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26641

26641

Based on record review and staff interviews, the facility failed to assure that Psychosocial Assessments for seven (7) of eight (8) active sample patients (02, 05, 08, 09, 14, 15, and 17) contained conclusions and recommendations that described the anticipated social work roles in treatment and discharge planning. This failure results in a lack of input to the treatment team about the endeavors of the social work staff.

Findings include:

A. Record Review

All of the Psychosocial Assessments (02 dated 4/14/2014; 05 dated 4/22/2014; 08 dated 4/14/2014; 09 dated 4/21/2014; 14 dated 4/10/2014; 15 dated 4/23/2014; and 17 dated 4/09/2014) lacked a description of the social worker's role in treatment and discharge planning.

B. Staff Interview

On 4/29/2014 at 11:05 a.m., the Director of the Social Work Department was shown the Psychosocial Assessments of Patients 02, 08, and 15 as examples of the deficiency noted in all the Psychosocial Assessments. The Director agreed that the Psychosocial Assessments lacked any description of what the efforts of the social work staff would be in treatment or discharge planning.

Based on record review and interview, it was determined that the facility failed to ensure that physicians performed and documented an estimate of memory functioning in seven (7) of eight (8) psychiatric evaluations (02, 08, 09, 11, 14, 15, and 17). The failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions.

Findings include:

A. Record Review

For the following Psychiatric Evaluations (dates in parentheses), no assets were identified for the patients: Patient 02 (4/15/2014), Patient 08 (4/13/2014), Patient 09 (4/21/2014), Patient 11 (2/25/2014), Patient 14 (4/11/2014), Patient 15 (4/24/2014) and Patient 17 (4/20/2014).

B. Staff Interview

In an interview on 4/30/2014 at 9:40 p.m., the Director of Inpatient Psychiatric Services stated you must have a baseline for memory. " If there not there, there not there. The admission psychiatric evaluation must have memory and assets of the individual patient."

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient.

Findings include:

A. Record Review

For the following Psychiatric Evaluations (dates in parentheses), no assets were identified for the patients: Patient 02 (4/15/2014), Patient 05 (4/25/2014), Patient 08 (4/13/2014), Patient 09 (4/21/2014), Patient 11 (2/25/2014), Patient 14 (4/11/2014), Patient 15 (4/24/2014) and Patient 17 (4/20/2014).

B. Staff Interview

In an interview on 4/30/2014 at 9:40 p.m., the Director of Inpatient Psychiatric Services stated that if the surveyors couldn't find assets in the psychiatric evaluations he wouldn't be able to. "If they're not there, they're not there."

Based on interview and record review, the facility failed to develop Master Treatment Plans (MTPs) that included measurable goals that delineated specific outcome behaviors for eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17). These deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record review (MTP dates in parenthesis)

1. Patient 02 (4/21/14)

a. For problem, "(Patient) is combative with staff during care. (Patient) has thrown (his/her) feces at staff while attempting care at the skilled nursing facility," a goal was stated as "Will engage in three out five (sic) individual or group therapy secessions (sic) over the next seven days." This goal was stated as compliance/ participation in treatment, rather than a behavioral outcome to evaluate whether the patient's stated problem has been resolved/reduced.

b. For problem, "(Patient) has been verbally aggressive with staff and residents as evidenced by making threatening statements," a non-measurable goal was stated as "Will display a decrease in verbal aggression by 50 % daily over the next seven days."

3. Patient 05 (4/23/14)

For problem, "(Patient) has been experiencing physical aggression at the skilled nursing facility, i.e. throwing things," a non-measurable goal was stated as "(Patient) will display a 50% reduction in physical aggression over the next seven days."

Additional goals for this problem were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as: "Will engage in a minimum of three out of five individual or group therapy secessions (sic) over the next seven days," "Will engage in a minimum of two out of six group programs daily over the next seven days" and "will accept medication as prescribed daily over the next seven days."

3. Patient 08 (4/14/14)

For problem, "(Patient) experiences anxiety as evidenced by her fear to touch anything (s/he) believes to have germs on it; i.e. facet, toilet, utensils," goals were stated, as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as: "Will practice relaxation techniques a minimum of one time daily over the next sever days...;" "Will engage in individual and/or group therapy a minimum of three out of five times offered daily for the next seven days;" and "Will participate in a minimum of two of six group programs daily for the next seven days to build appropriate social interactions. "

4. Patient 09 (4/21/14)

a. For problem, "(Patient) has displayed physical aggression at the skilled nursing facility; (Patient) hit another resident with her lap buddy and then with (her/his) hand," a non-measurable goal was stated as "Will display 50% reduction occurrences (sic) of physical aggression over the next seen days."

Additional goals for this problem were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as: "(Patient) will engage in a minimum of two out of six group programs daily over the next seven days" and "Will engage in individual and/or group therapy three out of five times offered over the next seven days."

b. For problem, "(Patient) displays intrusive behaviors and poor boundaries...," a non-measurable goals were written as "Will decrease intrusive behaviors by 50% over the next seven days" and "(Patient) will display an increase in appropriate boundaries (arms length) by 50% over the next seven days."

Additional goals for this problem were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as: "(Patient) will engage in a minimum of two out of six group programs daily over the next seven days" and "Will engage in individual and/or group therapy three out of five times offered over the next seven days."

5. Patient 11 (4/25/14)

a. For problem, "(Patient) has been experiencing hallucinations...," a goal was stated, as "(Patient) will report one out of three episodes of hallucinations to staff." This goal was non-measurable.

b. For problem, "(Patient) has been experiencing delusions...," a goal was stated, as "(Patient) will report one out of three delusions to staff." This goal was non-measurable and unrealistic for this patient."

c. Additional goals for this patient were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as: "(Patient) will meet with psychologist daily for individual or group therapy" and "(Patient) will meet with psychiatrist as necessary."

6. Patient 14 (4/11/14)

a. For problem, "(Patient) displays physical aggression as evidenced by causing a staff member at (another facility) to have workman's compensation (Patient) also has punched a nurse in the stomach and kicked a CNA (Certified Nursing Assistant)," goals were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were: "Will attend three out of six group programs to build appropriate social interaction and structure daily over the next seven days," "Will meet with psychology a minimum of three out of five times offered over the next seven days" and "will accept medication as prescribed daily for the next seven days."

b. For problem, "(Patient) displays signs of paranoia as evidenced by tensing and looking around when staff assist (him/her)," a non-measurable goal was listed as "Will display a decrease in paranoia by 50% over the next seven days. "

7. Patient 15 (4/25/14)

a. For problem, "(Patient) has a long history of physical abuse. While at the skilled nursing facility (Patient) punched staff and patients," a non-measurable goal was listed as "(Patient) will experience a 50% reduction in physical aggression over the next seven days."

Additional goals for this problem were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as "will engage with psychologist a minimum of three out of five times offered over the next seven days" and "Will engage in three out of six group programs daily over the next seven days."

b. For problem, "(Patient) experiences anxiety with care; (Patient) becomes anxious when staff assists (sic) him with activities of daily living and medication," a non-measurable goal was listed as "(Patient) will experience a 50% reduction in anxiety over the next seven days."

Additional goals for this problem were stated as compliance/participation in treatment, rather than behavioral outcomes to evaluate whether the patient's stated problem has been resolved/reduced. These were written as "Will accept assistance with care two out of three times offered daily," "Will accept medications as prescribed daily over the next seven days," "Will engage with psychologist a minimum of three out of five times offered over the next seven days" and "Will engage in three out of six group programs daily over the next seven days."

8. Patient 17 (4/7/14)

For problem, "(Patient) is displaying signs/symptoms of paranoia. (Patient) believes that the skilled nursing staff is injecting cinnamon into (his/her) anus," a non-measurable goal was stated as "Will experience a decrease in paranoid thought by 50% over the next seven days."

Another goal for this problem was aimed at participation in treatment, rather than directly relating to the problem was stated as "(Patient) will meet with psychologist daily for individual or group therapy for the next seven days."

B. Interview:

During interview on 4/29/14 at 1:30 p.m., the Director of Social Work, SW7, and the Director of Nursing (DON) verified that the majority of the goals in all treatment plans are generic or were stated as compliance/participation in treatment, rather than behavioral outcomes.

Based on interview and record review, the facility failed to adequately develop and document individualized treatment interventions with specific purpose and focus based on the needs of eight (8) of eight (8) active ample patients (02, 05, 08, 09, 11, 14, 15, and 17). The majority of interventions were generic role functions and/or failed to include focus of treatment. This deficiency resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review (MTP dates in parenthesis)

1. Patient 02 (4/21/14)

a. The only identified physician intervention in this treatment plan was "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. A psychology intervention was stated as "Psychology will encourage participation (Patient) (sic) in a minimum of three out of five individual or group therapy secessions (sic) over the next seven days." This intervention failed to include focus of treatment.

c. A nursing intervention was stated as "Nursing staff will offer care a minimum of three times daily over the next seven days and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

For identified problems, "throwing feces at staff" and "verbally aggressive with staff and residents," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

d. An activity staff intervention was stated as "Activities staff will encourage participation in a minimum of one group program daily for the next seven days." This intervention failed to include focus of treatment.

e. Social work interventions were stated as generic role functions: "Will provide a minimum of one update to family and/or skilled nursing facility over the next seven days" and "Will initiate and facilitate discharge planning as necessary daily over the next seven days."

2. Patient 05 (4/23/14)

a. The only identified physician intervention in this treatment plan wasstated as, "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. A psychology intervention was stated as "Psychology will provide individual and/or group therapy." This intervention failed to include focus of treatment.

c. An activity therapy intervention was stated as "Activities staff will provide a minimum of six group programs daily to build structure, interpersonal skills, and appropriate social skills." This intervention failed to include title of groups that patient was to attend.

d. A generic nursing intervention was listed as "Nursing staff will provide medication daily and report all refusals."

For identified problems, "physical and verbal aggression" and "paranoid delusions," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

e. A social work intervention was stated as a generic role function, "Will initiate and facilitate discharge planning as necessary."

3. Patient 08 (4/14/14)

a. The only identified physician intervention in this treatment plan was stated as, "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. A psychology intervention was stated as "Psychology will encourage participation in individual or group therapy three out of five times over the next seven days." This intervention failed to include focus of treatment.

c. An activity staff intervention was stated as "Activities staff will encourage participation in a minimum of three group programs daily for the next seven days." This intervention failed to include title of groups and focus of treatment.

d. Social work interventions were stated as generic role functions as "Will provide updates a minimum of one time over the next seven days," "Will meet with treatment team to ensure a safe discharge" and "Will initiate and facilitate discharge planning as necessary daily for the next seven days."

e. A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

Even though identified problems for this patient were listed as, "Experiences anxiety as evidenced by (his/her) fear to touch anything she believe to have germs on it; i.e. facet, toilet, utensils" and "Refuses care and medication;...reports (s/he)...believes medication is contaminated and refuses it, and (s/he) does not want to touch anything that may have germs on it," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

4. Patient 09 (4/21/14)

a. The only identified physician intervention in this treatment plan related to medication. This intervention was stated as "Psychiatry will complete medication management daily." This intervention failed to include specific medication.

b. An activity staff intervention was stated as "Activities staff will provide six group programs daily to increase and build appropriate social interactions and structure." This intervention failed to include title of groups that the patient was to attend.

c. A psychology intervention was stated as "Psychology will provide individual or group therapy a minimum of five days over the next seven days." This intervention failed to include focus of treatment.

d. A generic nursing intervention was listed as "Nursing staff will provide medication as ordered daily and report all refusals."

A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

Even though an identified problem for this patient was potential physical aggression, there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

e. A social work intervention was stated as a generic role function as "Social services will initiate and facilitate discharge planning as necessary."

5. Patient 11 (4/25/14)

a. There were no specific interventions listed for the physician, nursing and social work.

b. Interventions were listed in this plan for observation and monitoring of "inappropriate sexual behavior" and "delusions," but no specific interventions to guide the staff if these behaviors were presented by the patient.

6. Patient 14 (4/11/14)

a. The only identified physician intervention in this treatment plan was stated as, "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. An activity staff intervention was stated as "Activities staff will encourage (Patient) to attend and participate in a minimum of three out of six group programs daily for the next seven days." This intervention failed to include title of groups that the patient was to attend. Focus of the groups was also absent.

c. A psychology intervention was stated as "Psychology will encourage (Patient) to engage in either group or individual therapy a minimum of three out of five times offered daily over the next seven days." This intervention failed to include focus of treatment.

d. Generic nursing interventions were listed as "Nursing staff will report all refusals of medication daily for the next seven days" and "Nursing staff will report any refusals of care daily for the next seven days."

Even though identified problems for this patient was potential physical aggression and paranoia, there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

e. A social work intervention was stated as a generic role function as "Social services will initiate and facilitate discharge planning as necessary over the next seven days."

7. Patient 15 (4/25/14)

a. The only identified physician intervention in this treatment plan was "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. A psychology intervention was stated as "Psychology will provide individual or group therapy a minimum of three times weekly." This intervention failed to include focus of treatment.

c. An activity staff intervention was stated as "Activities staff will provide individual or group programming to build social, interpersonal, and structure daily." This intervention failed to include title of groups.

d. A social work intervention was stated as a generic role function as "Social services will initiate and facilitate discharge planning as necessary."

e. A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

A generic nursing intervention was listed as "Nursing staff will provide medication as ordered daily and report all refusals."

Even though this patient had potential aggression towards others and experienced anxiety when provided care by others, there were no specific interventions to guide nursing personnel in the care of this patient in the clinical area.

8. Patient 17 (4/7/14)

a. The only identified physician intervention in this treatment plan was "Psychiatry will complete medication management daily for the next seven days." This intervention failed to include specific medication.

b. An activity staff intervention was stated as "Activities staff will encourage participation in a minimum of four group programs daily for the next seven days." This intervention failed to include title of groups that the patient was to attend. Focus of the groups was also absent.

c. A psychology intervention was stated as "Psychology will meet with (Patient) daily for individual or group therapy over the next seven days." This intervention failed to include focus of treatment.

d. Generic nursing interventions were listed as "Nursing staff will provide redirection/reorientation as necessary daily over the next seven days" and "Nursing staff will offer assistance with care a minimum of three times daily for the next seven days." This intervention failed to include type of care to be provided.

Even though identified problems for this patient was "paranoia" and refusal of care and medication, there were no specific interventions to guide nursing personnel in the care of this patient in the clinical area.

e. Social work interventions were stated as generic role functions: "Social services will provide updates regarding care and behavior a minimum of one time over the next seven days" and "Will initiate and facilitate discharge planning as necessary daily over the next seven days."

B. Interviews:

1. During interview on 4/29/14 at 11:00 a.m. with the Director of Psychology, Psychologist 2 and the Activities Director, the Director of Psychology stated "The specific group with focus should be in the treatment plan. "

2. During interview on 4/29/14 at 1:30 p.m. with the Director of Social Work, SW7 and the DON, the DON stated " Interventions should be more specific. "

3. During interview on 4/30/14 at 9:30 a.m., the Director of Inpatient Psychiatric Services verified that the only physician intervention in the treatment plans was a general statement about the prescription of medications. He stated, " The plans need to include physician interventions about working with patients regarding their needs. "

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) of eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

A. Record Review (MTP dates in parentheses)

1. Patient 02 (4/21/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will observe/monitor/report all incidents of verbal abuse daily for the next seven days."

2. Patient 05 (4/23/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide redirection as necessary for physical aggression."

3. Patient 08 (4/14/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will encourage (patient) to consume a minimum of 50% of her meals daily for the next seven days."

4. Patient 09 (4/21/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will encourage appropriate (arm's length) boundaries daily."

5. Patient 11 (2/24/2014)
The MTP included no staff names or disciplines for the listed intervention: "(Patient) will accept redirection from hospital staff two out of three times daily for the next seven days."

6. Patient 14 (4/11/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will observe/monitor/report all incidents of paranoia daily for the next seven days."

7. Patient 15 (4/25/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will observe/monitor/report all occurrences of anxiety with care daily."

8. Patient 17 (4/07/2014)
The MTP included no staff names or disciplines for the listed intervention: "Treatment team will observe/monitor/report all signs/symptoms and reported paranoid thoughts daily for the next seven days."

B. Staff Interview

1. In an interview on 4/29/2014 at 11:25 a.m., when asked which specific member of the treatment team was responsible for documenting on interventions that have the "treatment team" identified as being responsible, Social Worker 1 stated, "I don't know."

2. During interview on 4/29/14 at 1:30 p.m. with the Director of Social Work, SW7 and the Director of Nursing (DON), the DON stated, "The specific person responsible for interventions should be in plan."

Based on record review, and interview, the Medical Director failed to:

I. Ensure that physicians performed and documented an estimate of memory functioning in seven (7) of eight (8) psychiatric evaluations (02, 08, 09, 11, 14, 15, and 17). The failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

II. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

III. Develop Master Treatment Plans (MTPs) that included measurable goals that delineated specific outcome behaviors for eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17). These deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions. (Refer to B121)

IV. Develop and document individualized treatment interventions with specific purpose and focus based on the needs of eight (8) of eight (8) active ample patients (02, 05, 08, 09, 11, 14, 15, and 17). The majority of interventions were generic role functions and/or failed to include focus of treatment. This deficiency resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

V. Ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the MTPs of eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15, and 17). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

Based on interview and record review, the Director of Nursing (DON) failed to develop and document nursing interventions in the treatment plans based on individual needs of eight (8) of eight (8) active sample patients (02, 05, 08, 09, 11, 14, 15 and 17). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of nursing care provided, and to plan revisions based on individual patient needs and findings.

Findings include:

A. Record Review (MTP dates in parenthesis)

1. Patient 02 (4/21/14)

A nursing intervention was stated as "Nursing staff will offer care a minimum of three times daily over the next seven days and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

For identified problems, "throwing feces at staff " and "verbally aggressive with staff and residents," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

2. Patient 05 (4/23/14)

A generic nursing intervention was listed as "Nursing staff will provide medication daily and report all refusals."

For identified problems, "physical and verbal aggression" and "paranoid delusions," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

3. Patient 08 (4/14/14)

A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

Even though identified problems for this patient were listed as "Experiences anxiety as evidenced by (his/her) fear to touch anything (s/he) believe to have germs on it; i.e. facet, toilet, utensils " and "Refuses care and medication;...reports (s/he)...believes medication is contaminated and refuses it, and (s/he) does not want to touch anything that may have germs on it," there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

4. Patient 09 (4/21/14)

A generic nursing intervention was listed as "Nursing staff will provide medication as ordered daily and report all refusals."

A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

Even though an identified problem for this patient was potential physical aggression, there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

5. Patient 11 (4/25/14)

There were no specific nursing interventions identified in the treatment plan.

The plan included generalized interventions for observation and monitoring of "inappropriate sexual behavior" and "delusions," but no specific interventions to guide nursing personnel to address these behaviors presented by the patient.

6. Patient 14 (4/11/14)

Generic nursing interventions were listed as "Nursing staff will report all refusals of medication daily for the next seven days" and "Nursing staff will report any refusals of care daily for the next seven days. "

Even though identified problems for this patient was potential physical aggression and paranoia, there were no identified interventions to guide nursing personnel in the care of this patient in the clinical area.

7. Patient 15 (4/25/14)

A nursing intervention was stated as "Nursing staff will offer assistance with care a minimum of three times daily and report all refusals." This intervention failed to include type of care to be provided and intervention(s) to care for the patient if and when the refusals occur other than reporting these events.

A generic nursing intervention was listed as "Nursing staff will provide medication as ordered daily and report all refusals."

Even though this patient had potential aggression towards others and experienced anxiety when provided care by others, there were no specific interventions to guide nursing personnel in the care of this patient in the clinical area.

8. Patient 17 (4/7/14)

Generic nursing interventions were listed as "Nursing staff will provide redirection/reorientation as necessary daily over the next seven days" and "Nursing staff will offer assistance with care a minimum of three times daily for the next seven days." This intervention failed to include type of care to be provided.

Even though identified problems for this patient was "paranoia" and refusal of care and medication, there were no specific interventions to guide nursing personnel in the care of this patient in the clinical area.

B. Interview:

During interview on 4/29/14 at 1:30 p.m. with the Director of Social Work, SW7 and the Director of Nursing (DON), the DON stated "Interventions should be more specific."