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Based on interview and documentation, the facility failed to ensure the protection of privacy for patients who are using the telephone to communicate with others outside the hospital community, including times when the patient is required to seek a permission pass. The facility requires the patient to state who they are calling and why. When using telephones during free time, the areas are monitored (within hearing range) by staff.

The findings include:

Each patient admitted for treatment at The Willough of Naples care facility receives a summary of the Florida Patients' Bill of rights upon entry. The written summary of the rights and responsibilities of patients includes but is not limited to a statement saying, "A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with the protection of his or her need for privacy."

Facility telephones are free to patients at all times and patients are asked to consider the time they use during scheduled times are in consideration of other patients' need for telephone.

During an interview with the therapist, on 1/10/12 at 2:45 p.m., the therapist verified what the open telephone times for the facility were. She also indicated the use of the facility telephones is permitted at times other than when there are open telephone hours, if there is a circumstance where there may be an emergency need. She explained that if a patient wants to make an outside call, at a time other than during the open call hours, the patient needs to obtain a "permission phone pass" signed by the therapist. She indicated if a therapist was not available in the facility to sign for a pass, the licensed nurse was allowed to sign permission for an emergency call.

The therapist indicated in making the emergency call, all the patient has to do is dial 9 to get an outside line. She also indicated the telephone areas are visible from the nursing stations but are not audibly monitored.

During the review of the "permission pass" slip, the therapist was asked if there were any questions asked in regards to obtaining a permission pass. The therapist said, "They are asked who they are calling and why." She stated, "They usually want to call a family member when it is an emergency call, but if they don't even say who they are calling and get defensive, I might give the pass to them once, but no more, until they talk to me in group."

She stated also, "If they just say it's personal, I will usually consider what their personal experiences have been before I would turn them down. If they are missing groups, inattentive, defensive, etc., the radar goes up and I request they come to see me before I give permission for a call."

At 3:15 p.m., after the interview, the therapist accompanied the surveyor to the 200 wing hall for observation of the telephone area. The telephone line is available in a room across from the nurses' station, which has an open cutout area allowing the nurses and other staff to visualized the open room.

A discussion with the staff present in the nursing station indicated when there is someone in the room making a telephone call during the call times, the patient is observed by a staff person who is stationed by the entry way in the room. One of the staff was asked to point out exactly where the monitor (staff) would be standing during the calls. The staff person was then asked to approximate about how close the monitor would be to the telephone. The staff person said about 10-15 feet.

On 1/7/12, between 8:30 a.m., and 9:00 a.m., four patients were stopped at random, on the unit, and asked whether they felt the open dayroom allowed them an environment of privacy:

One patient said he/she was thankful for the phone, but felt there were times when the monitor could have been listening in. The patient did not see the system as being very private and said, "There are times when you get hassled."

This Condition of Participation is not met based on the facilities failure to have an effective, ongoing, hospital-wide, data-driven, quality assessment and performance improvement program to meet the needs of the population the hospital serves.

These failures present a substantial probability to adversely affect all patients' physical health, safety, and well-being.


The findings include:

1. Based on staff interview, facility record review, and observation the facility failed to demonstrate measurable improvements and failed to demonstrate appropriate monitoring approaches resulting in evidence to improve health outcomes encompassing the patient population at the facility.

2. Based on staff interview, facility record review, and observation the facility failed to demonstrate measurable improvements and failed to demonstrate appropriate monitoring approaches resulting in evidence to improve health outcomes encompassing the patient population at the facility.


3. Based on observations, staff interviews, and facility record review the facility failed to evaluate the effectiveness of the Performance Improvement interventions and measure the impact of the program.

Based on staff interview, facility record review, and observation the facility failed to demonstrate measurable improvements and failed to demonstrate appropriate monitoring approaches resulting in evidence to improve health outcomes encompassing the patient population at the facility.

The findings include:

A meeting with the Quality Assurance Performance Improvement (QAPI) Committee was conducted on 01/10/2011 at 1:15 p.m. The meeting included the Risk Manager (RM) - QAPI Director, Director of Nursing (DON), the Medical Director and facility Administrator. The RM explains the hospital had identified Medical Errors / Medication Administration as one of the Quality Indicators chosen by the quality committee. The RM explained the team reviewed the previous Agency survey and the resulting deficiencies were influential to adding medication administration as a quality indicator. The RM stated, "This would include errors in medication administration." When asked to further outline what that meant to the facility, the DON commented, "The goal is reduction in medication errors and administering medications according to policy." The DON continued by stating, "The right patient, right drug, right time, right dose, and right route." The RM and DON confirm the medical director explained the "auditor" will have the quality data documentation needed for the quality program.
The RM presented the medication administration data. A review of the November and December facility form entitled "Monthly Compliance Summary" reveals a threshold for Med (Medication) Pass Administration. The sheet documents 100% for the Med Pass Administration threshold. Another threshold is noted as Nurse Competency Medication Administration. The entry for this threshold is documented as N/A (Not Applicable).

The RM commented the facility had a 100% compliance rate for medication administration. When asked about the repeated 100% for each week over the last 2 months, the RM commented she would get the staff educator to explain the data findings. The staff educator explained the 100% indicated he had completed the task but did not reflect the audit data or findings regarding medication administration.

Further review of the documentation reveals the staff educator identified 19 questions to determine medication administration compliance. The staff educator stated, "I use this form when I review medication administration with the nurse." When asked, the educator denied gathering the question results and findings, compiling results, evaluating results, or developing data for report. He stated the 100% was not compliance with medication pass but his compliance with accomplishing the task.

The educator continued by stating "I have only completed the questions with the nurses on the day shift." The educator agreed the asking of the questions and providing education as needed did not reflect an accurate assessment of the medication administration compliance by stating "No, I did not look at each question independently and gather data for each question." The educator also commented he would agree the nurses "on each shift" should be included. The medical director confirmed this by stating "We would have discovered data mechanism was not optimal at the next meeting." The medical director agreed the data documented did not demonstrate or reflect the actual compliance for medication administration, by stating, "I understand the mechanism is faulty."

The findings from the medication administration observation conducted on 1/09/2012 were reviewed with the RM, DON, Medical Director and Administrator. The findings included (not limited to) medication administration errors, medications not administered as ordered by the physician, dosage errors, transcribing errors, medication documentation omissions, and failure to monitor and clarify dosage parameters.

An interview with the DON on 01/10/2011 at 4:10 p.m., revealed the facility does not currently have a "formal" proactive method to evaluate the nurse competency. The DON presented the facility "RN-LPN Orientation Checklist-Clinical Aspects" grid stating "This has not been implemented here, but is used at other facility." The DON continued by stating, "It will be implemented here soon." The Monthly Compliance Summary lacked competency evaluation.

The facility failed to provide a program utilizing the facility thresholds in an effective manner to monitor intervention effectiveness to improve patient outcomes.

Based on observation, staff interview, and facility record review the facility failed to provide focused performance improvement activities involving an identified high-risk, high volume, problem-prone area of medication administration and patient quality of care.The findings include:

The facility Quality Assurance and Performance Improvement (QAPI) Committee records were reviewed with members of the committee on 01/10/2011. The Risk Manager (RM) was interviewed and explained the medication administration was identified as a problem for patient safety in July after the facility's previous survey. The DON explained transcribing of physician orders; medication administration documentation and accurate medication administration were some of the problems identified. A review of the performance improvement activities revealed the staff educator performed the activities for the improvement of medication safety and administration.

The staff educator explained the 100% indicated he had completed the task but did not reflect the audit data or findings regarding medication administration. Further review of the documentation reveals the staff educator identified 19 questions to determine medication administration compliance. The staff educator stated, "I use this form when I review medication administration with the nurse." When asked, the educator denied gathering the question results and findings, compiling results, evaluating results, or developing data for report. He stated the 100% was not compliance with medication pass but his compliance with accomplishing the task.


The educator continued by stating, "I have only completed the questions with the nurses on the day shift." The educator agreed the asking of the questions and providing education as needed did not reflect an accurate assessment of the medication administration compliance by stating "No, I did not look at each question independently and gather data for each question." The educator also commented he would agree the nurses "on each shift" should be included. The medical director confirmed this by stating, "We would have discovered data mechanism was not optimal at the next meeting." The medical director agreed the data documented did not demonstrate or reflect the actual compliance for medication administration, by stating, "I understand the mechanism is faulty."

The findings from the medication administration observation conducted on 1/09/2012 were reviewed with the RM, DON, Medical Director, and Administrator. The findings included (not limited to) medication administration errors, medications not administered as ordered by the physician, dosage errors, transcribing errors, medication documentation omissions, and failure to monitor and clarify dosage parameters.

An interview with the DON on 01/10/2011 at 4:10 p.m., revealed the facility does not currently have a "formal" proactive method to evaluate the nurse competency. The DON presented the facility "RN-LPN Orientation Checklist-Clinical Aspects" grid stating, "This has not been implemented here, but is used at other facility." The DON continued by stating, "It will be implemented here soon." The Monthly Compliance Summary lacked competency evaluation.

The facility failed to provide a program utilizing the facility thresholds in an effective manner to monitor intervention effectiveness to improve patient outcomes.

Based on observations, staff interviews, and facility record review the facility failed to evaluate the effectiveness of the Performance Improvement interventions and measure the impact of the program.

The findings include:

An interview with the Risk Manager (RM), Director of the Quality Assurance Performance Improvement (QAPI) was conducted on 01/10/2012. The RM verified the Medical Errors/Medication administration was identified as a Quality Indicator. This is documented in the August, 2011 meeting minutes in the "Nursing" section of the minutes. The minutes document "Will develop new indicators. Revision of the Nursing Policies including Medication Management" The RM was asked about the measurement of the effectiveness of the indicators and policy revision. The RM explained the staff educator would have that data information.
A joint interview with the staff educator and the QAPI Committee was conducted to review the data collection regarding the medication administration.

The staff educator explained the 100% indicated he had completed the task but did not reflect the audit data or findings regarding medication administration. Further review of the documentation reveals the staff educator identified 19 questions to determine medication administration compliance. The staff educator stated, "I use this form when I review medication administration with the nurse." When asked, the educator denied gathering the question results and findings, compiling results, evaluating results, or developing data for report. He stated the 100% was not compliance with medication pass but his compliance with accomplishing the task.


The educator continued by stating, "I have only completed the questions with the nurses on the day shift." The educator agreed the asking of the questions and providing education as needed did not reflect an accurate assessment of the medication administration compliance by stating "No, I did not look at each question independently and gather data for each question." The educator also commented he would agree the nurses "on each shift" should be included. The medical director confirmed this by stating "We would have discovered data mechanism was not optimal at the next meeting." The medical director agreed the data documented did not demonstrate or reflect the actual compliance for medication administration, by stating, "I understand the mechanism is faulty."

The findings from the medication administration observation conducted on 1/09/2012 were reviewed with the RM, DON, Medical Director and Administrator. The findings included (not limited to) medication administration errors, medications not administered as ordered by the physician, dosage errors, transcribing errors, medication documentation omissions, and failure to monitor and clarify dosage parameters.

The facility failed to provide a program utilizing the facility thresholds in an effective manner to monitor intervention effectiveness and improve patient outcomes.

Based on record review, observation and interview the facility nursing staff failed to follow physician orders; failed to accurately document on the Medication Administration Record and failed to follow the standard of practice for medication administration for 10 (Patients #1, #2, #3, #4, #7, #9, #11, #23, #31, and #32) out of a sample of 39 records reviewed.

The findings include:

1. On 1/9/12 at 9:30 a.m. an observation on the 100 wing revealed a nursing station that was accessible through an unlocked door behind the nursing station and the medication room/door was also accessed without difficulty. Two nurses were observed in the medication room. On the top of the medication cart was a tuberculin syringe. The syringe was filled with a clear liquid substance (1 unit). This syringe was not labeled. In addition three medications were observed on the top of the medication cart. These medications were observed with a pharmacy label but lacked a patient label.
One staff nurse was asked about the medications. The staff nurse commented she was not assigned medications for that day and directed me to speak with the medication nurse. This staff nurse continued by stating the medication nurse was on break. The staff nurse then turned her back to the medication cart and continued to "check orders" with the other staff nurse who also had her back turned to the medication room cart and door. At this time a housekeeping staff member entered the medication room. The housekeeping staff was observed emptying trash bins in the medication room.

The staff nurse, at this time, observed the medications on the cart and stated, "I believe these med's (medications) were obtained from the other nursing station until we receive the medications from pharmacy." The nurse also commented she did not know what the substance was in the syringe. The nurse took the syringe and disposed of the syringe and its contents in the sharps container stating, "This isn't labeled it should be labeled, so I am just going to get rid of it."

The medication nurse returned to the medication room. When asked about the medications on top of the cart the medication nurse commented, the medications were obtained from the other nursing station for the 10:00 a.m., medication pass. The medication nurse then asked about the location of the syringe. The medication nurse was told by the staff nurse the syringe was discarded because it was not labeled. The medication nurse explained the syringe was a "PPD" (Purified Protein Derivative- an injectable liquid substance use to test for Tuberculin reaction). The medication nurse continued to comment the night nurse had filled the syringe but did not have time to administer the PPD, so she had agreed to administer the PPD. The medication nurse continued to explain that she was going to administer the unlabeled PPD for the night nurse, stating she trusted the night nurse and would have administered the unlabeled PPD drawn by the night nurse. The other medications were then placed into patient medication bins as the nurse explained the medications were for those patients.

Standard of practice for administration of medications includes security of the medications and the proper labeling of all medications including the name of the patient and the date, time, drug, and nurse initials on pre-drawn syringes.

2. Medication Administration Records were reviewed between 8:30 a.m., and 9:00 a.m., on 1/11/12, for patients receiving blood pressure medication based on parameters. The following was revealed:

Patient #2 has a physicians order written on 1/8/12 for Clonidine 0.2 mg, po (by mouth), q (every) 6-8 hrs, prn (as necessary), for SBP (systolic blood pressure) greater than 170 and DBP (diastolic blood pressure) greater than 95. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6-8 hours to determine if it was necessary to administer the medication. It was also acknowledged that the order required clarification relating to time of administration (every 6 hours or every 8 hours).

Patient #3 has a physician order written on 1/7/12 for Norvase, 10 mg, qam, hold Norvase for B/P (blood pressure) over or equal to 100/60. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the order to hold the Norvase was not transcribed onto the Medication Administration Record, and the patient's blood pressure was not being evaluated prior to administration of the medication at 10:00 a.m. each day (see 3. below)

Patient #9 has a physician order written on 12/20/11 for Lisinopril, 10 mg, 1 daily, hold if BP (blood pressure) less than or equal to 100. The patient's blood pressure was documented as being taken and recorded every day at 6 a.m. There was no documentation that the patient's blood pressure was taken prior to the administration of medication at 10:00 a.m., each day. Upon interview, the Nursing Supervisor stated that the patient's blood pressure is taken by a technician, written on a small piece of paper, and given to the patient to hand to the licensed nurse prior to receiving the medication at 10:00 a.m. The Nursing Supervisor and licensed nurse administering medications acknowledged that there was no documented record of the blood pressure being taken and evaluated relating to the parameter. In addition, it was also acknowledged that the parameter of 100 did not indicate systolic or diastolic and required physician clarification.

Patient #11 has a physician order written on 1/2/12 for Clonidine, 0.1 mg, po, q6h, prn, BP greater than 160/100. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

Patient #31 has a physician order written on 12/19/11 for Clonidine, 0.1 mg, po, q8h, prn for BP greater than 140/90. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

Patient #32 has a physician order written on 12/18/11 for Clonidine, 0.1 mg, po, q6h, prn for BP greater than 140/90. Upon interview, the Nursing Supervisor and licensed nurse administering the medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

3. A total of 11 patient medication administrations were observed during the 10:00 a.m., medication pass on 1/9/11 on the 100 unit. The findings for the medication pass include:
Patient #1 was observed to refuse a daily dose of Miralax 17 gram dose. The nurse was observed documenting on the MAR (Medication Administration Record) after the medications for that patient was completed. The nurse stated, "I want to document on the MAR before I go on to the next patient."
A review of the 10:00 a.m., entries on the MAR was conducted at 1:00 p.m. This review revealed the nurse had entered her initials indicating the Miralax was administered. This was confirmed through an interview with the Pharmacist at 2:00 p.m. The pharmacist revealed the entry was inappropriate, commenting this entry indicates the patient received this medication at 10:00 a.m. The pharmacist continued by stating, "Even if the medication was offered at a later time as a follow up, the 10:00 a.m., dose should be marked as refused." The pharmacist continued to explain if the medication was administered at a different time, which time would be entered with an explanation and the nurse's initials. The pharmacist commented when a medication is refused, held, or missed the medication time is circled with an explanation of why the medication was not given. The pharmacist continued by stating, "The nurse should initial by the circled entry and then notify the physician." The pharmacist also commented the nurses had been inserviced (provided education) on medication administration, medication administration documentation, and medication administration expectations for the facility including a process to maintain a patient medication bin in the medication cart.
A review of the MAR on 1/10/12 did not contain a correction of the 1/09/2012 MAR documentation for the refused Miralax dose. In addition, the MAR did include a new order for the Miralax 17 Grams to be given as a prn medication. The nurse failed to document the refused dose appropriately.

Patient #3 was observed to receive Norvasc 10 mg by mouth during the 10:00 a.m., medication pass. The nurse did not take the patient blood pressure prior to the medication administration. A review of the MAR and physician orders was conducted at 1:00 p.m. The physician order dated 1/7/12 documented at 7:58 p.m., as "hold Norvasc for BP less than or equal to 100/60." The MAR did not include this order.
In addition the MAR also includes an order for "Clonidine HCL (Hydrochloride) 0.1 MG q4h prn po for blood pressure 150/100. This medication is documented as given at 6:00 a.m., on 1/7/12 but does not include the BP reading at the time of administration. On 01/08/12 a 6:00 a.m., administration of this medication documents the blood pressure at 156/90 and on 01/08/12 a 6:00 p.m., administration of this medication documents the blood pressure at 154/100. The systolic and diastolic parameters were not clarified relating to the Clonidine order.

Patient #4- The nurse was observed to explain to Patient #4 that she was waiting for the Bacitracin (topical antibiotic) from the pharmacy. The patient commented that he had the medication in his room and was applying the medication himself. A review of the MAR revealed that the Bacitracin was to be applied to "new nasal piercing after shower daily, times 10 days."
This medication was not administered at 10:00 a.m., on 01/09/12. The review of the MAR at 1:00 p.m. on 01/09/2012 revealed that the nurse's initials documented the medication was administered. An interview with the pharmacist at this time revealed the medication was not to be applied by the patient unless there was a specific physician order indicating the patient was allowed to self-administer this drug. A joint review of the physician's orders revealed the chart did not contain an order for self-administration.

The medication nurse documented the medication as administered and did not check the orders for self-administration or recover the medication from the patient when the patient advised he had the medication in his room.
Patient #7 received a tablet labeled as 8.6 Sennosides and 50 Docusate. The nurse explained the tablet was a Senna tablet. The MAR documented the patient was to receive Senna 100 mg 1 tablet at 10:00 a.m. The nurse was asked about the label not indicating the medication as Senna 100 mg. The nurse replied, "This is what I have always used for Senna." The patient was administered also administered Colace (Docusate) 100 mg at this time per physician orders.

An interview with the Pharmacist at 2:30 p.m., on 1/9/11 confirmed the tablet labeled 8.6 Sennosides and 50 Docusate is Senna S. The pharmacist continued to explain the Senna table is without the Docusate (Colace).

The nurse did not follow physician orders for Senna 100 mg and administered Senna S, containing 50 mg of Docusate (Colace). Thus, the patient received 150 mg of Colace, instead of the 100 mg as order by the physician.

In addition, Patient #7 presented at the medication window with a 3 X 5 paper stating "BP 118/78." The medication nurse was asked about the information on the paper. The nurse stated the technician marks the BP for us and the patient will bring it to the window. The nurse continued to explain the BP was from the morning vital signs.

4. An interview with the acting Director of Nursing (DON) was conducted on 01/10/2012 at 9:30 a.m., regarding the blood pressure medication orders including the blood pressure orders with and without parameters, symbol utilization and meaning for < and > (with and without a line underneath this symbol) and the monitoring of blood pressures. The DON explained that vital signs, including blood pressures, are checked at 6:00 for all patients. This is documented on the flow sheet daily. The DON was asked about the blood pressures being done for prn orders for blood pressure medications and for blood pressure medications being given, on a continuum, based on specific parameters. The DON explained that blood pressures would be taken as needed and documented on the MAR. When asked why blood pressure readings were being written on a small piece of paper and that this piece of paper was observed being handed to the nurse at the 10:00 a.m., medication pass; the DON stated, "We do not have a procedure like that." The DON was not able to clarify if blood pressure parameters were for both the systolic and the diastolic (top number systolic- bottom number diastolic) blood pressures, or if just one (systolic or diastolic) number was needed to meet the criteria for medication administration. The DON commented that administering medications, according to the physician orders, was an expectation according to the facility policy.
A review of the policy, for accepted symbols used in the facility, did not include the > (greater than) symbol or < (less than) symbol with a line under the symbol to indicate equal to.

5. On 01/10/2012 an interview with the medication nurse, assigned to the 100 hall, was conducted at 10:30 a.m. The nurse was asked about the Bacitracin order for Patient #4. The nurse stated, "This is what he was given today." The nurse presented a "for individual use only" foil packet labeled as "Triple Antibiotic." The 1/10/12 medication nurse stated, "I have not entered my documentation onto the MAR yet." Review of the MAR and physician order, at this time, revealed that the patient was to have Bacitracin applied to "new nasal piercing after shower daily." The 1/10/12 medication nurse did not follow the physician order for Bacitracin.

6. Record review of the Medication Administration Record for Patient #23 revealed the lack of document evidence of administration medications, according to physician's orders, as follows:

a) Mobic, 15 mg., one tablet by mouth, daily: no doses documented on 1/8/12;
b) Lobid, 600 mg., one tablet by mouth, twice a day: no doses documented on 1/8/12 and at 10:00 a.m. on 1/9/12 (left facility at 1/9/12 at 4:15 p.m.);
c) Subutex 8 mg., SL, four times daily: no doses documented, as ordered, at 1800 and 2200 on 1/7/12 and also no doses documented for 1/8/12; doses also not documented for
6:00 a.m. and 1:00 p.m. on 1/9/12 (left facility at 1/9/12 on 1/9);
d) Seroquel 100 mg., one tablet by mouth at bedtime: no doses documented for 2100 on
1/8/12;
e) Cyclobenzaprine HCL 10 mg., one tablet three times a day: no doses documented on 1/8/12, and no doses documented on 6:00 a.m. and 1:p.m. doses on 1/9/12 (left facility at
1/9/12 at 4:15 p.m. on 1/9);
f) Lopressor 25 mg., one tablet by mouth twice a day: no doses documented on 1/8/12, and at 10:00 a.m. on 1/9 (left facility at 1/9/12 at 4:15 p.m.);
g) Neurontin 900 mg., three tablets (3=900), by mouth, four times a day: no doses
documented on 1/8, and no documentation for 6:00 a.m. and 1:00 p.m. doses for
1/9/12. (left facility at 1/9/12 at 4:15 p.m.). .
h) Clonzepam 1 mg., one tablet, by mouth, four times a day: no doses documented, as
ordered on 1/8, and no documentation of the 6:00 a.m. and 1:00 p.m. doses on
1/9/12 (left facility at 1/9/12 at 4:15 p.m.);
i) Dilantin 100 mg. take two caps. (2=200 mg.), three times a day: no doses documented, as ordered on 1/8/12, and no doses documented for 6:00 a.m. and 1:00 p.m.(left facility at 1/9/12 at 4:15 p.m.);
j) Zoloft 100 mg., take two tablets (2=200), by mouth, at bedtime: no doses documented, as ordered on 1/8/12.
k) Ambien 10 mg., one tablet, by mouth, at bedtime: no dose documented, as ordered, on
1/8/12.

During an interview with the registered nurse supervisor, at 3:37 p.m., on 1/10/2012, the nurse acknowledged the missing documentation of medications to be administered for Patient #23, and could not give the reason why the medication was not documented, as the physician ordered.

During a review and interview with the Medical Records staff at 8:45 a.m., on 1/9/2012, and as stated in the patient's nursing notes, the Medical Records Director verified the patient was discharged from the facility at 4:15 p.m., on 1/9/2012. No physician order was available to indicate Patient #23 was not to receive the ordered medications on the date of discharge, up to the time of leaving the facility at 3:37 p.m.

During an initial facility entry tour of Patient #23's room on 1/9/12, a small plastic cup containing what appeared to be thickened crème was observed sitting on the dresser.

The tour of the room was accompanied by the registered nurse supervisor. When asked what was in the cup, she stated, "I don't know what it is. It smells like menthol, but I don't know for sure why it is sitting here." At the time of the tour, neither of the two residents was in the room.
The nursing supervisor took the cup and said she would investigate what the cream like substance is and why it is there.

At 3:37 p.m., on 1/10/2012, a discussion was held with the supervisor about her findings related to the cup. She said, "It is a sports crème like Bengay, used for pain." She went on to say she had discovered the patient was given the cup of crème to rub on her sore hip area immediately when received. The supervisor said, "Instead, she decided to take a shower and left the medication sitting in her room until a later time."

A record review of Patient #23's Medication Administration Record (MAR) revealed there was a physician order, dated 1/6/12, for, "Sports crème to right hip , four times a day, for five days." The medication was received on the morning of 1/7/12 by the facility, in time for the day's 1:00 p.m., 6:00 p.m., and 9:00 p.m., doses. There was also documentation of a 1:00 a.m., dose to administer the medication. On 1/8/12, there is no documentation by nursing of the patient having received or refused any of the physician ordered pain medication since the 1:00 a.m., dose on 1/8/12.

During the interview with the nursing supervisor, she indicated the medication cart is kept inside the medication room, and said, "The nurse is supposed to apply the crème for pain herself, or ask the nurse manager to go to the patient's room to do it." She agreed there was no MAR documentation of administration of the crème, after 1:00 a.m., on 1/8/12.

Based on record review, observation and interview the facility nursing staff failed to follow physician orders; failed to accurately document on the Medication Administration Record and failed to follow the standard of practice for medication administration for 10 (Patients #1, #2, #3, #4, #7, #9, #11, #23, #31, and #32) out of a sample of 39 records reviewed.

The findings include:

1. On 1/9/12 at 9:30 a.m. an observation on the 100 wing revealed a nursing station that was accessible through an unlocked door behind the nursing station and the medication room/door was also accessed without difficulty. Two nurses were observed in the medication room. On the top of the medication cart was a tuberculin syringe. The syringe was filled with a clear liquid substance (1 unit). This syringe was not labeled. In addition three medications were observed on the top of the medication cart. These medications were observed with a pharmacy label but lacked a patient label.
One staff nurse was asked about the medications. The staff nurse commented she was not assigned medications for that day and directed me to speak with the medication nurse. This staff nurse continued by stating the medication nurse was on break. The staff nurse then turned her back to the medication cart and continued to "check orders" with the other staff nurse who also had her back turned to the medication room cart and door. At this time a housekeeping staff member entered the medication room. The housekeeping staff was observed emptying trash bins in the medication room.

The staff nurse, at this time, observed the medications on the cart and stated, "I believe these med's (medications) were obtained from the other nursing station until we receive the medications from pharmacy." The nurse also commented she did not know what the substance was in the syringe. The nurse took the syringe and disposed of the syringe and its contents in the sharps container stating, "This isn't labeled it should be labeled, so I am just going to get rid of it."

The medication nurse returned to the medication room. When asked about the medications on top of the cart the medication nurse commented, the medications were obtained from the other nursing station for the 10:00 a.m., medication pass. The medication nurse then asked about the location of the syringe. The medication nurse was told by the staff nurse the syringe was discarded because it was not labeled. The medication nurse explained the syringe was a "PPD" (Purified Protein Derivative- an injectable liquid substance use to test for Tuberculin reaction). The medication nurse continued to comment the night nurse had filled the syringe but did not have time to administer the PPD, so she had agreed to administer the PPD. The medication nurse continued to explain that she was going to administer the unlabeled PPD for the night nurse, stating she trusted the night nurse and would have administered the unlabeled PPD drawn by the night nurse. The other medications were then placed into patient medication bins as the nurse explained the medications were for those patients.

Standard of practice for administration of medications includes security of the medications and the proper labeling of all medications including the name of the patient and the date, time, drug, and nurse initials on pre-drawn syringes.

2. Medication Administration Records were reviewed between 8:30 a.m., and 9:00 a.m., on 1/11/12, for patients receiving blood pressure medication based on parameters. The following was revealed:

Patient #2 has a physicians order written on 1/8/12 for Clonidine 0.2 mg, po (by mouth), q (every) 6-8 hrs, prn (as necessary), for SBP (systolic blood pressure) greater than 170 and DBP (diastolic blood pressure) greater than 95. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6-8 hours to determine if it was necessary to administer the medication. It was also acknowledged that the order required clarification relating to time of administration (every 6 hours or every 8 hours).

Patient #3 has a physician order written on 1/7/12 for Norvase, 10 mg, qam, hold Norvase for B/P (blood pressure) over or equal to 100/60. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the order to hold the Norvase was not transcribed onto the Medication Administration Record, and the patient's blood pressure was not being evaluated prior to administration of the medication at 10:00 a.m. each day (see 3. below)

Patient #9 has a physician order written on 12/20/11 for Lisinopril, 10 mg, 1 daily, hold if BP (blood pressure) less than or equal to 100. The patient's blood pressure was documented as being taken and recorded every day at 6 a.m. There was no documentation that the patient's blood pressure was taken prior to the administration of medication at 10:00 a.m., each day. Upon interview, the Nursing Supervisor stated that the patient's blood pressure is taken by a technician, written on a small piece of paper, and given to the patient to hand to the licensed nurse prior to receiving the medication at 10:00 a.m. The Nursing Supervisor and licensed nurse administering medications acknowledged that there was no documented record of the blood pressure being taken and evaluated relating to the parameter. In addition, it was also acknowledged that the parameter of 100 did not indicate systolic or diastolic and required physician clarification.

Patient #11 has a physician order written on 1/2/12 for Clonidine, 0.1 mg, po, q6h, prn, BP greater than 160/100. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

Patient #31 has a physician order written on 12/19/11 for Clonidine, 0.1 mg, po, q8h, prn for BP greater than 140/90. Upon interview, the Nursing Supervisor and the licensed nurse administering medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

Patient #32 has a physician order written on 12/18/11 for Clonidine, 0.1 mg, po, q6h, prn for BP greater than 140/90. Upon interview, the Nursing Supervisor and licensed nurse administering the medications acknowledged that the patient's blood pressure was not being monitored every 6 hours to determine if it was necessary to administer the medication.

3. A total of 11 patient medication administrations were observed during the 10:00 a.m., medication pass on 1/9/11 on the 100 unit. The findings for the medication pass include:
Patient #1 was observed to refuse a daily dose of Miralax 17 gram dose. The nurse was observed documenting on the MAR (Medication Administration Record) after the medications for that patient was completed. The nurse stated, "I want to document on the MAR before I go on to the next patient."
A review of the 10:00 a.m., entries on the MAR was conducted at 1:00 p.m. This review revealed the nurse had entered her initials indicating the Miralax was administered. This was confirmed through an interview with the Pharmacist at 2:00 p.m. The pharmacist revealed the entry was inappropriate, commenting this entry indicates the patient received this medication at 10:00 a.m. The pharmacist continued by stating, "Even if the medication was offered at a later time as a follow up, the 10:00 a.m., dose should be marked as refused." The pharmacist continued to explain if the medication was administered at a different time, which time would be entered with an explanation and the nurse's initials. The pharmacist commented when a medication is refused, held, or missed the medication time is circled with an explanation of why the medication was not given. The pharmacist continued by stating, "The nurse should initial by the circled entry and then notify the physician." The pharmacist also commented the nurses had been inserviced (provided education) on medication administration, medication administration documentation, and medication administration expectations for the facility including a process to maintain a patient medication bin in the medication cart.
A review of the MAR on 1/10/12 did not contain a correction of the 1/09/2012 MAR documentation for the refused Miralax dose. In addition, the MAR did include a new order for the Miralax 17 Grams to be given as a prn medication. The nurse failed to document the refused dose appropriately.

Patient #3 was observed to receive Norvasc 10 mg by mouth during the 10:00 a.m., medication pass. The nurse did not take the patient blood pressure prior to the medication administration. A review of the MAR and physician orders was conducted at 1:00 p.m. The physician order dated 1/7/12 documented at 7:58 p.m., as "hold Norvasc for BP less than or equal to 100/60." The MAR did not include this order.
In addition the MAR also includes an order for "Clonidine HCL (Hydrochloride) 0.1 MG q4h prn po for blood pressure 150/100. This medication is documented as given at 6:00 a.m., on 1/7/12 but does not include the BP reading at the time of administration. On 01/08/12 a 6:00 a.m., administration of this medication documents the blood pressure at 156/90 and on 01/08/12 a 6:00 p.m., administration of this medication documents the blood pressure at 154/100. The systolic and diastolic parameters were not clarified relating to the Clonidine order.

Patient #4- The nurse was observed to explain to Patient #4 that she was waiting for the Bacitracin (topical antibiotic) from the pharmacy. The patient commented that he had the medication in his room and was applying the medication himself. A review of the MAR revealed that the Bacitracin was to be applied to "new nasal piercing after shower daily, times 10 days."
This medication was not administered at 10:00 a.m., on 01/09/12. The review of the MAR at 1:00 p.m. on 01/09/2012 revealed that the nurse's initials documented the medication was administered. An interview with the pharmacist at this time revealed the medication was not to be applied by the patient unless there was a specific physician order indicating the patient was allowed to self-administer this drug. A joint review of the physician's orders revealed the chart did not contain an order for self-administration.

The medication nurse documented the medication as administered and did not check the orders for self-administration or recover the medication from the patient when the patient advised he had the medication in his room.
Patient #7 received a tablet labeled as 8.6 Sennosides and 50 Docusate. The nurse explained the tablet was a Senna tablet. The MAR documented the patient was to receive Senna 100 mg 1 tablet at 10:00 a.m. The nurse was asked about the label not indicating the medication as Senna 100 mg. The nurse replied, "This is what I have always used for Senna." The patient was administered also administered Colace (Docusate) 100 mg at this time per physician orders.

An interview with the Pharmacist at 2:30 p.m., on 1/9/11 confirmed the tablet labeled 8.6 Sennosides and 50 Docusate is Senna S. The pharmacist continued to explain the Senna table is without the Docusate (Colace).

The nurse did not follow physician orders for Senna 100 mg and administered Senna S, containing 50 mg of Docusate (Colace). Thus, the patient received 150 mg of Colace, instead of the 100 mg as order by the physician.

In addition, Patient #7 presented at the medication window with a 3 X 5 paper stating "BP 118/78." The medication nurse was asked about the information on the paper. The nurse stated the technician marks the BP for us and the patient will bring it to the window. The nurse continued to explain the BP was from the morning vital signs.

4. An interview with the acting Director of Nursing (DON) was conducted on 01/10/2012 at 9:30 a.m., regarding the blood pressure medication orders including the blood pressure orders with and without parameters, symbol utilization and meaning for < and > (with and without a line underneath this symbol) and the monitoring of blood pressures. The DON explained that vital signs, including blood pressures, are checked at 6:00 for all patients. This is documented on the flow sheet daily. The DON was asked about the blood pressures being done for prn orders for blood pressure medications and for blood pressure medications being given, on a continuum, based on specific parameters. The DON explained that blood pressures would be taken as needed and documented on the MAR. When asked why blood pressure readings were being written on a small piece of paper and that this piece of paper was observed being handed to the nurse at the 10:00 a.m., medication pass; the DON stated, "We do not have a procedure like that." The DON was not able to clarify if blood pressure parameters were for both the systolic and the diastolic (top number systolic- bottom number diastolic) blood pressures, or if just one (systolic or diastolic) number was needed to meet the criteria for medication administration. The DON commented that administering medications, according to the physician orders, was an expectation according to the facility policy.
A review of the policy, for accepted symbols used in the facility, did not include the > (greater than) symbol or < (less than) symbol with a line under the symbol to indicate equal to.

5. On 01/10/2012 an interview with the medication nurse, assigned to the 100 hall, was conducted at 10:30 a.m. The nurse was asked about the Bacitracin order for Patient #4. The nurse stated, "This is what he was given today." The nurse presented a "for individual use only" foil packet labeled as "Triple Antibiotic." The 1/10/12 medication nurse stated, "I have not entered my documentation onto the MAR yet." Review of the MAR and physician order, at this time, revealed that the patient was to have Bacitracin applied to "new nasal piercing after shower daily." The 1/10/12 medication nurse did not follow the physician order for Bacitracin.

6. Record review of the Medication Administration Record for Patient #23 revealed the lack of document evidence of administration medications, according to physician's orders, as follows:

a) Mobic, 15 mg., one tablet by mouth, daily: no doses documented on 1/8/12;
b) Lobid, 600 mg., one tablet by mouth, twice a day: no doses documented on 1/8/12 and at 10:00 a.m. on 1/9/12 (left facility at 1/9/12 at 4:15 p.m.);
c) Subutex 8 mg., SL, four times daily: no doses documented, as ordered, at 1800 and 2200 on 1/7/12 and also no doses documented for 1/8/12; doses also not documented for
6:00 a.m. and 1:00 p.m. on 1/9/12 (left facility at 1/9/12 on 1/9);
d) Seroquel 100 mg., one tablet by mouth at bedtime: no doses documented for 2100 on
1/8/12;
e) Cyclobenzaprine HCL 10 mg., one tablet three times a day: no doses documented on 1/8/12, and no doses documented on 6:00 a.m. and 1:p.m. doses on 1/9/12 (left facility at
1/9/12 at 4:15 p.m. on 1/9);
f) Lopressor 25 mg., one tablet by mouth twice a day: no doses documented on 1/8/12, and at 10:00 a.m. on 1/9 (left facility at 1/9/12 at 4:15 p.m.);
g) Neurontin 900 mg., three tablets (3=900), by mouth, four times a day: no doses
documented on 1/8, and no documentation for 6:00 a.m. and 1:00 p.m. doses for
1/9/12. (left facility at 1/9/12 at 4:15 p.m.). .
h) Clonzepam 1 mg., one tablet, by mouth, four times a day: no doses documented, as
ordered on 1/8, and no documentation of the 6:00 a.m. and 1:00 p.m. doses on
1/9/12 (left facility at 1/9/12 at 4:15 p.m.);
i) Dilantin 100 mg. take two caps. (2=200 mg.), three times a day: no doses documented, as ordered on 1/8/12, and no doses documented for 6:00 a.m. and 1:00 p.m.(left facility at 1/9/12 at 4:15 p.m.);
j) Zoloft 100 mg., take two tablets (2=200), by mouth, at bedtime: no doses documented, as ordered on 1/8/12.
k) Ambien 10 mg., one tablet, by mouth, at bedtime: no dose documented, as ordered, on
1/8/12.

During an interview with the registered nurse supervisor, at 3:37 p.m., on 1/10/2012, the nurse acknowledged the missing documentation of medications to be administered for Patient #23, and could not give the reason why the medication was not documented, as the physician ordered.

During a review and interview with the Medical Records staff at 8:45 a.m., on 1/9/2012, and as stated in the patient's nursing notes, the Medical Records Director verified the patient was discharged from the facility at 4:15 p.m., on 1/9/2012. No physician order was available to indicate Patient #23 was not to receive the ordered medications on the date of discharge, up to the time of leaving the facility at 3:37 p.m.

During an initial facility entry tour of Patient #23's room on 1/9/12, a small plastic cup containing what appeared to be thickened crème was observed sitting on the dresser.

The tour of the room was accompanied by the registered nurse supervisor. When asked what was in the cup, she stated, "I don't know what it is. It smells like menthol, but I don't know for sure why it is sitting here." At the time of the tour, neither of the two residents was in the room.
The nursing supervisor took the cup and said she would investigate what the cream like substance is and why it is there.

At 3:37 p.m., on 1/10/2012, a discussion was held with the supervisor about her findings related to the cup. She said, "It is a sports crème like Bengay, used for pain." She went on to say she had discovered the patient was given the cup of crème to rub on her sore hip area immediately when received. The supervisor said, "Instead, she decided to take a shower and left the medication sitting in her room until a later time."

A record review of Patient #23's Medication Administration Record (MAR) revealed there was a physician order, dated 1/6/12, for, "Sports crème to right hip , four times a day, for five days." The medication was received on the morning of 1/7/12 by the facility, in time for the day's 1:00 p.m., 6:00 p.m., and 9:00 p.m., doses. There was also documentation of a 1:00 a.m., dose to administer the medication. On 1/8/12, there is no documentation by nursing of the patient having received or refused any of the physician ordered pain medication since the 1:00 a.m., dose on 1/8/12.

During the interview with the nursing supervisor, she indicated the medication cart is kept inside the medication room, and said, "The nurse is supposed to apply the crème for pain herself, or ask the nurse manager to go to the patient's room to do it." She agreed there was no MAR documentation of administration of the crème, after 1:00 a.m., on 1/8/12.

Based on facility records reviewed, policy and procedure review, and staff interview, the facility failed to ensure patient records were completed within 30 days following discharge.

The findings include:

1. An interview was conducted with the medical records staff on 1/10/11 from 9:30 a.m., to 11:00 a.m. She stated she audits discharge patient records on the 31st day of discharge. They will write a letter to the physicians who have not completed discharge patient records within 30 days of discharge. They will then audit the records again within one week and what is not completed they will write another letter to the physician notifying them of the incomplete patient records. In the past year they wrote a letter to one physician notifying him of the possible suspension because he has not completed patient records with numerous letters of reminders. She stated there is a policy and procedure they follow for this process.

A review of the policy and procedure #IM-XI-100 refers to discharge summaries. The Health Information Management Director reviews patient discharge records weekly. If the discharge summaries are delinquent 60 days past the discharge date the physician's clinical privileges may be suspended. The first letter gives the physician 10 days to complete these discharge patient records. The second notice to the physician, the facility may fine them for each patient record incomplete and they have another 10 days to complete these charts. The third letter notifies the physician needs to complete these charts within 10 days or the physician's privileges may be suspended.

A review of the last 3 months of letters sent to physicians show the following:
- November 2011 letters showed 19 of 45 letters sent to the physicians showed patient discharge records are delinquent by 60 days or more.
- December 2011 letters showed 14 of 24 letters sent to the physicians showed patient discharge records are delinquent by 60 days or more.
- January 2012 letters showed 5 of 8 letters sent to physicians showed patient discharge records are delinquent by 60 days or more.

The medical records staff stated they sent one letter to one physician regarding possible suspension. They have not given any other physician a possible suspension letter even though they have had several delinquent discharge patient records. Also, they have not fined any physician even though these physician have received several letters for delinquent patient charts.

2. The medical records staff also stated they make a grid weekly to show the therapist who are delinquent on their documentation of the patient discharge records. A review of the past 2 months of this grid shows the following:
- November 1, 2011 - 145 delinquent patient discharge records.
- November 18, 2011 - 139 delinquent patient discharge records.
- November 15, 2011 - 167 delinquent patient discharge records.
- November 30, 2011 - 266 delinquent patient discharge records.
- December 7, 2011 - 212 delinquent patient discharge records.
- December 13, 2011 - 183 delinquent patient discharge records.
- December 22, 2011 - 203 delinquent patient discharge records.

An interview was conducted with the medical record staff. She stated she sends this grid to the therapists' supervisor. The supervisor is suppose to ensure the therapists complete these discharge patient records. The follow-up the medical record staff is capable of doing for these therapist is to review these delinquent patient charts weekly to ensure compliance.

Based on interview and record review the facility failed to ensure the facility's approved menus, including therapeutic menus were annually reviewed and approved by the Registered Dietitian (RD).

The findings include:

The facility's approved menus were reviewed on 1/09/12 at 1:30 p.m. Present during the review were the Food Service Director (FSD), Registered Dietitian (RD), and the Cooperate FSD.
The menus included a two week cycle, to include flow sheets documenting all the therapeutic diet restrictions provided by the facility. Review of the menus indicated the menus were signed and approved, and dated on 4/2009, by a previously employed RD. Further review of the nutritional analysis also revealed those documents were signed and approved on 4/2009.

The RD was interviewed related to whether she had signed and approved the menus and the nutrition analysis, the RD commented that, "I had only been here (meaning employed) since March of 2010, and the previous RD should have signed and reviewed the menus."

Review of the facility's approved job description for the RD, signed 3/14/11 which was the RD date of hire, reads as follows; under the section titled "Specific Areas of Responsibility to Position."

1. Develop, implement, coordinate, monitor, and evaluate nutritional treatment plans appropriate and timely.
2. Develop and organize menu systems to ensure a varied meal schedule appropriate per physician's orders, and patient/staff nutritional needs.
3. Develops and implements nutrition services policies and procedures to ensure compliance with all applicable governing bodies.

This Special Condition is not met based on record reviews and interviews, the facility failed to meet all the special provisions applying to this psychiatric hospital. Please refer to the following regulations: B0100 and B0101.

These failures present a substantial probability to adversely affect all patients' physical health, safety, and well-being.

The findings include:

B0100 - Based on record reviews and interviews, the facility failed to meet the requirements for:
482.1 - Medical Records
482.21 - Quality Assessment and Performance Improvement


B0101 - Based on record reviews and interviews, the facility failed to maintain clinical records that permit determination of the degree and and intensity of treatment furnished to Medicare beneficiaries as outlined in 482.61.

Based in record reviews and interviews, the facility failed to meet the requirements for:
482.1 - Medical Records
482.21 - Quality Assessment and Performance Improvement

The findings include:

1. Based on record reviews and interviews, the facility failed to document the reason for admission as stated by the patient for 4 of 4 open records reviewed.

2. Based on record reviews and interviews, the facility failed to document Social Service notes related to interviews with patient, family or others in order to assess for home plans, family attitudes and availability of community resources as well as a social history for 5 of 5 open records reviewed.

3. Based on record reviews the facility failed to document on the psychiatric evaluation the onset of illness and the circumstances leading to admission for 5 of 5 open records reviewed.

4. Based on record reviews the facility failed to document on the psychiatric evaluation a description of the attitudes and behaviors of the patient at admission for 5 of 5 open records reviewed.

Based on record reviews and interviews, the facility failed to maintain clinical records that permit determination of the degree and and intensity of treatment furnished to Medicare beneficiaries as outlined in 482.61.

The findings include:


1.) On 1/11/12, a review of the medical record for Patient #15 revealed the following:
He was admitted on 12/19/11 with a dual diagnosis of "psych" (not-specific) and "ETOH Dependency."

Review of the document "Clinical Therapist Patient Group Record" revealed the following for a sample of 15 therapy meetings:

1. 1/8/12 - (Sunday) 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

2. 1/7/12 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

3. 1/6/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Finally shared in depth

4. 1/6/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Alert and quiet

5. 1/5/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Very alert and supportive

6. 1/5/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Emotional/connected

7. 1/4/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Only introduced himself to others


8. 1/4/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Excellent sharing - learned about his history ___ ___

9. 1/2/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Shared worries about his wife

10. 1/2/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: ________________

11. 1/1/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

12. 12/31/11 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

13. 12/30/11 2:30 p.m. - Psychoeducation Group
Patient was absent
Required "Reason for Absence" was blank.

14. 12/30/11 - 12 noon - Therapist Process Group
Strategies/Participation: Audio/visual
Purpose: Gain coping skills
Response: Not responsive
Evaluation: No further teaching needed on topic/issues
Comments: ________________

15. 12/30/11 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: __________________
Response:__________________
Evaluation:_________________
Comments: ________________

None of the therapy group meetings documented in these patient records have a record of the content of the meeting, the subject (issues/topics) of the meeting or documentation of the purpose of the particular therapy, making identification of degree and intensity of treatment difficult.

Interview with the program director on 1/11/12 at about 2:30 p.m., after his brief review of the clinical record, revealed his agreement that the document utilized to record therapy sessions lacks the information necessary to understand what therapy was rendered, what means of treatment was utilized and what outcomes were attained.

2.) Patient #26 was admitted on 12/31/11 with a admission diagnosis of "Bipolar Disorder and Alcohol Dependency."

Review of the document "Clinical Therapist Patient Group Record" revealed the following:

1. 1/8/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist.

2. 1/7/12 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Decrease symptoms of depression and anxiety
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

3. 1/1/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforce Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist.

4. 12/31/11 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Decrease symptoms of depression and anxiety
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist

Over a 12-day period, patient only attended 1 group therapy.

3.) Patient #27 was admitted to the facility on 1/5/12 with an admission diagnosis of Schizophrenia disorder and ETOH (Alcohol) Dependency.

The clinical record fails to document any therapy treatments since admission. Record contains assessments, progress notes, discharge planning and nursing flow sheets. No documentation could be located related to treatments and attendance in group meetings.

This Special condition is not met based on record reviews and interviews, the facility failed to document degree and intensity of treatments provided to Patients #15, #26, and #27 (3 of 4 records reviewed). Documentation failed to show what subject was presented and content of the meeting.

These failures present a substantial probability to adversely affect all patients' physical health, safety, and well-being.

The findings include:

1.) On 1/11/12, a review of the medical record for Patient #15 revealed the following:
He was admitted on 12/19/11 with a dual diagnosis of "psych" (not-specific) and "ETOH Dependency."

Review of the document "Clinical Therapist Patient Group Record" revealed the following for a sample of 15 therapy meetings:

1. 1/8/12 - (Sunday) 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

2. 1/7/12 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

3. 1/6/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Finally shared in depth

4. 1/6/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Alert and quiet

5. 1/5/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Very alert and supportive

6. 1/5/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Emotional/connected

7. 1/4/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Only introduced himself to others


8. 1/4/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Excellent sharing - learned about his history ___ ___

9. 1/2/12 - 12 noon - Therapy Process Group
Strategies/Participation: Discussion
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: Shared worries about his wife

10. 1/2/12 - 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: Gain coping skills
Response: Voiced partial understanding
Evaluation: Reinforced Practice
Comments: ________________

11. 1/1/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

12. 12/31/11 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

13. 12/30/11 2:30 p.m. - Psychoeducation Group
Patient was absent
Required "Reason for Absence" was blank.

14. 12/30/11 - 12 noon - Therapist Process Group
Strategies/Participation: Audio/visual
Purpose: Gain coping skills
Response: Not responsive
Evaluation: No further teaching needed on topic/issues
Comments: ________________

15. 12/30/11 4:00 p.m. - Psychoeducation Group
Strategies/Participation: Explain/Demonstrate
Purpose: __________________
Response:__________________
Evaluation:_________________
Comments: ________________

None of the therapy group meetings documented in these patient records have a record of the content of the meeting, the subject (issues/topics) of the meeting or documentation of the purpose of the particular therapy, making identification of degree and intensity of treatment difficult.

Interview with the program director on 1/11/12 at about 2:30 p.m., after his brief review of the clinical record, revealed his agreement that the document utilized to record therapy sessions lacks the information necessary to understand what therapy was rendered, what means of treatment was utilized and what outcomes were attained.

2.) Patient # 26 was admitted on 12/31/11 with a admission diagnosis of "Bipolar Disorder and Alcohol Dependency."

Review of the document "Clinical Therapist Patient Group Record" revealed the following:

1. 1/8/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist.

2. 1/7/12 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Decrease symptoms of depression and anxiety
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Attentive

3. 1/1/12 - (Sunday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Increase support systems
Response: Voiced understanding
Evaluation: Reinforce Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist.

4. 12/31/11 - (Saturday) - 11 a.m. - Therapist Group
Strategies/Participation: Patient/Discussion
Purpose: Decrease symptoms of depression and anxiety
Response: Voiced understanding
Evaluation: Reinforced Practice
Comments: Absent
Patient was absent but his responses were recorded and signed by the therapist

Over a 12-day period, patient only attended 1 group therapy.

3.) Patient #27 was admitted to the facility on 1/5/12 with an admission diagnosis of Schizophrenia disorder and ETOH (Alcohol) Dependency.

The clinical record fails to document any therapy treatments since admission. Record contains assessments, progress notes, discharge planning and nursing flow sheets. No documentation could be located related to treatments and attendance in group meetings.

Based on record reviews and interviews, the facility failed to document the reason for admission as stated by the patient for 5 (Patients # 14, #15, #21 #26, and #27) of 5 open records reviewed.

The findings include:

On 1/11/12, a review of the clinical records for Patients # 14, #15, #21 #26, and #27 revealed the lack of documentation as to the reason for admission as stated by the patient and/or others significantly involved.

On 1/11/12, an interview with a therapist confirmed the lack of this informatin in the clinical record.

Based on record reviews and interviews, the facility failed to document Social Service notes related to interviews with patient, family or others in order to assess for home plans, family attitudes and availability of community resources as well as a social history for 5 (Patients #14, #15, #21 #26, and #27) of 5 open records reviewed.

The findings include:

On 1/11/12, a review of the clinical records for Patients # 14, #15, #21 #26, and #27 revealed the lack of documentation by a Social Worker related to reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.


On 1/11/12, an interview with the program director verified this ommission and stated that he signs off on records when the therapists do the notes. He verified the notes were not written by a Social Worker.

Based on record reviews the facility failed to document on the psychiatric evaluation the onset of illness and the circumstances leading to admission for 5 (Patients #14, #15, #21, #26, and #27) of 5 open records reviewed.

The findings include:

On 1/11/12, a review of the psychiatric evaluations for Patients #14, #15, #21, #26, and
#27 failed to reveal documentation of the onset of illness and the circumstances leading to this admission.

Based on record reviews the facility failed to document on the psychiatric evaluation a description of the attitudes and behaviors of the patient at admission for 5 (Patients #14, #15, #21 #26, and 27) of 5 open records reviewed.

The findings include:

On 1/11/12, a review of the psychiatric evaluations for Patients #14, #15, #21, #26, and
#27 failed to reveal documentation of any attitudes or behaviors exhibited at admission.