraband.

Review of Policy and Procedure titled "Tobacco Free Campus" dated 6/15/92 last reviewed 5/25/11 states, "Patients with nicotine dependence shall have the problem identified in their treatment plan with behavioral and pharmacological strategies & coping strategies considered."


30524

During medical record review for patient #23 it was noted that on the Individual Plan of Service (IPOS) dated 9/13/12, states under Axis I diagnosis "3. Nicotine addiction, in remission due to institutionalization." A progress note dated 9/20/12 at 9:23 am states, "...went into room...to get pt for a meeting with the team...pts observed smoking...asked pts to put out the cigarette they flushed it." A progress note that same date at 10:10 am states the staff asked patient for any cigarettes or lighter and "(the) only contraband found was the lighter that the pt gave to staff." A progress note dated 10/5/12 at 1 pm states, "Pt admits to smoking on the unit on a very frequent basis. Pt stated he does not want to give up smoking in the hospital although he knows that this is not a smoking facility."

Review of the patient's Individual Plan of Service does not address the problem of smoking in the bathroom or the possession of contraband thus failing to reduce the risk of harm to this patient and all others in the facility.

Based on interview, policy review, and medical record review, the facility failed to provide an environment safe from all forms of abuse, neglect and harassment. The facility failed to take actions specified in policies to reduce the risk of harm for 1 of 3 patients' identified by staff as being possible abuse victims (patient #3)out of a total of thirty medical records reviewed. Findings include:

**During review of the policy titled, "Complaint Investigation, Reports and Remediation" on 12/17/12 at approximately 0900 it was found procedure #5 states, "Investigation shall be initiated immediately in cases involving alleged abuse, neglect, serious injury, or death...".

During an interview with staff #21 on 12/11/12 at approximately 10:40am, when asked about the patient with maggots, patient #3, it was confirmed the patient had maggots on his bed, clothing, in a dirty laundry basket caused by soiled food on the bed. When asked how the situation could have gotten this far to produce maggots when patients are supposed to be monitored at all times, she provided no explanation.

During an interview of staff #27 on 12/11/12 at approximately 3:35pm, when asked to explain about patient #3 and the maggots found on the bed, the response was: "....the patient had been in soiled bed linen and clothes for several days." Upon assessment the patient had a horrible foot stench and it appeared that the patient had not changed his socks in several weeks. When the socks were removed it was found that sock fibers were imbedded into his feet.

During review of an e-mail in regards to the maggot situation with patient #3, on 12/12/12 at approximately 10:00am, it was found that on 11/19/12 at 12:51pm, an e-mail was sent from staff #6 to staff #2, #5 and #9, with the subject: Alleged Neglect, it reads, "I was informed this morning that the physician on call found the patient (#3) with maggots on his cloths and in socks, bed, etc. No documentation or referral was made or indication that staff on duty even new about the problem. He is on unit 6. I am reporting it because I believe it reflects neglect." When staff #1 was asked if an Incident Report had been completed as of the day of this survey, her response was "No".

Based on documents reviewed, policies reviewed, and interview, the facility failed to maintain an effective hospital wide Quality Assessment Performance Improvement program with review processes that identified opportunities for improvement.



The facility failed to identify problems evident relative to poor attendance at mandatory policy revision inservices, poor attendance of a Mock code training exercise, and a lack of adherence to patient smoking policies. (A-283).
The facility failed to follow through with the quality indicators and were not sure if the staff members were educated and they did not ensure that the staff were made aware of what was required of them during a mock code. The facility was unsure of what was and was not working for them during for their QAPI program because there were no outcomes monitored.

The facility failed to provide a sanitary, safe environment according to accepted standards of practice in order to reduce the risk of infection and provide evidence that fire drills were conducted as required.(A-286)

The cumulative effect of which is the facilities inability to identify problems for QAPI focus that will serve to improve health outcomes for all patient's served.

Based on interview, policy, record and document review, the facility failed to identify opportunities for improvement to enhance patient care processes to avert negative outcomes for potentially all patient's served by the facility. Findings include:
**On 12/17/12 the "Incident Reporting" policy (SOP 201 revised 2/1/12),was reviewed. It states:
B "All unusual incidents shall be reported on Incident Report form (DCH-0044)."
Unusual Incident is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual.
21. "The Treatment Team "reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
N. "The Hospital Director /Designee and Chief of Clinical Affairs shall review Incident reports as schedules and assure that:(4) Actions required to prevent recurrence were taken and documents on the Incident Report form, as necessary."
During document review on 12/17/12 it was noted that the facility revised the Incident Reporting form (SOP 201) on 2/01/12. An "SOP Update Memo" released shortly thereafter specified that the Training Coordinator was to coordinate an in-service for staff about the new policy's expectations. Review of the personnel list noted 96 currently employed nurses (as of March 2012). Further review of documentation confirming attendance at the required in-service noted 49 nursing personnel had attended. An interview conducted at 12/17/12 at 11:00am with the facility director of nursing, confirmed that it was expected that all nursing personnel would attend the mandatory in-service. The facility failed to identify that approximately half of their nursing staff not attending a mandatory in-service was a problem to focus process improvement efforts upon.









27408


On 12/17/12 at approximately 1:00pm during review of the Quality Performance program, it was determined that there was no evidence that the facility discussed an incident that took place on 07/28/12. It was noted that a, "mock code" was called by the on-call physician at approximately 2:15pm. According to the incident report, no staff responded to the "mock code". One of the nurses, who responded to the code after 2 minutes, "Opened the door, raised her voice and loudly exclaimed she was not responding to a mock code, and slammed the door behind her, as she exited without entering. Then, ...nothing". There was no documentation that the facility reviewed their emergency code policy, educated nursing staff as to their role in a code, there was no documentation that there was a mandatory educational class for all staff to attend or read, or that the incident was discussed at the quality meeting.

On 12/11/12 at approximately 1:00pm during an interview with the Director of Nursing, it was determined that the incident was not discussed with the nursing department. There was no evidence that the one nurse who responded to the "mock code" who refused to help out, was not educated on her (non)role in the code. According to the policy titled, "Medical Emergencies" there is a specific job for each person as they show up to the emergency. The problem in this case was that no one showed up to a mock code and the facility failed to monitor this problem with measurable goals to determine where they needed to improve.

On 12/17/12 at approximately 1:30pm during review of the quality assurance documents titled, "Performance Improvement Indicator Monitoring Report" it was noted that all of the results of the monitoring always had the outcome results of "100 %".

On 12/11/12 at approximately 2:00pm during an interview with Staff #3, it was determined that "those were always the results. It's pretty hard to improve when you have 100% all the time. The problem is we don't have 100% all the time but it sure does look good".


30988


**Review of Policy and Procedure titled "Tobacco Free Campus" dated 6/15/92 last reviewed 5/25/11 states ...."Patients with nicotine dependence shall have the problem identified in their treatment plan with behavioral and pharmacological strategies & coping strategies considered."

During medical record review for patient #5, documentation of frequent smoke in the bathroom and contraband being found in the vent grill of the bathroom on 11/30/12 at 7:55 pm was noted. The RN noted ".... smell of burned up paper, wet ashes in toilet", a room search was ordered, performed and documented but "No contraband found." On 12/2/12 12:17 pm again documented, "strong smell of burned paper", another room search ordered, performed and documented but still, "no contraband found". On 12/4/12 7:37 pm the RN again "smelled burned paper", the room was searched but this time documented "Found contraband/cigarette in bathroom vent"

Review of patient #5's Individual Plan of Service does not address the problem of the patient smoking in the bathroom or the possession of contraband. There was no documentation that this information was tracked and analyzed in the QAPI program.

In addition, the facility failed to assure that the director of of Nutrition services (emp #24) collected data for participation in the QAPI program.

Findings include:

**Review of Standard Operating Procedure:3-10 revised 1/12, states, "The Food & Nutrition Services shall be responsible for the safe and accurate provision of food and nutrition products" and "Nourishments are delivered to each unit at 9:30 am and 1:30 pm and are to be served by nursing at 10:00 am and 2:00 pm."

On 12/10/12 at approximately 11:30 am during a survey tour of the kitchen staff #24 was interviewed and stated "I don't attend the QAPI meetings or send a report (relative to dietary services). During review of the QAPI meeting minutes for the facility, there was no issues related to dietary services and no notes were located regarding problems with dietary or plans for improvement.

Based on observation and interview, the facility failed to provide a sanitary and safe environment according to accepted standards of practice relative to risk of infection and lack of fire drills, to minimize the potential for infection and safety compromise for all employees and patients served . Findings include:


13069

Based on observation, interview and policy review the facility failed to meet this standard as evident by;

During our record review of the fire drill and evaluation of staff knowledge documentation;

1. Many sheets were improperly filled out and/or missing follow up documentation, data, and locations as to where the repeat of the fire drill was taking place;

2. No cross reference between the old and the new sheets;

3. Unit 5 failed the drill and no follow up documentation is on file for 7/20/2012; and

4. Inconsistent location of fire drill locations or improper documentation to reflect location of start of fire drill were also observed missing for 2/6/2012, 5/21/2012, 6/25/2012, and 9/24/2012.

Based on observation, interview and record review the facility's Director of Nursing failed to ensure that the nursing staff developed and kept current nursing care plans on all patients. The facility failed to ensure that the nursing staff developed and kept current nursing care plans for 12 of 20 charts reviewed.(A 396) The facility's Director of Nursing failed to ensure that the registered nurses were competent and qualified for all patient care (A-397) and supervised and monitored the care of patients (A-393).The facility failed to provide a safe environment and make sure all patients are free from all forms of abuse, neglect and harassment. The facility failed to take actions specified in policies to reduce the risk of harm for 1 of 3 patient's reviewed (MR #3) (A- 145). Findings include:

-There were no signatures of patient's or physicians on care plans, evidence that care plans were updated periodically, or care plans that reflected the individualized needs of patient's.

-There was no documented evidence that reflected yearly competencies had been completed according to the facility's policy.

The cumulative effect of which results in the potential for nursing services not being competently provided for all of the patient's served by the facility.

Based on interview, policy review, and medical record review, the facility failed to provide a safe environment and make sure all patients are free from all forms of abuse, neglect and harassment. The facility failed to take actions specified in policies to reduce the risk of harm for 1 of 3 patient's reviewed (patient #8). Findings include:

On 12/11/12 at approximately 2:55pm during medical record review for patient #8, it was noted that on the Individual Plan of Service (IPOS) dated 05/14/12, ordered the patient to be monitored for "Blood Glucose levels before breakfast, before lunch, before dinner, and before bed." According to the MAR (medication acceptance record) dated from 06/12 to 09/12, shows that the patient was not monitored according to the physician orders as follows:
-For the month of June 2012, the patient should have been monitored 4 times a day for 30 days (total 120 times). The patient was monitored 21(twenty-one) times for the month.
-For the month of July 2012, the patient should have been monitored 4 times a day for 31 days (total 124 times). The patient was monitored 31(thirty-one) times for the month.
-For the month of August 2012, the patient should have been monitored 4 times a day for 31 days (total 124 times). The patient was monitored 8 (eight) times for the month.
-For the month of September 2012, the patient should have been monitored 4 times a day for 30 days (total 120 times). The patient was monitored 5 (five) times for the month.

Review of the document titled, "Medical Emergencies" noted that patient was "found in bed moaning & lethargic, RBS 21%"(sic) on 08/17/12. It was determined that the physician was paged and was given emergency medications (blood glucose 24mg/dl). The ambulance arrived and the patient was transferred to the hospital.

On 12/11/12 at approximately 1600 during review of the patient's Individual Plan of Service, it does not address the problem of the diabetic patient refusing to have her blood glucose monitored, that the patient was refusing to eat, or that the patient was refusing her insulin injections.. There was no documentation that the attending physician was made aware.

On 12/11/12 at approximately 1630 during review of the patient's "MAR" (medication administration record) it was noted that the patient returned back to the facility on 10/10/12 with a peg tube.

Based on record review, policy review and interview the facility failed to ensure that the nursing staff developed and kept current nursing care plans for 12 of 20 charts reviewed for nursing care plans.(Patient ' s #3, #4, #5, #8, #10, #11, #14, #16, #18, #23, #29, and # 30) Findings include:

Patient #8's chart revealed that there was only a document titled "Psychiatric Individualized Plan of Services" care plan dated 11/11/12. There was no document for nursing care plan noted.

Patient #10 's care plan dated 11/15/12, did not contain the signature of the patient and the physician. The last update was noted to be over one year after the patient admission.

Patient #29's care plan dated 09/01/12, did not contained any updates by the nursing staff.

Patient # 30's care plan dated 10/13/12, did not contain any updates by the nursing staff.



On 12/11/12 at 1530, Staff #22 confirmed that the facility did not follow the policy titled "Nursing Care Plans".







27065


On 12/11/12 at approximately 2 pm, patient #11 was observed during a survey tour of the facility, barefoot and with discolored, thick toe nails extending approximately .5 cm. above the top of the toe. Patient #11 was interviewed and stated that he did not remember being asked whether he would like to have them trimmed. Review of patient #11's medical record though revealed that he had been referred to the Podiatrist on 1/19/12, 2/16/12 and 3/1/12 for, "long, unkempt, mycotic toe nails" but documentation reflected that he had "refused" treatment. There was nothing in patient #11's Interdisciplinary Plan of Service (IPOS) indicating that treatment refusals had been addressed with the patient or identified as a treatment goal. The patient's nurse (staff #17) was interviewed thereafter and stated that she was aware of the patient's need for nail care. Continued review of the clinical record revealed no nursing documentation relative to the patient's toe nails or evidence that the care plan was updated reflecting such. These findings were verified on 12/11/12 at approximately 2 pm with the Performance Improvement Coordinator.


30524


During medical record review for patient #23 on 12/17/12, it was noted on the group progress notes dated 7/6/12 through 10/22/12 that patient #23 attended 23 of 57 group therapies for an attendance ratio of 40%. The group progress notes indicated patient #23 was either absent, refused, or sleeping for all missed group therapy sessions. This problem was not addressed on the "Person Centered Planning Individual Plan of Service (IPOS)" dated 10/3/12, 10/31/12, and 11/1/12. It was also noted on the IPOS dated 10/3/12 that, "He attends all of his groups and works in the therapy program without major problems." The nursing staff failed to keep the patient's IPOS current and accurate.






30988


During record review for patients #3, #4, #5, and #14 on 12/10/12 through 12/17/12, it was noted on the group progress notes that the patients refused to attend or are marked absent for almost all groups. This problem is not addressed on any of the patient documents titled "Person Centered Planning Individual Plan of Service (IPOS)."


29313

During medical record review on 12/10/12 during the hours of 1200-1300 it was found medical records #16 and #18 had documentation that reflected they had "refused" to attend any group therapy sessions. There was nothing in these patient charts "Interdisciplinary Plan of Service" (IPOS) indicating that treatment refusals had been addressed with the patients or identified as a treatment goal. At the time of review staff #20 confirmed these findings.

Based on interview and record review the facility's Director of Nursing failed to ensure that the nursing staff was competent and qualified to give patient care according to the facility's policy, for 6 of 6 nursing personnel files reviewed. Findings include:

On 12/11/12 at approximately 2:45pm during nursing staff personnel file review, it was determined that 6 out of 6 files contained a document titled, "For Probationary Ratings, Progress Reviews, and Annual Ratings." The documents were copied from the year prior for 3 out of 6 performance reviews. There was no documentation for inservicing or educating the nursing staff, in response to the "mock code" where no one showed up to the simulated "medical emergency". There was documentation for 6 out or 6 nursing staff who were "competent" in updating care plans, yet no care plans were updated and if they were the words, "remains the same, no changes, or refuses to participate" were always documented.
On 12/12/12 at approximately 1445 during interview with staff #3 it was determined that the yearly competencies were not completed according to the facility's policy.

Based on observation, interview and document review, the facility failed to assure that the director of of Nutrition services (emp #24) followed established policies and procedures relative to the supervision of work and personnel performance, and failed to assure that patients were provided with diets as planned and in accordance with nationally recognized dietary standards potentially adversely affecting every patient served by the facilities Nutrition Services.

Findings include:

**Review of Standard Operating Procedure:3-10 revised 1/12, states, "The Food & Nutrition Services shall be responsible for the safe and accurate provision of food and nutrition products" and "Nourishments are delivered to each unit at 9:30 am and 1:30 pm and are to be served by nursing at 10:00 am and 2:00 pm."

On 12/17/12 beginning at 11:00 am Observation of the lunch meal pass with staff #24.

On 12/17/12 lunch observation on floor R4 began at approximately 11:30. At 11:30 the carts holding the lunch trays were already on the floor awaiting staff. There was no one in the dinning room. After 10 minutes I proceeded to the nursing station and inquired if anyone was aware that lunch trays were here, and was told "NO" (they were not aware) by the secretary. The RCA #32 stated "we wait for the medications to be passed." Staff #24 reported that the Nurses were the ones who set up the times for meals to come to fit their schedule. The lunch trays did not begin to be served until 11:52. Staff #24 stated "This is an ongoing problem". The lunch trays were not checked for temperature after sitting in the hall for 22 minutes. There was no garnish on the plates, the dilled peas were not served but a vegetable blend was served instead (they had not been kept warm and they were not covered).

On 12/17/12 lunch observation on floor R6 began at approximately 12:00, the trays arrived at 12:00, the nursing staff was not told the trays had arrived, and no one was in the dining room. After 5 minutes I proceeded to the nursing station and was told they were not aware the trays were here and again I was told that they were waiting for the medication to be passed. At 12:05 an RCA began passing trays. 3 trays were missing altogether, and again the menu was not followed, no dilled peas, instead mixed vegetable blend uncovered & no garnish for anyone. Patient #31 Diet order 2000 calorie weight reduction diabetic heart health- Entree' 2 pieces white bread with 2 slices of cheese and nothing else on the plate. Patient #32 Heart Healthy diet 2 slices white bread and 2 slices cheese and nothing else on the plate.

On 12/17/12 lunch observation on floor R5; trays arrived at 12:28pm. At 12:32 one of the patients began yelling at the staff that the trays had arrived. An RCA began passing trays, it was observed that 2 trays arrived without a cover over the entree. The 2:00pm snacks had arrived on a tray on top of the lunch trays (earlier than necessary), the RCA began putting the snacks on the lunch trays, Staff #24 stopped her and the RCA then removed them from the trays and put them in the kitchen. Again the same problem of not following the menu, no dilled peas, Pears instead of bananas, cheese and bread, and no garnish.

Observation of lunch pass on 12/17/12. Printed menu: Salmon patty w/egg sauce, parslied red potatoes, dilled peas, skim milk, hot slaw, banana, Vegetarian-oven fried fish, Garnish- lemon wedge.
Actual- mixed vegetable instead of peas, pears instead of banana, bread and cheese instead of fish, and no hot slaw.

On 12/12/12 at approximately 1400 (2:00 pm) an interview with staff #25 revealed : " Menu is not followed, substitutions are random and nutritional analysis for therapeutic diets are not done, portions are not correct- using incorrect serving size utensil."

Staff #25 presented a printed document "Meal Quality Monitoring" with dates beginning 11/5/12. A sample includes: Regular eggs used instead of egg substitute for low cholesterol diets, regular sugar instead of sugar substitute for calorie controlled diet, Macaroni salad served instead of lettuce salad, cake/cobbler used in place of an apple, chicken and bean enchiladas recipe not followed ( no lettuce, no tomatoes, no tortillas), filling over corn chips with no nutritional analysis, no gravy available to add to texture modified diets, recipe calls for 8 ounce ladle- using 4 ounce or 6 ounce instead, insufficient grinding to meet mechanical soft texture guidelines

Based on observation, interview and document review the facility failed to adhere to the posted menus that are balanced and ensure they are meeting the nutritional needs of its patients.

Findings include:


On 12/17/12 lunch observation on floor R4 began at approximately 11:30. At 11:30 the carts holding the lunch trays were already on the floor awaiting staff. There was no one in the dinning room. After 10 minutes I proceeded to the nursing station and inquired if anyone was aware that lunch trays were here, was told "NO" by the secretary. The RCA #32 stated "we wait for the medications to be passed. Staff #24 reported that the Nurses were the ones who set up the times for meals to come to fit their schedule. The lunch trays did not begin to be served until 11:52. Staff #24 stated "this is an ongoing problem". The lunch trays were not checked for temperature after sitting in the hall for 22 minutes. There was no garnish on the plates, the dilled peas were not served but a vegetable blend was served instead (they had not been kept warm and they were not covered). Several patients took one look at the food on the plate and handed it back to the staff and left without eating, the staff did not make a list or try to call the kitchen for anything else for them to eat.

On 12/17/12 lunch observation on floor R6 began at approximately 12:00, the trays arrived at 12:00, the nursing staff was not told the trays had arrived, and no one was in the dining room. After 5 minutes I proceeded to the nursing station and was told they were not aware the trays were here and again I was told that they were waiting for the medication to be passed. At 12:05 an RCA began passing trays. 3 trays were missing altogether, and again the menu was not followed, no dilled peas, instead mixed vegetable blend uncovered & no garnish for anyone. Patient #31 Diet order 2000 calorie weight reduction diabetic heart health- Entree' 2 pieces white bread with 2 slices of cheese and nothing else on the plate. Patient #32 Heart Healthy diet 2 slices white bread and 2 slices cheese and nothing else on the plate. Several patients took one look at the food on the plate and handed it back to the staff and left without eating, the staff did not make a list or try to call the kitchen for anything else for them to eat.


On 12/17/12 lunch observation on floor R5 trays arrived at 12:28, at 12:32 one of the patients began yelling at the staff that the trays had arrived. An RCA began passing trays, 2 trays arrived to the floor with out any cover over the entree. The 2:00 snacks had arrived on a tray on top of the lunch trays, the RCA began putting the snacks on the lunch trays, Staff #24 stopped her and she then removed them from the tray and put them back in the kitchen. Again the same problem of not following the menu, no dilled peas, Pears instead of bananas, cheese and bread, and no garnish. Several patients took one look at the food on the plate and handed it back to the staff and left without eating, the staff did not make a list or try to call the kitchen for anything else for them to eat.

Review of Standard Operating Procedure: 2-10 revised 1/12 states "The Director of Food & Nutrition Services/Designee shall be notified of any menu substitutions. All substitutions must be documented."

Review of Standard Operating Procedure:3-10 revised 1/12 states "nourishments are delivered to each unit at 9:30 am and 1:30 pm and to be served by nursing at 10:00 am and 2:00 pm" "The Food & Nutrition Services shall be responsible for the safe and accurate provision of food and nutrition products." "F. In the event that a patient does not like the meal served (or item served), nursing shall contact the kitchen for an appropriate substitution..."

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated December 12, 2012 for Life Safety Code.

Based on observation and interview, the facility failed to provide a sanitary environment and patient care according to hospital policies and accepted standards of practice to reduce the risk of infection for all patients. Findings include:

On 12/11/12 at approximately 11:10 am patient #39 was observed in bed during a survey tour of the unit. A sign posted outside patient #39's door indicated that contact precautions were in effect. A Unit Manager (staff #15) stated that patient #39 has a diagnosis of colonized MRSA (Methicillin-Resistant Staphylococcus aureus). Patient #39 had 6-8 small open areas on the lower back, near 6-8 round stained areas on the bottom sheet. The stains were dark brown/red, resembling dried blood. Patient #39 was unable to state how long the stained sheet had been there. A Resident Care Attendant (staff #37) entered the room, balled up the sheet, carried it through unit hallways, unbagged, then threw it down the laundry chute in room # 331. The Unit Manager (staff #15) was asked whether the patient's soiled linens had been handled properly. Staff #15 stated that it was not handled properly but was unable to locate a policy showing how the linens should have been handled. Prior to survey exit, a policy pertaining to patient's with suspected communicable infections, revised 10/10, was provided. It states: "Patients suspected to have a specific communicable infection should be placed in the appropriate type of isolation precautions..." The policy stated: "A single bagging technique is used to remove linen, trash, specimens and contaminated articles."

On 12/11/12 at approximately 2:25 pm the treatment room where a contractually employed Podiatrist treats patients (B 16 B) was toured. A bottle of "cuticle nipper oil," was open, was less than half full with a brush applicator inside. Pieces of a tan substance were floating in the solution and a black ring was observed around the lower rim. This finding was confirmed by the Performance Improvement Coordinator who was unable to explain why this contaminated vial was stored in a patient treatment room.



27408


On 12/10/12 at approximately 11;45am survey observation of the second floor with Staff #22 noted visible dust, dirt, debris, shower heads that were leaking, toilets that were leaking, and drains not properly functioning. All walls in the patient rooms, dining room ,doors, and drawers were dirty with dried splattered substances in various colors. The exercise bike in the dining room had a dried white substance all over seat and handles. Staff #22 stated, "I don't think the housekeepers can get into this room without a key", When asked if there was some type of maintenance schedule that the nursing staff reviewed, Staff #22 stated she, "....didn't think so." Patient rooms were cluttered with piles of garbage, clothing, and bedspreads that had huge, frayed holes the size of a watermelon.

Interview with Staff #22 during the observational tour, determined that the facility does not maintain the facility according to policy.









29313

During the initial tour of the facilities forth floor on 12/10/12 during the hours of 1100-1300 with staff #20 the following was observed throughout the unit, visible dust, dirt, debris, shower heads that were dirty, toilets that were leaking and dirty, and bath tubs not cleaned. All walls in the patient rooms, dining room, doors, and drawers were dirty with dried splattered substances in various colors. The Hoyer lift in the tub room had stains along the base and on the bars of the lift. The medication room food and medication freezer had a large amount of ice build up. Laundry room had debris on the floor. The pantry freezer had yellow frozen substance on the bottom. The floors and beds in the patient rooms were cluttered with bags of patients' belongings. In the dining area, each table top had bits of food debris and had not been cleaned since breakfast that morning. All floors throughout the unit had grossly visible dust and debris. Staff #20 confirmed these findings at the time of the tour.

During policy and procedure review on 12/17/12 at approximately 0930 it was found in the policy titled, "Infection Control Manual", states, "Appliances are to be cleaned and defrosted on a regular basis", "Eating and food preparation surface areas must be cleaned with a fresh solution of detergent and water and clean cloth before and after using. Floors should be swept to maintain a clean, crumb-free environment".


30524

On 12/10/12 at approximately 11:30 am during the survey tour of R5 it was observed that:

The floors and beds in the patient rooms were cluttered with bags of patients' belongings. Four rooms, that included enough beds for 4 patients in each room, lacked bedside tables or storage options for the patients located on the window side of the room. One patient was asked where she could store her belongings, she indicated there were lockers on the other side of the room, but didn't utilize because she would have to enter her roommates space to get to her designated locker.

In the dining area, each table top had bits of food debris and had not been cleaned since breakfast that morning. All floors throughout the unit had grossly visible dust and debris.











30988

On 12/10/12 at approximately 12:30 pm during tour of R 6 with staff #19 and #24 it was found;

All floors had visible dust, dirt and debris. The locked public areas are ie: laundry room, linen room, clean supply room, dirty laundry chute rooms x 2, dinning room, dayroom, treatment room, medication room need to be swept and mopped. All walls ,doors, and drawers are dirty with dried splattered substances in various colors. Staff #19 stated " housekeeping has to be let into the locked rooms for cleaning", when asked if there was a schedule for them to be let in to clean stated "No." Patient rooms are cluttered with piles of personal belongings on the floor beside the beds and night stands, staff #19 stated "some of the patients keep to much in their rooms, they do have a locked locker but they have more than will fit." The dayroom has a broken dirty (covered with thick dust) treadmill awaiting repair, staff #19 stated "its been broken for awhile."

Based on observation and document review, the responsibilities of the chief executive officer, medical staff and director of nursing services failed to ensure that the hospital-wide quality assurance program and training programs address problems identified by the infection control officer and would be responsible for the implementation of successful corrective action plans in affected problem areas.
Findings include:

During observation of the facility unit on the forth floor on 12/10/12 during the hours of 11:00am-1:00pm and infection control meeting minute document review from the previous six months on 12/11/12 at approximately 10:40am, it was found that problems identified by the infection control officer and reported to the quality and performance improvement committee, were not being addressed by the responsible parties aforementioned. They failed to implement a successful corrective action plan in the facility.

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

I. Ensure that individualized psychiatric care was provided for 3 of 12 active sample patients (C1, D25 and E24), and 3 of 3 non-sample patients (C8, C14 and C43) who were added to the sample for review of active treatment. These patients were scheduled for groups which they would not attend, or groups which they had attended in multiple previous "cycles" of the same groups and would not continue to attend over again. In spite of these obvious refusals, treatment plans were not revised to meet patient needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement. (Refer to B125, Part I)

II. Ensure that staff developed methods to help patients follow their treatment plans. There were no clear expectations given to patients by staff about the patients' involvement in treatment. Staff alleged that facility policy prevented them from developing methods to encourage patient participation in treatment; few staff prompts were given to patients to support group/activity attendance; instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimens. This failure results in lack of active treatment for patients. (Refer to B125, Part II)

III. Provide sufficient intensity of treatment via treatment groups/activities to realistically enable patients to improve. Each patient was limited to two structured group sessions a day, from the Psychosocial Rehabilitation (PSR) Groups held on each unit, and which were conducted in 45 minute sessions at 10:00 a.m. and 3:00 p.m. each day Monday through Friday in a twelve-week cycle. None were held on the weekends. There was one week after each cycle entitled "evaluation/documentation week" that did not include any structured programming or therapeutic groups for patients at all. Groups were repetitive from one group cycle to the next, and group design did not target individual patient needs. In addition, there were only unstructured games and other leisure activities offered on evenings and weekends. This failure results in lack of active treatment for all patients in the hospital. (Refer to B125, Part III)

IV. Ensure that the few scheduled groups/activities were conducted regularly and in a timely manner. During the survey, on 4 of the 5 Units (R-2, R-4, R-5 and R-6), scheduled groups/activities were late starting and some groups were canceled. When groups were canceled, patients scheduled for those groups were moved into another group based on group availability, rather than individualized patient need. This failure results in lack of active treatment for these patients. (Refer to B125, Part IV)

Based on record review and interview the facility failed to develop master treatment plans (MTPs) that included specific nursing interventions based on the each patient's individual problems and goals for 6 of 12 active sample patients (A30, B19, B25, C1, C21 and E24). Instead, the MTPs included routine nursing functions that failed to address behaviors presented by the patients (aggression, irrational behavior, etc.) This failure results in lack of guidance to nursing staff in providing consistent and effective treatment related to patients' identified problems and goals.

Findings include:

A. Record review:

1. Patient A30-Master Treatment Plan dated 10/16/12:

Problem #1: "Mood lability with psychosis. The patient has mood lability with manic symptoms as evidenced by [his/her] being hyperverbal, intrusive, illogical, with pressured speech and significant tangentiality. [S/he] has paranoid/persecutory delusions as evidenced by [his/her] verbalizing that people are against [him/her] and trying to hurt [him/her], leading [him/her] to get agitated and aggressive towards others and property."

The treatment plan failed to identify nursing interventions to address the patient's delusions and paranoia other than "provide reality orientation as needed." There were no specific nursing interventions to address potential for violence.

2. Patient B19- Master Treatment Plan dated 11/8/12:

Problem #1 was stated as "Poor impulse control, as evidenced by [s/he] easily becomes very irritable and angry and get [sic] into verbal and physical altercation with staff and peers. The patient is very delusional and paranoid and [s/he] acts on [his/her] delusions.... The patient is unable to sleep at night. The patient at times pacing (sic) and talking to [himself/ herself]. The patient is also neglecting [his/her] hygiene and grooming. The patient is also isolative and withdrawn. [S/he] has shown severe mood swings and [s/he] has several episodes of violent behavior, aggressive and combative behavior.....While [s/he] was at the Center for Forensic Psychiatry, [s/he] stabbed the staff with a sharpened tooth brush. [S/he] tried to break the new plasma TV in the Center for Forensic Psychiatry. [S/he] has no insight of mental illness and need for treatment."

The treatment plan failed to identify nursing interventions to address the patient's behavior in the clinical areas related to delusions and paranoia and the potential for violence.

3. Patient B25-Master Treatment Plan with review dated 10/16/12:

Problem #1 was stated as "NGRI status....The patient has a long history of thought disorder and poor impulse control and manic symptoms, and the patient has been treated in inpatient treatment several times. The patient is very delusional and paranoid....The patient at times acts on [his/her] paranoid thinking and [s/he] gets into physical fights and arguments with peers and staff....The patient at times appears preoccupied with internal stimuli. The patient mumbles to [himself/herself] and smiles to [himself/herself]. [S/he] has no insight of mental illness and need for treatment."

The treatment plan failed to identify nursing interventions to address the patient's behavior in the clinical areas related to delusions and paranoia other than "provide reality orientation as needed."

4. Patient C1-Master Treatment Plan review dated 11/7/12:

Problem #1 was stated as: "NGRI status. The patient has a history of killing [his/her] father under the command of auditory hallucinations and severe paranoid delusions. [S/he] continues to have paranoid ideations and suspiciousness towards the treatment team and most probably these paranoid ideations have been the reasons for [his/her] continued rehospitalizations (sic) from outpatient treatment and [s/he] has not been able to stay in less restrictive environment."

Nursing role functions listed as interventions were: "The RN will educate the patient on medications and side effects, and compliance will be encouraged both now and upon discharge. The staff will meet with the patient at the start of each shift and go over the activities of the day, encouraging PSR [Psychosocial Rehabilitation] and other activities. The patient will be provided with a safe and secure environment."

The only intervention to address the patient's "paranoid ideations and suspiciousness" was listed as "The assigned RN will meet with the patient 30 minutes weekly or as tolerated to discuss abnormal thinking and paranoid ideation." This intervention would result in nursing staff encouraging discussion about irrational ideas.

5. Patient C21-Master Treatment Plan with review dated 11/7/12:

Problem #1: "Long lasting psychotic symptoms, especially thought disorganization and the content of thinking would include self-centered delusion of paranoid and grandiose one. The patient __________ (not completed) even the own family including [his/her] daughter and staff her (sic), including physician are plotting against [his/her] money (sic). Due to the psychotic symptoms the patient had violent (sic) towards others and has not been able to live in less-restrictive environment."

Nursing role functions listed as interventions were: "The RN will educate the patient on [his/her] medication regimen, including the use and side effects, compliance will be encouraged both now and upon discharge. The patient will be met with each in (sic) activities of the day including PSR will be encouraged (sic)."

The treatment plan failed to identify nursing interventions to address the patient's behavior in the clinical areas related to delusions and paranoia. The only intervention related to the patient ' s potential violence was stated as "The patient will be educated on coping skills in order to deal stressors (sic) to prevent assaultive and threatening behavior."

6. Patient E24 Master Treatment Plan dated 10/4/12:

Problem #1: "Neglecting basic care needs due to delusions and hallucinatory experiences."

Nursing role functions listed as interventions were: "The RN/LPN will administer mood stabilizing medication and monitor its effectiveness." This role function was listed as an intervention without individualization.

The plan failed to identify nursing interventions to guide nursing personnel in how to respond to the patient when presenting delusions and hallucinations in the clinical area.

Interview:

In a meeting with the DON and Director of Social Work on 12/12/12 at 9:15 a.m., both stated that interventions should focus on behaviors (patient), instead of role functions (staff).

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

I. Ensure that individualized psychiatric care was provided for 3 of 12 active sample patients (C1, D25 and E24), and 3 of 3 non-sample patients (C8, C14 and C43) who were added to the sample for review of active treatment. These patients were scheduled for groups which they would not attend, or groups which they had attended in multiple previous "cycles" of the same groups and would not continue to attend over again. In spite of these obvious refusals, treatment plans were not revised to meet patient needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement.

II. Ensure that staff developed methods to help patients follow their treatment plans. There were no clear expectations given to patients by staff about the patients' involvement in treatment. Staff alleged that facility policy prevented them from developing methods to encourage patient participation in treatment; few staff prompts were given to patients to support group/activity attendance; instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimens. This failure results in lack of active treatment for patients.

III. Provide sufficient treatment groups/activities based on the individualized needs of patients. Structured programming consisted of Psychosocial Rehabilitation (PSR Groups (3-5 groups presented simultaneously) on each unit conducted in 45 minute sessions at 10:00 a.m. and 3:00 p.m. each day Monday through Friday for a twelve-week cycle. There was one week after each cycle entitled "evaluation/ documentation week" that did not include any structured programming or therapeutic groups. Groups were repetitive from one group cycle to the next and group design did not target individual patient needs. In addition, there were only unstructured games and other leisure activities offered evenings and weekends. This failure results in lack of active treatment for all patients in the hospital.

IV. Ensure that scheduled groups/activities were conducted and performed in a timely manner. During the survey, on 4 of the 5 Units (R-2, R-4, R-5 and R-6), scheduled groups/activities were late starting and some groups were canceled. When groups were canceled, patients scheduled for those groups were moved into another group based on group availability, rather than individualized patient need. This failure results in lack of active treatment for these patients.

Findings include:

I. Failure to provide active treatment based on individual patient needs:

A . Sample Patient C1 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the annual psychiatric evaluation (4/27/12) Patient C1 continued to have "paranoid delusions and suspiciousness towards the treating team...This patient continues to be reluctant and reticent to talk about discharge...The patient continues to report improvement in every aspects (sic), especially [his/her] sleeping and has not had any behavioral problems with aggression, assaultiveness..."

2. Review of Patient C1's group progress notes revealed that this patient refused to attend 24 of 24 (100 %) scheduled groups (Nutrition and Social Recreation) from 10/28/12 through 12/10/12. According to the group progress notes Patient C1 refused to attend 100 % of his/her bi-weekly group psychotherapy sessions from 8/2/12 through 12/6/12. A psychologist note regarding these sessions (undated) stated, "[S/he] takes no responsibility for [his/her] actions or [his/her] need to think about doing what would be necessary therapeutically for [him/her] to leave the hospital ...Did not respond well to Group Psychotherapy this Cycle." An activity therapy progress note (11/15/12 to 12/7/12) stated "Pt. [Patient] declines to participate in groups, partly due to patient having attended most groups offered in [his/her] past hospitalizations."

3. Observations on Unit R-4 revealed Patient C1 to be in bed asleep on 12/10/12 at 3:20 pm (Patient was scheduled to attend a Nutrition Education group at this time) and on 12/11/12 at 10:10 am (Patient was scheduled to attend a Community Re-Entry group at this time). When the patient was asked why she was in bed during his/her group time, Patient C1 responded, "My medication was recently changed."

4. Interviews:

a. During interview on 12/10/12 at 2:40 p.m., RN1 stated that Patient C1 "stays in bed a lot." She added that the patient "used to go to activities, but now says that [s/he] has been to all of them (activities)."

b. During interview on 12/11/12 at 9:15 a.m. Physician 1 stated that Patient C1 "is doing well. The patient denies psychotic symptoms. (Patient) would have been discharged 2-3 years ago if (patient) would agree to write a letter applying for NGRI (application to begin process for placement)." He reported "(Patient) was very engaged in treatment, but now (patient) says [s/he] has been therapized, educated and trained enough. For the last 7-8 months (patient) has been non-compliant, and has isolated self, not involved or engaged."

c. During interview on 12/11/12 at 10:10 a.m., RN8 reported that Patient C1 has been to every class many times and does not want to go to any groups now. She added that the patient "has quit participating for the last year or so."

d. During interview on 12/11/12 at 4:00 p.m., Psychologist 3 reported that Patient C1 has refused treatment for several weeks. She added, "The patient likes it here, [s/he] feels safe."

5. Review of Patient C1's master treatment plan, with review 11/7/12 revealed no change in treatment schedule (groups and 1:1) as of 12/11/12, even though s/he is non-compliant in all areas other than medication regime. Patient C1's treatment plan failed to specifically address his/her continued non-compliance in treatment.

B. Non-sample Patient C8 was admitted on 12/1/11 with diagnosis of Chronic Undifferentiated Schizophrenia.

1. As documented in the annual psychiatric evaluation (11/30/12) Patient C8 continued to "admit to having auditory hallucinations and [his/her] thinking was not rational ...has not been doing good...responding to internal stimuli."

2. As documented in the annual psychosocial assessment (11/29/12), Patient C8 "has not made significant progress...observed talking to [him/her]self. [S/he] stays to [him/her]self with minimal interaction with peers...Psychosocial Rehabilitation (PSR) groups attendance is sporadic with little focus when [s/he] does attend sessions."

3. A review of the Ward R-4 group/activities schedule revealed Patient C8 was only assigned to attend Substance Abuse group 3 times/weekly, Life Skills group 3 times/weekly and Benefits for Leisure group 3 times/weekly. A review of Patient C8's group progress notes revealed that this patient attended his/her assigned Life Skills groups but from 10/29/12 to 12/7/12 refused to attend 10 of 10 (100%) of scheduled Benefits of Leisure groups. This patient's recent attendance in the assigned Substance Abuse groups was not provided to the surveyors; however, his/her attendance progress note from 10/24/12 through 11/9/12 showed that Patient C8 attended 3 of 6 (50%) of these scheduled groups sessions.

4. Observations on Unit R-4 on 12/11/12 at 10:10 a.m., accompanied by RN8, revealed Patient C8 to be in his/her bed asleep. This patient was scheduled to attend a Benefits of Leisure group. At that time, RN8 did not address with the patient his/her lying in bed, rather than attending his/her assigned group session.

5. During interview on 12/11/12 at 11:00 a.m., Recreation Therapist (RT)11 reported that Patient C8 refused to attend many assigned sessions.

6. Review of Patient C8's master treatment plan, with review 11/30/12, revealed that this patient's poor treatment compliance was not specifically addressed.

C. Non-sample Patient C14 was admitted on 7/12/12 with diagnosis of Chronic Undifferentiated Schizophrenia.

1. As documented in the admitting psychiatric evaluation (7/13/12) Patient C14 "was very inappropriate in [his/her] thinking and mumbled around."

2. Review of Patient C14's group progress notes revealed that this patient refused to attend 21 of 35 scheduled groups from 10/29/12 through 12/11/12. Even though Patient C14 attended some groups, the majority of the time the notes stated that patient was "on the fringe" or left the group after 5 minutes. According to a recreational therapist note (undated) in the group progress notes, Patient C14 "Barely attends even w/ [with] 1:1 prompting by nursing and A.T. [Activity Therapy] staff. Poor tolerance of group (sic)."

3. Observations on Unit R-4 on 12/11/12 at 10:10 a.m., accompanied by RN8, revealed Patient C14 to be in his/her bed asleep. This patient was scheduled to attend a Benefits of Leisure group. At that time, RN8 did not address with this patient his/her lying in bed, rather than attending his/her assigned group session.

4. During interview on 12/11/12 at 11:00 a.m., RT11 reported that Patient C14 "walks around the unit. We ' re lucky if [s/he] attends any activities."

5. Review of Patient C14's master treatment plan, with review 11/13/12, revealed that this patient's lack of treatment compliance was not specifically addressed.

D. Non-sample Patient C43 was admitted on 3/23/05 with diagnosis of Bipolar disorder, Type 1.

1. As documented in the annual psychiatric evaluation (3/26/12) Patient C43 "continues to be the same, a rapid cycling bipolar disorder with depressive episode characterized by a catatonic like seizures [sic]."

2. The annual psychosocial assessment (3/22/12) states "encouraged to attend all scheduled PSR groups...The patient is reported to be attending sporadically. Participating when [s/he] does join the session."

3. A review of Ward R-4's group schedule revealed that Patient C43 was assigned two 45 minutes groups each day Monday through Friday. A review of his/her Precaution (falls) documentation forms from 12/2/12 through 12/11/12 revealed that Patient C43 did not attend any groups/activities during that time.

4. Observations on Unit R-4 revealed Patient C43 to be in bed asleep on 12/10/12 at 3:20 pm (Patient was scheduled to attend a Social Recreation group at that time) and on 12/11/12 at 10:10 am (Patient was scheduled to attend a Community Re-Entry group at that time).

5. Review of Patient C43's master treatment plan, with review 11/13/12, revealed that this patient's lack of treatment compliance was not specifically addressed.

E. Sample Patient D25 was readmitted 8/2/11 with a diagnosis of Schizoaffective Disorder, Bipolar Type; Polysubstance Abuse by History and Nicotine Dependence. S/he was returned on NGRI status from ALS (Administrative Leave Status) Contract for violation of smoking rules in a group home.

1. Review of Patient D25's Group Progress Notes, revealed:

The summary note by nursing dated 10/12/12 for the ADL Group stated "pt. often refused. Continue with ADL group next cycle." The summary note by nursing for Health and Wellness dated 10/26/12 indicated patient attended 12 of 45 sessions during the period of 8/2/12-10/12/12. It further stated "encourage continued compliance."

The summary note by social worker dated 11/8/12 indicated patient attended 13 of 22 sessions for the period of 7/30/12-11/8/12, "below the 80 - 100% threshold." No additional group progress notes were provided to the surveyors.

2. Observation on Unit R-5 revealed the patient in bed asleep 12/11/12, 10:10 a.m. (S/he was scheduled to be in ADL Group at that time.) S/he was again observed to be asleep in his/her bedroom 12/11/12, 3:10 p.m. The patient was scheduled to be in Life Skills Group at that time.

3. Master Treatment Plan, with review dated 10/10/12, stated patient "did not show any evidence of impulsive behavior, such as suicidal or self-injurious behavior, however continues to violate smoking rules...." The plan did not reflect a change in treatment schedule and did not address his/her continued non-compliance in treatment.

4. Monthly review for Treatment Planning, dated 11/7/12, stated patient was "not making any progress in hospital." The review did not address the patient's lack of treatment compliance.

5. During interview 12/10/12, at 4:15 p.m., patient stated, "I already know groups." When asked to elaborate s/he explained s/he has been through the same groups before.

6. During interview 12/11/12, 11:55 a.m., Physician 3 reported that the patient " has no motivation. If [s/he] would control smoking [s/he] probably could be out. [S/he] is no longer disorganized. ADL's are poor and [s/he] has no motivation. [S/he] wants to be in [his/her] room. I tell [him/her] that as long as[s/he's] not motivated, [s/he] will end up here."

F. Sample Patient E24 was admitted on 4/3/12 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

1. Review of Patient E24's Group Progress Notes for the scheduled groups from 10/28/12-12/10/12 revealed the notes only denoted attendance or absence. The notes revealed for ADL Group, pt. did not attend 8 of 11 (72%); for Stress Management Group, pt. did not attend 12 of 16 (75%); for Health and Wellness Group, pt. did not attend 6 of 15 (40%); for Personal Growth and Development Groups, pt. did not attend 4 of 12 (33%), a total of 56% of scheduled groups missed.

2. An Activity Therapy Monthly Progress Note dated 11/27/12 revealed "from 11/2/12-11/27/12, patient attended Stress Management x 2 (<60 minutes). (Patient) generally stays to [him/herself] and isolates...progress is limited."

3. Observations on Unit R-6 on 12/10/12 at 10:50 a.m., revealed patient in his/her bed. S/he was scheduled to attend Stress Management Group, but SW2 reported patient had not attended group. Patient was observed asleep in room 12/10/12 at 3:15 p.m.; s/he was scheduled to attend Health and Wellness Group. S/he was again observed asleep in his/her room 12/11/12, 10:45 a.m. At that time s/he was scheduled to attend ADL Group. On 12/11/12, Patient refused formal interview with surveyor, responding, "I don't want to (talk), I want to sleep."

4. Interviews:

a. During interview 12/10/12 at 11 a.m., Physician 2 described patient as having false beliefs, does not shower adequately and urinates on his/her clothes. Physician 2 further stated "[s/he] does not usually attend groups."

b. During interview 12/10/12 at 1:30 p.m. SW1 stated "[s/he] only attends groups sporadically."

c. During interview with the treatment team on 12/11/12 at 10:45 a.m. when asked about patient E24's group attendance and alternative treatment when s/he refuses, Physician 2 stated, "Patient is too psychotic to attend. [S/he] is not able to comprehend.... we can't force (patients) to participate."

d. In the interview on 12/11/12 at 10:45 a.m., SW2 stated, "Patients don't want to do anything and staff can't do anything about it. They (patients) don't see it (participation) as being related to progress, treatment, discharge or the need to make it in the real world."

II. Failure to present clear expectations to patients regarding participation in treatment:

A. Observations and Interviews

1. Observations on 12/10/12 with RN5 and RN6 on Unit R4 from 3:15 to 3:45 p.m. revealed 17 of 43 (40%) patients in their beds, including sample Patients C1 and non-sample patients C8, C14 and C43. All of these patients were assigned to attend a group/activity from 3:00 to 3:45 p.m. RN5 asked several patients why they had not attended their assigned group, making no comment about the need or their responsibility to attend. Some patients reported that they did not know they were supposed to be at a group. In interview at that time, RN5 said they (staff) could not force a patient to attend groups as this was against the patients' rights. When asked if there were requirements for attendance with rewards/incentives for attendance, she responded, "We're not able to do this now due to policy change."

2. In an observation on Unit R-2 on 12/11/12 between 10:00 to 10:45 a.m. with the Director of Psychiatric Services and the floor RN, it was observed that three groups were in process (ADL Group, Community Re-entry, and Community Transitions Skills). A total of 19 patients were present in all three groups out of a unit census of 37 patients. The surveyor observed many patients in beds in their rooms and asked the nurse about this. The nurse stated that the policy is to encourage patients to attend, but beyond that there was nothing they (staff) could do.

3. During interview about patients' failure to attend treatment on 12/11/12 at 9:15 a.m., Physician 1 reported that hospital programs were no longer able to have a step program based on rewards even though they had a good "behavior modification" program until about 1- 1.5 years ago. He reported that since that time patients stayed in bed and often refused to attend activities.

4. Observations on 12/11/12 with RN8 from 10:10 to 10:30 a.m. revealed 24 of 43 patients in their beds or walking the halls, including sample Patients C1 and non-sample patients C8, C14 and C43. All of these patients were assigned to attend a group/activity from 10:00 to 10:45 a.m. RN8 asked several patients why they had not attended their assigned group, making no comment about the need or their responsibility to attend. In interview at that time, RN8 said they (staff) could not force a patient to attend groups as this was against the patients' rights. She stated that staff "could not tie going to groups to rewards. We used to be able to give ground passes to patients who attended their scheduled groups. Now patients can go to activities such as dances and unsupervised walks outside even if they do not attend their groups."

5. Observation on 12/11/12 at 10:30 a.m. on R6 with Director of QI revealed 27 of 41(66%) patients in bed or walking the hallway. All patients were assigned to be in group. Of the four groups scheduled for 10:00 a.m. only two groups were in progress, Coping Skills and Assertiveness Training. Two groups (Good Mental Health and the ADL group) were not held. The group leaders, (SW2 and LPN1 respectively) stated they did not hold these groups as "no patients came." At that time, the surveyor asked Psychologist 1 about alternative treatment when patients refuse or do not attend group. She stated, "we offer them to go to one of the other groups."

6. During interview on 12/11/12 at 10:45 a.m., when asked about patient E24's group attendance and alternative treatment when s/he refuses, Physician 2 stated, "....we can't force (patients) to participate."

7. During interview on 12/11/12, 10:45 a.m., SW2 stated "Patients don't want to do anything and staff can't do anything about it....They (patients) don't see it (participation) as being related to progress, treatment, discharge or the need to make it in the real world." She further stated the staff "feel disempowered since the policy changed from level system."

8. During interview of 12/11/12 at 11:25 a.m., SWI stated patients "often hide out in their rooms. There are no repercussions."

9. During interview on 12/11/12 at 2:20 p.m., the Risk Manager reported that the hospital used to have a "level system" for patients. This system included ground privileges. She reported that consequences for behaviors were now viewed as punishment in the hospital and that the hospital policy (based on Michigan Department Community Health Policy) prohibited all "step programs."

10. Observations on 12/11/12 from 3:00 to 3:15 p.m. on Unit R-2 revealed that five groups/activities were scheduled simultaneously from 3:00 to 3:45 p.m. 15 of 39 patients (38%) failed to attend their scheduled groups. These patients were in their rooms, sitting in the halls or walking around the unit.

11. During interview on 12/11/12 at 3:30 p.m., the PSR Coordinator stated, "Attendance is a struggle and has been more challenging since the policy change. We can't force patients to go to treatment. The lack of expectations, and patient choice, ties our hands."

12. During interview on 12/12/12 at 9:15 a.m., the CEO reported that he supported using incentives to improve patient compliance in treatment. He stated that he felt that "staff are mad since we can no longer take away patients' cards (ground privileges), and (staff) use this as an excuse (not to design incentives)."

B. Policy Review:

1. The Walter Reuther policy, SOP Number 243, "Ground Access/Freedom of Movement" with approval date of 12/10/12 [sic] and effective date of 12/14/12 [sic] states "Freedom of Movement: means the right of a patient to the least restrictive conditions necessary to achieve the purpose of treatment with due safeguards for safety of persons and property. This definition includes the right of the patient to freedom of movement on the grounds and in the building and areas within the hospital suitable for and designated for recreational or vocational activities or for social interaction. Limitation: means constraint of the freedom of movement of a patient. Step level programs are prohibited."

This policy's references include Michigan Mental Health Code MCL 330.1744 and DCH Policy 10.6.4, Freedom of Movement.

2. The State of Michigan Department of Community Health Policy, "Freedom of Movement," with effective date of May 14, 2010 states the above definitions as documented in the Walter Reuther policy. In addition, this policy lists a "Standard" on page 3 as "A limitation where the target behavior is the result of an active substantiated psychiatric diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders need not be reviewed and approved by the Behavior Treatment Committee."

3. The State of Michigan Mental Health Code 330.1744 Freedom of Movement states "The freedom of movement of a recipient shall not be restricted more than is necessary to provide mental health services to him or her, to prevent injury to him or her or to others or to prevent substantial property damage, except that security precautions appropriate to the condition and circumstances of an individual admitted by order of a criminal court or transferred as a sentence-servicing convict from a penal institution may be taken."

4. As reflected in above policies and the Michigan code, staff interpretations have been added to the Walter Reuther and Michigan Department of Mental Health Policies which prohibit "Step Level Programs." Although the state and hospital policies said staff cannot restrict patients' freedom unless required by their clinical status, it does not say that the staff could not use positive methods to motivate patients. There was no evidence that rewards and privileges were formally utilized as incentives for treatment compliance for patients who required this type of plan.

III. Failure to provide sufficient groups/activities based on patient needs:

Structured programming consisted of Psychosocial Rehabilitation (PSR) Groups on each unit conducted in two 45 minute sessions each day Monday through Friday for a twelve-week cycle. There was one week after each cycle entitled "evaluation/documentation week" that did not include any structured programming or therapeutic groups. Groups were repetitive from cycle to cycle and group design did not target individual patient needs. Only recreational/leisure activities for the general patient population were offered on evenings and weekends.

Findings include:

A. Observations

1. Patient E26 attended Health and Wellness Group, 12/10/12, 3:10 p.m. on the topic Thyroid. The patient ' s medical problems were identified as Type II Diabetes Mellitus and Inguinal Hernia. In an interview, the leader was asked how this group related to the goals for Patient E26; the leader stated "it (group) is not related to the individual. It's a knowledge thing." During interview 12/10/12, 3:55 p.m., RN7 stated "Health and Wellness covers a variety of topics and is general education."

2. Observation on 12/11/12 at 10:30 a.m. during rounds on R6 with Director of QI revealed 27 of 41(66%) patients in bed or walking the hallway. All patients were assigned to be in group. Of the four groups scheduled only two groups, were in progress, Coping Skills and Assertiveness Training. Two groups (Good Mental Health and the ADL group) were not held. The group leaders, (SW2 and LPN1 respectively) stated they did not hold these groups "no patients came." At that time, the surveyor asked Psychologist 1 about alternative treatment when patients refuse or do not attend group. She stated, "we offer them to go to one of the other groups."

B. Document Review:

Review of Unit Schedules that were provided by the PSR Coordinator revealed one evening leisure activity on each unit 7 days/weekly. The weekend activity schedule provided by the Activity Director indicated that the recreation activity center was open for all hospital patients on Tuesday through- Friday from 1- 7:30 p.m. and on Saturday 9:30 a.m.-3p.m.

C. Interviews:

1. During interview 12/10/12, 3:55 p.m., when asked about evening and weekend activities, RN7 explained these were generally games and leisure activities: "Whatever nursing puts together."

2. During interview on 12/10/12 at 4:00 p.m., sample Patient D11 stated groups "are the same over and over" and stated that s/he does not like weekends. "We don't do nothing. I sleep all day." When asked about the evening schedule, s/he stated "I take meds, eat snacks and watch TV." During interview with sample Patient D25 on 12/10/12 at 4:15 p.m., when asked about activities, the patient stated "We don't really have any. We lay around and walk the hall a lot." When asked about participating in assigned groups, s/he reported that s/he already knew the groups.

3. During interview 12/11/12 at 3:00 p.m., the AT Director reported Activity staff worked until 7:30 p.m. Tuesday - Friday and on Saturday 9:30 a.m.-3 p.m. She explained that the Activity Center was open to patients with unsupervised ground privileges and to those patients that staff escorted to the center. She further stated that there were no structured activities provided for evenings and weekends.

4. During interview on 12/11/12 at 3:30 p.m., when asked about the repetition of groups and group content, the PSR Coordinator reported "The treatment team assigns patients to the same groups and that is a problem."

5. During interview 12/10/12 at 11 a.m. non-sample Patient D21 stated, "Social Skills is video bowling and Music/Relaxation is people arguing what to listen to. We have 40 minutes a day of actual treatment."

IV: Failure to ensure that scheduled therapeutic groups were conducted and in a timely manner.

A. Observations and Interviews:

Unit R-2:

1. In observations on Unit R-2 on 12/11/12 between 10:00 to 10:45 am with the Director of Psychiatric Services and the floor RN, it was observed that of the four groups scheduled during that time slot only three were actually occurring (ADL Group, Community Re-entry, and Community Transitions Skills). The surveyor was told that there was no leader that day for the Life Skills Group and that those patients were sent to the ADL group instead. The regular leader for the Community Transitions Skills was absent and the substitute was playing a video game with the 6 patients present.

2. Observations on 12/11/12 from 2:55 to 3:15 p.m. on Unit R-2 revealed that five groups/activities were scheduled from 3:00 to 3:45 p.m.

At 3:05 p.m. a surveyor overheard 2 nursing personnel discussing who was responsible for conducting the "Personal Growth and Development" group. At 3:10 p.m., the surveyor overheard 3 of the 11 patients in the room (where the group was to be held) discussing whether anyone was going to come and lead the group. The group started about 3:15 p.m.

The "Task Skills" group was cancelled. Three of the patients scheduled to attend this group joined another group, "Cognitive Stimulation."

Unit R-4:

Observations on 12/10/12 from 2:50 to 3:45 p.m. on Unit R-4 revealed that four groups/activities were scheduled from 3:00 - 3:45 p.m.:

The "Nutrition Education" group started at 3:07 p.m.
The "Health/Wellness" group started at 3:20 p.m.
The "Leisure Skills" group started about 3:10 p.m.
The "Life Skills" group was cancelled. The PSR [Psychosocial Rehabilitation] Coordinator reported that the patients scheduled to attend that group would "go into" one of the other groups. She reported that the staff member assigned to conduct the "Life Skills" group on Monday does not work on Mondays, so this group is always cancelled.

Unit R-5

On 12/11/12, during observation on R-5, the ADL group had not started at 10:10 a.m.

On 12/11/12 at 3:10 p.m., of the four groups scheduled on Unit R5, there were three groups provided: Personal Growth and Development Group, Social Skills Group, and Music Group. Surveyor was told there would be a substitute leader (an LPN was filling in for an RN) for Personal Growth and Development Group. The Group had not yet started at 3:10. The Social Skills/Life Skills groups on Unit R-5 scheduled for 3:00 p.m. were combined and facilitated by a substitute leader. The group was playing a video game.

Unit R-6

Observation on 12/11/12 at 10:30 a.m. on R6 with Director of QI revealed 27 of 41(66%) patients in bed or walking the hallway. All patients were assigned to be in group. Of the four groups scheduled only two groups, were in progress, Coping Skills and Assertiveness Training. Two groups (Good Mental Health and the ADL group) were not held. The group leaders, (SW2 and LPN1 respectively) stated they did not hold these groups "no patients came."

Surveyor attended "Health and Wellness Group" on 12/10/12 scheduled for 3:00 p.m. on R-6. There were patients present in the Day room waiting for group. At 3:07 p.m. the leader began instructing staff to gather group members and the group started at 3:10 p.m. with five patients present.

Based on interview and document review, the facility failed to assure that the Medical Director and the Director of Nursing (DON) monitored active treatment and took needed corrective actions. Specifically,

I. The Medical Director failed to provide adequate medical leadership. The Medical Director failed to:

A. Ensure that individualized psychiatric care was provided for 3 of 12 active sample patients (C1, D25 and E24), and 3 of 3 non-sample patients (C8, C14 and C43) who were added to the sample for review of active treatment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B144)

B. Ensure that staff developed methods to reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment. There were no clear expectations given to patients about their treatment compliance. Few staff prompts were given to patients to support group/activity attendance, instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimen. This failure results in lack of active treatment opportunities for patients. (Refer to B144)

C. Assure that staff provided sufficient treatment groups/activities to realistically enable patients to improve. Structured programming for each patient consisted of Psychosocial Rehabilitation (PSR) Groups on each unit conducted in two 45 minute sessions each day Monday through Friday for a twelve-week cycle. There was one week after each cycle entitled "evaluation/documentation week" that did not include any structured programming or therapeutic groups for patients. Groups were repetitive cycle to cycle and group design did not target individual patient needs. In addition, only general recreational/leisure activities were offered on evenings and weekends. This failure results in lack of active treatment for all patients in the hospital. (Refer to B144)

D. Ensure that scheduled groups/activities were regularly conducted and in a timely manner. During the survey, on 4 of the 5 Units (R-2, R-4, R-5 and R-6), scheduled groups/activities were often late starting and some groups were canceled. When groups were canceled, patients scheduled for those groups were moved into another group based on group availability, rather than individualized patient need. This failure results in lack of active treatment for these patients. (Refer to B144)

II. The Director of Nursing failed to:

A. Develop treatment plans that included specific nursing interventions based on the each patient's individual problems and goals for 6 of 12 active sample patients (A30, B19, B25, C1, C21 and E24). This failure results in lack of guidance to nursing staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B148)

B. Ensure that staff developed methods to reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment. There were no clear expectations given to patients about their treatment compliance. Few staff prompts were given to patients to support group/activity attendance, instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimen. This failure results in lack of active treatment opportunities for patients. (Refer to B148)

Based on record review and interview the Director of Clinical Services (MD-Clinical Director) failed to adequately assure quality and appropriateness of services provided by the medical and clinical staffs. Specifically, the Clinical Director failed to:

I. Ensure that individualized psychiatric care was provided for 3 of 12 active sample patients (C1, D25 and E24), and 3 of 3 non-sample patients (C8, C14 and C43) who were added to the sample for review of active treatment. These patients were hospitalized without the provision of alternative treatment modalities for their special needs to move them to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B125, Part I)

II. Ensure that staff developed methods to reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment. There were no clear expectations given to patients about their treatment compliance. Few staff prompts were given to patients to support group/activity attendance, instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimen. This failure results in lack of active treatment opportunities for patients. (Refer to B125, Part II)

III. Assure staff provided sufficient treatment groups/activities to realistically enable patients to improve. Structured programming consisted of Psychosocial Rehabilitation (PSR) Groups on each unit conducted in two 45 minute sessions each day Monday through Friday for a twelve-week cycle. There was one week after each cycle entitled "evaluation/documentation week" that did not include any structured programming or therapeutic groups. Groups were repetitive from cycle to cycle and group design did not target individual patient needs. Only recreational/leisure activities of a general nature were offered on evenings and weekends. This failure results in lack of sufficient active treatment for all patients in the hospital. (Refer to B125, Part III)

IV. Ensure that scheduled groups/activities were regularly conducted and in a timely manner. During the survey, on 4 of the 5 Units (R-2, R-4, R-5 and R-6), scheduled groups/activities were often late starting and some groups were canceled. When groups were canceled, patients scheduled for those groups were moved into another group based on group availability, rather than individualized patient need. This failure results in lack of active treatment for these patients.
(Refer to B125, Part IV)

Based on observation, interview and document review, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Develop treatment plans that included specific nursing interventions based on the each patient's individual problems and goals for 6 of 12 active sample patients (A30, B19, B25, C1, C21 and E24). Instead, the MTPs included routine nursing functions failed to address behaviors presented by the patients (aggression, irrational behavior, etc.) This failure results in lack of guidance to nursing staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B122)

II. Ensure that staff developed methods to reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment. There were no clear expectations given to patients about their treatment compliance. Few staff prompts were given to patients to support group/activity attendance; instead patients were allowed to remain in bed, walk the halls and chat with each other, rather than participate in their treatment regimen. Staff stated that they had no methods to use to engage patients in their treatment regimens. This failure results in lack of active treatment opportunities for patients. (Refer to B125, Part II)