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Based on interview and record review, the facility failed to complete training noted in the Plan of Correction placing all 198 current patients at increased risk of harm resulting from staff failure to follow patient care policies and procedures. Findings include:

Record Review:

On 4/11/2013 at approximately 2:30 pm the Acting Director of Nursing provided documentation of the following training:
1. Standard Operating Procedure (SOP) #249, "Patient Property and Searches," 138 of 222 (required)nursing staff had been trained.
2. SOP #261, "Individual Plan of Service," 178 of 222 (required) nursing staff had been trained.
Interview:

On 4/11/2013 at approximately 2:30 pm the Acting Director of Nursing (ADON) stated that the above training was incomplete. The ADON stated that the facility would take immediate action to complete all training.








30988

Based on document review, and interview it was revealed that the facility failed to complete the required staff training to reduce the risk of harm for all 198 of the patients served by the facility

Findings include:
On 4/10/2013 at approximately 10:00 am during the tour of the second floor unit, Staff #F the charge nurse was interviewed in the absence of the floor manager. Staff #F produced the copies of the updated policies and procedures that have been recently inserviced with the attached signature sheets. Including:
1. Blood Sugar Monitoring- no date
2. Incident Reporting -3/23/13
3. Feeding tube care-3/23/13
4. Personal Alarms-3-23-13
5. Employee Injury-3/23/13
6. Norovirius- 3/23/13
7. Abuse and neglect reporting-3/23/13
8. Abuse and neglect monitoring-3/23/13
9. Tube feeding Documentation-3/28/13
10. Lab Request Culture-3/28/13
11. Patient Handoff-4/3/13
12. Meal Guidelines-4/4/13

Staff #F stated " the employee signature means the staff has read the policy and procedure and understands the information. They are held accountable for the information." No post tests were available for review and no list for remedial training that is needed.

Interview of staff I at 2:30 PM "there is no master list for inservices, post tests, or remedial training."







30524

Based on record review and interview, the facility failed to complete training on SOP #261, "Individual Plan of Service" and to review patient elopements and identify individual interventions and processes to reduce elopements resulting in increased risk of harm for all patients. Findings include:

Record Review:

1. On 4/11/2013 at approximately 2:30 pm the Acting Director of Nursing provided documentation of the following training for this Standard, with a completion date of 3/25/13:
-- SOP #261, "Individual Plan of Service," only 178 of 222 nursing staff had documentation of training.
2. On 4/11/13 at approximately 3 pm the QA/UR (Quality Assurance/Utilization) Coordinator verified the following from the "Unauthorized Leave of Absence (2013)" Log, Safety Department Reports and Incident Reports:
a. On 1/18/13, patient #15 was observed eloping by punching out an entrance door on Unit 6. The only actions taken by the facility, noted on the 1/18/13 Incident Report, involved notifications.
b. On 1/18/13 patient #14 eloped while signed-out (from Unit 6) for off-ward dining. According to the Incident Report, dated 1/18/13, "Received call from safety to do a head count. This patient was signed out for OWD (Off Ward Dining) and was not in sunset room for OWD." The report states that the patient's status became ULA (Unauthorized Leave of Absence). The only actions taken by the facility, noted on the 1/18/13 Incident Report, involved notifications. There was no documentation that the facility analyzed how the patient eloped without being seen or any follow-up actions to address findings. c. On 2/6/13 a Safety Department Report states that patient #15 eloped during a transfer to Annapolis hospital. The patient had not been discharged from Walter Reuther Psychiatric Hospital (WRPH) but was not being supervised by WRPH staff during hospitalization. No follow-up actions by the facility were documented, except notifications.
d. On 3/17/13 a Safety Department Report states that patient #16 eloped from staff while at Annapolis Hospital for evaluation. Follow-up actions included only notifications only.
e. On 3/28/13 a Safety Department Report states that patient #17 kicked open the emergency exit door on Unit 4 and eloped down a stairway and out of the hospital. Follow-up actions included only staff and police notification.
f. Individual Treatment Plans for two current patients in the above list (#14 and #17) did not have updates to their treatment plans as a result of the elopements.

Interview:

1. On 4/11/13 at approximately 2:30 pm the Acting Director of Nursing (ADON) verified that only 178 of 222 nursing staff had documentation of completing training in SOP #261. The ADON stated that the facility would take immediate action to complete all training.
2. On 4/11/13 at approximately 1:55 pm Safety Officer O verified that the above events were listed on the Safety Department's 2013 "Unauthorized Leave of Absence" Log.
3. On 4/11/13 at approximately 3 pm the Quality Assurance/Utilization Review (QA/UR) Coordinator was asked whether any facility Safely or Quality committees had reviewed the (above) unauthorized leaves or discussed process improvements to reduce unauthorized leaves. The QA/UR Coordinator stated that the Safety Committee had met since some of the above incidents but that none of these incidents had been reviewed for quality assurance purposes.
4. On 4/11/13 at approximately 3 pm the QA/UR Coordinator provided a "Comparative Statistics Report" indicating that the facility's rate of patient elopements had increased since 12/2012 and was above both national and state rates.




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30988

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

I. Based on record review and interview, the facility failed to revise the treatment plans to include a treatment regime based on the current treatment needs for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of continued 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 B118)

II. Develop master treatment plans (MTPs) that included specific staff interventions based on the individual needs of the patient. There was an absence of interventions by discipline; interventions were statements of goals; or interventions were descriptions of routine staff role functions for 8 of 8 active sample patients (B20, C2, C8, C15, D24, D32, E13, and E19). This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B122)

III. Ensure that individualized psychiatric care was provided for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of these observed 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)

Based on record review and interview, the facility failed to revise the treatment plans to include a treatment regime based on the current treatment needs for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of continued 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.

Findings include:

A . Non-sample Patient B6 was admitted on 4/15/10 with a diagnosis of Schizophrenia Chronic, Undifferentiated Type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 1/13/13 with review date of 4/1/13, it stated "still refuses the medication at times...taking Lorazepam 2 mg at 8:00 AM, 1:00 p.m. and 9:00 p.m. for agitation...Prolixin 10 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for delusional thinking and Valproic acid 2000mg orally at bedtime for mood swings and aggression and 500 mg in the morning for aggression." The summary reported that s/he had been a victim of assault on 11/28/12 while in the hospital.

2. Based on the programming schedule (PSR) Patient B6 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient B6 had only attended one of his/her scheduled groups from 3/27/13 through 4/9/13. The participation note for this Medication Management group documented that Patient B6 was sleeping.

3. Interviews:

a. During interview with RN C1, RN C9 and SW C7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient B6 had been "decompensating." She stated that this patient would not get off the ward except to go to meals. RNC9 stated that the patient was "too sick to go to most groups."

b. During interview on 4/10/13 at 3:10 p.m., Health Care Technician (HCT) B14 reported that Patient B6 was "waiting to go home" and refused to attend groups.

4. Review of Patient B6's master treatment plan revision (1/9/13) with reviews (1/11/13, 2/1/13, 2/6/13, 4/1/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant in all areas of treatment. Patient B6's treatment team failed to develop a treatment regime based on his/her current behaviors.

B. Non-sample Patient B22 was admitted on 3/8/13 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 4/2/13, Patient B22 "continues to threaten the staff...continues to have persecutory delusions and thinks that people are out to harm [him/her]...[S/he] also has flashbacks of [his/her] childhood trauma where [s/he] was sexually abused as a child...[S/he] also has a history of alcohol use, marijuana and crack cocaine abuse."

2. Based on the programming schedule (PSR) Patient B22 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance notes provided by the staff on 4/10/13, Patient B22 had refused to attend all scheduled groups since admission. The only treatment other than on-going assessment by the psychiatrist was a 10-15 minute weekly session with the social worker.

3. Interviews:

a. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B22 refused to attend all groups and "stays in bed except to eat."

b. During interview on 4/10/13 at 4:00 p.m., RN B13 stated that Patient B22 refused to attend all treatment, stating "[S/he] only wants out of the hospital."

4. Review of Patient B22's master treatment plan (4/2/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with the current plan. Patient B22's treatment team failed to develop a treatment regime based on his/her current behaviors.

C. Sample Patient C2 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 2/20/13 with review of 3/2/13, it stated "The intensity and frequency of the auditory or visual hallucinations have not changed since the decrease of the dose of Risperdal... [s/he] does not want to try a different medication..."

2. Review of Patient C2's group progress notes revealed that from 3/27/13 through 4/9/13 this patient refused to attend 19 of 19 (100%) scheduled groups (Anger Management, Task Skills and Medication Management). A psychiatrist progress note (3/26/13) documented, "[S/he] does not participate in therapeutic groups activities." A recreation therapy note (4/2/13) stated "...no programming attended this review [sic]." Based on a review of the record, the only documented treatment for this patient was reflected in a monthly social work progress note (3/12/13) that stated, "Supportive therapy on Monday 10-15 minutes at 2:15 pm with social worker."

3. Interviews:

During interview with Physician C12, RN C1 and SW (Social Worker) C9 on 4/10/13 at 11:35 a.m., Physician C12 reported that Patient C2 continued to refuse all treatment groups. He stated agreement that the treatment plan had not been changed and that even though a psychologist had worked with the patient in the past, there had been no recent psychological assessment of this patient about his/her continued refusal to engage in treatment other than medications. SW C9 stated, "We need to do something different with this patient."

4. Review of Patient C2's master treatment plan revision (2/20/13) with review (3/2/13) revealed no change in treatment schedule (groups and 1:1) as of 4/10/13, even though s/he was non-compliant in all areas of treatment other than medications. Patient C2's treatment team failed to develop a treatment regime based on his/her current behaviors.

D. Non-sample Patient C37 was admitted on 9/9/08 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of Patient B37's master treatment plan, revision dated 3/15/13, Pt. B37 was "less angry and hostile but continues to be so. It is agreed that this patient is still hallucinating most of the day...delusionses [sic] persist. [His/her] demeanor and attitude denote a severe paranoid feeling..."

2. Based on the programming schedule (PSR) Patient C37 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient C37 had only attended 2 of his/her scheduled groups for a brief period of time from 3/27/13 through 4/9/13.

3. Interviews:

During interview with RNC1, RN C9 and SWC7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient C37 "is decompensating. [S/he] won't get off ward except to go to meals." She added, "This patient is too sick to go to most groups. [S/he] is very psychotic."

4. Review of Patient C37's master treatment plan revision (3/15/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with current treatment. Patient C37's treatment plan failed to develop a treatment regime based on his/her current behaviors.

E. Sample Patient D24 was admitted on 8/2/11 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

1. As documented in the summary and treatment section of the master treatment plan with most recent review date of 1/8/13, the patient, "who had been on NGRI (Not Guilty by Reason of Insanity) status, returned from ALS (Authorized Leave Status) contract for violation of smoking rules in the group home...During this review period [s/he] continues to be involved in smoking."

2. Group Progress notes for patient D24 in assigned Anger Management, Substance Abuse, and Group Psychotherapy modalities were reviewed. Progress notes for the assigned twice per week ADL Group were not provided. The notes provided showed attendance at 5 of 13 (38%) of assigned groups. The monthly psychiatric medication review note, monthly psychiatric progress note of 4/9/13 documented: "[S/he] continues having poor insight and poor motivation, as evidenced by needing several prompts to do [his/her] ADLs, taking medications, attending groups." The psychologist's group progress notes of 3/28/13, 4/4/13 and 4/9/13 all documented: "did not come when called." Social work group progress notes for 3/27/13, 3/29/13 and 4/1/13 documented: "Did not attend." The note from 4/3/13 documented: "did not attend-encouraged."

3. During an interview with the psychologist group leader on 4/9/13 he stated that the patient was, ironically, an active participant when s/he came to group but that there were no available options to motivate this patient to attend if s/he didn't want to attend.

4. Review of Patient D24's master treatment plan with most recent review 1/8/13, revealed no change in treatment schedule (groups and 1:1) as of 4/9/13, even though s/he was frequently non-compliant with group attendance. Patient D34's treatment team failed to develop a treatment regimen based on his/her current behaviors.

Based on record review and interview, the treatment plans included deficient goal statements for 7 of 8 active sample patients (B20, C8, C15, D24, D32, E13 and E19). Goals were stated in non-measurable terms that did not identify or delineate specific outcome behaviors for patients. In addition, some statements listed as goals for the patient to achieve were actually interventions staff would make. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient B20-Master Treatment Plan most current revision date of 2/13/13:

a. Problem #P1: "Psychosis as evidenced by responding to internal stimuli, delusional thinking, paranoid delusions and thinking that people are out to harm him and grandiose delusions..."

A short term goal was listed in non-measurable terms as "Patient will improve to the extent that [s/he] can function in the community in the supervised setting in the community without dangerousness. In next (sic) three months patient has (sic) decreased incidents of delusional thinking, grandiose delusions and responding to internal stimuli..."

a. Problem #P2: "Mood swing (sic) as evidenced by irritable mood, agitation, verbal aggression, physical aggression, pressured speech, screaming behavior, loud speech, argumentative behaviors, threatening behaviors."

A short term goal was listed in non-measurable terms as "...should have decreased incidents of physical aggression and decreased incidents of argumentative, hostile and verbal aggression." "Patient's mood will stabilize such that [s/he] maintains a normal level of activity, reasonably social, outgoing..."

b. Problem #PS1: "Poor social interaction skills as evidenced by being paranoid and suspicious, easily agitated/irritable, responding to internal stimuli, argumentative and delusional."

A short term goal was listed in non-measurable terms as "By 5/12/2013, patient will participate in AT/PSR group discussions in a relevant manner 25% of the sessions."

2. Patient C8-Master Treatment Plan dated 3/18/13 (no recent plan revision):

a. Problem #P1: "Chronic psychotic symptoms with disorganized thought, poor, insight, paranoid delusions, and poor compliance with medications. It also appears that family support is not that good..."

Statements on the plan were actually staff interventions, rather than short term goals that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued on medications...[S/he] will be seen by me regularly, twice a week to see how [his/her] symptoms are improving." "The patient will be assigned to groups and will ask [him/her] to attend the groups at least two groups (sic)."

b. Problem #P2: "Substance Abuse Problem: [S/he] has been drinking alcohol almost every day. [S/he] says [his/her] preferred drink has been Grey Goose and smoking marijuana a regular basis along with his family members."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued to be educated about the importance of staying off from the drugs because it has a negative impact on [his/her] mental illness as well as [his/her] medications."

3. Patient C15-Initial Master Treatment Plan (1/10/13) with review (3/9/13). No treatment plan revision):

Problem #P1: "The patient with a long history of psychotic symptoms especially disorganized thinking and loose associations, tangential and disorganized at times. [His/her] speech has been incoherent, and paranoid delusions were present. [S/he] has been consistently getting angry and demanding things. [S/her] has been unable to live in a less restrictive environment and has poor judgment and impulse control problem."

A short term goal was stated in non-measureable terms as "In four weeks, the patient will have relevant conversation during therapy session twice a seek, and will start understanding [his/her] auditory hallucinations and delusions, showing some insight into them."

4. Patient D24-Master Treatment Plan dated 1/8/13:

a. Problem #P1: "The patient returned from NGRI status/ALS status for smoking in the group home and showing poor impulse control in [his/her] smoking behavior."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient should attend three PSR groups, 45 minutes each, five days a week, able to discuss (sic) [his/her] problems with smoking and suggest the methods how to quit smoking to get out of this hospital, by April 08, 2013."

b. Problem #P2: "Illogical thinking disorganized thought process about smoking and about the dangerousness in the group home."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will attend at least three PSR groups, 45 minutes each, twice a day, five days a week, and able to show progress with good reality testing about [his/her] smoking problems and suggest ways to get rid of [his/her] smoking problem and how [s/he] remains smoking free when in the hospital and also after discharge into the community, by April 8, 2013 (sic)."

c. Problem #PS1: "Poor impulse control, as evidenced by poor judgment and smoking in unauthorized areas, also mood swings at times displaying slight agitation when redirected."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "By April 8, 2013, the patient will attend at least two groups each for 20 minutes."

5. Patient D32-Master Treatment Plan dated 2/8/13:

Problem #P3: "Lack of insight and judgement (sic) into her mental illness, need for continuing to take the medications, and substance abuse problems and the need to keep her out from the hospitals with ALS contract."

A short term goal was stated in non-measurable terms: "[S/he] will discuss the affects (sic) and side effects of the medications, the untoward effects of substance abuse and able (sic) to discuss the need to continue taking the medications, affects (sic) and side effects of the medications while in the hospital and also after discharge into the community by 05/08/2013."

6. Patient E13-Master Treatment Plan dated 3/27/13:

Problem #P1: "Aggressive behavior related to paranoid thinking and neglecting [his/her] basic care needs, including disheveled hair, long beard, unkept (sic) and interfered with [his/her] eating and [his/her] hygiene. [S/he] was also prompted to shower and put on clean clothing."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

7. Patient E19-Master Treatment Plan dated 4/3/2013:

a. Problem #P1: "Psychosis and also delusional behaviors..."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

b. Problem #P3: "Aggressive behavior..."

Short term goals were stated in non-measurable terms: "1) Comply with the medication evaluation to identify if medications will help abort the angry/assaultive outbursts. 2) Take medications as prescribed. 3) Attend all the recommended PSR groups and also discuss with the therapist about lack of aggressive behavior control and to learn about healthy alternative coping skills. 4) Learn to express feelings in a nonviolent manner."

c. Problem #PS1: "Impaired social skills..."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the stated problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will improve socialization and attend at least one group per week as able with 1-2 prompts."

B. Interviews

a. An interview with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m. with the Chief of Medical Affairs, the Director of Nursing and the Director of Social Work. They agreed that many of the goals on the treatment plans were not measurable.

b. In an interview with the Chief of Medical Affairs on 4/11/13 at 9:00 a.m., he acknowledged that the short term goals for Patient D24 were confusing and written as interventions. In addition he acknowledged that correcting dictation errors was an ongoing problem which may contribute to the lack of clarity in Master Treatment Plan language.

Based on record review and interview the facility failed to develop master treatment plans (MTPs) that included specific staff interventions based on the individual needs of the patient. There was an absence of interventions by discipline; interventions were statements of goals; or interventions were descriptions of routine staff role functions for 8 of 8 active sample patients (B20, C2, C8, C15, D24, D32, E13, and E19). This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals.

Findings include:

A. Record Review

1. Patient B20-Master Treatment Plan with latest revision date of 2/13/13:

a. Problem #P2: "Mood swing (sic) as evidenced by irritable mood, agitation, verbal aggression, physical aggression, pressured speech, screaming behavior, loud speech, argumentative behaviors, threatening behaviors."

Nursing failed to list specific interventions to respond to and/or prevent verbal and physical aggression, screaming and argumentative behavior presented by Patient B20 in the clinical area.

b. Problem #PS1: "Poor social interaction skills as evidenced by being paranoid and suspicious, easily agitated/irritable, responding to internal stimuli, argumentative and delusional."

The Activity Therapy interventions failed to specify focus for assigned groups. These were stated as "Will see patient in Basic Academic Skills...Will see patient in Stress Management."

2. Patient C2-Master Treatment Plan revision dated 2/20/13 with review of 3/2/13:

Problem #P1: "NGRI. Due to his chronic suspiciousness and paranoid delusions, [s/he] would become frustrated easily when we talk about [his/her] discharge and probably [s/he] became institutionalized and not very willing to leave the institution and get very angry when disused (sic) about discharge plan with some threatening to the team members to sue them and then [s/he] will not follow with the discharge planning for dependent placements."

The only physician intervention was stated as "Will see [him/her] on a regular basis and will talk to [him/her] about discharge plans on a regular basis."

Even though this patient's suspicious, paranoid and anger was identified in the problem statement, the treatment plan failed to identify nursing interventions to address these behaviors in the clinical area.

During interview with review of treatment plan on 4/10/13 at 11:35 a.m., Physician C12, RN C1 and SW C9 stated agreement with above findings.

3. Patient C8-Master Treatment Plan dated 3/18/13 (no later revision):

Problem #P2: "Substance Abuse Problem: [S/he] has been drinking alcohol almost every day. [S/he] says [his/her] preferred drink has been Grey Goose and smoking marijuana on a regular basis along with [his/her] family members."

Social Work: Patient goals were stated as social work interventions, "Patient will identify two to three significant things that can happen while using mood altering substance to [his/her] physical health. The patient will address how drugs will impact his compliance with medication treatment in the community. The patient will verbalize two to three reasons why [s/he] need (sic) to not use mood altering substance and impact on [his/her] medications...The patient will learn how drug and alcohol affect [his/her] mental health, [his/her] physician health, and result in frequent hospitalizations when [s/he] is unable to remain in the community. The patient will also give understanding how it impact (sic) [his/her] mental health and [his/her] medications as well." These are statements of patient goals, rather than interventions that social work staff will undertake with the patient to help the patient achieve the goals.

4. Patient C15-Initial Master Treatment Plan (1/10/13) with review (3/9/13). No later treatment plan revision:

a. Problem #P1: "The patient with a long history of psychotic symptoms especially disorganized thinking and loose associations, tangential and disorganized at times. [His/her] speech has been incoherent, and paranoid delusions were present. [S/he] has been consistently getting angry and demanding things. [S/her] has been unable to live in a less restrictive environment and has poor judgment and impulse control problem."

Social Work: Patient goals were stated as social work interventions, "The patient will identify and verbalize 2-3 symptoms of [his/her] illness that [s/he] is able to recognize. The patient will be able to carry on a goal directed conversation and [s/he] will be able to verbalize [his/her] concerns and issues in a calm and appropriate manner. The patient will be able to maintain reality orientation and have a decrease in psychotic thinking and behaviors. The patient will understand and recognize and exhibit and show improvement in [his/her] insight and judgment regarding [his/her] mental illness." These are statements of patient goals, rather than interventions that social work staff will undertake with the patient to help the patient achieve the goals.

Nursing interventions were stated in generalized terms that were non-specific to the individual patient: "The patient will be educated on his medication including dosage and side effects. The patient will be encouraged to verbalize any needs and concerns and side effects to the staff...the patient will be encouraged to attend (his/her) PSR (Psychosocial) groups and participate."

Activity Therapy intervention failed to include the type and topic focus of specific group assignment. It was stated as, "The patient will be included in at least one PSR group per day. Focus will be to get him to attend, participate to the best of his ability with no behavior disruptions noted."

b. Problem #PS1: "The patient as a significant history of treatment resistance and might partially (sic) due to noncompliance as part of his lack of insight."

Physician intervention was a general role function, "[Doctor] will monitor [his/her] medications and see for any side effects."

Social Work: Patient goals were stated as social work interventions, "The patient will be able to verbalize understanding of his mental illness and the need for continued treatment while here in the hospital and once [s/he] returns to the community. The patient will verbalize the need for continued treatment...the patient will verbalize two or three reasons why it is important to remain compliant with medication and treatment...The patient will verbalize 2-3 symptoms that occur without medication use and that impact his [his/her] physical health as well. The patient will verbalize any concerns or issues that [s/he] has while here at the hospital..." These are statements of patient goals, rather than interventions that social work staff will undertake with the patient to help the patient achieve the goals.

5. Patient D24-Master Treatment Plan dated 1/8/13 (no recent plan revision):

a. Problem #P1: "The patient returned from NGRI status/ALS status for smoking in the group home and showing poor impulse control in [his/her] smoking behavior."

Despite the need for nursing supervision around the patient's smoking behavior, no nursing interventions were identified.

b. Problem #P2: "Illogical thinking disorganized thought process about smoking and about the dangerousness in the group home."

Despite identifying a cause of the patient's smoking as psychosis, no physician interventions were identified.

6. Patient D32-Master Treatment Plan dated 2/8/13 (no recent plan revision):

a. Problem #P2: "Auditory hallucinations, delusional thinking, mood swings and impulsive behaviors."

Despite identifying a psychiatric problem of psychosis requiring medication intervention, the physician intervention failed to include medication intervention in the intervention planned: "Psychiatric Intervention: Patient will be seen on one-to-one basis for about ten minutes once a week, three times a month or as when needed. Patient will be tested for reality orientation. [S/he] will be encouraged to talk about the precipitating factors that are making [him/her] to have agitated with impulsive behaviors (sic). [S/he] will continue taking the medications at this time and also after discharged (sic) to the community."

7. Patient E13-Master Treatment Plan dated 3/27/13:

a. Problem #P1: "Aggressive behavior related to paranoid thinking and neglecting his basic care needs, including disheveled hair, long beard, unkept (sic) and interfered with his eating and his hygiene. He was also prompted to shower and put on clean clothing."

No Activity Therapy interventions were listed.

b. Problem #3: "Chemical Dependency; As evidenced by consistent use of mood altering substances, exacerbates primary or secondary psychotic symptoms as a result of the use of (sic) withdrawal from mood altering illicit substances. Denies that chemical dependency is a problem, the substance use is effecting (sic) functioning of relationships. Use of substances despite medical warnings, interactions of psychotropic medications and illicit substances."

Physician intervention was a general role function: "Psychiatric Intervention: The psychiatrist will see the patient once a week and as needed. Patient will be monitored for the complaints for the prescribed medications, monitored for the side effects of the medications; Reinforce compliance to learn the coping skills and increase the client (sic) to learn about the recovery process."

8. Patient E19-Master Treatment Plan dated 4/3/13:

Problem #P2: "Medication Noncompliance. 1) In consistently (sic) taking psychotropic medications as prescribed; 2) Lack of knowledge of medications, usefulness and potential side effects."

Nursing interventions were stated in generalized terms that were non-specific to the individual patient: "Nursing Intervention: Patient will be educated about [his/her] medication doses, side effects and the importance of [his/her] remaining compliant while in the hospital and during discharge. Patient will be encouraged to attend all scheduled PSR activities. The patient is encouraged to verbalize any concerns about [his/her] medication or treatment to staff. Patient is also encouraged to utilize [his/her] coping skills and verbalize any concerns in a calm and positive manner."

B. An interview with three clinical staff with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m. The Chief of Medical Affairs related that the physician intervention for Patient C15 was a role function rather than a specific intervention for this patient. The Director of Nursing stated, "We need to learn to think 'out of the box' for patients (referring to Patient C2)." The Director of Social Work related that patient goals should not have been listed as staff interventions.





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Based on observation, interview and document review, the facility failed to ensure that individualized psychiatric care was provided for 2 of 8 active sample patients (C2 and
D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of staff observation of and documentation of these 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.

Findings include:

A . Non-sample Patient B6 was admitted on 4/15/10 with a diagnosis of Schizophrenia Chronic, Undifferentiated Type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 1/13/13 with review date of 4/1/13, it stated "still refuses the medication at times...taking Lorazepam 2 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for agitation...Prolixin 10 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for delusional thinking and Valproic acid 2000mg orally at bedtime for mood swings and aggression and 500 mg in the morning for aggression." The summary reported that [s/he] had been a victim of assault on 11/28/12 while in the hospital.

2. Based on the programming schedule (PSR) Patient B6 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient B6 had only attended one of [his/her] scheduled groups from 3/27/13 through 4/9/13. The participation note for this Medication Management group documented that Patient B6 was sleeping.

3. Observations on Unit R3 revealed Patient B6 to be in bed asleep during his/her assigned groups on 4/9/13 at 11:00 a.m. and 3:40 p.m. During these times this patient was scheduled to attend Exploring [Gender] Issues and Personal Growth and Development groups. Observations on Unit R3 on 4/10/13 at 10:45 a.m. and 3:10 p.m. revealed Patient B6 to be asleep in bed. At these times, [s/he] was scheduled to attend Medication Management and Cognitive Stimulation groups. When interviewed about [his/her] failure to attend treatment groups, the patient responded, "I don't feel well."

4. Progress Notes:

a. A physician note (3/28/13) stated "As pt [patient] is increasingly delusional will increase the dose of Saphris (an atypical antipsychotic)."

b. An RN progress note (4/6/13) stated "Pt [Patient] refusing meds. [medications]."

c. An RN progress note (4/9/13) documented "Patient was prompt (sic) to attend PSR (Psychosocial group). Patient staff (sic) that [s/he] don't go to PSR because [s/he] don't have head (sic)."

d. A physician progress note (4/9/13) stated "[S/he] is refusing all oral medications off and on. Will order Ativan 1 mg IM (intramuscular) tid (three times daily) for refusal of Ativan oral dose and Prolixin 5 mg IM for refusal of oral dose of prolixin."

5. Interviews:

a. During interview on 4/9/13 at 11:10 a.m. 3:40 p.m., HCT B5 (Health Care Technician B5) reported that Patient B6 does not go to [his/her] assigned groups, staying in bed most of the time.

b. During interview with RN C1, RN C9 and SW C7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient B6 has been "decompensating." She stated that this patient will not get off the ward except to go to meals. RNC9 stated that the patient is "too sick to go to most groups."

c. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B6 is "waiting to go home" and refuses to attend groups.

6. Review of Patient B6's master treatment plan revision (1/9/13) with reviews (1/11/13, 2/1/13, 2/6/13, 4/1/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he is acutely psychotic and non-compliant in all areas of treatment. Patient B6's treatment team failed to develop a treatment regime based on his/her current behaviors.

B. Non-sample Patient B22 was admitted on 3/8/13 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 4/2/13, Patient B22 "continues to threaten the staff ...continues to have persecutory delusions and thinks that people are out to harm [him/her]...[S/he] also has flashbacks of [his/her] childhood trauma where [s/he] was sexually abused as a child...[S/he] also has a history of alcohol use, marijuana and crack cocaine abuse."

2. Based on the programming schedule (PSR) Patient B22 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance notes provided by the staff on 4/10/13, Patient B22 had refused to attend all scheduled groups since admission. The only treatment other than on-going assessment by the psychiatrist was a 10-15 minute weekly session with the social worker.

3. Observations on Unit R3 revealed Patient B22 to be in bed asleep during his/her assigned groups on 4/9/13 at 11:00 a.m. and 3:40 p.m. During these times this patient was scheduled to attend Dual Diagnosis and Social Skills groups. Observations on Unit R3 on 4/10/13 at 10:45 a.m. and 3:10 p.m. revealed Patient B22 to be asleep in bed. At these times, [s/he] was scheduled to attend Medication Management and Health and Wellness groups. When interviewed about [his/her] failure to attend treatment groups, the patient responded, "I don't feel well."

4. Progress Notes:

a. A physician note (4/4/13) stated, "...does not attend the group therapy."

b. An RN progress note (4/5/13) stated, "Pt [Patient] remains delusional, pt [patient] does not attend group."

5. Interviews:

a. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B22 refused to attend all groups and "stays in bed except to eat."

b. During interview on 4/10/13 at 4:00 p.m., RN B13 stated that Patient B22 refuses to attend all treatment stating "[S/he] only wants out of the hospital."

6. Review of Patient B22's master treatment plan (4/2/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with the current plan. Patient B22's treatment team failed to develop a treatment regime based on his/her current behaviors.

C. Sample Patient C2 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan dated 2/20/13 with review of 3/2/13, it stated "The intensity and frequency of the auditory or visual hallucinations have not changed since the decrease of the dose of Risperdal...[s/he] does not want to try a different medication..."

2. Review of Patient C2's group progress notes revealed that from 3/27/13 through 4/9/13 this patient refused to attend 19 of 19 (100 %) scheduled groups (Anger Management, Task Skills and Medication Management). A psychiatrist progress note (3/26/13) documented, "[S/he] does not participate in therapeutic groups activities." A recreation therapy note (4/2/13) stated "...no programming attended this review [sic]." Based on a review of the record, the only documented treatment for this patient was reflected in a monthly social work progress note (3/12/13) that stated, "Supportive therapy on Monday 10-15 minutes at 2:15 pm with social worker."

3. Observations on Unit R4 revealed Patient C2 to be in bed asleep on 4/9/13 at 10:45 a.m. and 3: 20 p.m. During these times this patient was scheduled to attend Anger Management and Tasks Skills groups. When the patient was asked why s/he was in bed during group time, Patient C2 responded, "I don't have the energy. I've been to all those groups. I know more than they know." Observations on Unit R4 on 4/10/13 at 10:35 a.m. revealed Patient C2 to be lying in bed. At this time, s/he was scheduled to attend Medication Management group.

4. Interviews:

a. During interview on 4/9/13 at 11:00 a.m. Dietitian D17 reported that Patient C2 walks in the ward hallways and attends off-ward dining but continued to refuse group activities.

b. During interview with Physician C12, RN C1 and SW C9 on 4/10/13 at 11:35 a.m., Physician C12 reported that Patient C2 continued to refuse all treatment groups. He stated agreement that the treatment plan had not been changed and that even though a psychologist had worked with the patient in the past, there had been no recent psychological assessment of this patient about his/her continued refusal to engage in treatment other than medications. SW C9 stated, "We need to do something different with this patient."

5. Review of Patient C2's master treatment plan revision (2/20/13) with review (3/2/13) revealed no change in treatment schedule (groups and 1:1) as of 4/10/13, even though s/he was non-compliant in all areas of treatment other than medications. Patient C2's treatment team failed to develop a treatment regime based on his/her current behaviors.

D. Non-sample Patient C37 was admitted on 9/9/08 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of Patient B37's master treatment plan, revision dated 3/15/13, "less angry and hostile but continues to be so. It is agreed that this patient is still hallucinating most of the day...delusionses (sic) persist. [His/her] demeanor and attitude denote a severe paranoid feeling..."


2. Based on the programming schedule (PSR) Patient C37 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient C37 has only attended 2 of [his/her] scheduled groups for a brief period of time from 3/27/13 through 4/9/13.

3. Observations on Unit R4 revealed Patient C37 to be in bed asleep on 4/9/13 at 10:45 a.m. and 3:20 p.m. During these times this patient was scheduled to attend ADL [Activities of Daily Living] and Tasks Skills groups. Observations on Unit R4 on 4/10/13 at 10:35 a.m. and 3:10 p.m. revealed Patient C37 to be asleep in bed. At these times, s/he was scheduled to attend Symptoms Management and Nutrition Education groups.

4. Interviews:

During interview with RNC1, RN C9 and SWC7 on 4/10/13 at 11:50 a.m., RNC9 report that Patient C37 "is decompensating. [S/he] won't get off ward except to go to meals." She added, "This patient is too sick to go to most groups. [S/he] is very psychotic."

5. Review of Patient C37's master treatment plan revision (3/15/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with current treatment. Patient C37's treatment plan failed to develop a treatment regime based on his/her current behaviors.

E. Sample Patient D24 was admitted on 8/2/11 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

1. As documented in the summary and treatment section of the master treatment plan with most recent review date of 1/8/13: The patient, "who had been on NGRI (Not Guilty by Reason of Insanity) status, returned from ALS (Authorized Leave Status) contract for violation of smoking rules in the group home...During this review period [s/he] continues to be involved in smoking."

2. Group Progress notes for patient D24 in assigned Anger Management, Substance Abuse, and Group Psychotherapy modalities were reviewed. Progress notes for the assigned twice per week ADL Group were not provided. The notes provided showed attendance at 5 of 13 (38%) of assigned groups. The monthly psychiatric medication review note, monthly psychiatric progress note of 4/9/13 documented: "[S/he] continues having poor insight and poor motivation, as evidenced by needing several prompts to do [his/her] ADLs, taking medications, attending groups." The psychologist's group progress notes of 3/28/13, 4/4/13 and 4/9/13 all documented: "did not come when called." Social work group progress notes for 3/27/13, 3/29/13 and 4/1/13 documented: "Did not attend." The note from 4/3/13 documented: "did not attend-encouraged."

3. On Unit R5 on 4/9/13 at 3:10 PM, the patient was in his/her room. When asked why s/he was not in the assigned Group Psychotherapy session, the patient responded: "it's not a good time of the day."

4. During an interview with the psychologist group leader on 4/9/13 he stated that the patient was, ironically, an active participant when s/he comes but that there were no available options to motivate this patient to attend if s/he didn't want to attend.

5. Review of Patient D24's master treatment plan, with most recent review 1/8/13, revealed no change in treatment schedule (groups and 1:1) as of 4/9/13, even though s/he was frequently non-compliant with group attendance. Patient D34's treatment team failed to develop a treatment regimen based on his/her current behaviors.

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. Assure that treatment plans were revised to include a treatment regime based on the current treatment needs for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of continued 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 B144)

B. Assure that the treatment plans included measurable goal statements for 7 of 8 active sample patients (B20, C8, C15, D24, D32, E13 and E19). Goals were stated in non-measurable terms that did not identify or delineate specific outcome behaviors for patients. In addition, some goals listed were actually staff interventions. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions. (Refer to B144)

C. Assure that master treatment plans (MTPs) included specific physician interventions based on the individual needs of the patient for 5 of 8 active sample patients (C2, C15, D24, D32 and E13). This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B144)

D. Ensure that individualized psychiatric care was provided for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that staff documented that the patients failed to attend. In spite of these observed refusals, treatment plans were not revised by staff 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 B144)

II. The Director of Nursing failed to:

A. Meet the educational and/or on-going training requirements necessary for her administrative position as Executive Nurse within this facility. (Refer to B147)

B. Develop treatment plans that included specific nursing interventions based on the each patient's individual problems and goals for 5 of 8 active sample patients (B20, C2, C15, D24, and E19). 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. (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. Assure the treatment plans were revised to include a treatment regime based on the current treatment needs for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of continued 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.

Findings include:

A. Non-sample Patient B6 was admitted on 4/15/10 with a diagnosis of Schizophrenia Chronic, Undifferentiated Type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 1/13/13 with review date of 4/1/13, it stated "still refuses the medication at times...taking Lorazepam 2 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for agitation...Prolixin 10 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for delusional thinking and Valproic acid 2000 mg orally at bedtime for mood swings and aggression and 500 mg in the morning for aggression." The summary reported that s/he had been a victim of assault on 11/28/12 while in the hospital.

2. Based on the programming schedule (PSR) Patient B6 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient B6 had only attended one of his/her scheduled groups from 3/27/13 through 4/9/13. The participation note for this Medication Management group documented that Patient B6 was sleeping.

3. Interviews:

a. During interview with RN C1, RN C9 and SW C7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient B6 had been "decompensating." She stated that this patient would not get off the ward except to go to meals. RNC9 stated that the patient was "too sick to go to most groups."

b. During interview on 4/10/13 at 3:10 p.m., Health Care Technician (HCT) B14 reported that Patient B6 was "waiting to go home" and refused to attend groups.

4. Review of Patient B6's master treatment plan revision (1/9/13) with reviews (1/11/13, 2/1/13, 2/6/13, 4/1/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant in all areas of treatment. Patient B6's treatment team failed to develop a treatment regime based on his/her current behaviors.

B. Non-sample Patient B22 was admitted on 3/8/13 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 4/2/13, Patient B22 "continues to threaten the staff...continues to have persecutory delusions and thinks that people are out to harm [him/her]...[S/he] also has flashbacks of [his/her] childhood trauma where [s/he] was sexually abused as a child...[S/he] also has a history of alcohol use, marijuana and crack cocaine abuse."

2. Based on the programming schedule (PSR) Patient B22 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance notes provided by the staff on 4/10/13, Patient B22 had refused to attend all scheduled groups since admission. The only treatment other than on-going assessment by the psychiatrist was a 10-15 minute weekly session with the social worker.

3. Interviews:

a. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B22 refused to attend all groups and "stays in bed except to eat."

b. During interview on 4/10/13 at 4:00 p.m., RN B13 stated that Patient B22 refused to attend all treatment, stating "[S/he] only wants out of the hospital."

4. Review of Patient B22's master treatment plan (4/2/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with the current plan. Patient B22's treatment team failed to develop a treatment regime based on his/her current behaviors.

C. Sample Patient C2 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 2/20/13 with review of 3/2/13, it stated "The intensity and frequency of the auditory or visual hallucinations have not changed since the decrease of the dose of Risperdal...[s/he] does not want to try a different medication..."

2. Review of Patient C2's group progress notes revealed that from 3/27/13 through 4/9/13 this patient refused to attend 19 of 19 (100%) scheduled groups (Anger Management, Task Skills and Medication Management). A psychiatrist progress note (3/26/13) documented, "[S/he] does not participate in therapeutic groups activities." A recreation therapy note (4/2/13) stated "...no programming attended this review [sic]." Based on a review of the record, the only documented treatment for this patient was reflected in a monthly social work progress note (3/12/13) that stated, "Supportive therapy on Monday 10-15 minutes at 2:15 pm with social worker."

3. Interviews:

During interview with Physician C12, RN C1 and SW (Social Worker) C9 on 4/10/13 at 11:35 a.m., Physician C12 reported that Patient C2 continued to refuse all treatment groups. He stated agreement that the treatment plan had not been changed and that even though a psychologist had worked with the patient in the past, there had been no recent psychological assessment of this patient about his/her continued refusal to engage in treatment other than medications. SW C9 stated, "We need to do something different with this patient."

4. Review of Patient C2's master treatment plan revision (2/20/13) with review (3/2/13) revealed no change in treatment schedule (groups and 1:1) as of 4/10/13, even though s/he was non-compliant in all areas of treatment other than medications. Patient C2's treatment team failed to develop a treatment regime based on his/her current behaviors.

D. Non-sample Patient C37 was admitted on 9/9/08 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of Patient B37's master treatment plan, revision dated 3/15/13, Pt. B37 was "less angry and hostile but continues to be so. It is agreed that this patient is still hallucinating most of the day...delusionses [sic] persist. [His/her] demeanor and attitude denote a severe paranoid feeling..."

2. Based on the programming schedule (PSR) Patient C37 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient C37 had only attended 2 of his/her scheduled groups for a brief period of time from 3/27/13 through 4/9/13.

3. Interviews:

During interview with RNC1, RN C9 and SWC7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient C37 "is decompensating. [S/he] won't get off ward except to go to meals." She added, "This patient is too sick to go to most groups. [S/he] is very psychotic."

4. Review of Patient C37's master treatment plan revision (3/15/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with current treatment. Patient C37's treatment plan failed to develop a treatment regime based on his/her current behaviors.

E. Sample Patient D24 was admitted on 8/2/11 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

1. As documented in the summary and treatment section of the master treatment plan with most recent review date of 1/8/13, the patient, "who had been on NGRI (Not Guilty by Reason of Insanity) status, returned from ALS (Authorized Leave Status) contract for violation of smoking rules in the group home...During this review period [s/he] continues to be involved in smoking."

2. Group Progress notes for patient D24 in assigned Anger Management, Substance Abuse, and Group Psychotherapy modalities were reviewed. Progress notes for the assigned twice per week ADL Group were not provided. The notes provided showed attendance at 5 of 13 (38%) of assigned groups. The monthly psychiatric medication review note, monthly psychiatric progress note of 4/9/13 documented: "[S/he] continues having poor insight and poor motivation, as evidenced by needing several prompts to do [his/her] ADLs, taking medications, attending groups." The psychologist's group progress notes of 3/28/13, 4/4/13 and 4/9/13 all documented: "did not come when called." Social work group progress notes for 3/27/13, 3/29/13 and 4/1/13 documented: "Did not attend." The note from 4/3/13 documented: "did not attend-encouraged."

3. During an interview with the psychologist group leader on 4/9/13 he stated that the patient was, ironically, an active participant when s/he came to group but that there were no available options to motivate this patient to attend if s/he didn't want to attend.

4. Review of Patient D24's master treatment plan with most recent review 1/8/13, revealed no change in treatment schedule (groups and 1:1) as of 4/9/13, even though s/he was frequently non-compliant with group attendance. Patient D34's treatment team failed to develop a treatment regimen based on his/her current behaviors.


II. Assure that the treatment plans included measurable goal statements for 7 of 8 active sample patients (B20, C8, C15, D24, D32, E13 and E19). Goals were stated in non-measurable terms that did not identify or delineate specific outcome behaviors for patients. In addition, some goals listed were actually staff interventions. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient B20-Master Treatment Plan most current revision date of 2/13/13:

a. Problem #P1: "Psychosis as evidenced by responding to internal stimuli, delusional thinking, paranoid delusions and thinking that people are out to harm him and grandiose delusions..."

A short term goal was listed in non-measurable terms as "Patient will improve to the extent that [s/he] can function in the community in the supervised setting in the community without dangerousness. In next (sic) three months patient has (sic) decreased incidents of delusional thinking, grandiose delusions and responding to internal stimuli..."

a. Problem #P2: "Mood swing (sic) as evidenced by irritable mood, agitation, verbal aggression, physical aggression, pressured speech, screaming behavior, loud speech, argumentative behaviors, threatening behaviors."

A short term goal was listed in non-measurable terms as "...should have decreased incidents of physical aggression and decreased incidents of argumentative, hostile and verbal aggression." "Patient's mood will stabilize such that [s/he] maintains a normal level of activity, reasonably social, outgoing..."

b. Problem #PS1: "Poor social interaction skills as evidenced by being paranoid and suspicious, easily agitated/irritable, responding to internal stimuli, argumentative and delusional."

A short term goal was listed in non-measurable terms as "By 5/12/2013, patient will participate in AT/PSR group discussions in a relevant manner 25% of the sessions."

2. Patient C8-Master Treatment Plan dated 3/18/13 (no recent plan revision):

a. Problem #P1: "Chronic psychotic symptoms with disorganized thought, poor, insight, paranoid delusions, and poor compliance with medications. It also appears that family support is not that good..."

Statements on the plan were actually staff interventions, rather than short term goals that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued on medications...[S/he] will be seen by me regularly, twice a week to see how [his/her] symptoms are improving." "The patient will be assigned to groups and will ask [him/her] to attend the groups at least two groups (sic)."

b. Problem #P2: "Substance Abuse Problem: [S/he] has been drinking alcohol almost every day. [S/he] says [his/her] preferred drink has been Grey Goose and smoking marijuana a regular basis along with his family members."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will be continued to be educated about the importance of staying off from the drugs because it has a negative impact on [his/her] mental illness as well as [his/her] medications."

3. Patient C15-Initial Master Treatment Plan (1/10/13) with review (3/9/13). No treatment plan revision):

Problem #P1: "The patient with a long history of psychotic symptoms especially disorganized thinking and loose associations, tangential and disorganized at times. [His/her] speech has been incoherent, and paranoid delusions were present. [S/he] has been consistently getting angry and demanding things. [S/her] has been unable to live in a less restrictive environment and has poor judgment and impulse control problem."

A short term goal was stated in non-measureable terms as "In four weeks, the patient will have relevant conversation during therapy session twice a seek, and will start understanding [his/her] auditory hallucinations and delusions, showing some insight into them."

4. Patient D24-Master Treatment Plan dated 1/8/13:

a. Problem #P1: "The patient returned from NGRI status/ALS status for smoking in the group home and showing poor impulse control in [his/her] smoking behavior."

The statement on the plan was actually a staff intervention, rather than a short term goal that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient should attend three PSR groups, 45 minutes each, five days a week, able to discuss (sic) [his/her] problems with smoking and suggest the methods how to quit smoking to get out of this hospital, by April 08, 2013."

b. Problem #P2: "Illogical thinking disorganized thought process about smoking and about the dangerousness in the group home."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will attend at least three PSR groups, 45 minutes each, twice a day, five days a week, and able to show progress with good reality testing about [his/her] smoking problems and suggest ways to get rid of [his/her] smoking problem and how [s/he] remains smoking free when in the hospital and also after discharge into the community, by April 8, 2013 (sic)."

c. Problem #PS1: "Poor impulse control, as evidenced by poor judgment and smoking in unauthorized areas, also mood swings at times displaying slight agitation when redirected."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "By April 8, 2013, the patient will attend at least two groups each for 20 minutes."

5. Patient D32-Master Treatment Plan dated 2/8/13:

Problem #P3: "Lack of insight and judgement (sic) into her mental illness, need for continuing to take the medications, and substance abuse problems and the need to keep her out from the hospitals with ALS contract."

A short term goal was stated in non-measurable terms: "[S/he] will discuss the affects (sic) and side effects of the medications, the untoward effects of substance abuse and able (sic) to discuss the need to continue taking the medications, affects (sic) and side effects of the medications while in the hospital and also after discharge into the community by 05/08/2013."

6. Patient E13-Master Treatment Plan dated 3/27/13:

Problem #P1: "Aggressive behavior related to paranoid thinking and neglecting [his/her] basic care needs, including disheveled hair, long beard, unkept (sic) and interfered with [his/her] eating and [his/her] hygiene. [S/he] was also prompted to shower and put on clean clothing."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

7. Patient E19-Master Treatment Plan dated 4/3/2013:

a. Problem #P1: "Psychosis and also delusional behaviors..."

Short term goals were stated in non-measurable terms: "1. Cooperate with services focused on stabilizing the current acute psychotic episode. 2. Report a decrease in psychotic symptoms through the consistent use of psychotropic medications; 3. Identify the early warning signs and symptoms, exacerbation and decompensation. 4. Verbalize the acceptance of mental illness and to participate in the treatment recommended PSR groups and learn about mental illness."

b. Problem #P3: "Aggressive behavior..."

Short term goals were stated in non-measurable terms: "1) Comply with the medication evaluation to identify if medications will help abort the angry/assaultive outbursts. 2) Take medications as prescribed. 3) Attend all the recommended PSR groups and also discuss with the therapist about lack of aggressive behavior control and to learn about healthy alternative coping skills. 4) Learn to express feelings in a nonviolent manner."

c. Problem #PS1: "Impaired social skills..."

The statement on the plan was actually a staff intervention, rather than a short term goal related to the stated problem that the patient could achieve, thereby hindering staff and patient's ability to measure the patient's change in response to treatment: "The patient will improve socialization and attend at least one group per week as able with 1-2 prompts."

B. Interviews

a. An interview with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m. with the Chief of Medical Affairs, the Director of Nursing and the Director of Social Work. They agreed that many of the goals on the treatment plans were not measurable.

b. In an interview with the Chief of Medical Affairs on 4/11/13 at 9:00 a.m., he acknowledged that the short term goals for Patient D24 were confusing and written as interventions. In addition he acknowledged that correcting dictation errors was an ongoing problem which may contribute to the lack of clarity in Master Treatment Plan language.


III. Assure master treatment plans (MTPs) included specific physician interventions based on the individual needs of the patient for 5 of 8 active sample patients (C2, C15, D24, D32 and E13). This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals.

Findings include:

A. Record Review

1. Patient C2-Master Treatment Plan with revision dated of 2/20/13 and review of 3/2/13:

Problem #P1: "NGRI. Due to [his/her] chronic suspiciousness and paranoid delusions, [s/he] would become frustrated easily when we talk about [his/her] discharge and probably [s/he] became institutionalized and not very willing to leave the institution and get very angry when disused [sic] about discharge plan with some threatening to the team members to sue them and then [s/he] will not follow with the discharge planning for dependent placements."

The only physician intervention was stated as "Will see [him/her] on a regular basis and will talk to [him/her] about discharge plans on a regular basis."

During interview with review of treatment plan on 4/10/13 at 11:35 a.m., Physician C12 stated agreement with above findings.

2. Patient C15-Initial Master Treatment Plan (1/10/13) with review (3/9/13):

Problem #PS1: "The patient has a significant history of treatment resistance and might partially [sic] due to noncompliance as part of [his/her] lack of insight."

Physician intervention was a general role function, "[Doctor] will monitor [his/her] medications and see for any side effects."

3. Patient D24-Master Treatment Plan dated 1/8/13 (No recent revision):

Problem #P2: "Illogical thinking disorganized thought process about smoking and about the dangerousness in the group home."

Despite identifying a cause of the patient's smoking as psychosis, no physician interventions were identified.

4. Patient D32-Master Treatment Plan dated 2/8/13 (No recent revision):

Problem #P2: "Auditory hallucinations, delusional thinking, mood swings and impulsive behaviors."

Despite identifying a problem requiring psychopharmacologic intervention, the physician intervention failed to include this aspect: "Psychiatric Intervention: Patient will be seen on one-to-one basis for about ten minutes once a week, three times a month or as when needed. Patient will be tested for reality orientation. [S/he] will be encouraged to talk about the precipitating factors that are making [him/her] to have agitated with impulsive behaviors [sic]. [S/he] will continue taking the medications at this time and also after discharged [sic] to the community."

5. Patient E13-Master Treatment Plan dated 3/27/13 (No recent revision):

Problem #3: "Chemical Dependency; As evidenced by consistent use of mood altering substances, exacerbates primary or secondary psychotic symptoms as a result of the use of (sic) withdrawal from mood altering illicit substances. Denies that chemical dependency is a problem, the substance use is effecting [sic] functioning of relationships. Use of substances despite medical warnings, interactions of psychotropic medications and illicit substances."

Physician intervention was a general role function: "Psychiatric Intervention: The psychiatrist will see the patient once a week and as needed. Patient will be monitored for the complaints for the prescribed medications, monitored for the side effects of the medications; Reinforce compliance to learn the coping skills and increase the client [sic] to learn about the recovery process."

B. An interview with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m. The Chief of Medical Affairs related that the physician intervention for Patient C15 was a role function rather than a specific intervention for this patient.

IV. Ensure that individualized psychiatric care was provided for 2 of 8 active sample patients (C2 and D24) and 3 of 3 non-sample patients (B6, B22 and C37) who were added to the sample for review of active treatment. These patients were scheduled for groups that they failed to attend. In spite of these observed 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.

Findings include:

A. Non-sample Patient B6 was admitted on 4/15/10 with a diagnosis of Schizophrenia Chronic, Undifferentiated Type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 1/13/13 with review date of 4/1/13, it stated "still refuses the medication at times...taking Lorazepam 2 mg at 8:00 a.m, 1:00 p.m. and 9:00 p.m. for agitation...Prolixin 10 mg at 8:00 a.m., 1:00 p.m. and 9:00 p.m. for delusional thinking and Valproic acid 2000mg orally at bedtime for mood swings and aggression and 500 mg in the morning for aggression." The summary reported that [s/he] had been a victim of assault on 11/28/12 while in the hospital.

2. Based on the programming schedule (PSR) Patient B6 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13, Patient B6 had only attended one of [his/her] scheduled groups from 3/27/13 through 4/9/13. The participation note for this Medication Management group documented that Patient B6 was sleeping.

3. Observations on Unit R3 revealed Patient B6 to be in bed asleep during his/her assigned groups on 4/9/13 at 11:00 a.m. and 3:40 p.m. During these times this patient was scheduled to attend Exploring [Gender] Issues and Personal Growth and Development groups. Observations on Unit R3 on 4/10/13 at 10:45 a.m. and 3:10 p.m. revealed Patient B6 to be asleep in bed. At these times, [s/he] was scheduled to attend Medication Management and Cognitive Stimulation groups. When interviewed about [his/her] failure to attend treatment groups, the patient responded, "I don't feel well."

4. Progress Notes:

a. A physician note (3/28/13) stated "As pt [patient] is increasingly delusional will increase the dose of Saphris (an atypical antipsychotic)."

b. An RN progress note (4/6/13) stated "Pt [Patient] refusing meds. [medications]."

c. An RN progress note (4/9/13) documented "Patient was prompt (sic) to attend PSR (Psychosocial group). Patient staff (sic) that [s/he] don't go to PSR because [s/he] don't have head (sic)."

d. A physician progress note (4/9/13) stated "[S/he] is refusing all oral medications off and on. Will order Ativan 1 mg IM (intramuscular) tid (three times daily) for refusal of Ativan oral dose and Prolixin 5 mg IM for refusal of oral dose of prolixin."

5. Interviews:

a. During interview on 4/9/13 at 11:10 a.m. 3:40 p.m., HCT B5 (Health Care Technician B5) reported that Patient B6 does not go to [his/her] assigned groups, staying in bed most of the time.

b. During interview with RN C1, RN C9 and SW C7 on 4/10/13 at 11:50 a.m., RNC9 reported that Patient B6 has been "decompensating." She stated that this patient will not get off the ward except to go to meals. RNC9 stated that the patient is "too sick to go to most groups."

c. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B6 is "waiting to go home" and refuses to attend groups.

6. Review of Patient B6's master treatment plan revision (1/9/13) with reviews (1/11/13, 2/1/13, 2/6/13, 4/1/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he is acutely psychotic and non-compliant in all areas of treatment. Patient B6's treatment team failed to develop a treatment regime based on his/her current behaviors.

B. Non-sample Patient B22 was admitted on 3/8/13 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan, revision dated 4/2/13, Patient B22 "continues to threaten the staff...continues to have persecutory delusions and thinks that people are out to harm [him/her]...[S/he] also has flashbacks of [his/her] childhood trauma where [s/he] was sexually abused as a child...[S/he] also has a history of alcohol use, marijuana and crack cocaine abuse."

2. Based on the programming schedule (PSR) Patient B22 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance notes provided by the staff on 4/10/13, Patient B22 had refused to attend all scheduled groups since admission. The only treatment other than on-going assessment by the psychiatrist was a 10-15 minute weekly session with the social worker.

3. Observations on Unit R3 revealed Patient B22 to be in bed asleep during his/her assigned groups on 4/9/13 at 11:00 a.m. and 3:40 p.m. During these times this patient was scheduled to attend Dual Diagnosis and Social Skills groups. Observations on Unit R3 on 4/10/13 at 10:45 a.m. and 3:10 p.m. revealed Patient B22 to be asleep in bed. At these times, [s/he] was scheduled to attend Medication Management and Health and Wellness groups. When interviewed about [his/her] failure to attend treatment groups, the patient responded, "I don't feel well."

4. Progress Notes:

a. A physician note (4/4/13) stated, "...does not attend the group therapy."

b. An RN progress note (4/5/13) stated, "Pt [Patient] remains delusional, pt [patient] does not attend group."

5. Interviews:

a. During interview on 4/10/13 at 3:10 p.m., HCT B14 reported that Patient B22 refused to attend all groups and "stays in bed except to eat."

b. During interview on 4/10/13 at 4:00 p.m., RN B13 stated that Patient B22 refuses to attend all treatment stating "[S/he] only wants out of the hospital."

6. Review of Patient B22's master treatment plan (4/2/13) revealed no change in treatment plan, including scheduled groups, as of 4/10/13, even though s/he was acutely psychotic and non-compliant with the current plan. Patient B22's treatment team failed to develop a treatment regime based on his/her current behaviors.

C. Sample Patient C2 was admitted on 7/25/08 with diagnosis of schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of the master treatment plan dated 2/20/13 with review of 3/2/13, it stated "The intensity and frequency of the auditory or visual hallucinations have not changed since the decrease of the dose of Risperdal... [s/he] does not want to try a different medication..."

2. Review of Patient C2's group progress notes revealed that from 3/27/13 through 4/9/13 this patient refused to attend 19 of 19 (100%) scheduled groups (Anger Management, Task Skills and Medication Management). A psychiatrist progress note (3/26/13) documented, "[S/he] does not participate in therapeutic groups activities." A recreation therapy note (4/2/13) stated "...no programming attended this review [sic]." Based on a review of the record, the only documented treatment for this patient was reflected in a monthly social work progress note (3/12/13) that stated, "Supportive therapy on Monday 10-15 minutes at 2:15 pm with social worker."

3. Observations on Unit R4 revealed Patient C2 to be in bed asleep on 4/9/13 at 10:45 a.m. and 3: 20 p.m. During these times this patient was scheduled to attend Anger Management and Tasks Skills groups. When the patient was asked why s/he was in bed during group time, Patient C2 responded, "I don't have the energy. I've been to all those groups. I know more than they know." Observations on Unit R4 on 4/10/13 at 10:35 a.m. revealed Patient C2 to be lying in bed. At this time, s/he was scheduled to attend Medication Management group.

4. Interviews:

a. During interview on 4/9/13 at 11:00 a.m. Dietitian D17 reported that Patient C2 walks in the ward hallways and attends off-ward dining but continued to refuse group activities.

b. During interview with Physician C12, RN C1 and SW C9 on 4/10/13 at 11:35 a.m., Physician C12 reported that Patient C2 continued to refuse all treatment groups. He stated agreement that the treatment plan had not been changed and that even though a psychologist had worked with the patient in the past, there had been no recent psychological assessment of this patient about his/her continued refusal to engage in treatment other than medications. SW C9 stated, "We need to do something different with this patient."

5. Review of Patient C2's master treatment plan revision (2/20/13) with review (3/2/13) revealed no change in treatment schedule (groups and 1:1) as of 4/10/13, even though s/he was non-compliant in all areas of treatment other than medications. Patient C2's treatment team failed to develop a treatment regime based on his/her current behaviors.

D. Non-sample Patient C37 was admitted on 9/9/08 with a diagnosis of Schizoaffective disorder, bipolar type.

1. As documented in the summary and treatment section of Patient B37's master treatment plan, revision dated 3/15/13, "less angry and hostile but continues to be so. It is agreed that this patient is still hallucinating most of the day...delusionses (sic) persist. [His/her] demeanor and attitude denote a severe paranoid feeling..."


2. Based on the programming schedule (PSR) Patient C37 was scheduled to attend 2 groups daily Monday-Fridays. According to the group attendance rosters provided by the staff on 4/10/13,

Based on interview and document review, the Director of Nursing failed to meet the educational and/or on-going training requirements necessary for her administrative position as Executive Nurse within this facility.

Findings include:

A. At the time of this survey the Director of Nursing position was vacant; the person in the role was serving as Acting Director of Nursing.

B. Review of the Acting Director of Nursing's educational credentials revealed that she has an Associate Degree in Nursing.

C. Review of the credentials of the nursing consultant for the Department of Nursing revealed that she has a Masters in Health Administration, rather than Psychiatric Nursing. Additional review revealed e-mail messages reflecting a supportive relationship, rather than on-going documentation regarding the issues and problems related to the Department of Nursing and care provided to patients at this facility.

D. During interview on 4/11/13 at 9:15 a.m., the Acting Director of Nursing stated that she was aware that she does not have the educational qualifications required for the Director of Nursing position.

Based on interview and document review, the Director of Nursing (DON) failed to provide adequate oversight to ensure that nursing staff develop treatment plans that included specific nursing interventions based on the each patient's individual problems and goals for 5 of 8 active sample patients (B20, C2, C15, D24, and E19). 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 B20-Master Treatment Plan with latest revision date of 2/13/13:

Problem #P2: "Mood swing (sic) as evidenced by irritable mood, agitation, verbal aggression, physical aggression, pressured speech, screaming behavior, loud speech, argumentative behaviors, threatening behaviors."

Nursing failed to list specific interventions to respond to and/or prevent verbal and physical aggression, screaming and argumentative behavior presented by Patient B20 in the clinical area.

2. Patient C2-Master Treatment Plan with revision date of 2/20/13 and review date of 3/2/13:

Problem #P1: "NGRI. Due to his chronic suspiciousness and paranoid delusions, [s/he] would become frustrated easily when we talk about [his/her] discharge and probably [s/he] became institutionalized and not very willing to leave the institution and get very angry when disused (sic) about discharge plan with some threatening to the team members to sue them and then [s/he] will not follow with the discharge planning for dependent placements."

Even though this patient's suspicious, paranoid and anger was identified in the problem statement, the treatment plan failed to identify nursing interventions to address these behaviors in the clinical area.

During interview with review of treatment plan on 4/10/13 at 11:35 a.m., RN C1 stated agreement with above findings.

3. Patient C15- Master Treatment Plan (1/10/13) with review (3/9/13). No treatment plan revision):

Problem #P1: "The patient with a long history of psychotic symptoms especially disorganized thinking and loose associations, tangential and disorganized at times. [His/her] speech has been incoherent, and paranoid delusions were present. [S/he] has been consistently getting angry and demanding things. [S/her] has been unable to live in a less restrictive environment and has poor judgment and impulse control problem."

Nursing interventions were stated in generalized terms that were non-specific to the individual patient: "The patient will be educated on [his/her] medication including dosage and side effects. The patient will be encouraged to verbalize any needs and concerns and side effects to the staff ...the patient will be encouraged to attend (his/her) PSR (Psychosocial) groups and participate."

4. Patient D24-Master Treatment Plan dated 1/8/13 (No recent revision):

Problem #P1: "The patient returned from NGRI status/ALS status for smoking in the group home and showing poor impulse control in [his/her] smoking behavior."

Despite the need for nursing supervision around the patient's smoking behavior, no nursing interventions were identified.

5. Patient E19-Master Treatment Plan dated 4/3/13:

Problem #P2: "Medication Noncompliance. 1) In consistently [sic] taking psychotropic medications as prescribed; 2) Lack of knowledge of medications, usefulness and potential side effects."

Nursing interventions were stated in generalized terms that were non-specific to the individual patient: "Nursing Intervention: Patient will be educated about [his/her] medication doses, side effects and the importance of [his/her] remaining compliant while in the hospital and during discharge. Patient will be encouraged to attend all scheduled PSR activities. The patient is encouraged to verbalize any concerns about [his/her] medication or treatment to staff. Patient is also encouraged to utilize [his/her] coping skills and verbalize any concerns in a calm and positive manner."

B. During an interview with review of treatment plan findings was conducted on 4/11/13 at 9:45 a.m., the Director of Nursing stated, "We need to learn to think' out of the box' for patients (referring to Patient C2)."