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Based on record review and interview, the facility failed to:

I. Document recommendations for social work care in psychosocial assessments for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure results in an inadequate database for patients' psychosocial needs and compromises the effective development and formulation of quality treatment plans resulting in negative impact to quality of patient care. (Refer to B108)

II. Document a psychiatric evaluation for 1 of 8 active sample patients (A3) (Refer to B110). For other sample patients, the facility failed to document psychiatric evaluations that: (a) estimate intellectual functioning for 2 of 8 active sample patients (A5 and A6), estimate memory functioning for 2 of 8 active sample patients (A1 and A6), and estimate orientation for 5 of 8 active sample patients (A2, A4, A6, A7 and A8) (Refer to B116); and (b) identify an inventory of assets for 4 of 9 active sample patients (A5, A6, A7 and A8) (Refer to B117). Failure to complete psychiatric evaluations or/or document required elements can result in lack of identification of pathology, which may be pertinent to the current mental illness, and compromises future comparative re-examinations to assess patient's response to treatment interventions.

III. Develop Master Treatment Plans (MTPs) that: (a) utilize patient strengths/assets for 4 of 8 active sample patients (A1, A2, A3 and A4) (Refer to B119); (b) specify appropriate, measurable short term goals stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and develop short-term goals for suicidal patients that were not limited to patient self-report for 4 of 8 active sample patients (A3, A6, A7 and A8) (Refer to B121); (c) identify specific staff interventions to be used to address each patient goal for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) (Refer to B122); and name staff responsible for the listed interventions for 4 of 8 active sample patients (A1, A2, A3 and A4) (Refer to B123). The absence of an integrated, comprehensive treatment plan with all needed components and team member involvement can result in lack of continuity of care and failure to provide all needed treatment modalities to assure patient improvement and successful discharge.

lV. Ensure that discharge summaries: (a) were dictated, transcribed and filed within 30 days of discharge for 1 of 5 discharge records reviewed (B3) (Refer to B133); (b) contained documentation of follow-up appointments for 4 of 5 patients whose discharge records were reviewed (B1, B2, B4 and B5) (Refer to B134); and (c) contained a summary of the patients' condition at discharge for 2 of 5 reviewed discharge records (B1 and B5) (Refer to B135). These deficiencies result in a failure to communicate with outpatient providers in a timely manner thus impacting negatively on continuity of treatment and also decrease the possibility of patients attending outpatient treatment. These failures can lead to repeat hospitalizations.

Based on record review and interview it was determined that the facility failed to document recommendations for social work care in 8 out of 8 psychosocial history/assessments (Patients A1, A2, A3, A4, A5, A6, A7 and A8). This failure to document recommendations in psychosocial history/assessments results in inadequate database for patients' psychosocial needs and compromises the effective development and formulation of quality treatment plans resulting in negative impact to quality of patient care.

Findings include:

A. Record Reviews

1. Patient A1 was admitted on 12/01/2012. The psychosocial assessment completed on 12/03/2012 did not document recommendations for care.

2. Patient A2 was admitted on 11/30/2012. The psychosocial assessment completed on 12/03/2012 did not document recommendations for care.

3. Patient A3 was admitted on 11/29/2012. The psychosocial assessment completed on 12/01/2012 did not document recommendations for care.

4. Patient A4 was admitted on 12/02/2012. The psychosocial assessment completed on 12/03/2012 did not document recommendations for care.

5. Patient A5 was admitted on 11/29/2012. The psychosocial assessment completed on 11/30/2012 did not document recommendations for care.

6. Patient A6 was admitted on 11/16/2012. The psychosocial assessment completed on 11/19/2012 did not document recommendations for care.

7. Patient A7 was admitted on 11/27/2012. The psychosocial assessment completed on 11/30/2012 did not document recommendations for care.

8. Patient A8 was admitted on 11/29/2012. The psychosocial assessment completed on 12/03/2012 did not document recommendations for care.

B. Staff Interview

During an interview on 12/05/12 at 02:00 p.m., the Director of Social Work Service stated, "I agree with you the recommendations are not there in our psychosocial assessments. We are lacking that. That will be an easy thing to add."

Based on record review, policy review, and staff interview, it was determined that the facility failed to document a psychiatric evaluation for 1 of 8 active sample patients (A3). The absence of this patient information hinders the clinicians' ability to make an accurate diagnosis and plan appropriate treatment.

Findings include:

A. Record Review

Patient A3 was admitted on 11/29/2012. The medical record included a physician's admission note dated 11/29/2012; however the medical record did not include a comprehensive psychiatric evaluation.

B. Policy Review:

The facility policy dated 08/01/2012 and titled "Document Requirement" , stated, "Admission Psychiatric Assessment/Physical Examination to be completed by the attending physician within 24 hours of admission."

C. Staff Interview

During an interview on 12/05/2012 at 1:10 p.m., the Director of Quality Improvement and Risk Manager stated, "It is supposed to be the psychiatric evaluation (referring to the physician's admission note date 11/29/2012); it will not work because the physician's admission note does not have all the components of a comprehensive psychiatric evaluation."

Based on record review and staff interview, it was determined that the facility failed to document in the psychiatric evaluations an estimate of intellectual functioning in 2 of 8 active sample patients (A5, A6); an estimate of memory functioning in 2 of 8 active sample patients (A1, A6); and orientation in 5 of 8 active sample patients (A2, A4, A6, A7, A8). This failure can result in lack of identification of pathology, which may be pertinent to the current mental illness, and it compromises future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The psychiatric evaluation completed on 12/01/2012 did not document an estimate of memory functioning.

2. Patient A2 was admitted on 11/30/2012. The psychiatric evaluation completed on 12/01/2012 did not document orientation.

3. Patient A4 was admitted on 12/02/2012. The psychiatric evaluation completed on 12/02/2012 did not document orientation.

4. Patient A5 was admitted on 11/29/2012. The psychiatric evaluation completed on 11/30/2012 did not document an estimate of intellectual functioning.

5. Patient A6 was admitted on 11/16/2012. The psychiatric evaluation completed on 11/17/2012 did not document an estimate of intellectual functioning, an estimate of memory functioning, and orientation.

6. Patient A7 was admitted on 11/27/2012. The psychiatric evaluation completed on 11/28/2012 stated, "oriented x2" without any clarifying information.

7. Patient A8 was admitted on 11/29/2012. The psychiatric evaluation completed on 11/29/2012 stated, "oriented x2 with poor effort" without any clarifying information.

B. Staff Interview

During an interview on 12/05/2012 at 09:40 a.m., when asked about the aforementioned missing elements in the mental status examinations, the Medical Director stated, "I agree with you our mental status examinations are missing those elements. I will work with my medical staff to fix that."

Based on record review and staff interview, it was determined that the facility failed to document an inventory of assets in the psychiatric evaluation of 4 of 9 active sample patients (A5, A6, A7, A8). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings include:

A. Record Review

1. Patient A5 was admitted on 11/29/2012. The psychiatric evaluation completed on 11/30/2012 did not document an inventory of assets.

2. Patient A6 was admitted on 11/16/2012. The psychiatric evaluation completed on 11/17/2012 did not document an inventory of assets.

3. Patient A7 was admitted on 11/27/2012. The psychiatric evaluation completed on 11/28/2012 did not document an inventory of assets.

4. Patient A8 was admitted on 11/28/2012. The psychiatric evaluation completed on 11/29/2012 did not document an inventory of assets.

B. Staff Interview

During an interview on 12/05/2012 at 09:40 a.m., when asked about the aforementioned missing elements in the mental status examinations, the Medical Director stated, "I agree with you our mental status examinations are missing those elements. I will work with my medical staff to fix that."

Based on interview and record review, the facility failed to develop and document comprehensive multidisciplinary treatment plans based on the individual needs of patients. Specifically the facility failed to:

I. Formulate Master Treatment Plans (MTPs) that utilized patient assets for 4 of 8 active sample patients (A1, A2, A3 and A4). Failure to incorporate patient assets into treatment plans can reduce the patient's success in attaining established goals and diminish the effectiveness of treatment. (Refer to B119)


II. Ensure that MTPs identified appropriate, patient-related short-term goals in observable, measurable behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Lack of appropriate measurable, patient-specific goals hamper the treatment team's ability to assess changes in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs. In addition, 4 of 8 active sample patients had short-term goals that required patients to deny thoughts of suicide (A3, A6, A7 and A8). Requiring patients to self-report suicidal thoughts can lead staff to incorrectly assess a patient as non-suicidal based solely on the patients' response. (Refer to B121)


III. Formulate MTPs that included individualized treatment interventions with a specific purpose and focus for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed. (Refer to B122)

lV. Ensure that staff members responsible for each intervention were specifically identified in the master treatment plan for 4 of 8 active sample patients (A1, A2, A3 and A4). This failure results in the patient and other staff being unaware of which staff person was assuming responsibility for the interventions being implemented and documented. (Refer to B123)

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 4 of 8 active sample patients (A1, A2, A3 and A4) that utilized patient strengths/assets. The MTPs included a preprinted list of patient traits or external support resources labeled as "strengths/limitations." There was no documentation of how the chosen strengths would be used to support the patient's inpatient treatment. Failure to identify and utilize patient strengths when planning individualized care can reduce the patient's success in attaining established goals and diminish the effectiveness of treatment.

Findings include:

A. Record Review

1. Patient A1: The patient's MTP dated 12/04/2012 listed "Cooperative with Treatment" and "Religious/Spiritual Support" as patient "strengths." There was no evidence of how those assets would be used to support the patient's treatment during the hospitalization.

2. Patients A2: The patient's MTP dated 12/03/2012 listed "Capacity for insight," "Cooperative with treatment," "Involvement in hobbies/leisure" and "Religious/Spiritual Support" as patient "strengths." There was no evidence of how those assets would be used to support the patient's treatment during the hospitalization.

3. Patients A3: The patient's MTP dated 12/01/2012 listed only "limitations" and failed to list "strengths" that could be used to support the patient's treatment during hospitalization.

4. Patient A4: The patient's MTP dated 12/03/2012 listed "Cooperative with treatment," "Involvement in hobbies/leisure," "Nutrition" and "Religious/Spiritual Support" as patient "strengths." There was no evidence of how those assets would be used to support the patient's treatment during the hospitalization.

B. Interview

1. In an interview on 12/05/2012 at 10:00 a.m., the Risk Manager stated "All our patients have assets and those should be built into the treatment." The Risk Manager agreed that the treatment plans did not sufficiently identify patient strengths or incorporate them into the plan of care.

2. In an interview on 12/06/2012 at 11:00 a.m., Therapist 1 agreed that patient strengths/assets were not adequately addressed in the written treatment plans.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-centered short term goals stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Lack of measurable, patient-specific goals hamper the treatment team's ability to assess changes in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

In addition, 4 of 8 active sample patients had short-term goals that required patients to deny thoughts of suicide (A3, A6, A7 and A8). Requiring patients to self- report suicidal thoughts can lead staff to incorrectly assess a patient as non-suicidal based solely on the patients' response.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The MTP dated 12/04/2012, for the identified problem "Aggression/Anger" had the short-term goal "Pt (patient) will show increased number of appropriate words that express acceptance of responsibility for angry feelings and aggressive behaviors at least 5 out of 7 days this period." For the identified problem "Homicidal Ideation" the MTP documented the short-term goal as "Pt will begin using behavioral and cognitive coping skills for homicidal urges 5 out of 7 days this review period."

2. Patient A2 was admitted on 11/30/2012. The MTP dated 12/03/2012, for the identified problem "Aggression/Anger/Self-Harm" had the short-term goal "Pt will show increased number of appropriate words that express acceptance of responsibility for angry feelings and aggressive behaviors at least 5 out of 7 days this review period." For the identified problem "Mood/Sadness" the MTP documented the short-term goal as "Pt will begin using behavioral and cognitive coping skills for depression and anxiety 5 out of 7 days this review period."

3. Patient A3 was admitted on 11/29/2012. The MTP dated 12/01/2012, for the identified problem "Parent child relational problems" had the short-term goal "Pt. and family will id. (identify) Three [sic] barriers to health and harmony." For the identified problem, "Depressed Mood" the MTP documented the short-term goal as "Pt will verbalize decreased depressive symptoms, deny suicidal ideation 7 out of 7 days this review period."

4. Patient A4 was admitted on 12/02/2012. The MTP dated 12/03/2012, for the identified problem "Marijuana Abuse/Family conflict" had the short-term goal "Pt will explore 3 marijuana relapse prevention plan [sic] and learn to respect and cooperate with family."

5. Patient A5 was admitted on 11/29/2012. The MTP dated 11/30/2012, for the identified problem "Depressed Mood with Suicidal Ideation," had the short-term goal, "Pt. will report anxiety as 8 on scale of 1-10 for 3 consecutive days prior to discharge."

6. Patient A6 was admitted on 11/16/2012. The MTP dated 11/19/2012, for the identified problem "Depressed Mood with Suicidal Ideation," had the short-term goal, "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them."

7. Patient A7 was admitted on 11/27/2012. The MTP dated 11/29/2012, for the identified problem "Depressed Mood with Suicidal Ideation" had the short-term goal, "Patient will deny suicidal thoughts for 3 days."

8. Patient A8 was admitted on 11/29/2012. The MTP dated 11/30/2012, for the identified problem "Hospital Readmission" had the short-term goal "Patient will demonstrate enjoyment in social/recreational activity." For the identified problem "Depressed Mood with Suicidal Ideation," documented the short-term goal as, "Patient will deny suicidal thoughts for 3 days."

B. Interview

1. In interview on 12/05/2012 at 9:15 a.m., the Chief Executive Officer, who was directly involved in improving treatment plans, stated, "That's not measureable" when shown the short-term goal for Patients A1 and A2. During the same interview, the Director of Nursing stated, "I see what you mean."

2. In interview on 12/05/2012 at 10:00 a.m., the Risk Manager, when shown samples of Master Treatment Plans, stated that the goals were "hard to measure."

Based on record review and interview, the facility failed to develop Master Treatment Plans for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) that included individualized treatment interventions with a specific purpose and focus. Many of the listed interventions were generic monitoring or routine clinical functions with identical wording for patients with different problems and needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The MTP dated 12/04/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for homicidal urges 5 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing mood instability and monitor for negative side effect and monitor overall treatment progress within the next 7 days." The documented Nursing intervention for this goal was "Daily monitoring of residents [sic] progress regarding homicidal ideation. Will document regarding resident's progress a minimum of once per week." The documented Expressive Therapy intervention for this goal was "Pt will participate in structured therapeutic activities and process at least one leisure related coping skill that can be used for stress during the next 7 days." The documented Milieu Staff intervention for this goal was "Staff will monitor pt for increased verbalizations of taking responsibility for behaviors on unit and facilitate rehab groups including anger management, social skills, moral development."

2. Patient A2 was admitted on 11/30/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for depression and anxiety 5 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing mood instability and monitor for negative side effect and monitor overall treatment progress within the next 7 days." The documented Nursing intervention for this goal was "Daily monitoring of residents [sic] progress regarding mood stabilization. Will document regarding resident's progress a minimum of once per week." The documented Expressive Therapy intervention for this goal was "Pt will participate in structured therapeutic activities and process at least one leisure related coping skill that can be used for stress during the next 7 days." The documented Milieu Staff intervention for this goal was "Staff will monitor pt for increased verbalizations of taking responsibility for behaviors on unit, and facilitate rehab groups including anger management, social skills, moral development."

3. Patient A3 was admitted on 11/29/2012. The MTP dated 12/01/2012 listed the short-term goal, "Pt will verbalize decreased depressive symptoms, deny suicidal ideation 7 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing symptoms and monitor for negative side effect and monitor overall treatment progress within the next 7 days." The documented Nursing intervention for this goal was "Daily monitoring of residents [sic] progress regarding depression and suicidal ideation. Will document regarding resident's progress a minimum of once per week." The documented Expressive Therapy intervention for this goal was "Pt will participate in structured therapeutic activities and process at least one leisure related coping skill that can be used for stress during the next 7 days." The documented Milieu Staff intervention for this goal was "Staff will monitor pt use of coping strategies for depression and suicidal ideation on milieu 7/7 days, and facilitate rehab groups including anger management, social skills, moral development."

4. Patient A4 was admitted on 12/02/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will explore 3 marijuana relapse prevention plan [sic] and learn to respect and cooperate with family." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in decreasing symptoms and monitor for negative side effect and monitor overall treatment progress within the next 7 days." The documented Nursing intervention for this goal was "Daily monitoring of residents [sic] progress regarding marijuana abuse and family conflict. Will document regarding resident's progress a minimum of once per week." The documented Expressive Therapy intervention for this goal was "Pt will participate in structured therapeutic activities and process at least one leisure related coping skill that can be used for stress during the next 7 days." The documented Milieu Staff intervention for this goal was "Staff will monitor pt for increased verbalizations of taking responsibility for behaviors on unit and facilitate rehab groups including anger management, social skills, moral development."

5. Patient A5 was admitted on 11/29/2012. The MTP dated 11/30/2012 listed the short-term goal, "Pt. will report anxiety as 8 on scale of 1-10 for 3 consecutive days prior to discharge." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn (as needed) medications for: Anxiety."

6. Patient A6 was admitted on 11/16/2012. The MTP dated 11/19/2012 listed the short-term goal, "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

7. Patient A7 was admitted on 11/27/2012. The MTP dated 11/29/2012 listed the short-term goal, "Patient will deny suicidal thoughts for 3 days." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

8. Patient A8 was admitted on 11/29/2012. The MTP dated 11/30/2012 listed the short-term goal, "Patient will deny suicidal thoughts for 3 days." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

B. Interview

1. In interview on 12/05/2012 at 10:00 a.m., the Risk Manager stated that the interventions were routine discipline practice, the same for multiple patients and did not individualize the treatment to the patient's needs.

2. In interview on 12/05/2012 at 11:00 a.m., Therapist 1 stated "Yes. I understand what you are saying. It's (modalities) not individualized."

Based on record review and interview, the facility failed to ensure that staff members responsible for each intervention were specifically identified in the Master Treatment Plan (MTP) for 4 of 8 active sample patients (A1, A2, A3 and A4). This failure results in the patient and other staff being unaware of which staff person was assuming responsibility for the interventions being implemented and documented.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The MTP dated 12/04/2012 listed the person responsible for interventions assigned to "Milieu Staff" as "Program Manager or designee" without indicating a staff name.

2. Patient A2 was admitted on 11/30/2012. The MTP dated 12/03/2012 listed the person responsible for interventions assigned to "Milieu Staff" as "Program Manager or designee" without indicating a staff name.

3. Patient A3 was admitted on 11/29/2012. The MTP dated 12/01/2012 listed the person responsible for interventions assigned to "Milieu Staff" as "Program Manager or designee" without indicating a staff name.

4. Patient A4 was admitted on 12/02/2012. The MTP dated 12/03/2012 listed the person responsible for interventions assigned to "Milieu Staff" as "Program Manager or designee" without indicating a staff name.

B. Interview

In interview on 12/05/2012 at 10:00 a.m., the Risk Manager agreed that the "Program Manager or designee" title failed to identify who was responsible for the assigned interventions, making it difficult to know who was accountable.

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure that the discharge summary was dictated, transcribed and filed within 30 days of discharge, as required by hospital policy, for 1 of 5 (B3) discharge records reviewed. This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of labs and testing, anticipated problems, and discharge plans with outpatient providers.

Findings include:

A. Record Review

Patient B3 was discharged on 10/12/2012. The discharge record of patient (B3) when reviewed on 12/05/2012 did not include a discharge summary.

B. Policy Review:

The facility policy dated 08/01/2012 and titled "Document Requirement", stated "Discharge summary to be completed by the attending psychiatrist upon discharge within 30 days post discharge."

C. Staff Interview:

During an interview on 12/05/2012 at 09:40 a.m., the Medical Director stated, "Our policy requires medical staff to complete discharge summaries within 30 days of discharge. It (referring to missing discharge summary of patient (B3)) should have been completed. I will discuss with my medical staff."

Based on record review and staff interview, it was determined that the facility failed to ensure that the dates and times for follow-up appointments were included in discharge summaries for 4 of 5 patients (B1, B2, B4, and B5)) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do.

Findings include:

A. Record Review

1. Patient B1 was discharged on 10/23/2012. Discharge summary dictated on 10/24/2012 did not include the date and time for follow-up appointments.

2. Patient B2 was discharged on 10/30/2012. Discharge summary dictated on 10/30/2012 did not include the date and time for follow-up appointments.

3. Patient B4 was discharged on 10/18/2012. Discharge summary dictated on 10/18/2012 did not include the date and time for follow-up appointments.

4. Patient B5 was discharged on 10/30/2012. Discharge summary dictated on 10/30/2012 did not include the date and time for follow-up appointments.

B. Staff Interview

During an interview on 12/05/2012 at 09:40 a.m., when asked about the aforementioned missing elements in the discharge summaries, the Medical Director stated, "I agree with you our discharge summaries are missing those elements. I will address that with my medical staff."

Based on record review and staff interview, it was determined that the facility failed to ensure that the discharge summaries for 2 of 5 discharged patients (B1 and B5) contained a summary of the patients' condition on discharge. Therefore, critical clinical information indicating patients' level of psychiatric symptomatology and risk was not available to the aftercare providers.

Findings include:

A. Record Review

1. Patient B1 was discharged on 10/23/2012. Discharge summary dictated on 10/24/2012 did not include patient's condition on discharge.

2. Patient B5 was discharged on 10/30/2012. Discharge summary dictated on 10/30/2012 did not include patient's condition on discharge.

B. Staff Interview:

During an interview on 12/05/2012 at 09:40 a.m., when asked about the aforementioned missing element in the discharge summaries, the Medical Director stated, "I agree with you our discharge summaries missing patients' condition on discharge. I will address that with my medical staff."

Based on record review, policy review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. The Medical Director failed to assure that:

I. Social service assessments included recommendations for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure to document recommendations in psychosocial history/assessments results in inadequate database for patients' psychosocial needs and compromises the effective development and formulation of quality treatment plans resulting in negative impact to quality of patient care. (Refer to B108)

II. Physicians documented a psychiatric evaluation for 1 of 8 active sample patients (A3). The absence of this patient information hinders the clinicians' ability to make an accurate diagnosis and plan appropriate treatment. (Refer to B110)


III. Physicians documented in the psychiatric evaluations an estimate of intellectual functioning for 2 of 8 active sample patients (A5 and A6) an estimate of memory functioning for 2 of 8 active sample patients (A1 and A6); and orientation for 5 of 8 active sample patients (A2, A4, A6, A7 and A8). This failure can result in lack of identification of pathology, which may be pertinent to the current mental illness, and it, compromises future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)

IV. Physicians documented an inventory of assets in the psychiatric evaluation of 4 of 9 active sample patients (A5, A6, A7 and A8). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

V. Physicians included individualized treatment interventions with a specific purpose and focus on the MTP for 4 of 8 active sample patients (A1, A2, A3 and A4). The physician interventions were generic clinical functions with identical wording for patients with different problems and needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The MTP dated 12/04/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for homicidal urges 5 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing mood instability and monitor for negative side effect and monitor overall treatment progress within the next 7 days."

2. Patient A2 was admitted on 11/30/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for depression and anxiety 5 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing mood instability and monitor for negative side effect and monitor overall treatment progress within the next 7 days."

3. Patient A3 was admitted on 11/29/2012. The MTP dated 12/01/2012 listed the short-term goal, "Pt will verbalize decreased depressive symptoms, deny suicidal ideation 7 out of 7 days this review period." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in stabilizing symptoms and monitor for negative side effect and monitor overall treatment progress within the next 7 days."

4. Patient A4 was admitted on 12/02/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will explore 3 marijuana relapse prevention plan [sic] and learn to respect and cooperate with family." The documented Physician intervention for this goal was "Evaluate weekly medication effectiveness in decreasing symptoms and monitor for negative side effect and monitor overall treatment progress within the next 7 days."

B. Interview

1. In interview on 12/05/2012 at 10:00 a.m., the Risk Manager stated that the interventions were routine discipline practice, the same for multiple patients and did not individualize the treatment to the patient's needs.

2. In interview on 12/05/2012 at 11:00 a.m., Therapist 1 stated "Yes. I understand what you are saying. It's (modalities) not individualized."

VI. The discharge summary was dictated, transcribed and filed within 30 days of discharge for 1 of 5 (B3) discharged patients' records reviewed. This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of labs and testing, anticipated problems, and discharge plans with outpatient providers. (Refer to B133)

VII. The specific information on follow-up appointments was included in the discharge summaries for 4 of 5 patients (B1, B2, B4, and B5) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)

VIII. The discharge summaries for 2 of 5 (B1 and B5) discharged patients reviewed contained a summary of patients' condition on discharge. Therefore, critical clinical information indicating patients' level of psychiatric symptomatology and risk was not available to the aftercare providers. (Refer to B135)

IX. Registered nurses allowed to conduct the 1-hour face-to-face assessment of patients in seclusion or restrain had documented training to ensure that they were qualified and competent to conduct a physical and behavioral assessment of the patient. This failure places the patient at risk of being inappropriately assessed which could compromise patient safety and extend the length of the restriction. (Refer to B148)

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

l. Ensure that registered nurses allowed to conduct the 1-hour face-to-face assessment of patients in seclusion or restrain had documented training to ensure that they were qualified and competent to conduct a physical and behavioral assessment of the patient. This failure places the patient at risk of being inappropriately assessed which could compromise patient safety and extend the length of the restriction.

Findings include:

A. Record Review

1. Review of the policy "Emergency Interventions, Restraint/Physical Hold, Seclusion/Open Door/Hallway" Number PC-2.5, revised 6/12, revealed that the registered nurse conducting a 1-hour face-to-face assessment of a patient in seclusion or restraints would have "additional training" beyond that required by all clinical staff and would include "assessment of both physical and behavioral needs."

2. Review of the "Cedar Ridge Seclusion and Restraint One Hour Face to Face Evaluation" form to be completed by the RN during the assessment of patients in seclusion or restraint, revealed the heading- "to be completed by trained RN." The form contained checkboxes for the Review of Systems which included circulatory status, respiratory status, pulses and skin assessment.

3. Review of the "Cedar Ridge PI Monitors 2012" "One Hour Assessments Following Restraint" revealed that of the 68 restraint episodes from June 1, 2012-November 30, 2012, 66 (97%) had one hour assessments conducted by RNs.

B. Interviews

1. In interview on 12/05/2012 at 9:15 a.m., the Director of Nursing stated that there was training for all the staff on Seclusion and Restraint and that he went over with the RNs how to fill out the One Hour Face to Face Evaluation form. The DON was unable to present any documentation that the RNs received additional training involving assessment of both physical and behavioral needs or that the RNs had been individually assessed as competent to carry out this patient evaluation.

2. In interview on 12/05/2012 at 2:15 p.m., RN2 stated that she had placed a patient in a physical hold earlier in the day and had completed the one hour face-to-face assessment. When asked about training received in order to assess the patient, RN2 stated, "It's like a nursing assessment." RN2 further stated that the person who had provided seclusion and restraint training in her recent orientation had gone over the assessment form and told her how to fill it out. RN2 had no memory of any additional training regarding the face-to-face assessment.

II. Ensure that patient assets/strengths were utilized when formulating the MTP for 4 of 8 active sample patients (A1, A2, A3 and A4.) MTPs included a preprinted list of patient traits or external support resources labeled as "strengths/limitations" There was no documentation of how the chosen strengths would be used to support the patient's inpatient treatment. Failure to identify and utilize patient strengths when planning individualized care can reduce the patient's success in attaining established goals and diminish the effectiveness of treatment. (Refer to B119)

III. Ensure that patient-centered short term goals addresses in the Master Treatment Plans were stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Lack of measurable, patient-specific goals hamper the treatment team's ability to assess changes in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.
In addition, 4 of 8 active sample patients had short-term goals that required patients to deny thoughts of suicide (A3, A6, A7 and A8). Requiring patients to self- report suicidal thoughts can lead staff to incorrectly assess a patient as non-suicidal based solely on the patients' response.

IV. Ensure that the nursing interventions on the MTPs for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) were individualized with a specific purpose and focus. Many of the listed interventions were generic monitoring or routine clinical nursing functions with identical wording for patients with different problems and needs. Failure to clearly describe specific modalities on patients' MTPs can hamper the nursing staff's ability to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/01/2012. The MTP dated 12/04/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for homicidal urges 5 out of 7 days this review period." The documented Nursing intervention for this goal was "Daily monitoring of residents progress regarding homicidal ideation. Will document regarding resident's progress a minimum of once per week."

2. Patient A2 was admitted on 11/30/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will begin using behavioral and cognitive coping skills for depression and anxiety 5 out of 7 days this review period." The documented Nursing intervention for this goal was "Daily monitoring of residents progress regarding mood stabilization. Will document regarding resident's progress a minimum of once per week."

3. Patient A3 was admitted on 11/29/2012. The MTP dated 12/01/2012 listed the short-term goal, "Pt will verbalize decreased depressive symptoms, deny suicidal ideation 7 out of 7 days this review." The documented Nursing intervention for this goal was "Daily monitoring of residents progress regarding depression and suicidal ideation. Will document regarding resident's progress a minimum of once per week."

4. Patient A4 was admitted on 12/02/2012. The MTP dated 12/03/2012 listed the short-term goal, "Pt will explore 3 marijuana relapse prevention plan [sic] and learn to respect and cooperate with family." The documented Nursing intervention for this goal was "Daily monitoring of residents progress regarding marijuana abuse and family conflict. Will document regarding resident's progress a minimum of once per week."

5. Patient A5 was admitted on 11/29/2012. The MTP dated 11/30/2012 listed the short-term goal, "Pt. will report anxiety as 8 on scale of 1-10 for 3 consecutive days prior to discharge." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn (as needed) medications for: Anxiety."

6. Patient A6 was admitted on 11/16/2012. The MTP dated 11/19/2012 listed the short-term goal, "Patient will report any suicidal thoughts/impulses/urges to staff before acting on them." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

7. Patient A7 was admitted on 11/27/2012. The MTP dated 11/29/2012 listed the short-term goal, "Patient will deny suicidal thoughts for 3 days." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

8. Patient A8 was admitted on 11/29/2012. The MTP dated 11/30/2012 listed the short-term goal, "Patient will deny suicidal thoughts for 3 days." The documented Nursing intervention for this goal was "Administer routine medications at dosage and schedule ordered and prn medications for: Depression."

B. Interview

In interview on 12/05/2012 at 9:15 a.m., the Director of Nursing stated "that the interventions were routine nursing practice."

V. Ensure that nursing staff members responsible for each nursing intervention were specifically identified in the master treatment plan for 4 of 8 active sample patients (A1, A2, A3 and A4). This failure results in the patient and other staff being unaware of which staff person was assuming responsibility for the interventions being implemented and documented. (Refer to B123)