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Based on policy review, record review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) contained individualized problem statements for four (4) of 12 active sample patients (A5, A6, A7, and A8). Specifically, the MTPs included problem statements with diagnoses, generalized statements, diagnostic terms, or psychiatric jargon rather than individualized and behaviorally descriptive psychiatric problem statements based on each patient's clinical assessment data. This failure can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Policy Review

A review of the facility's policy titled, "Treatment Plan" with an effective date of 8/14/18, stipulated that, "Treatment planning shall be individualized, patient-centered, and informed by diagnoses ... and driven by the presenting problems ... The problems shall reflect the behavioral manifestations and/or the pathophysiological manifestation of the underlying diagnoses, or conditions, and prioritized by reason for admission ..." In addition, the policy required that, "The problem, goals, objectives and interventions should reflect the psychiatric documentation in the initial psychiatric evaluation ..." The facility failed to comply with this policy requirement consistently.

B. Record review

1. Patient A5's MTP, dated 8/7/18, included the following deficient psychiatric problem statement: "Episodes of aggressive behavior." This problem failed to describe how the patient precisely manifested aggressive behavior. There were no individualized descriptors of the patient's aggressive behaviors based on the following clinical information noted in the Psychiatric Evaluation, dated 7/16/18: " ... admitted for aggressive behavior towards [his/her] family and suicidal ideation ... [S/he] has been physically aggressive towards both her siblings and [his/her] mother since last discharge ... [S/he] describes wishing [s/he] were dead and having thoughts of killing [himself/herself] with a plan to jump out of a window or cut too deep ... reports that bullying by [his/her] [sibling] is the main precipitant that worsens [his/her] mood and SI [suicidal ideation]. This information was not included in the MTP to help the treatment team to formulate individualized goals and specific treatment modalities/interventions.

2. Patient A6's MTP, dated 8/31/18, included the following deficient psychiatric problem statement: "Psychosis." The problem was a diagnosis and did not describe how the patient precisely manifested the symptoms associated with the diagnosis. In addition, there were limited individualized descriptors noted in the Psychiatric Evaluation (PE), dated 7/9/18. This PE reported: " ... [S/he] stopped medication in early July after informing [his/her] psychiatrist [s/he] intended to do so ... [S/he] developed acute delusion, primarily grandiose, visual and auditory hallucinations, and bizarre and agitated behavior. [S/he] threatened to burn down the hospital where [his/her] father took [him/her] for care ..." This PE provided no information about the content of the delusion, hallucinations, and bizarre behavior, therefore making it more difficult to formulate an individualized treatment plan.

3. Patient A7's MTP, dated 9/4/18, included the following deficient psychiatric problem statement: "Psychosis." The problem was a diagnosis and did not describe how the patient precisely manifested the symptoms associated with the diagnosis. There were no individualized descriptors of how the patient precisely manifested the symptoms associated with the diagnosis. The Psychiatric Evaluation dated 8/14/18 noted: " ... [s/he] stopped taking medications because 'guides' told [him/her] to do so ... [s/he] was religiously preoccupied and delusional. [S/he] had been fasting and required admission to medical floor for dehydration ..." This information was not included in the MTP to facilitate the formulation of individualized goals and specific treatment modalities/interventions.

4. Patient A5's MTP, dated 9/4/18, included the following deficient psychiatric problem statement: "Suicidal Ideation." This problem failed to describe how the patient precisely manifested the symptoms identified. There were no individualized descriptors of the patient's suicidal ideation based on clinical information noted in the Psychiatric Evaluation, dated 8/21/18: " ... [his/her] mother called 911 when she received a call from [his/her] ex-[boyfriend/girlfriend] who had received a goodbye text ... [S/he] had cut [himself/herself] on the left forearm ... Patient states recent attempt related to triggers of losing job, loss of [boyfriend/girlfriend], fear of losing housing and increasing audio hallucinations ..." This information was not included on the MTP to facilitate the formulation of individualized goals and specific treatment modalities/interventions.

C. Interviews

1. In an interview on 9/5/18 at 12:10 p.m., the treatment plans were discussed with RN1. RN1 stated that the RN initiates the treatment plan problem and goal statements if the patient is admitted after hours. She did not dispute the findings that the problem for the problem statement for active sample patient A6 was not written in behavioral or descriptive terms.

2. In an interview on 9/6/18 at 10:45 a.m., the treatment plans for active sample patients A5, A6, A7, and A8 were discussed with the Director of Nursing. She did not dispute the findings that patient problems were not individualized. She shared that the electronic medical record limits the extent to which the plans can be individualized.

3. In an interview on 9/6/18 at 11:30 a.m., the lack of descriptive problem statements was discussed with the Medical Director and CEO. The Medical Director did not dispute the findings that the problems identified in the treatment plan lacked individualization and did not include how each patient precisely manifested symptoms associated with psychiatric diagnoses.

Based on record review, policy review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) contained individualized treatment modalities (called interventions by the facility) to address specific psychiatric treatment needs of four (4) of 12 active sample patients (A5, A6, A7, and A8). Specifically, MTPs contained interventions that were generic and routine discipline functions or job duties, failed to identify whether they would be delivered in individual or group sessions, and did not always identify a frequency of contact and a specific focus of treatment based on presenting psychiatric symptoms. These failures result in a lack of guidance for staff to provide coordinated and individualized active treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Policy Review

A review of the facility's policy titled, "Treatment Plan" with an effective date of 8/14/18, stipulated the following under "Master Treatment Plan, [Nursing staff, Social Work]: "responsible for writing patient-specific therapeutic interventions that relate to each problem, objective(s), specifying responsible discipline, services provided, frequency of service and target date for review ..." "Documentation is clear and concise, and portrays the active treatment being provided." The facility failed to follow the policy requirements regarding patient-specific interventions related to each problem and objective consistently. Also, the policy requirement regarding frequency of service was not always followed.

B. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (date of the plan in parenthesis): A5 (8/7/18); A6 (8/31/18); A7 (9/4/18); and A8 (9/4/18). This review revealed the following deficient interventions assigned to the psychiatrist (MD), registered nurse (RN, and social worker (SW). Most discipline intervention statements included routine job duties such as assessing and monitoring patient, instead of individualized and specific active treatment interventions held in individual or group sessions to assist patients to replace problem behaviors, accomplish treatment objectives, and to improve, reduce, or eliminate, presenting psychiatric symptoms.

1. Patient A5's MTP included the following deficient psychiatric intervention statements for the problem of "Episodes of aggressive behavior." The objectives included but were limited to: "Identify specific strategies and coping skills to manage symptoms and maintain safety." "Identify contributing factors such as exacerbation of underlying or comorbid diagnoses." "Remission of suicidal ideation."

MD Interventions: "Interview and assess patient." "Gather collateral from family, providers." "Will assess daily for SI, plan and intent." "Increase to 1:1 supervision for behavioral escalation as this requires higher level of supervision than that required to mitigate suicide risk ..." "Placed patient on 5-minute safety checks due to increased aggression while on Level 1 supervision for meals and off unit groups." These intervention statements were routine MD functions and would be performed as a part of regular hospital job duties. None of these interventions were related to assisting the patient to accomplish the identified objectives. There were no active treatment interventions on the MTP reflecting the psychiatrist meeting with this patient in individual sessions to provide information about medications and managing his/her aggression behaviors.

RN Interventions: "1:1 supervision out of room to proactively provide staff attention and redirection to reduce risk of escalation to physical aggression." "Placed patient on 5 minutes safety checks due to increased aggression while on Level 1 supervision, continue level 1 supervision for meals and off unit groups." "Will assess daily for SI, plan and intent." "Increase to 1:1 supervision for behavioral escalation as this requires higher level of supervision than that required to mitigate suicide risk ..." "Placed patient on 5-minute safety checks due to increased aggression while on Level 1 supervision for meals and off unit groups." These intervention statements were routine RN functions and would be performed as a part of regular hospital duties. None of these interventions were related to assisting the patient to accomplish the identified objectives. There were no active treatment interventions for this objective reflecting the RN meeting with this patient in individual or group sessions to provide information about managing his/her aggressive behaviors.

SW Interventions: "Coordinate with family and CMHC [Community Mental Health Center] for discharge planning." "Gather collateral from family, providers." These intervention statements were routine SW functions and would be performed as a part of routine hospital duties. None of these interventions were related to assisting the patient to accomplish the identified objectives. There were no active interventions on the MTP reflecting the SW meeting with this patient in individual sessions to provide information about managing his/her aggressive behaviors.

2. Patient A6's MTP included the following deficient psychiatric intervention statements for the problem of "Psychosis." The objective was: "Cooperate with services focused on stabilizing the current acute psychotic episode." Identify specific strategies and coping skills to manage symptoms and maintain safety." "Identify contributing factors such as exacerbation of underlying or comorbid diagnoses." "Remission of suicidal ideation."

MD Intervention: "Will acknowledge that [s/he] needs medication to control psychosis and maintain stability."

MD and RN Interventions: "Will comply with medication as prescribed by the physician." "Will acknowledge the effectiveness of the medications and side effects. "Demonstrate ability to tolerate gentle reality-based feedback from staff in response to expressed delusions." "Comply with scheduled mediations to avoid disruptive and aggressive behaviors ..."

The intervention statements above were mistakenly written as treatment interventions but were actually patient outcome statement regarding what the staff expected the patient to do, not the interventions the MD and RN would implement in individual or group sessions to assist the patient to resolve and manage presenting psychiatric problems.

MD and SW interventions: "Team is pursuing emergency guardianship to assist [Patient] in compensating from current psychiatric state, so that [s/he] can engage in tx [treatment] in a safe and reality-based way." This intervention statement was a clinical discipline task, not an intervention associated with helping the patient resolve his/her psychiatric symptoms.

RN interventions: "Nursing will provide an environment conducive to a restful night's sleep. Educate [Patient] on the benefit of good sleep hygiene." The first part of this intervention statement was a routine RN job duty. The latter part failed to include whether the education would be delivered in individual or group sessions and did not identify a frequency of contact.

3. Patient A7's MTP included the following deficient psychiatric intervention statements for the problem of "Psychosis." The objective was: "[Patient] will acknowledge that [s/he] has a mental illness and will comply with medication regiment (i.e. Abilify, Depakot [sic], Ativan)."

MD Interventions: "[Patient] will accept medications (i.e. Depakote, Ativan, Abilify) as indicated and prescribe by physician." This intervention statement was what the patient would be doing, not what the MD would do in individual sessions with the patient to help him/her to accept his/her medications and understand the benefits and side effect of medications prescribed.

RN Interventions: "Staff will monitor the client's medication compliance and effectiveness daily." "Nursing will provide an environment conducive to a restful night sleep. Educate [Patient] on the benefit of good sleep hygiene." NSG will meet with patient for 15 minutes every shift to assess for safety ..." These intervention statements included routine RN job duties. The statement regarding patient education failed to include whether the education would be delivered (individual or group sessions) and did not identify a frequency of contact.

MD and RN intervention: "[Patient] will receive education regarding illness, medication and address any other questions or concerns as needed." This intervention statement did not include a frequency of contact or whether the education would be delivered (individual or group sessions).

SW, MD, and RN intervention: "[Patient] will be able to express one to three benefits of medication compliance upon being prompted by staff ..." This statement was a patient outcome, not an intervention reflecting these discipline staff meeting with the patient in individual or group sessions to provide information regarding medication compliance associated with specified prescribed medication(s).

4. Patient A8's MTP included the following deficient psychiatric intervention statements for the problem of "Suicidal Ideation." The objectives were: "Acknowledge substance abuse as a precipitating factor in decompensation and suicidal ideation." "Verbalize hopeful statement regarding the future."

MD Interventions: "Assess the client for substance abuse and refer [him/her] to a substance abuse treatment program if necessary ..." "Psychology consultation for risk assessment and therapy." These intervention statements were routine MD functions of assessing and referring patients and would be performed as a part of regular hospital job duties. None of these interventions were related to assisting the patient to accomplish the identified objectives. There were no active interventions on the MTP reflecting the psychiatrist meeting with this patient in individual sessions to provide information about managing his/her presenting symptoms.

RN Interventions: "Nursing will focus [Patient] on the positive aspects of [his/her] life; ask [him/her] to provide a list of reasons to go on living." "Nursing will provide an environment conducive to a restful night's sleep. Educate [Patient] on the benefit of good sleep hygiene." "Nursing will provide verbal reinforcement to [Patient] for a more positive focus, hopeful statements ..." The intervention statement regarding obtaining a list and educating the patients did not identify a method of delivery or a frequency of contact. The intervention statement regarding providing a conducive environment was a routine RN functions and would be performed as a part of regular hospital duties. These interventions were not related to meeting with the patient in individual and group sessions to assist him/her to accomplish the identified objectives.

C. Interviews

1. In an interview on 9/5/18 at 12:10 p.m., interventions on the MTPs were discussed. RN1 did not dispute the findings that some nursing interventions were not active treatment intervention but were routine RN duties, not active treatment intervention reflecting what the staff would do to assist the patients to resolve his/her presenting symptoms. RN1 agreed that interventions did not always include a frequency of contact and did not dispute the finding that intervention statements did not identify the method of delivery for patient education.

2. In an interview on 9/6/18 at 10:45 a.m., the treatment plans for active sample patients A5, A6, A7, and A8 were discussed with the Director of Nursing. She did not dispute the findings that nursing intervention statements were routine RN job duties.

3. In an interview on 9/6/18 at 11:30 a.m. with the Medical Director, the Master Treatment Plans were discussed. He did not dispute the findings that MD interventions were routine MD functions.

Based on record review and interview, the facility failed to ensure that registered nurses and social workers adequately documented treatment interventions listed on the Master Treatment Plan to show detailed and comprehensive information about active treatment for four (4) of 12 active sample patients (A5, A6, A7, and A8). Specifically, documentation in the electronic medical did not consistently include the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

1. Patient A5's MTP, dated 8/7/18, included the problem of "Episodes of aggressive behavior." For the objective of: "Identify appropriate disposition and follow up care to manage aggressive behavior...," the MTP included the following RN interventions: "Nursing will meet with the patient for 5-15 minutes per shift to encourage [him/her] to seek out staff at any time if thoughts of harming self or others should occur." "Nursing staff will meet with patient for 5-15 minutes per shift to teach and encourage the use of safe alternatives to dangerous behaviors." A review of RN notes in the electronic medical record from 8/30/18 through 9/5/18 revealed no treatment notes reflecting that the RN met with the patient for 5 - 15 minutes to teach the use of safe alternatives. The patient teaching notes located were sparse and very vague. One RN note dated 9/1/18 at 10:14 p.m. reported, "Patient Teaching: Yes." "Patient Teaching Topic: Social Skills, Illness Management, Coping Skills." "Patient Teaching Outcome: Needs Reinforcement. These topics were very broad, and the notes did not record what the patient needed to reinforcement. Therefore, it was not possible to discern what information was provided during the intervention. These treatment note also failed to include the duration of contact identified in the intervention. Also, there was no specific information about the patient level of participation, level of understanding, and any specific comments made by the patient during the intervention.

2. Patient A6's MTP dated 8/31/18, included the problem of "Psychosis." For the objective of: "Cooperate with services focused on stabilizing the current acute psychotic episode," the MTP included the following intervention statement mistakenly written as a treatment modality: "Will acknowledge the effectiveness of the medications and side effect [sic]." During a review of RN notes in the electronic medical record from 8/31/18 through 9/5/18, no RN treatment notes were located regarding the patient acknowledging the effectiveness of medications and side effects. The patient teaching notes located were sparse and very vague. One RN note dated 9/4/18 recorded, "Patient Teaching: Yes." "Patient Teaching Topic: Social Skills, Medication Management, Coping Skills, Wellness Management." "Patient Teaching Outcome: Needs Reinforcement, Unable to comprehend." The topics were very broad the notes did not record what the patient needed to reinforcement or was not able to comprehend. Therefore, it was not possible to discern what information was provided during the intervention. This treatment note failed to specify information about the patient level of participation, level of understanding, and any specific comments made during the intervention given this patient's disorganized thinking.

3. Patient A7's MTP dated 9/4/18, included the problem of "Psychosis." For the objective of: "[Patient] will acknowledge that [s/he] has a mental illness and will comply with medication regiment (i.e. Abilify, Depakote [sic], and Ativan)," the MTP included the following RN intervention: "[Patient] will receive education regarding illness, medication ..." During review of RN notes in the electronic medical record from 8/31/18 through 9/5/18, no RN treatment notes were located reflecting specific information was provided regarding medications or the patient's illness. The patient teaching notes located were sparse and very vague. One RN note dated 9/5/18 recorded, "Patient Teaching: Yes." "Patient Teaching Topic: Medication Management, Coping Skills, Wellness Management." "Patient Teaching Outcome: Needs Reinforcement, Unable to comprehend." The topics were very broad; therefore, it was not possible to discern what information was provided during the intervention. This treatment note failed to specify information about the psychiatric medications identified, the patient's level of participation, level of understanding, and record any specific comments made during the intervention.

4. Patient A8's MTP dated 9/4/18, included the problem of "Suicidal Ideation." For the objectives of: "Acknowledge substance abuse as a precipitating factor in decompensation and suicidal ideation" and "Verbalize hopeful statement regarding the future," the MTP included the following RN interventions: "Nursing will focus [Patient] on the positive aspects of [his/her] life; ask [him/her] to provide a list of reasons to go on living." " ...Educate [Patient] on the benefit of good sleep hygiene." "Nursing will provide verbal reinforcement to [Patient] for a more positive focus, hopeful statements ..." During a review of RN notes in the electronic medical record from 8/31/18 through 9/5/18, no RN treatment notes were located reflecting specific information regarding the RN meeting with the patient to obtain a list from the patient or providing verbal reinforcement. The patient teaching notes located were sparse and very vague. One RN note dated 9/5/18 recorded, "Patient Teaching: Yes." "Patient Teaching Topic: Medication Management." "Patient Teaching Outcome: Able to comprehend." This topic was very broad and did not identify the specific medications or issues related to the medications discussed. The notes did not record what information the patient was able to comprehend. This treatment notes also failed to record the patient's level of participation and any specific comments made during the intervention.

B. Interview

In an interview on 9/6/18 at 10:45 a.m. with the Director of Nursing, RN treatment notes were discussed. She did not dispute the findings that RN treatment notes were sparse, not related to the interventions identified in the MTPs, and did not provide specific information about what was actually discussed with patients.

Based on record review and interview, it was determined that the Medical Director failed to:

I. Ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs) for four (4) of 12 active sample patients (A5, A6, A7, and A8). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B119)

II. Ensure that Master Treatment Plans (MTPs) contained individualized treatment modalities (called interventions by the facility) to address specific psychiatric treatment needs of four (4) of 12 active sample patients interventions (A5, A6, A7, and A8). Specifically, MTPs contained interventions that were generic and routine psychiatrists functions or job duties, failed to identify a frequency of contact, and a specific focus of treatment based on presenting psychiatric symptoms. This failure results in a lack of guidance for staff to provide coordinated and individualized active treatment, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)

Based on observation, record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. Master Treatment Plans (MTPs) contained individualized treatment modalities (called interventions by the facility) to address specific psychiatric treatment needs of four (4) of 12 active sample patients' interventions (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, MTPs contained interventions that were generic and routine registered nurses functions or job duties, failed to identify whether they would be delivered in individual or group sessions, and did not always identify a frequency of contact and a specific focus of treatment based on presenting psychiatric symptoms. There were no nursing interventions identified related to meeting with patients in individual or group sessions to provide information or education with a specific focus regarding each patient's identified psychiatric problems(s). This failure results in a lack of guidance for RN staff to provide coordinated and individualized active treatment, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)

II. Registered nurses documented treatment notes for interventions listed in the Master Treatment Plans (MTPs) for four (4) of 12 active sample patients (A5, A6, A7, and A8). Specifically, there was limited documented evidence of treatment notes reflecting that RNs met with patients to implement the interventions identified in MTPs. Also, there was limited documented evidence of the patients' response to treatment interventions. This deficiency potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

Based on record review and interview, the Director of Social Work failed to ensure that social work interventions on treatment plans stated specific treatment modalities for three (3) of eight (8) active sample patients (A5, A6, and A7). This deficiency results in treatment plans that failed to reflect comprehensive and individualized social work approaches to treatment. (Refer to B122)