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Based on observation, record review, and interview, the facility failed to ensure that the active treatment interventions assigned to registered nurses on the Master Treatment Plans (MTPs) were documented for five (5) of eight (8) active sample patients (A4, A5, A6, A7 and A8) and one (1) active non-sample patient (B1). Specifically, there was no documentation showing patients' participation or non-participating in these assigned active treatment interventions; the topic(s) discussed, and patients' level of response to the intervention provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' conditions, and revise the treatment plan if/when needed.

A. Record Review

The MTPs for the following patients were reviewed (date plans were signed in parentheses): A1 (2/21/18); A2 (2/19/18); A3 (1/29/18); A4 (2/26/18); A5 (2/21/18); A6 (2/26/18); A7 (2/26/18); A8 (2/26/18) and B1 (2/19/18). This review revealed that there were no treatment notes documented by registered nurses showing that they met with patients in group or individual sessions to provide the active treatment interventions assigned on MTPs.

1. Patients A4's MTP included the following nursing intervention: " ... Will provide medications and medication teaching as needed to decrease symptoms ..." There was no documentation that included the topic and name of the medication(s) discussed, and the patient's response to the intervention such as the patient's level of understanding and behavior (s) exhibited during the intervention.

2. Patients A5's MTP included the following nursing intervention: " ... Discuss with patient importance of continuing meds [medications] post follow [sic] discharge from hospital and follow up." There was no documentation that included the topic and name of the medication(s) discussed, and the patient's response to the intervention such as the patient's level of understanding and behavior (s) exhibited during the intervention.

3. Patients A6's MTP admitted 2/22/18 and Patient A7 admitted 2/23/18 both included the following identical nursing interventions: "Intervention for 3-5 Reduce outburst and anger by using new coping skills developed during admission [sic]." "Intervention for 5-7 days Increase mood stability by encouraging and educating med [medication] compliance." There was no documentation showing the patient's participation or non-participation. Also, there was no documentation to show that the RN met with the patient, identified the topic discussed and name of medication(s) discussed, and the patient's response to the intervention such as the patient's level of understanding and behavior (s) exhibited during the intervention.

4. Patient A8's MTP had the following nursing intervention: - "Nursing will provide pt [patient] teaching regarding: illness mgmt. [management], wellness recovery strategies." There was no documentation found in the medical record showing that the registered nurse had contacts with the patient to provide these specific interventions. There was no documentation that included the topic and the medication(s) discussed, and the patient's response to the intervention such as the patient's level of understanding and behavior (s) exhibited during the intervention.

5. Patients B1's MTP included the following nursing interventions: "Will provide medications and teaching of medications." Will provide groups and activities to learn coping skills to deal with voices." There was no documentation that included the topic and name of the medication(s) discussed, and the patient's response to the intervention such as the patient's level of understanding and behavior (s) exhibited during the intervention. In addition, there was no documented evidence in the electronic medical record to show that the RN met with this patient in group or individual sessions to assist him/her to learn coping skills to deal with voices. [Note: During an interview on 2/27/18 at 3:05 p.m. the Director of Nursing stated that RNs did not provide group treatment at the hospital.]

B. Staff Interview

During interviews on 2/27/18 at 3:05 p.m. and on 2/28/18 at 9:15 a.m., the Director of Nursing did not dispute the findings regarding the lack of treatment notes for assigned active treatment intervention assigned to RN. On 2/27/18 after searching for documentation on the electronic medical record, s/he said, "I do not disagree." S/he noted that RN could include more information about medications and the patient's response in the section of electronic medical record that avoided notes.