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Based on observation, interviews, policy reviews, and medical record reviews, the facility failed to:

1. Provide documented assessments of estimated intellectual functioning, memory functioning, and orientation for 8 of 8 sampled patients (A6, A10, B17, C16, D2, E4, F13 and G8). Absence of this detail can adversely affect clinical decision-making as to the need for more detailed clinical examination, specialized testing, and laboratory studies. This detail is also necessary to assess response to treatments provided, and to plan for dispositional needs. (Refer to B116)

2. Develop and document individualized Master Treatment Plans for 8 of 8 sampled patients (A6, A10, B17, C16, D2, E4, F13, and G8) that specified all elements necessary to direct patient care including: patient strengths and disabilities identified during assessments (Refer to B119), substantiated diagnoses (Refer to B120), measurable goals based on assessed patient needs (Refer to B121), individualized and focused interventions and modalities (Refer to B122), and designated specific team members to implement planned modalities (Refer to B123). This failed practice results in lack of specific plans to direct staff in the implementation, evaluation and revision of care.

Based on record review and interview, the facility failed to provide sufficient documentation of gross testing of the twelve cranial nerves as part of the screening neurologic examination for 5 of 8 sample patients (A6, A10, D2, E4 and F13). Absence of this detail can adversely affect clinical decision-making as to the need for more detailed neurologic examination and work-up.

Findings include:

A. Record Review

1. Patient A6 (Physical Examination dated 1/7/2011): In the section "Neurological Examination," under "cranial nerves," the only documentation provided was "Hearing intact."

2. Patient A10 (Physical Examination dated 11/19/2010): In the section "Neurological Examination," under "cranial nerves," documentation was limited to "Full extra ocular movements, Facial sensation intact, No facial droop, Hearing intact, Tongue protrudes in midline," only reflecting the testing of cranial nerves III, IV, VI, VII, VIII, and XII.

3. Patient D2 (Physical Examination dated 1/11/2011): In the section "Neurological Examination," under "cranial nerves," documentation was limited to "Pupils equally reactive to light, Full extra ocular movements, No facial droop, Normal swallowing, Tongue protrudes in midline," only reflecting the testing of cranial nerves III, IV, VI, VII, X, and XII.

4. Patient E4 (Physical Examination dated 12/29/2010): In the section "Neurological Examination," under "cranial nerves," documentation was limited to "Pupils equally reactive to light, Full extra ocular movements, No facial droop, Hearing intact, Good strength on shrug, neck rotation, Tongue protrudes in midline," only reflecting the testing of cranial nerves III, IV, VI, VII, VIII, XI, and XII.

5. Patient F13 (Physical Examination dated 1/8/2011): In the section "Neurological Examination," under "cranial nerves," documentation was limited to "Pupils equally reactive to light, No facial droop, Hearing intact, Good strength on shrug, neck rotation, Tongue protrudes in midline," only reflecting the testing of cranial nerves III, VII, VIII, XI, and XII.

B. Policy Review

Butler Hospital Policy and Procedure PPM No. 610.020, Section: "Patient Care," Title: "Physical Examination" (Effective Date: 7/29/09) states in item (7): "Physical examination Reports," states "Positive and negative physical findings and a screening neurological examination including gross testing of cranial nerve function II through XII should be documented."

C. Staff Interview

During an interview on 1/20/2011 at 12:00PM, both the Clinical Director and the Associate Medical Director of Quality and Regulation acknowledged that the Physical Examination documents reviewed did not contain complete descriptive commentary related to how the cranial nerves were examined.

Based on record review and interview, the facility failed to ensure sufficient documentation of estimated intellectual functioning, memory functioning, and orientation for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). Absence of this detail can adversely affect clinical decision-making as to the need to pursue more detailed clinical examination, specialized testing, and laboratory studies. It also adversely affects the ability to assess response to treatments provided, and to plan for dispositional needs.

Findings include:

A. Record Review

1. Patient A6 (Initial Psychiatric Evaluation dated 1/6/2011). In the section "Mental Status Examination [MSE]," the sub-section on "Patient's Age by Appearance" was completed with the comment "Stated." The remainder of the MSE was incomplete except for the comment "pt sleeping quietly in geri chair" in the sub-section "Comments on Appearance."

2. Patient A10 (Initial Psychiatric Evaluation dated 11/18/2010).In the section "Mental Status Examination," under "Orientation" the finding states "unremarkable"; under "Intellectual Capacity," the finding states "unremarkable."

3. Patient B17 (Initial Psychiatric Evaluation dated 1/10/2011). In the section "Mental Status Examination," under "Orientation" the finding states "unaware of time"; under "Memory," the finding states "unable to recall personal history"; under "Intellectual Capacity," the finding states "unable to assess."

4. Patient C16 (Initial Psychiatric Evaluation dated 1/13/2011). In the section "Mental Status Examination," under "Orientation" the finding states "unremarkable"; under "Intellectual Capacity," the finding states "unremarkable."

5. Patient D2 (Initial Psychiatric Evaluation dated 12/16/2010). In the section "Mental Status Examination," under "Orientation," there are no findings under "Memory." The findings; under "Intellectual Capacity" are stated as "unable to assess."

6. Patient E4 (Initial Psychiatric Evaluation dated 12/28/2010). In the section "Mental Status Examination," under "Orientation" the finding states "unremarkable"; under "Intellectual Capacity," the finding states "unremarkable."

7. Patient F13 (Initial Psychiatric Evaluation dated 1/7/2011), In the section "Mental Status Examination," under "Orientation" the finding states "unremarkable"; under "Intellectual Capacity," the finding states "unremarkable."

8. Patient G8 (Initial Psychiatric Evaluation dated 1/11/2011). In the section "Mental Status Examination," under "Orientation" the finding states "unremarkable"; under "Intellectual Capacity," the finding states "unremarkable."

B. Staff Interview

During an interview on 1/19/2011 at 10:45AM, the Director of Adult Services looked over the sample patients' Initial Psychiatric Evaluation reports with the surveyor. She acknowledged that descriptive detail was missing in the assessment of orientation, memory, and intellectual functioning.

Based on record review and interview, the facility failed to provide psychiatric assessments that included an inventory of personal patient strengths/assets that would be useful in treatment for 3 of 8 sample patients (A6, B17 and D2). Instead of identifying personal strengths/assets, community supports or other resources were noted. Failure to describe personal strengths and/or attributes that patients bring to treatment compromises the treatment team's ability to develop meaningful treatment plans and limits the team's ability to engage patients in therapy.

Findings include:

A. Record Review

1. Patient A6 (Initial Psychiatric Evaluation dated 1/6/2011). In the section "Patient Strengths," the findings stated "Positive family relationships, Self-directed." This patient is an elderly patient with vascular dementia admitted from a local nursing home who is not "self-directed" in actions and behavior.

2. Patient A10 (Initial Psychiatric Evaluation dated 11/18/2010). In the section "Patient Strengths," the findings stated "Housing/residential stability."

3. Patient D2 (Initial Psychiatric Evaluation dated 12/16/2010). In the section "Patient Strengths," the findings stated "Positive family relationships, Housing/residential stability, Self-directed." The patient is a child who is not "self-directed" and requires intensive support from parents and other personnel.

B. Interview

During an interview on 1/19/2011 at 10:45AM, the Director of Adult Services looked over sample patients' Psychiatric Evaluation reports with the surveyor. She agreed that personal strengths were not included.

Based on policy review, record review and interview, the facility failed to develop and document comprehensive, individualized Master Treatment Plans for 8 of 8 active sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). Specifically, the facility failed to:

1. Ensure that the Master Treatment Plans for 7 of 8 sample patients (A6, B17, C16, D2, E4 F13 and G8) were based on patient strengths and disabilities. The facility's failure to identify patient strengths and disabilities and use them for treatment plan development compromises the staff's ability to deliver individualized, clinically focused treatment. (Refer to B119)

2. Ensure that the Master Treatment Plans included a substantiated diagnosis as the primary focus of treatment for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). This failure compromises the staff's ability to deliver clinically focused treatment. (Refer to B120)

3. Ensure that the Master Treatment Plans for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8) identified measurable behavioral goals as treatment outcomes. In addition, the MTPs for 2 of 8 sample patients (A6 and B17) listed goals that were not appropriate and/or sufficient to address the patient's needs. This practice results in treatment plans that do not identify individualized expected treatment outcomes in a manner that can be used to determine the effectiveness of treatment. (Refer to B121)

4. Ensure that the Master Treatment Plans for 8 of 8 active sample patients (A6, A10, B17, C16, D2, E4, F13, and G8) specified treatment measures (interventions) that were based on individual patients' assessed needs. The interventions on the MTPs were generic discipline tasks. For sample patients A10 and B17, who had the same listed diagnosis, the interventions were identical. Failure to specify patient-specific interventions on treatment plans results in a lack of guidance for staff in providing individualized treatment that is purposeful and goal-directed. (Refer to B122)

5. Identify by name and discipline the staff person responsible for treatment modalities listed on the Master Treatment Plans of 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). This failed practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer B123)

The absence of an integrated, comprehensive treatment plan can result in a lack of coordinated and organized treatment.

Based on observations, policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans for 7 of 8 sample patients (A6, B17, C16, D2, E4 F13 and G8) were based on identified patient strengths and/or disabilities. The facility's failure to accurately identify patient strengths and disabilities and use them for treatment planning compromises the staff's ability to deliver individualized, clinically focused treatment. Failure to identify problems to be pursued during the course of hospitalization can adversely affect clinical decision-making regarding the need to pursue further consultation and treatment. It also prevents the patient from receiving necessary consultation/treatment in a timely manner.

Findings include:

A. Policy Review

Hospital Policy and Procedure Document entitled "Requirement for Interdisciplinary Treatment Plan: Inpatient and Partial Hospital - 370.050" (dated 11-1-2006) reads: "The plan shall include documentation of:
a. Identification and integration of assessments and identification of patient needs
b. Patient strengths and a description of how strengths will be utilized in treatment
c. Justification for level of care
d. The primary provisional diagnosis and target symptoms
e. Prioritization of the patient's needs and problems, which include identifying
needs which will not be addressed in the hospital.
f. Goals, i.e. behaviors to be achieved by the patient as a result of treatment that
serve as criteria for discharge
g. Objectives, i.e., patient behaviors that mark progress toward discharge, and
anticipated achievement dates
h. Discharge criteria"

B. Specific Patient Findings

1. Patient A6

a. The Master Treatment Plan dated 1/7/11 identified the problems "Fall Risk" and "Aggression." However, nursing night progress notes (1/9/11, 1/10/11, 1/11/11, 1/15/11/, 1/17/11, and 1/18/11) revealed that the patient was incontinent and was changed from wet clothes on a regular basis. The problem of incontinence was not identified on the patient's treatment plan as of 1/20/11 (end of survey).

b. In an interview on 1/19/11 at 8:30a.m., Nurse Manager 5 stated that patient treatment plans "would not include routine toileting for incontinent patients unless it was the result of an infection or something new."

2. Patient B17

a. The Master Treatment Plan dated 1/12/11 and the treatment plan update dated 1/19/11 stated that patient strengths were "self-directed" and that "family/community provide patient support." Observations and interviews (See c. and d. below) showed that patient B17 was not participating in treatment and had no known family or community support.

b. On 01/18/11 at 11:00a.m., at 2:00p.m., and 5:00p.m., patient B17 was observed in bed with the blanket over his/her head. At neither time would the patient respond to the staff's or surveyor's prompts to remove the blanket from covering his/her head and face.

c. On 01/19/11 at 9:00a.m., at 1:00p.m., and 3:00p.m., patient B17 was observed in bed with the blanket over his/her head. At no time would the patient respond to the staff's or the surveyor's prompts to remove the blanket from covering his/her head and face.

d. On 01/19/11 at 8:30a.m. in the treatment team meeting, Physician #6 stated that Patient B17 had refused all groups since s/he was admitted to the hospital and that the patient was difficult to engage. Physician #6 said that the patient continued to be actively psychotic and that his/her prognosis was guarded. Social Worker #4 (SW4) stated that all efforts to contact patient B17's family had thus far failed. SW4 stated that the patient told her s/he was homeless and "lives in the shelter near the 7-11."

3. Patient C16

a. The Master Treatment Plan, dated 1/14/2011, included the problem of substance dependence, but did not address the documented problem of exacerbated psychotic symptoms.

b. During an interview on 1/20/2011 at 12:00PM, after looking at Patient C16's MTP, the Clinical Director and Assoc. Medical Director of Quality and Regulation agreed that the problem "psychosis" was not included on the treatment plan.

4. Patient D2

a. The following two medical problems, one with increasing symptoms, were identified in the attending psychiatrist's progress notes but were not addressed in the relevant Treatment Plan reviews (MTP dates 12/30/2010; 1/07/2011; 1/14/2011):

(1). A Physician Progress Note (dated 12/24/2010) stated "[Patient D2] was noted to be constipated...which can increase ...irritability." The treatment plan review/update of 12/30/2010 did not address this problem.

(2). A Physician Progress Note (dated 12/30/2010) stated "[Patient D2] is having a very hard time. S/he is aggressive with staff multiple times during the day, banging on doors, walls, and windows...Pt is having small and different consistency BM's, that might be indicative of impaction and responcible [sic] for his/her poor mood and aggression at least in part." Neither the treatment plan review/update of 12/30/2010 nor the treatment plan review of 1/7/2011 included this problem.

(3). A Physician Progress Note (dated 1/9/2011) stated "Noted to be eating very little and heart rate is elevated." A Physician Progress Note (dated 1/10/2011) stated "Pt is refusing food and medication...Pt cont with fecal smears and incontinent at times." The treatment plan review of 1/14/2011 did not address either of these problems.

b. During an interview on 1/20/2011 at 12:00PM, the surveyor reviewed the Physician Progress Notes (12/24/2010 through 1/17/2011), the Master Treatment Plan (dated 12/17/2010) and the Treatment Plan reviews of 12/23/2010, 12/30/2010, and 1/7/2011, and 1/14/2011 for Patient D2 with the Clinical Director and Associate Medical Director of Quality and Regulation. The Clinical Director and the Associate Medical Director of Quality and Regulation acknowledged that the identified medical problems were not included in the treatment plans.

5. Patient E4. The Master Treatment Plan dated 12/29/10 was left blank for any patient strengths.

6. Patient F13

a. The Master Treatment Plan dated 1/10/2011, listed the problem "Depression...with worsening symptoms of depression, anxiety, and SI [suicidal ideation]..." A second problem seemingly related to pain, had goals, objectives, and interventions listed, but the specific problem itself was not described on the plan (that is, the medical problem section of the plan was left blank). "Tx Plan #2" dated 1/17/2011 (the first update for this patient) listed the previously mentioned depression problem, but did not include problems related to the patient's PTSD. The previous goals, objectives, and interventions related to the medical problem of pain disappeared from the plan. In addition, the Master Treatment Plan, including reviews, failed to document any patient assets/strengths.

b. In an interview held on 1/19/2011 at 3:20PM, when queried by the surveyor regarding the absent problem on Patient F13's Master Treatment Plan dated 1/10/2011, Physician #5 stated "I don't see why this is so important; anyone can tell from the interventions what the problem is."

7. Patient G8

a. The Master Treatment Plan (1/12/11) for Patient G8 only listed the problem "Alteration in Mood." However, the admission Psychiatric Evaluation, dated 1/11/11, stated that the patient said s/he "heard a voice telling [him/her] to harm another kid." This was not addressed on the MTP. A Physician Progress Note, dated 1/18/11, documented that the patient had a "history of substance abuse" and that s/he "continued...to have cravings to inhale aerosol." S/he also had been treated for a "burn on her arm." As of 1/20/11 (end of survey), the MTP did not include any of these issues as identified problems to be addressed in treatment.

b. In an interview on 1/18/11 at 4:00p.m., the Vice President of Quality and Regulation stated that she would expect more than one problem to be in the treatment plan of Patient G8. Furthermore, she stated, "Writing in the chart is our Achilles' heel."

C. Additional Staff Interview

In an interview on 1/20/2011 at 12:00PM, the MTP for Patients C16, D2 and F13 were reviewed with the Clinical Director and the Associate Medical Director of Quality, who agreed that the problems were not included in the treatment plans.

Based on policy review and record review, the facility failed to provide Master Treatment Plans that included substantiated diagnoses for 8 of 8 active sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). This practice compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Policy Review:

Hospital Policy and Procedure Document entitled "Requirement for Interdisciplinary Treatment Plan: Inpatient and Partial Hospital - 370.050" (dated 11-1-2006) reads: "The plan shall include documentation of: ...d. The primary provisional diagnosis and target symptoms..."

B. Record Review:

1. Patient A6, admitted 1/6/11. The Master Treatment Plan dated 1/7/11 did not include a substantiated diagnosis.

2. Patient A10, admitted 11/18/10. The Master Treatment Plan dated 11/19/10 did not include a substantiated diagnosis.

3. Patient B17, admitted 1/10/1. The Master Treatment Plan dated 1/12/11 did not include a substantiated diagnosis.

4. Patient C16, admitted 1/13/1. The Master Treatment Plan dated 1/14/11 did not include a substantiated diagnosis.

5. Patient D2, admitted 12/16/10. Neither the Master treatment plan dated 12/17/10 nor the update dated 1/14/11 included a substantiated diagnosis.

6. Patient E4, admitted 12/28/10. The Master treatment plan dated 12/29/10 did not include a substantiated diagnosis.

7. Patient F13, admitted 1/7/1. The Master treatment plan dated 1/10/11 did not include a substantiated diagnosis.

8. Patient G8, admitted 1/11/11. The Master treatment plan dated 1/12/11 did not include a substantiated diagnosis.

Based on policy review, record review, and interview, the facility failed to provide Master Treatment Plans that identified patient-related goals stated in observable, measurable, behavioral terms for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). In addition, for 2 of 8 sample patients (A6 and B17), the stated goals were not appropriate and/or sufficient to address the patient's identified needs. This deficient practice results in treatment plans that do not identify expected treatment outcomes in a manner that can be used by the treatment team to determine the effectiveness of treatment.

Findings include:

A. Policy Review:

Hospital Policy and Procedure Document entitled "Requirement for Interdisciplinary Treatment Plan: Inpatient and Partial Hospital - 370.050" (dated 11/1/2006) reads: "The treatment plan describes the desired results of treatment (goals) in specific and measurable terms (objectives)." "The plan shall include documentation of: ...f. Goals, i.e., behaviors to be achieved by the patient as a result of treatment that serve as criteria for discharge..."

B. Record Review (MTP dates in parentheses)

1. Patient A6.
The following two goals were identified on the Master Treatment Plan (1/7/11) for the problems "Fall risk" and "Aggression": "Patient will achieve maximal level of ambulation potential on the unit" and "Patient will reduce intensity and frequency of aggressive behaviors and verbalizations, to a level that will permit discharge to a lower level of care." These goals were not measurable as stated. They also did not adequately address the patient's risk of falls during the hospitalization.

2. Patient A10, admitted 11/18/10.
The Master Treatment Plan (11/19/10) identified the following goal for the problem of "psychosis:" "Patient will no longer demonstrate behaviors primarily driven by psychotic symptoms such as delusions or hallucinations." This goal was not measurable as stated.

3. Patient B17, admitted 1/10/11.
The Master Treatment Plan (1/12/11) identified the following two goals for the problem "psychosis:" "Patient will stabilize functioning adequately to allow return to community and outpatient setting," and "Patient will no longer demonstrate behaviors primarily driven by psychotic symptoms such as delusions or hallucinations." These goals were not measurable as stated.

The objectives (short-term goals) for the first goal listed in #3 (above) related to Patient B17's ability to perform activities of daily living (ADLs). However, every nursing progress note on the patient's medical record reported that the patient's ADL status was independent. Thus, these stated objectives were inappropriate.

4. Patient C16.
The following goal was identified on the Master Treatment Plan (1/14/11): "Patient will have a safe detoxification." This goal was not measurable as stated.

5. Patient D2.
The following goal was identified on the Master Treatment Plan (12/17/11): -- "Patient will request to communicate basic needs using conventional and understandable means." This goal was not measurable as stated.

6. Patient E4.
The following two goals were identified on the Master Treatment Plan (12/29/11): "Patient will report improved mood and show evidence of improved energy and engagement in activities and socialization" and "Patient will stabilize the current suicidal crisis." These goals were not measurable as stated.

7. Patient F13.
The following two goals were identified on the Master Treatment Plan (1/10/11): "Patient will report improved mood and show evidence of improved energy and engagement in activities and socialization" and "Patient will have acceptable level of pain as indicated on pain scale." These goals were not measurable as stated.

8. Patient G8.
The following two goals were identified on the Master Treatment Plan (1/12/11) for the only listed problem, "Alteration in Mood": "Patient will identify stressors and means of reducing triggers and alleviating stressors" and "Patient will report improved mood and show evidence of return to premorbid level of functioning." These goals were not measurable as stated.

C. Interviews

1. In an interview on 1/18/11 at 4:00p.m., the Vice President of Quality and Regulation stated "Writing in the chart is our Achilles' heel."

2. In an interview on 1/19/11 at 1:00p.m., the DON confirmed that the nearly identical treatment goals for Patients A10 and B17 did not reflect the individualized treatment that each patient was receiving. Furthermore, she stated including goals for ADLs on a treatment plan for an ADL-independent patient did not reflect an individual approach to care. She stated "It does not make sense." She also stated "Patient care does not always get translated into the medical record."

3. In an interview on 1/20/2011 at 12:00PM, the Clinical Director and the Associate Medical Director of Quality and Regulation acknowledged that the sample patient's treatment plans lacked observable/measurable objectives.

Based on policy review, record review and interview, the facility failed to develop Master Treatment Plans that specified individualized treatment measures (interventions) for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). The interventions on the MTPs were routine, generic discipline functions inappropriately labeled as individualized interventions. For sample patients A10 and B17, who had the same listed diagnosis, the interventions on the MTP were identical. Failure to specify patient-specific interventions on treatment plans results in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Policy Review

Hospital Policy and Procedure Document entitled "Requirement for Interdisciplinary Treatment Plan: Inpatient and Partial Hospital - 370.050" (dated 11/1/2006) reads: "1) The purpose of the Interdisciplinary Treatment Plan is to guide the team by defining the focus of treatment, detailing the interventions, and assigning responsibility."

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A6 (1/7/11)

a. For the problem "Fall Risk," the listed MTP interventions were:

RN/LPN: "Seat belt applied on an as needed basis secondary to patient's inability to cooperate with ambulation restrictions"; "Patient to be ambulated Q2 hrs while belt applied"; "Ongoing assessment of changes in patient's mobility status"; "Contact OT to reassess mobility when needed."
"OT": "Recommend PT consult"; "Assess gait and functional mobility."

b. For the problem "Aggression," the listed MTP interventions were:

CP (Care Planner) (facility's role title for person doing discharge planning): "Discuss with facility [staff] patient's problematic behaviors, interventions, level of care needs and appropriateness of placement prior to discharge."
RN: "Monitor compliance with meds and response to medications each shift."
MD: "Discuss with patient/surrogate adverse effects of medications as needed"; "Monitor response to medication on a daily basis"; "Prescribe medication to reduce behaviors daily"; "Discuss with patient/surrogate the need to utilize medications in order to alleviate problematic behavior throughout hospitalization."
CP/MD: "Educate family regarding illness and aggression as symptom of illness prior to discharge"; "Obtain history from family/facility/community to include progression of aggression which precipitated need for hospital level of care within 3 days of admission."
CP/MD/RN: "Obtain consent from patient or surrogate to address aggression by discussing issues with community/nursing home caregivers, PDP, outpatient psychiatrist/neurologist and family within 3 days of admission."

2. Patient A10 (11/19/10)

For the problem "psychosis," the listed MTP interventions were:

RN/MD: "Educate patient and significant other about the importance of medication use, dosage, and side effect recognition throughout hospitalization."
RN: "Monitor mental status, effectiveness, side effects, compliance, and provide medication education while administering each dose." "Ask patient to express his/her current thoughts and concerns and assess response to treatment, each waking shift."
MD: "Daily assessment of mental status and adjustment of medication as needed to increase effectiveness and reduce side effects" "Evaluate patient to determine need for antipsychotic medications daily and prescribe as appropriate"; "Assess dangerousness and/or suicidal ideation as clinical situation demands and discuss appropriate interventions with patient in individual sessions."
ALL [staff]: "Reduce level of stress and stimulation in milieu by speaking calmly, keeping noise level low and maintaining routine which is outlined in community meeting throughout hospitalization." "Encourage the client to seek frequent reality testing with trusted family, friends, or staff." "As needed, calmly provide reassurance, education and reality based explanation for symptoms."
RN/MHW/OT: "Redirect bizarre behaviors by engaging patient in milieu activities or simple tasks and encourage patient to focus his/her mind on activity each waking shift."
RN/OT: "Engage patient in social interaction and give feedback on appropriate social skills, each waking shift."

3. Patient B17 (1/12/2011)

For the problem "psychosis," the MTP listed the same generic interventions as those for Patient A10 above. These were:

RN/MD: "Educate patient and significant other about the importance of medication use, dosage, and side effect recognition throughout hospitalization."
RN: "Monitor mental status, effectiveness, side effects, compliance, and provide medication education while administering each dose"; "Ask patient to express his/her current thoughts and concerns and assess response to treatment, each waking shift.
MD: "Daily assessment of mental status and adjustment of medication as needed to increase effectiveness and reduce side effects"; "Evaluate patient to determine need for antipsychotic medications daily and prescribe as appropriate"; "Assess dangerousness and/or suicidal ideation as clinical situation demands and discuss appropriate interventions with patient in individual sessions."
ALL: "Reduce level of stress and stimulation in milieu by speaking calmly, keeping noise level low and maintaining routine which is outlined in community meeting throughout hospitalization"; "Encourage the client to seek frequent reality testing with trusted family, friends, or staff"; "As needed, calmly provide reassurance, education and reality based explanation for symptoms."
RN/MHW/OT: "Redirect bizarre behaviors by engaging patient in milieu activities or simple tasks and encourage patient to focus his/her mind on activity each waking shift."
RN/OT: "Engage patient in social interaction and give feedback on appropriate social skills, each waking shift."

4. Patient C16 (1/14/2011)

For the problem "substance dependence," the listed MTP interventions were:

RN/MHW: "Monitor the patient per observation level."
MHW: "Observe and report any physical, emotional or psychiatric symptom changes to Charge Nurse q shift."
RN: "conduct a review of systems on admission, monitor any physical instability, carry out treatment as ordered, and provide feedback to the physician daily"; "Provide medication as ordered, assess the effects of the medication q shift, and provide daily feedback to the physician."; "Assess patient on admission and provide ongoing assessment and feedback to the physician daily"; "Assess for withdrawal symptoms, at least q shift, medicate the patient as ordered per the BIWA [sic] protocol, and provide ongoing information to the physician regarding withdrawal status."
MD: "Assess physical, emotional and psychiatric symptoms daily"; "Assess the need daily for psychotropic medication, educate as to the risks/benefits and side effects of the medication and prescribe as needed"; "Assess daily regarding withdrawal needs, prescribe medication, and discuss risks, benefits and effects of the medication."

5. Patient D2 (12/17/2010)

For the problem of "poor communication of basic needs," the listed MTP interventions were:

MD: "Assess current means of initiating requests, taking into account both means of communication that are used pre-intentionally and the use of undesirable behavior to obtain desired items."
Program Director/RN/MHW/AT: "Provide contingent positive reinforcement (primary-edibles, social, activity; secondary-tokens, checkmarks, stars, etc.) for display of desired target behaviors."
CP: "Support patient's parents in patient's treatment as needed; liason [sic] with community resources regarding discharge plan."

6. Patient E4 (12/29/2010)

a. For the problem "depression," the listed MTP interventions were:

RN/MHW: "Monitor compliance and assess mood and affect each waking shift"; "Encourage patient's active social involvement with peers, staff and visitors daily"; "Support the patient's realistic and positive verbalizations of perceptions of self, others and world in 1:1 sessions and group daily."
CP: "Contact with family and outpt providers (SSMHC) regarding treatment team recommendations and disposition needs, and enxure [sic] appts are in place prior to discharge."
RN: "Administer medication, monitor for side effects and provide medication education." MD: "Inquire about patient's response to treatment, provide education about medication and treatment plan and monitor for side effects on a daily basis."

b. For the problem "suicidal ideation," the listed MTP interventions were:

RN/MD: "Assist patient in developing a suicide prevention plan and assess appropriateness of plan for managing suicidal impulses daily."

7. Patient F13 (1/10/2011)

a. For the problem "depression," the listed MTP interventions were:

MD: "Evaluate patient's depression and need for pharmacological intervention and ECT daily"; "Order medication and review R/B/A with patient and family as Indicated"; "Perform daily assessment of patient's response to treatment, monitor for side effects and adjust dose as needed"; "Prescribe medication. Review R/B/A with patient and family as indicated"; "Gradually decrease restrictions as appropriate for the patient's display of healthy thoughts and behavior throughout hospitalization."
RN/MHW: "Involve patient in structured group and social activities 1-3 times a day in context of therapeutic milieu."
RN/OT/MHW/MD/CP: "Provide reality testing, reassurance, and support during each encounter."
MD/RN/MHW: "Question patient daily about current functioning regarding current depressive symptoms"; "Provide verbal reinforcement to the patient for more hopeful and future oriented statements each waking shift"; "Help patient identify reasons to live each waking shift."
All [staff]: "Encourage patient and assist in development of a written safety plan throughout Hospitalization"; "Monitor patient's ability to actively participate in therapeutic milieu each waking shift"; "Encourage patient to verbalize thought and feelings in 1:1 and milieu each waking shift."
CP/MD: "Schedule family meeting to assess family functioning, prior to discharge"; "Provide education using learning preferences about depression to patient and family throughout hospitalization."
"CP": "Refer the patient to support groups (e.g. NAMI, MDDA) [sic] and provide resource information and meeting schedules prior to discharge."

b. The MTP for Patient F13 also included the following generic discipline tasks instead of interventions for pain management:

MD: "Prescribe analgesic medicines." "Order Neurology consult and follow through with recommendations"; "Order medicine consult and follow through with recommendations."
RN: "Assess q shift for presence, location and intensity of pain in relationship to pain scale"; "Administer analgesics as ordered and document effects"; "Obtain Release of Information to obtain history from current health care provider."
MD/RN: "Educate patient regarding role of current illness in exacerbating pain and assist in development of distress tolerance strategies on daily basis."

8. Patient G8 (1/12/2011)

For the problem "Alteration in Mood," the listed MTP interventions were:

RN: "Assist patient to complete Chapter 2 and work on daily goals to reduce stressors"; "Assess/document effects and side effects of medication daily"; "Provide medication education daily"; "Assist patient to complete self-control worksheet for SIB [sic]or suicide attempt."
MD: "Verbalize family stressors and school stressors in a family meeting.
prior to discharge" (a patient goal rather than an MD intervention); "Evaluate the need for psychotropic medication with patients and family, educate the patient and family about expected risk benefits and alternatives, and monitor the patient's medication compliance and efficacy daily"; "Assist patient in self-monitoring and reporting of target and adverse effects daily"; "Assess observation level daily and gradually advance as patient displays healthier thought patterns and increased self-management."
RN/AT/MHW: "Assist patient to complete Treatment Workbook and develop safety plan. Teach patient new coping skills and ways to manage depressive symptoms including use of sensory modalities."
CP: "Support patient's parents/caregivers in patient's treatment as needed prior to discharge"; "Liaison with providers to obtain collateral data regarding patient's pre-morbid functioning prior to discharge."

B. Interview

1. In an interview on 1/18/11 at 4:30p.m., after reviewing the record of Patient G8, the Vice President of Quality and Regulation stated that some of the discipline interventions were intermingled with expectations of patients. Specifically in the treatment plan (1/12/2011) for patient G8, an MD intervention was listed as: "Verbalize family stressors and school stressors in a family meeting prior to discharge." The VP of Quality and Regulations stated "This must be what the patient is supposed to do, not the doctor."

2. In an interview on 1/20/2011 at 12:00PM, the Clinical Director and the Associate Medical Director of Quality and Regulation acknowledged that many of the interventions on the sample patients' treatment plans were generic discipline tasks.

Based on policy review, record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans of 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13 and G8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include

A. Policy Review

Hospital Policy and Procedure Document entitled "Requirement for Interdisciplinary Treatment Plan: Inpatient and Partial Hospital - 370.050" (dated 11-1-2006) reads: "The purpose of the Interdisciplinary Treatment Plan is to guide the team by defining the focus of treatment, detailing the interventions, and assigning responsibility."

B. Record Review (MTP dates in parentheses)

Review of the Master Treatment Plans for patients A6 (1/7/11), A10 (11/19/10), B17 (1/12/11), C16 (1/14/11), D2 (12/17/10), E4 (12/29/10), F13 (1/10/11) and G8 (1/12/11) revealed that the plans only identified disciplines, rather than individual staff names, as being responsible for the listed interventions. The listed disciplines responsible for treatment were identified as "MD," "RN," "LPN," "MHW," "OT," and "CP" (care planner).

C. Interview

In an interview on 1/18/11 at 5:00p.m., the Director of Quality and Regulations and the Director of Adult Services acknowledged that the sample patient's treatment plans only identified disciplines rather than individual names of staff as being responsible for treatment interventions.

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

I. Ensure sufficient documentation of gross testing of cranial nerve function as part of the screening neurologic examination for 5 of 8 sample patients (A6, A10, D2, E4 and F13). Absence of this detail can adversely affect clinical decision-making regarding the need to pursue further consultation, including more detailed neurologic examination and work-up (Refer to B109).

II. Ensure sufficient documentation of estimated intellectual functioning, memory functioning, and orientation for 8 of 8 sample patients (A6, A10, B17, C16, D2, E4, F13, and G8). Absence of this detail can adversely affect clinical decision-making regarding the need to pursue further consultation, including more detailed clinical examination, specialized testing, and laboratory studies, as well as the assessment of response to treatments provided, and planning for dispositional needs. (Refer to B116)

III. Provide psychiatric assessments that included an inventory of patient strengths/assets described in descriptive, not interpretive terms for 3 of 8 sample patients (A6, B17 and D2). Instead of personal assets, only community supports or other resources were noted. Failure to describe personal strengths and/or attributes that patients bring to treatment compromises the treatment team's ability to develop meaningful treatment plans and limits the team's ability to engage patients in therapy. (Refer to B117)

IV. Ensure that the Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A6, A10, B17, C16, D2, E4, F13 and G8) were comprehensive (contained all appropriate
elements to guide staff in providing treatment). Specifically, the facility failed to provide MTPs for all sample patients that:
a. were based on identified patient strengths and disabilities (Refer to B119);
b. included substantiated diagnosis (Refer to B120);
c. included individualized patient goals, described in observable and/or measurable terms (Refer to B 121);
d. included individualized and appropriate treatment interventions/modalities (Refer to B122); and
e. specified the name and discipline of each treatment team member responsible for ensuring compliance with particular aspects of the patient's individualized treatment program. (Refer to B123)

Failure to develop Master Treatment Plans that contain all appropriate elements to guide staff in providing treatment compromises the team's ability to effectively address the patients' problems and to meet the patients' needs for successful and timely return to the community.

Based on record review and interview, the Chief Nursing Director (DON) failed to:

I. Ensure that the Master Treatment Plans of 7 of 8 sample patients (A6, A10, B17, C16, E4, F13 and G8) included individualized nursing interventions. Many of the nursing interventions listed in the sample patients' MTPs were assessments or routine generic tasks rather than specific interventions, based on individual patients' assessed needs. This potentially results in the facility not providing individualized nursing interventions needed for the patient's recovery.

Findings include:

A. Record Review (MTP date in parentheses)

1. Patient A6 (1/7/11).
RN intervention: "Monitor compliance with meds and response to medications each shift"
RN/LPN intervention: "Ongoing assessment of changes in patient's mobility status."

2. Patient A10 (11/19/10).
RN interventions: "Monitor mental status, effectiveness, side effects, compliance, and provide medication education while administering each dose"; "Ask patient to express his/her currents thoughts and concerns and assess response to treatment each waking shift."

3. Patient B17 (1/12/11).
RN interventions: "Monitor mental status, effectiveness, side effects, compliance, and provide medication education while administering each dose"; "Ask patient to express his/her currents thoughts and concerns and assess response to treatment each waking shift."

4. Patient C16 (1/14/11).
RN interventions: "Provide medication as ordered, assess the effects of the medication q shift and provide daily feedback to the physician"; "Assess for withdrawal symptoms, at least q shift, medicate the patient as ordered per the BIWA [sic] protocol, and provide ongoing information to the physician regarding withdrawal status."

5. Patient E4 (12/29/10).
RN/MHW interventions: "Monitor compliance and assess mood and affect each waking shift"; "Administer medication, monitor for side effects and provide medication education."

6. Patient F13 (1/10/11).
RN intervention: "Administer analgesics as ordered and document effects."
RN/MHW interventions: "Involve patient in structured group and social activites 1 - 3 times a day in context of therapeutic milieu."
RM/MHW interventions: "Help patient identify reasons to live each waking shift."

7. Patient G8 (1/12/11).
RN intervention: "Assess/document effects and side effects of medication daily"; "Provide medication education daily."

B. Interview

In an interview on 1/19/11 at 1:00p.m., the DON stated "Patient care does not always get translated into the medical record..."

II. Ensure that each staff person responsible for nursing interventions was identified on the Master Treatment Plans for 8 of 8 active sample patients (A6, A10, B17, C16, D2, E4 F13 and G8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

Each of the Master Treatment Plans for patients A6 (1/7/11), A10 (11/19/10), B17 (1/12/11), C16 (1/14/11), D2 (12/17/10), E4 (12/29/10), F13 (1/10/11), G8 (1/12/11) identified the RN, LPN, or MHW disciplines, rather than individuals, as being responsible for listed nursing interventions.

B. Interviews

1. In an interview on 1/18/11 at 4:00p.m., the VP of Quality and Regulations stated "Writing in the chart is our Achilles heel." "We used to identify the person responsible by name, but somewhere along the line, we changed it to just the discipline."

2. In an interview on 1/18/11 at 5:00p.m., the VP of Quality and Regulations acknowledged that the treatment plans only identify the nursing discipline rather than the individuals as being responsible for treatment.

3. In an interview on 1/19/11 at 1:00p.m., the DON stated "Patient care does not always get translated into the medical record."