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Based on record review and interview, the hospital's governing body failed to ensure that all hospital policies were reviewed per hospital policy, for 3 of 3 hospital locations (Oconomowoc, West Allis, Brown Deer).

Findings include:

The hospital's governing body failed to ensure that departmental policies were reviewed every three years per policy, for 3 of 3 hospital locations (Oconomowoc, West Allis, Brown Deer). (Reference A0043)

The cumulative effect of this governing body failure resulted in the hospital's inability to promote the health and safety of it's patients.

Evidenced by:

Oconomowoc site:
"Policy #23-001-0210-Policy/Procedure Formation and Administration, effective 2/15/10 (no documentation of revision date)" revealed "Review of Policies: Policies are to be reviewed at least every three years by the department managers... After review, the managers will forward... to the executive secretary. If policy is reviewed without revisions, the reviewer is to write his/her initials and date on the signature page of their copy of the policy and immediately provide to the executive secretary... Upon receipt, the executive secretary will note the date of review and reviewer's initials on the original policy that is maintained in her/his office." The review date on this policy was blank.

Record review of survey policies revealed:
"Informed Consent for Use of Medications, #02-011-1215, dated 2/23/2015",
"Employee Competencies, #25-007-0504, dated 5/31/2004",
"Food Purchasing, Receiving & Storage, #11-210-0809, dated 8/24/2009",
"Hand Hygiene, #21-020-0513, dated 5/20/2013",
"Laundry: Inpatient Personal Processing On-Site, #04-115-0809, dated 8/24/2009",
"Organ Donation, #02-009-0710, dated 8/10/10."

Per review of the "Universal Policies and Procedures Database, printed on 1/15/19", the following policies had no documented evidence of being reviewed and/or revised during the past three year period:
"Death of a Patient, #006", revised 08/07"
"Performance Improvement Files, #012, revised 03/03",
"Medical Staff Response, #056, revised 10/09"
"Continuing Medical Education Requirements, #205, revised 10/10""Elopement Precautions, #021, revised 04/07"
"Discharge, #025, revised 02/08"
"Seizure Precaution, #032, revised 09/04"
"Emergency Medical Code Blue, #047, revised 10/04",
"Room Change, #056, revised 04/00"
"Unit Shutdown, #075, revised 03/03"
"Behavioral Assessment- Older Adult, #098, revised 01/01"
"Medical Emergencies- Rapid Response, #113, revised 12/08"
"Medications and Controlled Substances, #232, revised 08/04"
"Medication renewal and discontinuation, #233, revised 02/01,
"Alarm Safety (Clinical) -Patient Rooms, #124, revised 04/15"
"Meal Service, #017, revised 08/09"
"Infection Control, #009, revised 03/13"
"Infection Control-Personal Protective Equipment, #010, 03/13"
"Bathroom/Restroom Cleaning, #005, 03/10",
"Infectious Linen Handling, #012, revised 03/15"
"Linen Storage and Distribution, #014, revised 02/06"

During interview on 1/16/19 at 8:40 AM, Regulatory Compliance Officer AA stated there was "no documented evidence of hospital policy review in the last 3 years" per the hospital policy.

Based on observation, record review and interview, facility staff failed to obtain informed consent and review medications prior to administration for 1 of 6 medication administrations observations (Patient #20).

Findings include:

West Allis site:
Review of facility policy "Informed Consent for Use of Medications, #02-011-1215, dated 2/23/2015" revealed "It is the policy of [facility] to obtain consent from the patient (14 years or older), or in the case of a minor from his/her parents or guardians, when any medications are administered in treatment and/or prescribed."

Per medical record review, Patient #20 was admitted to the facility on 1/10/2019. Review of Patient #20's informed consent for medications revealed Patient #20 and Patient #20's guardian provided written consent on 1/14/2019 for a antipsychotic medication that was prescribed and administered on 1/10/2019.

During an interview on 1/15/2019 at 3:30 PM, Clinical Services Manager N stated it wasn't clear why consent wasn't obtained at the time the medication was prescribed and staff "should be obtaining consent right away."

During West Allis observation on 1/15/2019 at 8:50 AM, Registered Nurse H administered oral medications to Patient #20 without first reviewing the medications, the purpose of the medications or potential side effects of the medications with Patient #20.

During an interview on 1/15/2019 at 4:30 PM, Chief Nursing Officer C stated "I would expect [the nurse] to review meds with patients."

Based on observation, record review and interview, facility staff failed to identify and mitigate potential environmental ligature risks on 4 of 4 inpatient units (Unit 1, Unit 2, Unit 3, Unit 5) at 1 of 3 inpatient facilities (West Allis). Failure to identify and mitigate potential ligature risk has the potential to affect 4 inpatients in the at-risk patient rooms (Patient #22, Patient #23, Patient #24, Patient #25) and all 33 patients receiving inpatient services on Unit 3 and Unit 5 at the time of the survey.

Findings include:

West Allis site:
On 1/15/2019 the following was observed:
1) On Unit 1 at 9:25 AM, the bathroom shower in room 1107 contained a lever-type handle.

On Unit 2 at 9:30 AM, the bathroom shower in room 1207 contained a lever-type handle. In room 1210 the bathroom contained a toilet paper dispenser that, per the facility's ligature risk checkpoint list, "can be used as an anchor point, for self-harm, or as a weapon."

During interview on 1/15/2019 at 9:30 AM, Facilities Manager I stated "those [shower handles] need to be addressed and the toilet paper holder needs to be gone."

2) On Unit 3 at 12:15 PM, the group room door located at the end of the patient hallway and around a corner had a circular non-ligature resistant door handle.

On Unit 5 at 12:10 PM, room 2601 had a door hinge that was accessible to patients from the hallway and was not in direct view of the nurses station.

Record review of the facility census sheet dated 1/15/2019 revealed there were 33 patients receiving care on Units 3 and 5 and 4 patients roomed in the identified at risk rooms on Units 1 and 2. Per medical record review, Patient #22 was admitted to room 1207 on 1/14/2019 with a "moderate risk" for self-harm; Patient #23 was admitted to room 1207 on 1/10/2019 with a "high risk" for self harm; Patient #24 was admitted to room 1210 on 12/13/2018 with a "high risk" for self harm; and Patient #25 was admitted to room 1107 on 1/14/2019 with a "high risk" of violence and aggression toward others.

During interview at 12:15 PM while conducting observations on Units 3 and 5, Facilities Manager I stated room 2601 is a "blind spot" and the group room on Unit 3 is "out of sight." Per Manager I, both the door hinge and the door handle would be considered ligature risks. When asked how the facility identifies and responds to environmental ligature risks, I stated "Our assessment [of the environment] did not reveal any issues... I spot checked the patient rooms, I wasn't aware of the issues. I should have looked in all the rooms."

Based on observation, record review and interview, the hospital failed to ensure that all nursing staff were competent to provide nursing services, for 1 of 5 non-licensed nursing staff (Patient Care Associate P) at 1 of 3 hospital sites (Oconomowoc); and failed to ensure that nursing staff developed individualized care plans with measurable goals, in 17 of 30 sampled patients (Patient #'s 1, 11,12,14, 15, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 and 32) in a total sample of 37 patients, at 3 of 3 hospital sites (Brown Deer, West Allis and Oconomowoc); and failed to ensure that nursing staff administered medications safely, in 2 of 6 patients medication observations (Patient #'s 12 and 36), in a total sample of 37 patients, at 2 of 3 hospital sites (West Allis and Brown Deer).

Findings include:

1) The hospital failed to ensure non-licensed nursing staff were trained and competent to perform direct patient care, as part of its orientation training, (Reference A0392)

2) The hospital failed to ensure that interdisciplinary care plans were developed when needed, contained individualized (patient-specific) measurable goals and were revised when necessary. (Reference A0396)

3) The hospital's nursing staff failed to follow hospital policy/procedure to ensure safe and timely medication administration. (Reference A0405)

The cumulative effects of these nursing service failures resulted the hospital's inability to promote the health and safety of the 30 patients on their child/adolescent behavioral health units.

Based on record review and interview, facility staff failed to ensure non-licensed nursing staff were trained and competent to perform direct patient care, as part of its orientation training, for 1 of 5 non-licensed nursing staff (Patient Care Associate P).

Findings include:

Oconomowoc site:
Record review of the Patient Care Associate (PCA) job description revealed "High school graduate, or equivalent, is required." There were no other requirements related to patient care skills. Job responsibilities included "2. Collect and record data to contribute to the treatment plan. A. Document patient progress, as appropriate. B. Obtain and record vital signs. C. Assume responsibility for location or assigned patient and complete rounds, flow sheets and safety checks. D. Accompany patients to meals, monitor food intake and behaviors, and document as appropriate. E. Interact with patients, offer one-on-one sessions, discuss patient goals to address psychosocial, spiritual, intellectual and physical needs. 3. Implement patient care."

Review of facility policy "Employee Competencies" No. 25-007-0504 dated 5/31/2004" revealed "1. Job specific orientation checklist and job specific competency were created by respective department managers and administration using licensing standards, job descriptions, and evaluation expectations, as well as patient care standards and established protocols... 6. New employees will have 90 days to complete the job specific orientation checklist...".

During an interview on 1/16/2019 at 1:40 PM, Human Resource Business Partner R stated that while nursing assistant certification is preferred for the Patient Care Associate role, it is not required. Per R, Patient Care Associates that are not certified upon hire receive additional clinical training that covers clinical components of the PCA job requirements. Per personnel file review, PCA P's hire date was 8/20/2018. There was no evidence that P had received the additional clinical competency training at the time of the review on 1/16/2019, more than 90 days after hire. R stated "it must not have been done."

Based on observation, record review and interview, the hospital failed to ensure that interdisciplinary care plans were developed when needed, contained individualized (patient-specific) measurable goals and were revised when necessary, in 17 of 30 sampled patients (Patient #'s 1, 11,12,14, 15, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 and 32) in a total sample of 37 patients, at 3 of 3 hospital sites (Brown Deer, West Allis and Oconomowoc).

Findings include:

Policy record review of the Quick Inventory of Depressive Symptomatology (QIDS) Process "Administration of Pre-and Post-QIDS on the Adult Inpatient Unit, effective date 1/19/19" revealed "When does this process occur: Within 12 hrs of Admission and Discharge". Step trigger under the column titled Description revealed "RN [Registered Nurse] delegates QIDS to PCA [Patient Care Assistant] at time of admission to the unit... RN receives email of QIDS result from... and enters results in adhoc." Under column titled Description revealed "Discharge" 1. "RN delegates QIDS to PCA day of discharge... RN receive email of QIDS results from... and enters results in adhoc charting."

Record review of the facility policy titled "Treatment Planning, #04-057-0119, effective date of 1/1/19" revealed:
"Standards: 1. Each LTG (long term goal) must have a minimum of one STG (short term goal) supporting the LTG.
2. Interventions should be specific as to the responsible discipline and include a frequency on how often the intervention will be performed. This can be documented in the intervention or in document in plan.
3. Each treatment plan is interdisciplinary, reflecting the various techniques utilized in assisting the patient to complete his/her treatment process. All disciplines involved in the care of the patient individualize the treatment plan by reviewing any/all goals/interventions and adding or deleting specific goals/interventions that target the individual patient's treatment problems.
4. Active medical problems are addressed on the treatment plan, unless deferred at the staffing. Problems that are deferred are indicated on the Master Treatment Plan as not requiring attention at this time.
5. Interventions (appropriate by program guidelines) identified by the patient as helpful, particularly from the Crisis Prevention section of the Admission Nursing Assessment or Social Services admission assessments, should be included in the treatment plan.
6. Patient-Specific goals that have been identified through the assessment process as treatment needs will be reviewed and prioritized with the top one to three listed as goals in the patient's master treatment plan.
7. Patient-Specific assessments will be used to identify individual interventions that are identified during the initial and master treatment planning processes. Daily reassessments may occur as they help define and meet the individual goals of each patient.
8. When any Rogers employee has identified an event or occurrences that are considered reportable or outside the current expectations of treatment the RN/Therapist will update the Interdisciplinary Plan of Care to outline the proper action steps or interventions needing change to assist the patient with meeting their treatment goals.
9. For a minor, the treatment plan will also include educational goals and other individualized goals based on their screening and presenting problems. Procedure: Initial Treatment Plan: Upon admission, an Initial Treatment Plan (IPOC) will be originated within the following timeframes based on level of care: a) Inpatient-The registered nurse will initiate the treatment plan, based on evaluation of assessment data within eight (8) hours of admission. (Nursing Specific).
Record review of the Master Treatment Plan Formation revealed "The attending physician, psychologist, registered nurse, social service staff, addictions counselor, patient and other appropriate disciplines will have input developing identified manifestations of problems, long-term goals, short-term goals, interventions and frequencies.
1. Problem/Diagnosis List: a. The Master Problem List is populated by the social service staff/addiction counselor/RN completing the initial assessments and as new problems arise. The physician/psychologist completes the Diagnosis List. b. Treatment Plan Problems are identified through the assessment process. Active problems, including active medical problems, should be included. Non-active problems are documented in the Problem List.
2. Patient Specific Goals are identified. a. Each problem has at least one long-term goal (goal that is intended to complete by the end of treatment) and at least one short-term goal (goal that assists in progressing toward the long-term goal. b. Goals- Patient- Specific goals will be used to identify goals that have been identified throughout he assessment process as treatment needs the patient has in this level of care. c. Goals should be measurable, patient-specific, and reasonable. The electronic health record provides a dictionary of sample goals. Rogers assessments are used to identify individualized goals for each patient.
3. Interventions-Patient-Specific Interventions, will be used to identify individual interventions that are identified during the assessment and reassessment process as helpful in meeting the individual goals of the patient. a. Each discipline responsible for a problem are responsible for identification of interventions that the discipline will be performing. b. Interventions should be based on individual needs and be specific to that patient... Treatment Plan Staffing Update: After the initial staffing the patient progress toward meeting the established goals is evaluated and documented in the Document in Plan section of the electronic health record and also in the Master Treatment Plan. 1. Evaluation is based, not only on team members' observations about patient functioning, but on feedback from the patient/significant others. 2. Failure to reach a goal may indicate either that the treatment approaches are not effective or that the goal is unrealistic, which would result in evaluation and change of that goal. 3. Revision of the treatment plan may then be necessary, based upon the circumstances.
4. The Master Treatment Plan is completed by the social service staff/addictions counselor. The 'update' type of staffing is documented in the Master Treatment Plan...
6. The social service staff/addictions counselor will review staffing and treatment plan information with patient and guardian. If the guardian is not available in person, document a verbal review of the treatment plan. Initials and dates will be obtained on the Treatment Plan Signature Sheet after formal staffing and indicate a review of the updates with each patient/guardian occurred.
7. The attending physician's/psychologist's signature on the Master Treatment Plan indicates that he/she reviewed the treatment plan, that it is appropriate, and approved. Treatment team signatures/initials should be completed for each update.
8. Unmet goals should transfer to the next level of care of the Discharge Instructions Powerform."

Brown Deer Site:
1) Record review revealed Patient # 26 was admitted on 1/10/19 with Suicidal Ideation (SI). Patient # 26's treatment plan included a primary problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ______ from ______ to ______." The nursing staff failed to complete the SI goal. There was no patient-specific (individualized), measurable goal identified for Patient #26.

2) Record review revealed Patient # 27 was admitted on 1/3/19 on 1:1 monitoring, after a suicidal attempt of cutting both wrists. Patient # 27's treatment plan included a primary problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ______ from ______ to ______." The nursing staff failed to complete the SI goal. There was no patient-specific measurable goal(s), and no documented problems or interventions addressing wound care (bilateral wrists) with prescribed interventions and/or nursing assessment/monitoring of areas, and no documented problem for being on 1:1 supervision for Patient #27.

An interview was conducted on 1/15/19 at 4:15 PM with Director of Nursing GG. When asked if it would be expected that a patient receiving wound care would have a problem on their treatment plan, Director of Nursing GG stated "Yes, I would expect that nursing would make a problem for that." When a policy & procedure request was made, Regulatory Compliance Staff HH stated "We do not have a policy on what is expected from nursing to do care plans."

3) Record review revealed Patient #28 was admitted on 1/6/19 with a previous history of increased Depression and Suicidal Ideation with a plan to overdose on medication or intravenous heroin/cocaine. Patient # 28's treatment plan included a primary problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ______ from ______ to ______ QIDS." The nursing staff failed to complete the SI goal. There was no patient-specific measurable goal(s).

4) Record review revealed Patient #29 was admitted on 1/7/19 with diagnosis of PTSD (Post Traumatic Stress Disorder), DMDD (Disruptive Mood Dysregulation Disorder), ADHD (Attention Deficit Hyperactivity Disorder) and increasing aggression towards property and animals, and verbal aggression toward people at home and school. Patient #29's treatment plan included a primary problem of "1:1 Monitoring due to Potential for Self Injury of Harm to Others" with a long term goal of "Poor Impulse Control as evidenced by scoring _____on admission, will reduce to _____" and a long term goal of "Reduce poor impulse control as evidenced by scoring ______on admission will reduce to_____." The nursing staff failed to complete patient-specific measurable goals for Patient #29.

5) Record review revealed Patient #30 was admitted on 1/10/19 with complaints of increased Depression and Suicidal Ideation. Patient #30's treatment plan included a primary problem of "Reduce/Eliminate SI/Plans" with a long term goal of "evidenced by reducing score on the ______from______to_____." There was no patient-specific measurable goals for Patient #30.

6) Record review revealed Patient #31 was admitted on 1/12/19 with a recent suicide attempt and a past history of Depression, self harming behaviors, and thoughts of suicide. Patient #31's treatment plan included a primary problem of "Reduce/Eliminate SI/Plans" with a long term goal of "evidenced by reducing score on the _____from_____to_____." There was no patient-specific measurable goals for Patient #31.

7) Record review revealed Patient #32 was admitted on 1/2/19 with increased Suicidal Ideation and self-harm by cutting. "Admission Psych evaluation" documented "Patient had twenty shallow, even cuts on left forearm. Patient #32's treatment plan included a primary problem of "At Risk for Self-Harm"and a long term goal of "Identify a Decrease in Frequency of _____ thoughts that contribute". There was no patient-specific measurable goals for self-harm, and no documented problems or interventions addressing wound care to cuts on left forearm with prescribed interventions and/or nursing assessment/monitoring of areas for Patient #32.



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West Allis site:
8) Per medical record review, Patient #14 received inpatient services from 1/4/2019 to 1/11/2019 for Depression and Suicidal Ideation. Patient #14's treatment plan included a primary problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ___ from __ to __." A nursing discharge note dated 1/11/2019 revealed "Goals achieved: Patient participated in interdisciplinary assessments including psychiatric evaluation and received medication management. Patient participated in family and group therapy. Patient worked on developing healthy coping skills to handle stressors, poor impulse control, as well as mood stabilization. Patient was encouraged to express thoughts and feeling." There was no patient-specific, measurable goal identified for Patient #14.

9) Per medical record review, Patient #15 received inpatient services from 12/21/2018 to 1/1/2019 for Bipolar Disorder and Suicidal Ideation. Patient #15 was scheduled to be discharged on 12/28/2018. A progress note dated 12/28/2018 at 11:59 AM revealed "Writer met with patient prior to discharge to complete a safety plan. ...Patient was unable to discuss a plan... Patient is at moderate risk for suicide and reports current thoughts of suicide." Patient #15's discharge was put on hold due to suicidal ideation on 12/28/2019. On 12/29/2018 at 6:40 PM "Patient developed a sudden case of volatile paranoia... wanted to leave the hospital and accused medical staff of holding [#15] against will... crying, falling on the floor, targeting staff. Code Green and MD called." The progress note stated Patient #15 required emergency medication administration to calm. Review of Patient #15's treatment plan did not include updated goals or interventions to reflect Patient #15's significant change in behavior or discharge status.

10) Per medical record review, Patient #20 was admitted to the facility on 1/10/2019 for Depression and attempted suicide. Per a medical consultation note dated 1/11/2019, a plan to "apply TAO [topical antibiotic ointment] twice daily for 7 days" to Patient #20's two lacerations on left wrist. There was no documentation in Patient #20's medical record that this medical consult information was care planned or applied. Per a medical progress note dated 1/13/2019, "Patient consult per request... for 2 left wrist deep lacerations. ...Upon assessment ...white pus noted." There was no care planned documentation of nursing re-evaluation to treat or care for Patient #20's wounds.

Per medical record review, Patient #20's treatment plan included a problem of "Anxiousness" with a long term goal to "Reduce anxiety as evidenced by reduction in score from __ at admit to __" and a problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ___ from __ to __." Patient #20's treatment plan did not include patient-specific, measurable goals.

11) Per medical record review, Patient #22 was admitted to the facility on 1/14/2019 for aggression and Suicidal Ideation. Patient #22's treatment plan included a problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ___ from __ to __." There was no patient-specific, measurable goal identified for Patient #22.

12) Per medical record review, Patient #23 was admitted to the facility on 1/10/2019 for homicidal and suicidal ideation. Patient #23's treatment plan included a problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ___ from __ to __." There was no patient-specific, measurable goal identified for Patient #23.

13) Per medical record review, Patient #24 was admitted to the facility on 12/13/2018 for depression and suicidal ideation. Patient #24's treatment plan included a problem of "Suicide Risk" with a long term goal to "Reduce/Eliminate SI/Plans as evidenced by reducing score on the ___ from __ to __." There was no patient-specific, measurable goal identified for Patient #24.

14) Per medical record review, Patient #25 was admitted to the facility on 1/14/2019 with a problem of "Poor Impulse Control" and a long term goal of "Reduce Poor Impulse Control as evidenced by scoring __ on admission will reduce to __." There was no patient-specific, measurable goal identified for Patient #25, there was no documentation of what scaling metric was being used to measure Patient #25's progress.



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15) Patient # 11's medical record revealed patient #11 was admitted 1/08/2018 with depression, suicidal ideation. Master Treatment Plan dated 1/9/2019 at 10:25 AM under Team Goals revealed "LTG [long-term goals] Reduce/Eliminate SI[suicidal ideation]/Plans as evidenced by reducing score on the _____ from _____ to _____... ID [identify] 4 positive qualities about self to improve self-esteem and verbalize to therapist Identify 2-3 coping skills that assist in dealing with ideation triggers." There are no long-term goal measurements, no positive qualities or coping skills documented in treatment plan.

16) Patient # 12's medical record revealed patient #12 was admitted 1/11/2018 with suicidal ideation. Master Treatment Plan dated 1/15/2019 at 10:33 AM under Team Goals revealed "LTG [long-term goals] Reduce/Eliminate SI[suicidal ideation]/Plans as evidenced by reducing score on the _____ from _____ to _____... ID [identify] 3-4 triggers and 2-3 coping skills to deal w [with] persistent challenges of intrusive thoughts." There are no long-term goal measurements, no triggers or coping skills documented in treatment plan.

On 1/15/19 at 12:28 PM during an interview with RN/Physician Adoption Specialist K, K stated that a patient self assessment QIDS (Quick Inventory of Depressive Symptomatology) test is administered by the PCA under the RN direction. K stated that the QIDS score is to be placed in the long term goals section of the master treatment plan. K confirmed the QIDS test was not documented in Patient #11 or #12's master treatment plan.


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Oconomowoc site:
17) Conference room observations on 1/15/19 at 10:10 AM of Patient #1, while attending the "safety" adult services inpatient group, revealed the patient had involuntary mouth (jaw) and head tremors (extrapyramidal side effects).

Record review of the 1/7/19 at 8:14 PM "Psychiatric Evaluation" revealed "The first thing I noticed when I walked into the room was Patient #1's masked face and stiff posture and tremors which I am not sure are tardive dyskinesia or related to Lithium but I definitely feel there is a component (and not a small one) of extrapyramidal symptoms."

Record review of the 1/15/1911/30/18 at 2:04 p.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of development of a nursing care plan to evaluate/monitor the symptoms of masked face and stiff posture and tremors and their impact on Patient #1's ADLs (activities of daily living).

Based on observation, record review and interview, nursing staff failed to follow hospital policy/procedure to ensure safe and timely medication administration in 2 of 6 patients medication observations (Patient #'s 12 and 36), in a total sample of 37 patients, at 2 of 3 hospital sites (West Allis and Brown Deer).

Findings include:

Record review of policy titled "Medication Procurement, dated 10/04/16" revealed "If the patient's medication is not available from the pharmacy or ADM [automated dispensing machine], home medications may be used if the medication is in its original bottle, is appropriately labeled, can be positively identified by the pharmacy and is ordered by the physician."

Record review of policy titled "Medication Administration dated 10/04/16" under Definitions and Standards "1. Standard times for medication administration" for "Daily (every day)" medication (adult) revealed "8:30 AM", "2. Scheduled medications are to be administered within a 60-minute timeframe around the scheduled time, specifically, one-half hour before or one-half hour after."

Review of the Medication Administration policy #04-230-1016 dated 10/4/16 revealed "Procedure: 5. Identify the patient by scanning the patient identification band and using the idenfitication photograph in the electronic health record. Administer medications."

West Allis site:
1.a.) West Allis observations of Unit 5 on 1/15/19 at 9 AM with Chief Nursing Officer (CNO) C, revealed that drawer 2 medication cart contained a plastic zip bag with Patient 12's drug store-labeled prescription bottle inside. The bottle revealed "Colchincine 0.6 mg. (milligrams), Take one tablet by mouth daily (used for Gout to decrease swelling and pain)."

During interview on 1/15/19 at 9 AM, Registered Nurse (RN) Z stated the medication bottle was in the medication drawer because "it needs a bar code from the (hospital) pharmacy, pharmacy puts the bar code on." When asked if a pharmacist had identified the home medication, RN Z stated "the medication came from the drug store" because the hospital does not carry that medication. When asked if the facility's pharmacist had identified the medication in the bottle, RN Z stated Z did not know their process.

Record review revealed "Patient care note" dated 1/11/19 at 11:24 PM by RN T revealed "spoke with medical about gout medication, due to no (drug) equivalent in the system." Pharmacy history revealed medication reconciliation for Colchicine 0.6 mg oral daily entered 1/12/19 at 11:18 AM by Staff U and reviewed by RN V on 1/12/19 at 4:49 PM. On 1/12/19 at 3:49 PM, Pharmacy staff W modified the order and routed to Advanced Practice Nurse Practitioner (APNP) X who authenticated the medication on 1/12/19 at 3:49 PM. The MAR (medication administration record) revealed the first dose of Colchicine 0.6 mg tablet was given to Patient #12 on 1/13/19 at 8:40 AM. There was no documented evidence of a pharmacist's identification/authentication of Patient #12's Colchicine.

During interview with Pharmacy Director B on 1/16/2019 at 10:30 AM, B stated "if the doctor gives an order for a medication that is not in our formulary, we use the patient's own supply." Per B, the pharmacist visually inspects the bottle and medication from home to ensure the drug is identifiable and labels it with a barcode. Director B stated "this situation was unusual, we were waiting for the medication to come from [Patient #12's] home, but then the nurse practitioner ordered it from Walgreen's (local public) pharmacy. We weren't notified when it came in so we never put a label on it. I'm not sure how pharmacy got left out of the loop, it should be communicated [to pharmacy staff]."

1.b.) Record review of Patient #12 revealed admission on 1/11/19 at 11:24 PM for Suicidal Ideation and chronic pain disorder. The "patient care note dated 1/11/19 at 11:24 PM" by RN T revealed "spoke with medical about gout medication, due to no equivalent in the system." Pharmacy history revealed medication reconciliation for Colchicine 0.6 mg oral daily was entered 1/12/19 at 11:18 AM by Pharmacy staff W and reviewed by RN V on 1/12/19 at 4:49 PM. On 1/12/10 at 4:49 PM, APNP X authenticated the order for Colchicine. Pharmacy administration record revealed first dose of Colchicine 0.6 mg tablet was given to Patient #12 on 1/13/19 at 8:40 AM (33 hours after need for daily medication was identified).

On 1/15/19 at 4:50 PM, RN/Physician Adoption Specialist K confirmed the first oral dose of Colchicine was given on 1/13/19 at 8:40 AM.



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Brown Deer site:
2) Observations on 01/15/19 at 5:05 PM revealed RN (Registered Nurse) II obtain sliding scale insulin dose for Patient #36. RN II failed to identify the patient by scanning the patient identification band prior to giving the patient the insulin.

During interview on 01/15/19 at 5:15 PM with DON GG, DON GG stated, "The patient should be identified by scanning their identification band prior to administering medication."

Based on observation, record review and interview, the hospital's dietitian failed to evaluate patient's abnormal physical symptoms that could impact their nutritional status, in 1 of 1 patients having abnormal face and mouth/jaw tremors (Patient #1), in a total sample of 37 patients, at 1 of 3 hospital sites (Oconomowoc).

Findings include:

Oconomowoc site:
Oconomowoc adult unit conference room observations on 1/15/19 at 10:10 AM of Patient #1, while attending the "safety" adult services inpatient group, revealed the patient had involuntary mouth (jaw) and head tremors (extrapyramidal side effects).

Record review of the 1/7/19 at 8:14 PM "Psychiatric Evaluation" revealed "The first thing I noticed when I walked into the room was Patient #1's masked face and stiff posture and tremors which I am not sure are tardive dyskinesia or related to Lithium but I definitely feel there is a component (and not a small one) of extrapyramidal symptoms."

Record review of the "Dietitian screen/assessment dated 1/8/19 at 2:14 PM" and the "Dietitian Consult/Follow-up Note dated 1/15/19 at 8:36 AM" revealed no information regarding this patient's abnormal involuntary movements of the face and jaw (extrapyramidal symptoms) or how they might impact on the patient's ability to eat.

During interview with CTS (Computer technology Specialist) BB, on 1/15/19 at 3:30 PM, BB stated "I do not see it (documentation by the dietitian)."

Based on observation, record review and interview, the hospital failed to ensure that all dietary staff were competent in their food preparation/storage duties, at 2 of 3 hospital sites (Oconomowoc and West Allis).

Findings include:

Review of facility policy "Food Purchasing, Receiving & Storage, #11-210-0809 dated 8/24/2009" revealed "Storage: 5. Food is not stored or served in the critical temperature zone 40 - 140 degrees Fahrenheit. ...10. All dry storage/canned food items are sealed, labeled and dated. ...Once the original case/package has been opened, Dining Services staff documents an 'opened' date. Items not marked with a manufacturer's 'use by' date are to be used within 6 months of 'received' date."

Facility policy titled "Personal Hygiene" dated 08/12/2016 revealed "5. Dining Service personnel must wear a hairnet or a cap to cover their hair."

West Allis site:
1) During observation on 1/15/2019 at 8:30 AM, the West Allis location kitchen contained large opened bags of white rice and brown rice, and large open containers of flour and sugar. None of the opened products were labeled with an open date or a manufacturer expiration date. Opened spices above the stove top were not labeled with an open date.

During an interview on 1/15/2019 at the time of the observation, Food Services Supervisor F stated "I always assumed there was a manufacturer expiration date that we go by... but I can't find it on these." When asked if opened food items are expected to be labeled with the date opened, F stated "we just go be the date received."

2) Per observation on 1/15/2019 at 8:40 AM, the temperature of the cottage cheese located on cold holding serving compartment was 44 degrees Fahrenheit.

During an interview at the time of the observation, Food Services Supervisor F stated the food is served for breakfast from 7 AM to 9 AM and cold foods "should be under 40" degrees.



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Oconomowoc site:
3) During an observation on 01/14/2019 at 11:30 AM in the Oconomowoc kitchen, observed Culinary Staff LL in the food prep area with hair outside of the hairnet on the nape of neck.

An interview was conducted with Dietary Services Manager KK on 01/14/2019 at 11:30 AM, Dietary Services Manager KK stated "Staff LL should have all hair in the net."

Based on observation, staff interview and review of maintenance records between 01/14/19 and 01/22/19, the Rogers Memorial Hospital failed to construct, install, and maintain the building systems to ensure life safety to patients.


42 CFR 482.41 Condition of Participation: Physical Environment is NOT MET


The facility was found to contain the following deficiencies.

Building #1
K311 Vertical Openings - Enclosure
K343 Fire Alarm System - Notification
K919 Electrical Equipment - Other

Building #3
K321 Hazardous Areas- Enclosure
K347 Smoke Detection

Building #4
K293 Exit Signage
K311 Vertical Openings - Enclosure
K341 Fire Alarm System - Installation
K374 Subdivision of Spaces - Smoke Barriers
K521 HVAC
K911 Electrical Systems - Other

Building #9
K341 Fire Alarm System - Installation
K911 Electrical Systems - Other

The cumulative effect of these deficiencies resulted in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interview and review of maintenance records between 01/14/19 and 01/22/19, the Rogers Memorial Hospital failed to construct, install, and maintain the building systems to ensure life safety to patients.

42 CFR 482.41(b) Standard: Life Safety from Fire was NOT MET


The facility was found to contain the following deficiencies.

Building #1
K311 Vertical Openings - Enclosure
K343 Fire Alarm System - Notification
K919 Electrical Equipment - Other

Building #3
K321 Hazardous Areas- Enclosure
K347 Smoke Detection

Building #4
K293 Exit Signage
K311 Vertical Openings - Enclosure
K341 Fire Alarm System - Installation
K374 Subdivision of Spaces - Smoke Barriers
K521 HVAC
K911 Electrical Systems - Other

Building #9
K341 Fire Alarm System - Installation
K911 Electrical Systems - Other

The cumulative effect of these deficiencies resulted in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, the hospital's infection control officer failed to ensure that aseptic technique was followed for infection prevention in the areas of hand hygiene, surface disinfection and laundry/linen handling, at 3 of 3 hospital sites (Oconomowoc, West Allis and Brown Deer) affecting 4 of 37 sampled patients (Patient #'s 19, 20, 21 and 36).

Findings include:

Review of facility policy "Hand Hygiene" No. 21-020-0513 dated 5/20/2013 revealed "2. Hand hygiene will minimally occur in the following circumstances: A. Before having direct contact with patients. ...D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings... E. After removing gloves. ...H. Prior to administration of medications and between each patient during medication administration."

Review of the facility policy titled "Bloodborne Pathogens Exposure Control Plan" #28-014-0418 dated 4/1/18 revealed "C. 1. Compliance Methods: Standard precautions will be observed at this facility in order to prevent contact with blood or potentially infectious material."

Per CDC (Centers for Disease Control) "Guidelines for Environmental Infection Control in Health-Care Facilities, dated June 6, 2003" under "Recommendations--Laundry and Bedding" "IV. Laundry Process A. If hot-water laundry cycles are used, wash with detergent in water greater than 160 degrees F for greater than 25 minutes."

Review of facility policy "Laundry: Inpatient Personal Processing On-Site" No. 04-115-0809 dated 8/24/2009 revealed "3. Laundry detergent is provided which has been approved by the Health and Wellness Coordinator."

West Allis site:
1) Per observation on 1/15/2019 at 8:50 AM, Registered Nurse H did not perform hand hygiene prior to administering oral medications to Patient #19.
After administering Patient #19's medications, Registered Nurse H administered Patient #20's medications without performing hand hygiene.
After Patient #20's medication administration, Registered Nurse H donned a pair of gloves and removed a bandage from Patient #20's wrist and performed wound care on the portable computer tray. Nurse H then placed a clean dressing on Patient #20's wound, removed gloves without performing hand hygiene.
After Dressing change, Nurse H prepared oral medications to be administered to Patient #21 without performing hand hygiene or disinfecting the surface of the computer tray.

During an interview on 1/15/2019 at 4:30 PM, Chief Nursing Officer C stated hand hygiene should be performed with medication administration and wound care. Per C, "Yes, I noticed that."

Oconomowoc site:
2) Observation of the adult and children's inpatient units on 1/14/2019 at 4:00 PM revealed laundry rooms containing laundry detergent "packs" for patient use.

During an interview on 1/14/2019 at 4:00 PM, Health and Wellness Coordinator A was unable to state that the detergent had been approved by A or the infection control committee and was unable to provide documentation that the detergent was reviewed and approved.



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3) On 01/14/19 at 1:03 PM observed clean linen storage located in the basement of facility (Oconomowoc) revealed one linen cart with contained towels, one linen cart with bed spreads, microfiber environmental cleaning clothes and rag type mop heads were stored uncovered.

Per interview on 01/14/19 at 1:05 PM, Facilities Manager I stated, "I don't know why those carts are not covered, they should be."

Brown Deer site:
4) On 01/15/19 at 9:00 AM during a tour of the Adult Unit and at 3:45 PM tour of the child/adolescent unit observed the clean linens are stored in a closet without a cover over the linens.

Per interview on 01/15/19 at 9:15 AM, Facility Manager EE stated, "well the door is the cover to the linen".

5) On 01/15/19 at 9:00 AM during a tour of the Adult Unit and at 3:45 PM tour of the child/adolescent unit the patient laundry rooms, no water temperature logs present.

Per interview on 01/15/19 at 9:00 AM, asked Facility Manager EE how do you ensure the water temperature reaches the appropiate temperature to kill bacteria? Facility Manager EE stated "the company wouldn't commit to how high the water temperature reaches."

6) Observations on 01/15/19 at 4:50 PM revealed Patient Care Associate JJ perform a blood glucose test on Patient #36. Patient Care Associate JJ obtained blood glucose testing supplies from the nurses station, donned gloves and went to Patient #36 who was seated at a table in the day room. Patient Care Associate JJ cleansed Patient #36 right ring finger with a alcohol pad, performed the finger stick with a lancet, placed the lancet in a paper cup, wiped the blood drop with a gauze and placed the bloody gauze on the table without a barrier. Patient Care Associate JJ performed the blood glucose test, cleaned the blood glucose meter with an alcohol pad and placed it in a plastic container. Patient Care Associate JJ then removed gloves and returned the blood glucose testing supplies in the common area of the nurses station.

Per interview on 01/15/19 at 5:15 PM, Director of Nursing (DON) GG stated "that bloody gauze should not of been placed on the table surface," and stated that Patient Care Associate JJ did not follow the hand hygiene policy and "should have performed hand hygiene after gloves were removed."

Based on record review and interview, the hospital staff failed to provide accurate and patient-specific discharge instructions for 2 of 9 patients discharged to home (Patient #'s 14 and 15), in a total sample of 37 patients, at 1 of 3 hospital sites (West Allis).

Findings include:

West Allis Site:
Review of facility policy "Medication Reconciliation" No. 04-282-0819 dated 8/29/2016 revealed "2. At the time of each transfer or discharge..., the Discharge Medication Reconciliation form is completed. ...B. The physician reviews the Admission Reconciliation and Current Medications and documents those that will continue or discontinue at discharge. ...C. The RN (Registered Nurse) ensures the discharge medications are available on the patient instructions in the Electronic Health Record depart process. The RN selects medication education as needed which will be attached to the patient instructions document."

Review of facility policy "Suicide--Risk Assessment, Prevention and Precautions" No. 04-284-0918 dated 9/1/2018 revealed "K. Patient/family education regarding precautions will be given and documented in the appropriate location in the medical record. L. At the time of discharge, if the patient's C-SSRS [Columbia -Suicide Severity Rating Scale] score rates at the medium or high level, the RN or social worker must alert the physician prior to the patient discharging."

1) Per medical record review, Patient #14 received inpatient services from 1/4/2019 to 1/11/2019 for Depression and Suicidal Ideation. Review of patient #14's C-SSRS at discharge on 1/11/2019 revealed "yes" to the following: "Wish to be dead; Suicidal Thoughts; Suicidal Thoughts with Method (without specific plan or intent)." During an interview on 1/15/2019 at 12:45 PM, when asked if the physician should be notified of the suicide screening results prior to discharge, Electronic Health Record Optimization Director M stated all at risk patients are discharged with a safety plan. Review of Patient #14's discharge instructions did not include a safety plan. Per Director M, "it could not be located."

Patient #14's home medications upon admission included Levalbuterol (bronchodilator) 45 mcg/inhalation every 4 hours as needed for a diagnosis of asthma. Levalbuterol was included in Patient #14's inpatient prescription medication list. Patient #14's discharge instructions included instruction to "No longer take the following medications: ...levalbuterol 45 mcg/inh (inhalation)." There was no documentation in Patient #14's medical record that the medication had been discontinued.

During an interview on 1/15/2019 at 12:35 PM, Director M stated "the admission and discharge home medication lists should match unless there was an order to change something."

2) Per medical record review, Patient #15 received inpatient services from 12/21/2018 to 1/1/2019 for Bipolar Disorder and Suicidal Ideation. Noncompliance with medication regimen was identified as a precipitating factor to Patient #15's admission. During the course of hospitalization, Patient #15 was treated with Aricept (cognitive enhancing medication) for a possible diagnosis of dementia. Patient #15 was discharged with a diagnosis of dementia, a new prescription for Aricept and referral to neurology. Patient #15's discharge instructions did not include any documentation or education regarding the new medication or diagnosis.

During an interview on 1/15/2019 at 1:40 PM, Chief Nursing Officer C stated new medication education would be expected to be provided at discharge.

Based on record review and interview, the hospital failed to ensure that their OPO (Organ procurement Organization) agreement policy was followed, in 1 of 1 patient deaths (Patient #6) in a total sample of 37 patients, at 1 of 3 hospital sites (Brown Deer).

Findings include:

Brown Deer site:
"Policy 02-009-0710-Organ Donation, effective 8/10/10" revealed "3. All deaths and imminent deaths are reported to the Wisconsin Donor Network (WDN)... 15. Documentation of activities related to donation will be made in the progress notes of the hospital's medical record. Notations will include: a. The WDN was contacted. b. If the donation was contraindicated, the reason for unsuitability. c. If the donation was accepted... 16. A review of the medical record of every death will be completed within 30 days to ensure the implementation of this process."

Record review revealed Patient #6 died unexpectedly on 1/18/18. There was no documented evidence of the hospital staff contacting the WDN, after discovery of death, to inform them of the death and to request services of a WDN designated organ donor requestor to initiate contact with patient representative. Record review of the 1/14/19 WDN compliance letter to the hospital revealed that no referrals were made to the WDN in the 12 months of 2018.

During interview with Regulatory Compliance Officer AA on 1/16/19 at 3:15 PM, AA stated "The staff did not contact the donor network."

Based on medical record review, policy review, and interview, the facility failed to provide a psychiatric evaluation that included individualized personal assets on which to base a meaningful treatment plan for seven (7) of 13 records reviewed (A1, A2, A3, B2, B5, B6 and C3) and failed to list patient assets for two (2) of 13 records reviewed (B1 and B4) . The failure to identify patient strengths has the potential to impair the treatment team's ability to choose treatment modalities which best utilize the patient's attributes in therapy.

Findings Include:

I. Medical Records

A. Lack of Individualized Personal Assets

1. Patient A1's Psychiatric Evaluation, dated 1/22/19, listed the non-individualized assets, "verbal, intelligent."

2. Patient A2's Psychiatric Evaluation, dated 1/18/19, listed the non-individualized assets, "verbal, cooperative."

3. Patient A3's Psychiatric Evaluation, dated 1/25/19, listed the non-individualized assets, "verbal, cooperative, intelligent."

4. Patient B2's Psychiatric Evaluation, dated 1/25/19, listed the non-individualized assets, "verbal, cooperative."

5. Patient B5's Psychiatric Evaluation, dated 1/25/19, listed the non- individualized assets, "verbal, cooperative."

6. Patient B6's Psychiatric Evaluation, dated 1/25/19, listed the non-individualized assets, "verbal, cooperative."

7. Patient C3's Psychiatric Evaluation, dated 1/24/19, listed the non-individualized assets, "verbal, cooperative, intelligent."

B. Lack of Patient Assets

1. Patient B1's Psychiatric Evaluation, dated 1/ 26/18, failed to contain patient assets.

2. Patient B3's Psychiatric Evaluation, dated 1/26/19, failed to contain patient assets.

II. Policy Review

Rogers Memorial Hospital - "Medical Staff Bylaws 2018," page 45, stated the following:
5.9 "Psychiatric evaluation. The psychiatric evaluation should be written or dictated, transcribed, and on the chart within 60 hours of admission. This evaluation should include at least the following: "Inventory of assets in descriptive fashion."

III. Interviews

1. During an interview on 1/ 29/19 at 10:00 a.m., the Medical Director concurred with the lack of individualized patient assets and absent individual assets as described.

2. During an interview on 1/29/19 at 2:00 p.m., the Director of Quality Improvement agreed that patient assets were missing or repetitive.

Based on record review, observation, and interview, the facility failed to develop and document Master Treatment Plans (MTPs) based on individual patient needs for one (1) of one (1) patients (E1) added to the sample in order to evaluate active treatment. Specifically, the MTP did not address the patient's individualized needs based on identified problems. In addition, the patient was unmotivated or unable to attend assigned groups and instead sat in the dayroom or stayed in his/her bed. This failure results in the patient not receiving individualized treatment based on identified needs. Failure to address the individualized needs of the patient can inhibit the patient's ability to accomplish the short-term goals listed on the treatment plan and negatively impact the patient's recovery.

Findings Include:

A. Specific Patient Findings

Patient E1 was admitted on 1/24/19 and discharged on 1/28/19. The Psychiatric Evaluation, dated 1/25/19 stated that the patient, who was an outpatient of the admitting psychiatrist, had become " ...worse, with an increase in auditory hallucinations, suicidal ideation, and feelings of hopelessness." The patient told his/her parents of " ...strong urges to run into traffic to harm [him/herself.]" According to the Psychiatric Evaluation, the admitting psychiatrist told Patient E1 that s/he would be expected to attend the programming offered on the unit.

During observation on the Adult Unit (Oconomowoc) on 1/28/19 at 1:15 p.m., Patient E1 was seen resting in his/her room. There was an Experiential Therapy Group being held off the unit from 1:00 p.m. - 2:00 p.m.

Patient E1's Master Treatment Plan (MTP), dated 1/25/19, for the problem, "Depressed Mood," had the short-term goal, "Recognize 5 healthy coping skills [s/he] can use to assist with escalating mood & discuss in group." For the problem, "Mood Instability," the short-term goal stated, "Patient will attend 3 groups per day."

Physician Progress Notes for Patient E1, dated 1/26/19 at 12:52 a.m., stated, "[Patient] is laying [sic] in bed and not participating in groups," and "[S/he] says it is hard to be around so many people."

Nursing Patient Care Notes for Patient E1, dated 1/28/19 at 2:49 p.m., stated, "Writer asked the patient what helped [him/her] during [his/her] stay, [s/he] stated, 'just sitting here getting my head back together, getting out of the house.' " The note further stated that Patient E1 was given a patient workbook on admission but had not entered any information. When the writer of the Patient Care Notes asked why s/he had not used the book, Patient E1 replied, "I don't know."

In interview on 1/28/19 at 1:25 p.m., Registered Nurse 1 (RN1) stated that Patient E1 had been admitted in order to adjust his/her medications. She further stated that the patient was seen on an outpatient basis by the admitting psychiatrist who was following him/her while in the hospital. When asked if the medications had been changed, RN1 said, "no." When asked if patient went to groups, RN1 said that his/her psychiatrist had verbally told them that Patient E1 didn't have to go to groups. RN1 and the Director of Nursing were unable to say what kind of active treatment the patient was receiving since s/he was not going to groups.

During observation on the Adult Unit (Oconomowoc) at 1/28/19 at 2:00 p.m., Patient E1 was observed going into a "Use of Distraction" group. Patient Care Associate 1 (PCA1) informed the therapist of the group that Patient E1 was not going to participate. Patient E1 did not participate and left 10 minutes later.

B. Interviews

1. During an interview on 1/28/19 at 1:50 p.m., Patient E1 stated that s/he does not go to groups because, "I get really nervous." When asked how s/he spent time during the day, Patient E1 stated, "I sit in the dayroom or lay in bed."

2. During an interview on 1/29/19 at 9:30 a.m., the admitting psychiatrist (P1) for Patient E1 stated that the patient had been a frequent patient on the adolescent unit where s/he had received individual programming but had recently turned 18 and was admitted to the Adult Unit where s/he would need to attend the groups with everyone else. P1 told the staff that Patient E1 did not need to go to groups due to his/her anxiety around others. P1 did not know what else had been offered as active treatment for this patient but did state that he told the staff to interact often with the patient.

Based on record review, policy review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified patient related short-term goals in observable, measurable, behavioral terms in 13 of 13 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, B5, B6, C1, C2, and C3). Goal statements that fail to give specific focus have the potential to lead to fragmentation of care and may prolong hospital stays.

Findings Include:

A. Record Review

1. Patient A1 (MTP dated 1/22/19) had the following short-term goal for the identified problem, "Anxiousness":

"Identify 2-3 unhealthy thought patterns associated with patient's anxiety and report in group." This goal was not specific to this patient and did not provide an individualized focus of treatment.

2. Patient A2 (MTP dated 1/21/19) had the following short-term goal for the identified problem, "Disordered Eating":
"Identify 3 triggers to restricting." This goal was not specific to this patient and did not provide an individualized focus of treatment.

3. Patient A3 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"ID [identify] 3-4 situations that contribute to depressed mood and share those situations with their therapist." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." These goals were not specific to this patient and did not provide an individualized focus of treatment.

4. Patient A4 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"ID [identify] 4 positive qualities about self to improve self-esteem and verbalize to therapist." "Identify 5 coping skills to use for depressed mood." These goals were not specific to this patient and did not provide an individualized focus of treatment.

5. Patient B1 (MTP dated 1/26/19) had the following short-term goal for the identified problem, "Substance Abuse":

"Recognize 5 healthy coping skills to manage cravings and report to therapist."
This goal was not specific to this patient and did not provide an individualized focus of treatment.

6. Patient B2 (MTP dated 1/15/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." These goals were not specific to this patient and did not provide an individualized focus of treatment.

7. Patient B3 (MTP dated 1/27/19) had the following short-term goals for the identified problem, "Poor Impulse Control":

"Implement 2-3 positive coping measures in dealing with emotions." "Patient will identify 3-4 acceptable actions to upsetting moods." These goals were not specific to this patient and did not provide an individualized focus of treatment.

8. Patient B4 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"State 3 positive traits about self and verbally share those in group." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." "Patient will report improved ability to fall and stay asleep." These goals were not specific to this patient and did not provide an individualized focus of treatment.

9. Patient B5 (MTP dated 1/24/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Patient will report to staff when having a depressed mood." These short-term goals were not specific to this patient and did not provide an individualized focus of treatment.

10. Patient B6 (MTP dated 1/24/19) had the following short-term goals for the identified problem, "Altered Thought Process":

"Takes medication as prescribed." "Recognizes Alterations in Thought." These short-term goals were not specific to this patient and did not provide an individualized focus of treatment.

11. Patient C1 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Patient will attend and participate in groups." These short-term goals were not specific to this patient and did not provide an individualized focus of treatment.

12. Patient C2 (MTP dated 1/30/19) had the following short-term goals for the identified problem, "Substance Abuse":

"Identify 3 ways to improve sleep hygiene and report in group." "Patient will attend groups." These short-term goals were not specific to this patient and did not provide an individualized focus of treatment.

13. Patient C3 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Substance Abuse":

"Identify and Avoid High Risk Situation." "Patient will attend groups." These goals were not specific to this patient and did not provide an individualized focus of treatment.

B. Policy Review

The facility policy titled "Treatment Planning" effective 1/1/19 stated, "Goals should be specific and measurable for each patient while in treatment." The facility did not adhere to this policy.

C. Interviews

1. During an interview on 1/29/19 at 9:20 a.m., the Director of Nursing at Rogers Hospital Oconomowoc stated, "No, the goals are not individualized."

2. During an interview on 1/29/19 at 10:00 a.m., the Medical Director at Oconomowoc concurred with the findings regarding short-term goals.

3. During an interview on 1/30/19 at 9:00 a.m., the Director of Social Work at Rogers Hospital Brown Deer agreed that the goals were not specific to each patient's needs.

4. During an interview on 1/30/19 at 9:00 a.m., the Medical Director at Rogers Hospital Brown Deer agreed that the goals were not individualized.

Based on record review, policy review, and interview, the hospital failed to develop individualized treatment interventions based on the individual needs of the patients for 13 of 13 patients in the sample (A1, A2, A3, A4, B1, B2, B3, B4, B5, B6, C1, C2, and C3). This failure has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Record Review

1. Patient A1 (MTP dated 1/22/19) had the short-term goal for the identified problem, "Anxiousness":

"Identify 2-3 unhealthy thought patterns associated with patient's anxiety and report in group." The non-individualized generic staff interventions for this goal were:

Physician: "Educate on medications" "Inform patient of Benefits of Adherence to Meds"

Nursing: "Support completion of exposure work"

2. Patient A2 (MTP dated 1/21/19) had the short-term goal for the identified problem, "Disordered Eating":

"Identify 3 triggers to restricting."

The non-individualized generic staff interventions for this goal were:

Expressive Therapy: "Encourage Identifying Feelings Thoughts Expressive Directives"

Social Services: "Provide Opportunities to Express Emotions"

Physician: "Monitor Lab Results"

3. Patient A3 (MTP dated 1/25/19) had the short-term goals for the identified problem, "Depressed Mood":

"ID [identify] 3-4 situations that contribute to depressed mood and share those situations with their therapist." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." The
non-idividualized generic staff interventions for this goal were:

Nursing: "Encourage group attendance"

Physician: "Recommend Discharge Plan"

Registered Nurse: "Encourage increased independence in Daily Living Activities"

4. Patient A4 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"ID [identify] 4 positive qualities about self to improve self-esteem and verbalize to therapist." "Identify 5 coping skills to use for depressed mood." The non-individualized generic staff interventions for this goal were:

Social Services: "Explore Contributing Factors to Mood", "Encourage use of daily routine and enjoyable activities"

Physician: "Monitor Labs for any Abnormal Results"

5. Patient B1 (MTP dated 1/26/19) had the following short-term goal for the identified problem, "Substance Abuse":

"Recognize 5 healthy coping skills to manage cravings and report to therapist." The non-individualized generic staff interventions for this goal were:

Registered Nurse: "Assess efficiency of detox medication", "Assess for changes in mood"

Physician: "Monitor Lab Results

6. Patient B2 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." The
non-individualized generic staff interventions for this goal were:

Social Services: "Explore Contributing Factors to Mood"

Registered Nurse: "Reinforce Positive Statements Made by Patient"

Physician: "Educate on Medications"

7. Patient B3 (MTP dated 1/27/19) had the following short-term goals for the identified problem, "Poor Impulse Control":

"Implement 2-3 positive coping measures in dealing with emotions." "Patient will identify 3-4 acceptable actions to upsetting moods." The non-individualized generic staff interventions for this goal were:

Nursing: "Provide Monitoring and Support", "Provide Positive Feedback for Positive Behavior"

Social Services: "Encourage Safe Expression of Feelings"

8. Patient B4 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"State 3 positive traits about self and verbally share those in group." "Learn medication regimen responsibilities, follow med schedule and report compliance to nurse daily." "Patient will report improved ability to fall and stay asleep." The non-individualized generic staff interventions for these goals were:

Registered Nurse: "Encourage Increased Independence in Daily Living Activities", "Assess Factors that pose a Risk to Safety."

Experiential Therapy: "Teach Positive coping Skills"

Physician: "Educate on Medication"

9. Patient B5 (MTP dated 1/24/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Patient will report to staff when having a depressed mood." The following non-individualized generic staff interventions for these goals were:

Social Services: "Explore Contributing Factors to Mood"

Registered Nurse: "Encourage Increased Independence in Living Activities", "Assess patient's mood Q [every] shift"

10. Patient B6 (MTP dated 1/24/19) had the following short-term goals for the identified problem, "Altered Thought Process":

"Takes medication as prescribed." "Recognizes Alterations in Thought."

The following non-individualized generic staff interventions for these goals were:

Registered Nurse: "Monitor for Signs of Preoccupation or Delusional Behavior", "Assess Effectiveness of Medications"

Social Services: "Support and Monitor in Group Settings"

11. Patient C1 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Depressed Mood":

"Recognize 5 healthy coping strategies they can use to assist with escalating mood and discuss in group." "Patient will attend and participate in groups."

The following non-individualized staff interventions for this patient were:

Social Services: "Explore Contributing Factors to Mood"

Nursing: "Encourage Group Attendance"

Physician: "Provide activity order"

12. Patient C2 (MTP dated 1/30/19) had the following short-term goals for the identified problem, "Substance Abuse":

"Identify 3 ways to improve sleep hygiene and report in group." "Patient will attend groups."

The non-individualized staff interventions for this patient were:

Registered Nurse: "Encourage Participation in Therapeutic Activities"

Social Services: "Provide Resources for After Care Plan"

Experiential Therapy: "Provide Group to Facilitate Stabilization and Recovery"

13. Patient C3 (MTP dated 1/25/19) had the following short-term goals for the identified problem, "Substance Abuse":

"Identify and Avoid High Risk Situation." "Patient will attend groups." The non-individualized staff interventions for this patient were:

Social Services: "Teach Coping Skills"

Registered Nurse: "Assess Factors That Pose a Risk to Safety", "Patient will attend group"

B. Policy Review

The facility policy titled "Treatment Planning" effective 1/1/19 stated the following:

"INTERVENTION......Staff action, not just monitoring to help the patient achieve/meet their goals. Intervention should be addressed before discharge, interventions should be specific and measurable and are related to the patient treatment problems."

C. Interview

1. During an interview on 1/29/19 at 11:30 a.m., the Chief Regulatory Officer agreed that interventions (physician, nursing and social work) were not individualized to address patients' needs.

2. During an interview on 1/29/19 at 1:00 p.m., the Director of Nursing (West Allis) concurred that the interventions were not individualized.

3. During an interview on 1/30/19 at 10:30 a.m., the Social Work Director (Brown Deer) agreed that interventions were not individualized for each patient.

4. During an interview on 1/30/19 at 11:00 a.m., the Director of Nursing (Brown Deer) stated, "No, they don't look individualized."

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

1. Ensure the provision of a psychiatric evaluation that includes individualized personal assets on which to base a meaningful treatment plan in seven (7) of 13 records reviewed (A1, A2, A3, B2, B5, B6, and C3)) and failed to list patient assets for two (2) of 13 records reviewed (B1 and B4). The failure to identify patient strengths has the potential to impair the treatment team's ability to choose treatment modalities which best utilize the patient's attributes in therapy. (Refer to B117)

2. Ensure the development and documentation of Master Treatment Plans (MTPs) based on individual patient needs for one (1) of one (1) patients (E1) added to the sample in order to evaluate active treatment. Specifically, the MTP did not address the patient's individualized needs based on identified problems. In addition, the patient was unmotivated or unable to attend assigned groups and instead sat in the dayroom or stayed in his/her bed. This failure results in the patient not receiving individualized treatment based on identified needs. Failure to address the individualized needs of the patient can inhibit the patient's ability to accomplish the short-term goals listed on the treatment plan and negatively impact the patient's recovery. (Refer to B118)

3. Ensure the development of Master Treatment Plans (MTP) that identified patient related short-term goals in observable, measurable, behavioral terms in 13 of 13 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, B5, B6, C1, C2 and C3). Goal statements that fail to give specific focus have the potential to lead to fragmentation of care and may prolong hospital stays. (Refer to B121)

4. Ensure the development of individualized treatment interventions based on the individual needs of the patients for 13 of 13 patients in the sample (A1, A2, A3, A4, B1, B2, B3, B4, B5, B6, C1, C2, and C3). This failure can result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

Interview

In an interview on 1/29/10 at 10:00 a.m., the Medical Director concurred with findings regarding assets in Psychiatric Evaluations, Treatment Planning, Short Term Goals, and Staff Interventions.

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions were individualized to each patient's needs in 13 out of 13 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, B5, B6, C1, C2, and C3). This failure resulted in staff being unable to provide direction, consistent approaches and focused treatment for patients' identified problems. (Refer to B122)