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Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

A-0724 - Failure to maintain the facility and its equipment and supplies to ensure an acceptable level of safety and quality

A-0726 - Failure to maintain the required hot water temperature for the eyewash station located kitchen area

Based upon observation and interview the facility did not meet the provisions of the 2012 edition of the NFPA 101 Life Safety Code and failed to provide a safe environment which could result in the potential for harm from fire for all patients. Findings include:

See the individually and below cited K-tags dated 10/31/17.

K-0222
K-0342
K-0346
K-0351
K-0355
K-0911
K-0916
K-0920

Based upon observation and interview, the facility failed to maintain the facility and its equipment and supplies to ensure an acceptable level of safety and quality resulting in the potential for harm to all patients and staff throughout the facility findings include:

On 10/31/2017 between the hours of 800 and 1600 the following observations were made:

1. The typical patient toilet room is not equipped with the required grabbar risking the potential for fall;

2. The exam room N568 adjacent to nurses' station on 5 North is not equipped with the required handwashing sink risking the potential for the spreading of infectious diseases;

3. Multiple live water lines are left abandoned risking the potential for bacteria growth and leading to Legionella. The abandoned water lines are dead ends/legs and are throughout the facility including but not limited to behind cooking stove in kitchen area, in toilet rooms serving N565-A and N565-B; and

4. The janitor closet serving level on north is having the chemical dispensing hose directly connected to the waterline without the use of the required waisting Tee subjecting the water line to contamination.

Above findings were confirmed by accompanying staff V, W, and X on 10/31/2017 at the time of the observation.

Based upon observation and interview, the facility failed to maintain the required hot water temperature for the eyewash station located kitchen area to provide working staff a safe and functional environment resulting in the potential for harm to all working staff in the kitchen area at the facility. Findings include:

On 10/31/2017 between the hours of 800 and 1600 the following observations were made:

1. The available eyewash station serving the kitchen area at the facility did not meet the requirement of ANSI Z258.1-2004. Hands free type with tepid water eyewash station is required in all areas where staff and/or patients are subjected to blood pathogens, handling of cleaning products including chemicals and corrosive materials. It was discovered during the survey that only cold water is provided to this non-compliant eyewash station (hand held type) subjecting all kitchen working staff to potential harm when an eye injury occurs. At least one eyewash station must be serving this kitchen. The typical eyewash station shall be provided to be hands free type with tepid water and readily accessible for use and to comply with applicable code. Areas where subjected to handling of blood and cleaning and handling of bleach and other corrosive materials are used to conduct daily services at this facility must have a fully compliant eyewash station(s) per OSHA/ANSI (Occupational Safety and Health Administration/American National Standards Institute) requirements ANSI Z358.1 - 2004;

2. The handwashing sink at the kitchen area next to the baking oven did not have th required mixing valve (blending valve) to allow for cold and hot water to properly mix. Staff have to choose between cold water or hot water use at any given time. The hot water was determined to be above maximum allowed of 120 degree Fahrenheit. The required mixing valve will allow the utilization of the handwashing sink without subjecting staff to potential hands burn harm.

Above findings were confirmed by accompanying staff V, W, and X on 10/31/2017 at the time of the observation.

Based on observation, interview and document review, the facility failed to ensure that two shower rooms on two of five units, and one restraint/isolation room out of five were maintained in sanitary condition, and failed to ensure that the Infection Control Program documented tracking and trending of infections, had a documented system for detecting and investigating healthcare associated infections (HAI), and documented the sources and methods used to determine the annual Infection Risk Assessment, resulting in the potential for missed opportunities to stop the spread of infectious illness to all patients in the facility. Findings include:

On 10/30/17 at 1000, during a tour of the B unit with Staff O, the following was observed. A locked shower room with a sign labeling it "clean" was observed to have multiple used personal care item wrappers on the shower floor. Staff O stated, "staff are supposed to clean between patients." At approximately 1015, the Unit Restraint/Seclusion room was inspected with Staff O, and the mattress was observed to have spatters of pale, dried, matter in multiple areas. When queried, Staff O stated, "It doesn't look very clean." when asked, Staff O reported that the restraint room had not been used in the past 48 hours.

On 10/31/17 at approximately 0945, the health system Infection Control Director, Staff Y was interviewed regarding the facility Infection Control Program and methods of surveillance for infections. Staff Y stated that he was not sure how the facility tracked and trended (looked for infections and calculated infection rates). Staff Y stated that the Infection Control Committee Physician, Staff AA "handles infections in the facility" and would notify the "facility Infection Control Point Person", Staff JJ of any infections. When queried, Staff Y stated that there were no logs, line listings or other method of documenting infections in the facility, and no calculations of facility infection rates. When asked about this, Staff Y stated that there were never any infections in the facility,"except maybe urinary tract infections (UTI)". Staff Y stated, "If someone's sick, they're sent out to the acute care hospital." Staff Y was asked whether there was a method of finding our about and documenting infections that started in the facility or were present on admission, but were not diagnosed until after the patient was sent out to the acute care hospital. When requested, Staff Y was unable to provide any written documentation that a system for capturing this was in place. Staff Y was unable to provide any policy or procedure for capturing infections that were diagnosed after the patient was sent to the emergency department (ED) from the facility for illness. When asked, Staff Y was unable to provide any evidence that infections diagnosed in the ED from facility patients sent there for illnesses were tracked and included in facility surveillance data. When queried, Staff Y was unable to provide any surveillance data or infection rates other than rates of staff and patient influenza (flu) immunizations. A list of patients who were transferred to the acute care hospital in the past year for symptoms of infectious illness was requested at this time, but was not produced by survey exit.

On 10/31/17 at approximately 1300 through 1400, the System Infection Control Director Staff Y, the Infection Control Committee Physician, Staff AA, the facility Pharmacist, Staff K, the Chief Quality Officer of the Health System, Staff BB, and the Health System Medical Director of Infection Prevention, Staff CC were interviewed regarding the Infection Control Program in the facility.

Staff AA stated that the facility Infection Control Program consisted of tracking of employee illnesses by Staff JJ, handwashing audits, and influenza vaccination of staff and patients.

When asked, Staff present during the interview were not able to provide documentation of surveillance of infections in the facility. There were no logs or line listing of infections and no calculation of infection rates. Staff AA stated that there was no log or line listing of patients with infections in the facility and stated that she did not see why one was necessary as, "Patients come to us from the emergency department (ED). They are medically healthy people with psychiatric illnesses. If they are sick, we send them to the ED. I follow any patient who's medically sick or has an infection and treat them. If someone's in acute respiratory distress, they're transferred downtown (acute care hospital). We discharge them from here, and send them to the ED if they're not responding to antibiotics, or if they need additional testing."

At this time, staff present were asked if patients who were transferred out because of illness would be noted by the facility Infection Control program. Staff CC stated, "The diagnosis is made through where the test is ordered." Staff Y stated, "We may not be capturing infections that are transferred out to the acute care hospital." A policy or procedure for capturing this information, or any documentation that this was noted, was requested but not provided by survey exit.

A list of patients who were treated for infections in the facility, or who were sent to the acute care hospital or ED for symptoms of infections was requested at this time, but was not provided by survey exit.

Staff AA stated at this time, "We've had no infections in the past year, nothing except a few cases of bedbugs and lice in the past few months. About a year ago, we had to close down a whole unit and exterminate the unit." When asked to provide names of patients affected, or documentation regarding the "cases of bedbugs and lice in the past few months", or when the whole unit was shut down, Staff AA stated that she couldn't remember exactly who, or when this occurred. Staff AA stated, "You can probably find out from the facility maintenance director. He probably has a record of the decontamination procedures." When asked, Staff AA stated that no patients had acquired bedbugs or lice in the facility, but was unable to provide documentation of any surveillance, investigation, or names, patient rooms or dates affected when requested. At this time,the facility staff present were requested to provide documentation of these incidents/infestations, but this was not provided by survey exit.

At approximately 1320 on 10/31/17, Staff AA stated, "I had an HIV positive (Human Immunodeficiency Virus) patient with a cough about a month ago. He was started on oral antibiotics because of possible pneumonia. He wasn't getting better, so I sent him out for further evaluation." When asked, Staff AA, Staff Y and none of the other staff present were able to provide the name of the patient, diagnosis or any other documentation that the infection was noted and documented by the Infection Control Program. When queried, the facility was unable to provide any documentation that a follow up was conducted to ensure that this patient did not have a respiratory infection with a drug resistant microorganism or other microorganism that could be spread by droplets. The facility was requested to provide documentation that they were notified of the final diagnosis and microbial culture results by the acute care hospital. No documentation was provided by survey exit.

Staff BB stated at this time, "I don't see that we need to have any surveillance logs or line listings, or track infections. We don't have patients with devices like foley catheters, ventilators, or central lines, and we don't do surgery here. The only thing we're required to track and report to the NHSN (Center for Disease Control 's National Healthcare Safety Network) is our influenza vaccination rates, and we do that. Show me the regulation that says we're required to track anything more than what NHSN benchmarks."

Staff Y was queried about Staff BB's statement at this time. When asked what nationally recognized professional resources were used for references in developing the facility's Infection Control Program, Staff Y stated, "The Association for Professionals in Infection Control and Epidemiology (APIC), The Centers for Disease Control (CDC) and the Society for Healthcare Epidemiology of America (SHEA)." When asked whether it was an APIC standard that an Infection Control program have a documented surveillance system for tracking infections in the facility, such as a log or line listing of infections, and an investigation to determine whether or not they were acquired in the facility (HAI), Staff Y said, "Yes." When asked if the facility did not need to conduct surveillance for infections because they did not have any of the procedure or devices related infections reportable to the NHSN, Staff Y stated that per APIC, surveillance should be targeted to infections identified in the facility's annual Infection Control Risk Assessment.

Review of the facility Infection Control 2017 Risk Assessment at this time with the staff present, revealed questions regarding the accuracy of the facility's assessment of the risk of infections occurring in the facility. The risk of outbreaks of listed communicable diseases was assessed as, "low risk" of occurring in the community. The facility assessed the risk of these infections being present on admission (occurring in the community) was documented as "low." The risk of healthcare associated infections (HAI) occurring inside the facility was assessed as low risk for all illnesses except for scabies (an itchy rash caused by microscopic mite infection) and lice, which were documented as at "medium risk" for occurring. When asked, no one present was able to explain how the risk assessments were determined, and no one was able to state where the data came from to determine these risks. Sources of data used to calculate the 2017 infection risk assessment were requested but not provided by exit.

When asked at this time, Staff AA stated that many of the patients admitted to the facility were homeless, resided in shelters, and many were intravenous drug users. When asked at this time, Staff Y stated that the risks of community outbreaks of transmissible diseases did not look accurate for the counties served by the facility, or for the high risk patients served by the facility. Staff Y stated, "It looks like they may have gotten the statistics for Influenza and Pneumonia from the health department during the summer (months outside of flu, norovirus and pneumonia season.)" When queried, Staff Y stated that the facility corporate health system had been advised of the current state emergency response system alert triggered by the outbreak of Hepatitis A (foodborne illness, also fecal oral transmission) in the local community. There was no notation of this in the facility's Infection Control Risk Assessment, or documentation of this in the provided Infection Control Plan. There was no documentation of surveillance for Hepatitis A (per the CDC, Hepatitis A has an incubation period of 28 days) in the facility."

On 11/2/17 at 0920, State Epidemiologist, Staff NN was interviewed regarding the 2016-2017 state Public Health Department's calculation of the risk of communicable diseases in the area served by the facility. Staff NN stated that the outbreak of Hepatitis A in the area had been going on for 14 months, but had now reached numbers where the state emergency response system was triggered. Staff NN stated that the two week online report of communicable diseases varies according to the season, but the yearly summary is available on the same website. Staff NN stated that the area (served by the facility), "leads the way for seasonal flu (influenza) activity." Staff NN stated, "Pneumonia rates are not accurately reported, but there is moderate sporadic risk throughout the year, peaking in flu season." Staff NN reported that the risk for diarrheal illness, including Norovirus infection, is moderate year around, but peaks to high risk during the winter months.

On 11/1/17 at 10:00, the facility "Infection Control Point Person", Staff JJ was interviewed in the presence of Staff Y, Staff AA, Staff BB, Staff B and Staff C. Staff JJ was unable to provide any documentation of infections in the facility, patients with isolation precautions, ectoparasite infestations (bedbugs, lice, scabies and fleas), or of infections reported back to the facility by the acute care hospital (for patients transferred there for illnesses) for the past 12 months when requested. When asked, Staff JJ stated that there had been no infections in the facility in the past 12 months. When asked specifically about pneumonia, norovirus, flu like illnesses and flu in the facility (seasonal outbreaks and high incidence in the local area documented by the health department during flu season of 2017-2017), Staff JJ stated that none of these had occurred in the facility during the past 12 months. When queried, Staff JJ stated that she tracked staff handwashing, staff absences, and staff and patient Influenza vaccination rates. Staff JJ stated that she did not keep documentation of infections, but reported communicable diseases to the local health department and the NHSN. When asked to provide documentation of this, Staff JJ produced documentation that Influenza vaccination rates were reported to the Health Department and to NHSN, but no documentation of a report of any communicable disease was provided by exit. When asked to provide documentation of screening of Dietary staff call-ins (absences) for exclusionary illnesses, Staff JJ was unable to do so, but stated, "The department head would notify me if staff were calling in for anything like that (exclusionary illness).

A list of patients who had positive laboratory results from 8/31/17 through 10/17 in the facility was provided per request and reviewed at this time with Staff JJ, and all staff present during this interview. Per Staff BB, this report could be obtained through the system electronic intranet. 10 of 10 culture results listed were noted as "possible hospital associated infection". When requested, the facility (all present) was unable to provide documentation that this was previously reviewed, noted or investigated by survey exit. When asked, Staff JJ was unable to provide admission dates for the 10 patients/staff in question, or any documentation that she had previously seen or reviewed the information. When queried, Staff JJ was unable to provide any documentation to indicate that she reviewed these laboratory reports on a regular basis.

On 11/1/17 at 1300, review of the provided Policy entitled, "Infection Prevention and Control Plan: 2017" revealed the following, "Monitoring of community acquired and hospital acquired infection. Data collection and analysis." A "goal" was documented as, "Decrease/effectively manage Scabies, Lice, Influenza/Influenza like illness, Bed Bugs, Norovirus and Gastroenteritis." There were no surveillance methods or notation of the need to document and track infections, and no notation of a need to calculate infection rates and methodology for doing so.

On 11/2/17 at approximately 1200, review of the APIC online text entitled, "The Basics of Infection Prevention" revealed the following guidance for Infection Prevention Programs in Behavioral Health Settings, "the most common infections occur in the eyes, ears, nose, throat, mouth and upper respiratory tract. Surveillance programs may be directed towards looking for upper respiratory infections."

On 11/1/17 at approximately 1315, review of the requested infection control surveillance policy, entitled, "Infection Control Program", dated 06/2012, revealed the following notations:

"To annually utilize an Infection prevention and Control Risk Assessment and set priorities based upon nationally recognized outcome measures when available or as defined by the Infection Prevention and Control Program",
"Identify, analyze, summarize and report infection surveillance data according to internal thresholds, external benchmarks when available, and as required by regulatory agencies or by law."
"Review infection prevention and control surveillance data."
"Routine surveillance will be performed concurrently when possible and reports generated monthly and/or quarterly depending on the frequency of the outcome."



28775


On 10/30/2017 at approximately 1010 a tour of Nursing unit Module (Mod) D was conducted with Nurse Manager Staff G. A community shower room was observed while accompanied by Staff G. A small blue disposable drinking cup and 2 small bottles of shampoo were observed on a grab bar in the shower stall. There were no patients or attendants in or near the unoccupied shower room.
At that time Staff G was asked to explain if the blue drinking cup and small bottles of shampoo in the shower room were for all patients and/or shared between patients. Staff G said no. When asked to explain who was responsible for removing cups and shampoo from the shower room Staff G stated, "Housekeeping was."

On 10/31/17 at approximately 1400 an interview was conducted with Director of Nursing Staff A regarding the aforementioned observations of the shower room on Mod D on 10/30/17. When queried Staff A said the "Tech's" were responsible for disposing of the cups and shampoo after each patient had completed their showers. Staff A stated, "Nothing should have been shared between patients."

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

I. Ensure that the Master Treatment Plans for two (2) of 10 active sample patients (A9 and C7) and one (1) non-sample patient (C11) were revised when these patients failed to participate in their prescribed treatment. The Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that Master Treatment Plans for seven (7) of 10 sample patients (A9, A25, B4, B8, C2, D4, and D18) included individualized physician and nursing interventions based on the psychiatric symptoms of each patient. This failure results in treatment plans that did not reflect an individualized approach to treatment and potentially led to inconsistent, ineffective care. (Refer to B122)

III. Ensure active treatment measures were provided for two (2) of 10 active sample patients (A9 and C7) and for one (1) non-sample patient (C11) added to the sample for review of active treatment. These patients were not able or unwilling to attend available groups conducted for the patients on their respective unit. Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend group therapies. These patients spent many hours sleeping or sitting in their assigned rooms. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning. (Refer to B125, Section I)

IV. Ensure that treatment modalities were provided as scheduled for all patients on all units. The groups/activities were started late and/or ended earlier than scheduled or were moved or canceled. This deficient practice results in patients lying in their beds and roaming the hallways and in fragmented treatment for patients. (Refer to B125, Section II)

Based on record review and interview, the facility failed to provide social work assessments that met professional social work standards including conclusions and recommendations that described anticipated social work treatment services for 10 of 10 active sample patients (A9, A25, B4, B8, C2, C7, D4, D18, W1, and W5). This deficiency resulted in the role of the social worker not being clearly delineated on the social work assessments, potentially impacting the formulation of the treatment plan.

Findings include:

A. Record Review

1. The social work assessment of Patient A9 (dated 10/5/17) had no anticipated social work treatment recommendations or conclusions.

2. The social work assessment of Patient A25 (dated 10/20/17) had no anticipated social work treatment recommendations or conclusions.

3. The social work assessment of Patient B4 (dated 10/26/17) had no anticipated social work recommendations or conclusions.

4. The social work assessment of Patient B8 (dated 10/25/17) had no anticipated social work recommendations or conclusions.

5. The social work assessment of Patient C2 (dated 10/24/17) had no anticipated social work recommendations or conclusions.

6. The social work assessment of Patient C7 (dated 6/26/17) had no anticipated social work recommendations or conclusions.

7. The social work assessment of Patient D4 (dated 10/27/17) had no anticipated social work recommendations or conclusions.

8. The social work assessment of Patient D18 (dated 10/24/17) had no anticipated social work recommendations or conclusions.

9. The social work assessments of Patient W1 (dated 10/26/17) had no anticipated social work recommendations or conclusions.

10. The social work assessments of Patient W5 (dated 7/27/17) had no anticipated social work recommendations or conclusions.

B. Interview

On 10/31/17 at 10:00 a.m., the Social Work Director agreed that there were no specific social work recommendations for treatment in the social work assessments.

Based on record review, document review and interview the facility failed to ensure that the Master Treatment Plans for two (2) of 10 active sample patients (A9 and C7) and 1 non-sample patient (C11) were revised when these patients failed to participate in their prescribed treatment. The Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient A9 (admitted on 10/4/17) had no revisions in the Master Treatment plan dated 10/5/17 despite the fact that the treatment team and progress notes (10/23/17 through 10/30/17) revealed that the patient attended only one group/activity during this time period. As of 10/31/17, there was a failure to revise Patient A9's treatment plan based on patient's continued non-compliance with the designated treatment regimen.

2. Patient C7 (admitted on 6/26/17) had no revisions in the Master Treatment Plan dated 6/26/17 despite the fact that it was continuously noted during treatment team meetings (6/29, 7/6, 7/13, 8/3, 8/24, 8/31, 9/7, 9/14, 9/21, 9/28, 10/5, 10/12, 10/19 and 10/26) that the patient was not participating in group therapies. There were no alternative treatment modalities in the Master Treatment Plan.

3. Patient C11 (patient admitted on 5/15/17) had no revisions in the Master Treatment plan dated 5/16/17 despite the fact that the treatment team and progress notes
(10/24/17 through 10/31/17) revealed that the patient attended only 9 of 28 groups/activities during this time period. As of 10/31/17, there was failure to revise Patient C11's treatment plan based on patient's continued non-compliance with designated treatment regimen.

B. Document Review

The facility policy titled "Interdisciplinary Plan of Care" and last revised 11/2014 stated, "The patient's Individualized Plan of Care will be reviewed and updated with any changes in condition based on the updated assessment and needs identified for or by the patient." The facility is not in compliance with their policy.

C. Interview

1. On 10/31/17 at 1:30 p.m., the Director of Nursing and the Director of Operations agreed that there were no alternative therapies being offered to Patients A9, C7 and C11 and the Master Treatment Plans were not revised to address non-attendance at groups.

2. On 10/31/17 at 10:00 a.m., the Social Work Director and the Activity Therapy Director concurred that the Master Treatment Plans for Patients A9, C7 and C11 had not been revised to reflect alternative therapies.

Based on record review, document review and interview, it was determined that treatment plans included poorly defined outcome patient goals for 10 of 10 sample patients (A9, A25, B4, B8, C2, C7, D4, D18, W1 and W5). Goals were stated in non-measurable terms and failed to identify or delineate specific outcome behaviors for patients. Deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient A9's Master Treatment Plan (dated 10/5/17) had the following problem statement: "depressed with suicidal thoughts and disruptive behavior along with psychosis." The sole short term goal was "To get better." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

2. Patient A25's Master Treatment Plan dated 10/19/17 had the following problem statement: "feelings of hopelessness and worthlessness, low energy, poor concentration ...mood swings, and chronic suicidal thoughts ...endorses auditory hallucinations commanding [him/her] to kill [him/herself]." The sole short term goal was stated as "[Patient] hopes to be able to 'be able to (sic) function without wanting to kill myself.'" This short-term goal is non-measurable and does not delineate specific outcome behaviors.

3. Patient B4 (Master Treatment Plan dated 10/26/17) had the following problem statement: "depressed and irritable mood, poor sleep, anhedonia." The sole short term goal was "Over the next 1-2 days, [patient] hopes to 'Get out of here'." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

4. Patient B8 (Master Treatment Plan dated 10/25/17) had the following problem statement: "erratic behavior, non-compliant with medications, irritable, verbally aggressive, distracted by flight of ideas." The sole short term goal was "Over the next 1-2 days, patient did not provide an answer." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

5. Patient C2 (Master Treatment Plan dated 10/23/17) had the following problem statement: "presents with auditory hallucinations (hearing the voices of multiple females and males), and paranoid (thinks others are plotting against [him/her]) and grandiose ..." The sole short term goal was "hopes to be able to 'eliminate these voices.'" This short-term goal is non-measurable and does not delineate specific outcome behaviors.

6. Patient C7 (Master Treatment Plan dated 6/26/17) had the following problem statement: "hallucinations, violence, disorganized/speech and behavior." The sole short term goal was "Over the next 1-2 days, [patient] hopes to be able to 'I don't know'." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

7. Patient D4 (Master Treatment Plan dated 10/25/17) had the following problem statement: "severe temper outbursts at least 3 times a week, sad, irritable or angry mood almost every day and reacts bigger than expected to the stressor ...often threatens suicide when [s/he] becomes upset." The sole short term goal was "hopes to be able to 'to (sic) do better.'" This short-term goal is non-measurable and does not delineate specific outcome behaviors.

8. Patient D18 (Master Treatment Plan dated 10/24/17) had the following problem statement: "impulsive behaviors like drinking urine and eating hot peppers on an empty stomach because [s/her] was dared to do so, was intoxicated with alcohol a day ago and was verbalizing suicidal ideas." The sole short term goal was "hopes to be able to 'improve [his/her] symptoms and develop better coping skills'." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

9. Patient W1 (Master Treatment Plan dated 10/26/17) had the following problem statement: "severe temper outbursts, sad, irritable or angry mood." The sole short term goal was "Over the next 1-2 days, [patient] hopes to be able to 'work on my anger, frustration, depression and work on being more respectful'." This short-term goal is non-measurable and does not delineate specific outcome behaviors."

10. Patient W5 (Master Treatment Plan dated 7/27/17) had the following problem statement: "aggression, impulsivity, irritability." The sole short term goal was "Over the next 1-2 days, [patient] hopes to be able to 'be good'." This short-term goal is non-measurable and does not delineate specific outcome behaviors.

B. Document Review

The facility policy titled "Interdisciplinary Plan of Care/Conference" and last revised 11/2014 states, "measurable goals/outcomes are added to the plan of care." The facility is not in compliance with their policy.

C. Interviews

1. During interview on 10/31/17 at 11:20 a.m. the Medical Director verified the above findings.

2. On 10/31/17 at 1:30 p.m., the Director of Nursing and Director of Operations agreed that the short-term goals were not measurable.

Based on record review, document review and interview, the facility failed to ensure that Master Treatment Plans for seven (7) of 10 sample patients (A9, A25, B4, B8, C2, D4, and D18) included individualized physician and nursing interventions based on the psychiatric symptoms of each patient. This failure results in treatment plans that did not reflect an individualized approach to treatment and potentially leads to inconsistent, ineffective care.

Findings include:

A. Record Review

1. Patient A9's Master Treatment Plan (dated 10/5/17) had the following problem statement: "depressed with suicidal thoughts and disruptive behavior along with psychosis."

A physician intervention was listed as "Provider will monitor medication compliance and tolerance daily. Medications will be optimized through this admission as necessary." This was a generic statement rather than specifying information based on this patient's needs, including specific medications.

There were no specific nursing interventions related to the safety of this patient in the clinical area even though s/he was suicidal. This patient remained in bed the majority of the time. There were no nursing interventions to address this behavior.

2. Patient A25's Master Treatment Plan dated 10/19/17 had the following problem statement: "feelings of hopelessness and worthlessness, low energy, poor concentration ...mood swings, and chronic suicidal thoughts ...endorses auditory hallucinations commanding [him/her] to kill [him/herself]."

A physician intervention was listed as "Monitor patient symptoms and adjust medications to improve eliminate (sic) SI, improve depression, control mood swings." This intervention failed to include specific medications for focus of treatment.

There were no specific nursing interventions related to the safety of this patient in the clinical area even though s/he was suicidal. Nursing failed to specify how nursing personnel were to respond to this patient's presenting hallucinations. Instead the following generic functions were listed:

"Assist and support a health sleep routine by minimizing disturbance during sleep, discouraging daytime napping, educate patent on health sleep hygiene daily."

"Encourage and prompt patient to complete ADL's [activities of daily living].
by providing items need (sic) such as toiletries, clothing, assistance and offer support as needed daily."

"Educate and practice 1-2 patient identified helpful DBT [dialectical behavior therapy] coping skills daily."

"Encourage and engage patient in a discussion about medication side effects, benefits, and importance of compliance."

3. Patient B4 (Master Treatment Plan dated 10/26/17) had the following nursing interventions for the problem, "depressed and irritable mood, poor sleep, anhedonia": "Ask patient to verbalize mood and acknowledge any improvements in altered thought process twice per day."

"Assist and support a healthy sleep routine."

"Encourage and prompt patient to complete ADLs [activities of daily living].

"Educate and practice 1-2 patient identified helpful DBT [dialectical behavior therapy] coping skills daily."

"Encourage and engage patient in a discussion about medication side effects, benefits, and importance of compliance."

"Staff will reorient the patient and encourage to do ADLs and participate in groups."

These interventions were generic, basic nursing job description modalities and were not individualized.

4. Patient B8 (Master Treatment Plan dated 10/25/17) had the following nursing interventions for the problem, "erratic behavior, non-compliant with medications, irritable, verbally aggressive, distracted by flight of ideas":

"Ask patient to verbalize mood and acknowledge any improvements in nothing [sic] twice per day."

"Assist and support a healthy sleep routine."

"Encourage and prompt patient to complete ADLs [activities of daily living]."

"Educate and practice 1-2 patient identified helpful DBT [dialectical behavioral therapy] coping skills daily."

"Encourage and engage patient in a discussion about medication side effects, benefits, and importance of compliance."

These interventions were generic, basic nursing job description modalities and were not individualized.

5. Patient C2 (Master Treatment Plan dated 10/23/17) had the following problem statement: "presents with auditory hallucinations (hearing the voices of multiple females and males), and paranoid (thinks others are plotting against [him/her] and grandiose ..."

Physician interventions were listed as "Monitor patient symptoms and adjust medications to improve hallucinations, delusions, and symptoms of mania" and "Start pharmacotherapy and titrate as tolerated." These interventions failed to include specific medications for focus of treatment.

There were no specific nursing interventions to specify how nursing personnel were to respond to this patient's presenting hallucinations and delusions in the clinical area. Instead only generic interventions were listed:

"Ask patient to verbalize mood and acknowledge any improvements in (add specific behavior here) twice per day."
Specific behaviors were not listed in this intervention.

"Assist and support a health sleep routine by minimizing disturbance during sleep, discouraging daytime napping, educate patent on health sleep hygiene daily."

"Encourage and prompt patient to complete ADL's by providing items need (sic) such as toiletries, clothing, assistance and offer support as needed daily."

"Educate and practice 1-2 patient identified helpful DBT coping skills daily."

"Encourage and engage patient n a discussion about medication side effects, benefits, and importance of compliance."

6. Patient D4 (Master Treatment Plan dated 10/25/17) had the following problem statement: "severe temper outbursts at least 3 times a week, sad, irritable or angry mood almost every day and reacts bigger than expected to the stressor ...often threatens suicide when [s/he] becomes upset."

Physician interventions were listed as generic role functions:

"Upon admission, complete a comprehensive behavioral health assessment and plan within the first 24 hours."

"Evaluate patient every 24 hours to assess the need for change of level of observation, or intervention."

"Monitor symptoms with expectation of stability or improvement within 5-7 days."

"Monitor patient symptoms and adjust medications to improve mood and poor impulse control." Specific medications for this patient were not identified in the plan.

"Assess for barriers to medication compliance and provide education discharge (sic)."

There were no specific nursing interventions listed to address this patient's stated problem. Instead only generic interventions were listed: "Ask patient to verbalize mood and acknowledge any improvements in (add specific behavior here) twice per day." Specific behaviors were not listed in this intervention.

"Assist and support a health sleep routine by minimizing disturbance during sleep, discouraging daytime napping, educate patent on health sleep hygiene daily."

"Encourage and prompt patient to complete ADL's by providing items need (sic) such as toiletries, clothing, assistance and offer support as needed daily."

"Educate and practice 1-2 patient identified helpful DBT coping skills daily."

"Encourage and engage patient in a discussion about medication side effects, benefits, and importance of compliance."

7. Patient D18 (Master Treatment Plan dated 10/24/17) had the following problem statement: "impulsive behaviors like drinking urine and eating hot peppers on an empty stomach because [s/her] was dared to do so, was intoxicated with alcohol a day ago and was verbalizing suicidal ideas."

There were no specific nursing interventions listed to address this patient's stated problem. Instead, only generic interventions were listed:

"Encourage and prompt patient to complete ADL's by providing items need (sic) such as toiletries, clothing, assistance and offer support as needed daily."

"Encourage and engage patient n a discussion about medication side effects, benefits, and importance of compliance."

"Administer medications and monitor for side effects every shift."

B. Document Review

The facility policy titled "Interdisciplinary Plan of Care/Conference" and last revised 11/14 states, "interventions are added to the POC [plan of care]. (Those that are inclusive to the care of that individual patient's unique needs are utilized)." The facility is not in compliance with this policy.

C. Interview

1. During interview on 10/31/17 at 11:20 a.m. the Medical Director verified the above findings.

2. On 10/31/17 at 1:30 p.m., the Director of Nursing and Director of Operations agreed that the nursing interventions were not individualized.

Based on observation, interview and record review, it was determined that the facility failed to:

I. Ensure active treatment measures were provided for 2 of 10 active sample patients (A9 and C7) and for 1 non-sample patient (C11) added to the sample for review of active treatment. These patients were not able or unwilling to attend available groups conducted for the patients on their respective unit. Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend group therapies. These patients spent many hours sleeping or sitting in their assigned rooms. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning.

II. Ensure that treatment modalities were provided as scheduled for all patients on all units. The groups/activities were started late and/or ended earlier than scheduled or were moved or canceled. This deficient practice results patient lying in their beds and roaming the hallways and in fragmented treatment for patients.

Findings include:

I. Findings related to ensure that active treatment measures were provided for Patients A9, C7 and C11 based on individual needs:

A. Patient A9 was a 32-year old patient admitted on 10/4/17 with a diagnosis of Schizophrenia disorder, bipolar type.

1. According to the psychiatric evaluation (10/5/17) Patient A9 was "at High risk for aggression" and "at risk of suicide ...currently suicidal with intention and plan."

2. Review of master treatment plan (dated 10/5/17 with treatment team notes through 10/30/17) revealed the following interventions:

SW interventions stated "SW will encourage [Patent] to engage in reality orientation and verbalize in logical and coherent manner by attending daily group therapy ...will be encouraged to participate in structured social work group therapy daily ...will identify 1-2 positive coping skills through CBT based group therapy."

An activity therapy intervention stated "encourage daily attendance to groups."

3. Patient observations and interview:
a. On 10/30/17 at 12:00 p.m. Patient A9 was observed in bed asleep with the light off. S/he refused to get out of bed and refused an interview. S/he reported that s/he "stays in bed" and is "sad."

b. On 10/30/17 at 2:15 p.m. and on 10/31/17 at 9:30 a.m. Patient A9 was observed in bed asleep with the light off. S/he refused to get out of bed and refused an interview. Groups were available at these time periods.

4. Staff Interview:

During interview on 10/30/17 at 12:00 p.m., the medical director reported that Patient A9 had been transferred to this unit (A) after having an altercation on another ward with a patient.

5. Review of progress notes (10/23/17 through 10/30/17) revealed that the patient refused to attend the majority of assigned groups/activities. Patient A9 did attend one group therapy session on 10/23/17.

a. Treatment Plan Meeting notes (10/23/17) stated "Isolative to [his/her] room, has not been attending group therapy sessions." "Mostly isolative to [his/her] room except during meal times." "Has continued to refuse to attend social work group despite continues (sic) verbal prompts." "continues not to attend daily leisure activities and DBT skill groups. [Patient] refuses to participate and isolates [him/herself] in [his/her] room." "Continue to encourage attendance of skills groups, and will be reviewed again in 7 days."

b. An RN note (10/30/17) stated "Limited towards the treatment goals as demonstrated by remaining in [his/her] room for most of the Day with no group attendance."

c. A social work note (10/30/17) stated "[S/he] remains isolative and refused to participate in social work group therapy despite several prompts."

d. An activity therapy note (10/30/17) stated "[S/he] is not attending groups despite encouragement. [Patient] isolated in rooms (sic)."

e. As of 10/31/17, there was failure to revise Patient A9's treatment plan based on patient's continued non-compliance designated treatment regimen. The treatment plan team note (10/30/17) stated "continue current regimen."

B. Patient C7 was a 27-year-old individual admitted on 6/26/17 with a diagnosis of Undifferentiated Schizophrenia.

1. According to the psychiatric evaluation dated 6/26/17 Patient C7 presented with "aggression, poor behavioral control, deficits in social cognitive or information processing abilities and command hallucinations to harm others."

2. Patient observations and interview:

Patient C7 was in bed on 10/30/17 at 2:00 p.m. The patient told the surveyor that he/she did not attend groups and "slept a lot." At 2:30 p.m. that day, as the other patients gathered to go to the gym for an activity, a Mental Health Aide approached the door of Patient C7's bedroom, glanced in and closed the door without addressing the patient. The surveyor immediately went into the patient's room and asked him/her about joining the group in the gym. He/she decided to attend the group.

3. Staff Interviews:

a. On 10/30/17 at 3:00 p.m., RN7 stated, "No, we don't do alternatives when patients do not attend groups. I usually just ask them why they didn't go."
b. On 10/31/17 at 1:30 p.m., the Director of Nursing and the Director of Operations stated that, "There are no alternative therapies for patients who do not attend groups."

4. Record Review

A review of the group notes revealed that Patient C7 attended only 3 activity/leisure groups during the week of 10/24-10/30. The patient did not attend any social work/therapy groups.

A review of the treatment team notes (Master Treatment Plan dated 6/26/17) for 6/29/17, 7/6/17, 7/13/17, 8/3/17, 8/24/17, 8/31/17, 9/7/17, 9/14/17, 9/21/17, 9/28/17, 10/5/17, 10/12/17, 10/19/17 and 10/26/17 consistently revealed that Patient C7 "is not attending group therapy sessions". On 9/14/17 a Social Work note on the Master Treatment Plan stated, "Patient resistant to participation in group therapy. If attending it is for short duration." Despite this behavior, the plan stated on 9/14/17, "no changes necessary at this time."

There were no alternative therapies noted in the Master Treatment Plan in response to Patient C7's lack of involvement in treatment.

5. As of 10/31/17 the Master Treatment Plan for Patient C7 had not been revised despite his/her non-compliance with therapies.

C. Patient C11 was a 28-year old patient admitted on 5/15/17 with a diagnosis of Schizoaffective disorder, bipolar type.

1. According to the psychiatric evaluation (5/16/17) Patient C11 was admitted for "aggressive behavior, non-compliance with medication ...endorsed visual and on command auditory hallucinations ..."

2. Review of master treatment plan (dated 5/16/17 with treatment team notes through 10/30/17) revealed the following interventions:

SW interventions stated "Provide daily CBT based group therapy with reinforcement of distress tolerance ..."

An activity therapy intervention stated "Offer and encourage patient to attend 2-3 treatment activities (gym, library, art therapy, DBT skills classes ..."

3. Patient observations and interview:

a. On 10/30/17 at 10:30 a.m. Patient C11 was in bed asleep and refused to get up. S/he reported that s/he goes to some groups but not all the time. S/he stated "I stay in bed most days."

b. On 10/30/17 at 2:10 p.m. Patient C11 was taking a shower while a group, "What Causes Psychiatric Symptoms," was offered.

c. During a group on 10/31/17 at 9:35 a.m., Patient C11 was in his/her room. When asked if s/he had been in bed all morning, the patient responded, "About 2 hours."

4. Staff Interviews:

a. During interview on 10/30/17 at 10:30 a.m., RN W1 reported that Patient C11was ready for discharge and "waiting for a bed."

b. During interview on 10/30/17 at 2:10 p.m. RN W2 reported that Patient C11 comes out of his/her room at shift change.

5. Review of treatment plan team meeting and progress notes (10/24/17 through 10/31/17) revealed that the patient attended only 9 of 28 groups/activities during this time period.

a. An RN note (10/24/17) stated "[S/he] attended gym but no groups."

b. A physician note (10/25/17) stated "Patient will be encouraged to attend groups."

c. An RN note (10/25/17) documented "[S/he] attended no groups and activities."

d. A social work note (10/26/17) stated "continues to isolate to room during group therapy times ...will continue to engage patient on daily basis to participate in treatment program."

e. An activity therapy note (10/26/17) stated "continues to refuse most AT (activity therapy) groups despite encouragement."

f. A treatment plan team meeting note (10/26/17) documented "continues to isolate to room during group therapy time." "Continues to refuse most AT groups." "Patient goals/interventions have been continued and will be reviewed again in 7 days."

g. A physician note (10/29/17) documented "[S/he] is not participating in the milieu ..."

6. As of 10/31/17, there was failure to revise Patient C11's treatment plan based on patient's continued non-compliance with designated treatment regimen.

II. Findings related to late/moved/canceled groups/activities

A. On 10/30/17 on Mod W (children's unit) a nursing group titled, "What Causes Psychiatric Symptoms" was scheduled for 11:30 a.m. This group was not held.

B. On 10/30/17 on Mod C (a male adult unit) a nursing group titled, "What Causes Psychiatric Symptoms" was scheduled from 2:00 p.m. until 2:30 p.m. The group began at 2:04 p.m. and concluded at 2:15 p.m. When asked about the early conclusion, RN 6 stated, "I lost their attention."

C. During interview on 10/30/17 at 2:10 p.m. RNW2 stated "sometimes groups are canceled. This would be due to availability of staff."

D. On 10/31/17 on Mod B (a female adult unit) a social work group was scheduled at 10:00 a.m. The group began at 10:10 a.m.

E. On 10/31/17 a group, "Group Therapy," on Mod D began late due to staff getting out late from the treatment team meeting

F. On 10/31/17 at 10:30 a.m. on Mod B, there were 8 patients in group, 1 patient pacing in the hall, and 4 patients were in their beds.

G. On 10/31/17 a group that was scheduled at 10:40 a.m. started at 9:40 a.m. on Mod C, there were 2 patients in group, 3 patients in the hall, and 4 in their beds

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

I. Ensure that the Master Treatment Plans for two (2) of 10 active sample patients (A9 and C7) and 1 non-sample patient (C11) were revised when these patients failed to participate in their prescribed treatment. The Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that Master Treatment Plans included deficient outcome patient goals for 10 of 10 sample patients (A9, A25, B4, B8, C2, C7, D4, D18, W1 and W5). Goals were stated in non-measurable terms and failed to identify or delineate specific outcome behaviors for patients. Deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions. (Refer to B121)

III. Ensure that Master Treatment Plans for seven (7) of 10 sample patients (A9, A25, B4, B8, C2, D4, and D18) included individualized physician and nursing interventions based on the psychiatric symptoms of each patient. This failure results in treatment plans that did not reflect an individualized approach to treatment and potentially led to inconsistent, ineffective care. (Refer to B122)

IV. Ensure active treatment measures were provided for two (2) of 10 active sample patients (A9 and C7) and for 1 non-sample patient (C11) added to the sample for review of active treatment. These patients were not able or unwilling to attend available groups conducted for the patients on their respective unit. Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend group therapies. These patients spent many hours sleeping or sitting in their assigned rooms. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning. (Refer to B125, Section I)

V. Ensure that treatment modalities were provided as scheduled for all patients on all units. The groups/activities were started late and/or ended earlier than scheduled or were moved or canceled. This deficient practice results in patients lying in their beds and roaming the hallways and in fragmented treatment for patients. (Refer to B125, Section II)

VI. Ensure timely review and corrective action of the death of Patient Z. The facility was notified of this patient's death one week after his/her discharge from this facility on 9/29/17 but as of 10/31/17 had not completed the review of his/her treatment and discharge. This hinders corrective action that may prevent appropriate treatment and proper discharges of all patients treated at this facility.

Findings include:

A. The survey team was given a list of recent incidents that had occurred in the hospital. This list included the death of a patient who died one week after discharge from the facility

B. During interview on 10/31/17 at 4:30 p.m. the Medical Director reported that the facility had not completed the review of Patient Z's treatment and discharge from this facility due to a visit from the Joint Commission and staff vacations. She reported that their meetings had been postponed twice.

Based on record review, document review and interview, the Director of Nursing failed to:

1. Ensure that seven (7) of 10 Master Treatment Plans (A9, A25, B4, B8, C2, D4 and D18) included individualized nursing interventions based on the psychiatric symptoms of each patient. This failure resulted in treatment plans that did not reflect an individualized approach to treatment and potentially led to inconsistent, ineffective care. (Refer to B122)

2. Ensure that active treatment measures were provided for two (2) of 10 active sample patients (A9 and C7) and for 1 non-sample patient (C11). These patients were unable or unwilling to attend available groups and no alternative therapies were provided. This failure resulted in patients not receiving active treatment during their hospitalization. (Refer to B125 I)

3. Ensure that nursing groups were provided as scheduled for all patients on 5 units (Mod A, Mod B, Mod C, Mod D and Mod W). (Refer to B125 II)

Based on record review and interview, the Director of Social Work failed to provide social work assessments which included conclusions and recommendations that described anticipated social work treatment services for 10 of 10 active sample patients (A9, A25, B4, B8, C2, C7, D4, D18, W1 and W5). This deficiency resulted in the role of the social worker not being clearly delineated on the social work assessments, potentially impacting the formulation of the treatment plan. (Refer to B108)