HospitalInspections.org

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

I. Provide individualized treatment based on the presenting needs 2 of 10 sample patients (D2 and D9). These patients did not participate in most of the group modalities listed on their Master Treatment Plans and were observed sitting alone in the dayroom or in their bedrooms during the times their group treatments were taking place. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement. (Refer to B125-I)

II. Provide individualized active treatment for 4 of 4 (D2, D3, D9, and D11) sample patients from Ward 4 West on evenings and weekends and for 6 of 6 (A13, A24, C10, C25, G6, and G19) sample patients from other wards on weekends. No groups/activities were scheduled for evenings or weekends for 1 of 7 wards (4 West). Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement.

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

I. Provide individualized treatment based on the presenting needs 2 of 10 sample patients (D2 and D9). These patients did not participate in most of the group modalities listed on their Master Treatment Plans and were observed sitting alone in the dayroom or in their bedrooms during the times their group treatments were taking place. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement.

II. Provide individualized active treatment for 4 of 4 (D2, D3, D9, and D11) sample patients from Ward 4 West on evenings and weekends and for 6 of 6 (A13, A24, C10, C25, G6, and G19) sample patients from other wards on weekends. No groups/activities were scheduled for evenings or weekends for 1 of 7 wards (4 West). Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement.

Findings are:

I. Failure to provide individualized treatment.

A. Patient D2:

1. The admission Psychiatric Evaluation, dated 7/21/09, stated that Patient D2 was a 24-year-old female admitted directly to the 4 West ward on 7/21/09.

2. During an observation on Ward 4 West on 7/20/10 at 10:15a.m., Patient D2 was observed lying in her bed with the covers over her head. The "4 West Schedule" stated that Patient D2 was to attend "Movement to Music" group. During an interview with Patient D2 at this time, she stated that she did not "feel comfortable" in groups and did not usually attend any groups. No staff efforts to engage patient in alternative treatments were observed.

3. During an observation on Ward 4 West on 7/20/10 at 1:25p.m., Patient D2 was observed lying in her bed with the covers over her head. The "4 West Schedule" stated that Patient D2 was to attend "Psychiatric Concerns" group. During an interview with Patient D2 at this time, she stated she had not attended groups on that day. No staff efforts to engage patient in alternative treatments were observed.

4. During an observation on Ward 4 West on 7/21/10 at 9:45a.m., Patient D2 was not observed in the "Stress Management" group being conducted on the ward. The Treatment Team Leader stated that Patient D2 was in the shower at that time.

5. The Master Treatment Plan, dated 7/14/10, identified Patient D2's problem as "Pt has long history of becoming assaultive towards others and she also attempts to harm herself by scratching, biting, and or banging her head." For "Objective 1A: Pt [patient] will reduce the frequency and severity of her negative behaviors towards others by verbalizing that she is upset and needs either medication and or remove herself from others," the only interventions other than medications were the following groups: "Psychiatric Concerns," "TC [therapeutic community] meeting," "Social Skills," "Activity of Daily Living," "Healthy Living," "Current Events," and "Leisure Skills." For "Objective 1B: [Patient D2] will participate in individual sessions with treatment team members when she is not able to attend program," the interventions other than "medications education," and "medication review" were individual sessions daily and as needed with the social worker and weekly with the psychologist. Although the medical record failed to document the participation of Patient D2 in the majority of her planned treatment groups or with individual therapy with the social worker, her master Master Treatment Plan was not revised as of 7/19/10.

6. During an interview on 7/20/10 at 12:45p.m., the Director of Nursing (DON) stated that the patient D2's Master Treatment Plan had not been revised with specific interventions to increase the patient participation in therapeutic groups or to provide alternative programming.

7. During an interview on 7/21/10 at 10:00a.m., the Treatment Team Leader for Patient D2 stated that the Master Treatment Plan had not been revised with specific interventions to increase Patient D2's participation in therapeutic groups or to provide alternative programming until 7/20/10. He stated that one of the "challenges" with Patient D2 was her refusal to attend groups or engage in group therapy.

8. During an interview with SW1 on 7/20/10 at 11:30a.m., she stated that Patient D2 did not currently attend groups. She stated that social work staff did not provide individual therapy for this patient.

9. During an interview with Psychologist1 on 7/20/10 at 1:40p.m., she stated that Patient D2 had not attended groups for approximately three weeks. Psychologist1 stated that the only individual therapy being provided Patient D2 was weekly sessions with Psychologist1.

B. Patient D9:

1. The Psychiatric Evaluation Update, dated 12/11/09, stated that Patient D9 was a 37-year-old male admitted on 2/16/02. He was transferred to the 4 West ward on 2/7/05 due to assaultive behaviors.

2. During an interview with Patient D9 on 7/19/10 at 11:00a.m., he stated that he usually attended about one group per month at the treatment mall. He stated that the ward was "boring, nothing to do" and said "all we do is eat and sleep."

3. During an observation on Ward 4 West on 7/19/10 at 1:40p.m., Patient D9 was observed sitting alone in the dayroom during the time of his scheduled "Leisure Skills" group.

4. During an interview with RN1 on 7/19/10 at 1:45p.m., he stated that the "Leisure Skills" group was not provided on the ward that day because the group leader was conducting another group in the main treatment mall.

5. During an observation on Ward 4 West on 7/20/10 at 9:35a.m., Patient D9 was observed sitting alone in the dayroom not participating in treatment during the time of his scheduled "Movement to Music" group. No staff efforts to engage patient in alternative treatments were observed.

6. The Master Treatment Plan, dated 10/23/09, identified Patient D9's problem as "Patient has a significant history of aggressive/assaultive behaviors. Patient feels that he has illicit drugs still in his system, which continues to have a negative affect [sic] on him. He has little or no insight into his behavior and does not take responsibility for his behavior." Other than medications, the only interventions for this problem included the following groups: "TC [therapeutic community] meeting," "Social Skills," "Activity of Daily Living," "Healthy Living," "Current Events," "Leisure Skills," "Movement to Music," and "Healthy Living." The facility was unable to provide documentation of attendance and participation in the group interventions. The medical record failed to document the participation of Patient D9 in the majority of his planned treatment groups and the facility was unable to provide documentation of his attendance or participation. His Master Treatment Plan was not revised until 7/20/10.

7. In an interview on 7/20/10 at 12:45 p.m., the DON stated that the Master Treatment Plan had not been revised with specific interventions to increase Patient D9's participation in therapeutic groups or to provide alternative programming.

8. During an interview on 7/21/10 at 10:00a.m., the Treatment Team Leader for Patient D9 stated that the Master Treatment Plan had not been revised with specific interventions to increase Patient D9's participation in therapeutic groups or to provide alternative programming until 7/20/10. He stated that Patient D9 had difficulty engaging productively in group therapy due to his paranoid ideation.

C. Interviews

1. In an interview on 7/20/10 at 11:30a.m., the Director of Social Work stated that the patients on Ward 4 West were not able to engage in the "discussion group" format of the 4 West groups. She stated that she conducted the "Current Events" group on this ward. She stated that many of the patients in this group had difficulty engaging in talking treatments and many slept or did not engage.

2. During an interview with the Deputy Director on 7/19/10 at 1:45 p.m., he stated "Little [group therapy] is done on the ward. Most of it is done on the mall."

3. During an interview with the Clinical Director on 7/20/10 at 3:30 p.m., he acknowledged that the patients on 4 West were often not engaged in group therapies.


II. Failure to provide individualized therapeutic modalities on evenings and/or weekends.

A. Record Review

1. For Patient A13, the Master Treatment Plan dated 12/3/09, updated 6/3/10, had no weekend therapeutic activities listed.

2. For Patient A24, the Master Treatment Plan dated 12/8/09, updated 6/8/10, had no weekend therapeutic activities listed.

3. For Patient C10, the Master Treatment Plan dated 6/30/10 had no weekend therapeutic activities listed.

4. For Patient C25 the Master Treatment Plan dated 5/20/10 had no weekend therapeutic activities listed.

5. For Ward 4 West Patient D2, the Master Treatment Plan dated 7/14/10 had no weekend or evening therapeutic activities listed.

6. For Ward 4 West Patient D3, the Master Treatment Plan dated 6/4/10 had no weekend or evening therapeutic activities listed.

7. For Ward 4 West Patient D9, the Master Treatment Plan dated 10/23/09, updated 4/23/10, had no weekend or evening therapeutic activities listed.

8. For Ward 4 West Patient D11, the Master Treatment Plan dated 10/30/09, updated 4/29/10, had no weekend or evening therapeutic activities listed.

9. For Patient G6 the Master Treatment Plan dated 5/25/10 had no weekend therapeutic activities listed.

10. For Patient G19 the Master Treatment Plan dated 12/23/09, updated 7/14/10, had no weekend therapeutic activities listed.

B. Document Review

1. On 7/19/10, the Director of Quality Management provided the surveyors with the following two schedules of therapeutic activities:

a. "Therapeutic Activity Schedule Spring/Summer" dated 4/26/10 - all therapeutic groups were conducted in the 3 Treatment Malls on the 5th and 11th floors. No weekend therapeutic programming was scheduled.

b. "4 WEST SCHEDULE" - All therapeutic groups were conducted on the 4 West ward. The schedule included no weekend or evening programming.

C. Interviews

1. In an interview with the Director of Quality Management, Deputy Director, and Clinical Director on 7/20/10 at 2:10p.m., the Director of Quality Management confirmed that the only activities for weekends listed on the "Therapeutic Activity Schedule Spring/Summer" were leisure activities.

2. In an interview on 7/20/10 at 3:30p.m., the Clinical Director confirmed that the "4 WEST SCHEDULE" demonstrated 4 hours of active therapeutic treatment hours during weekday hours on Tuesday, Wednesday and Friday, only 3 hours during weekday hours on Monday and Thursday, and no hours of therapeutic programming on evenings and weekends.

3. In an interview on 7/20/10 at 9:15a.m., the Director of Nursing stated that no groups or therapeutic activities were conducted on the wards on evenings and weekends for patients who did not attend the groups in the treatment mall areas.

4. In an interview on 7/20/10 at 11:40a.m., the Director of Nursing stated that activities on evenings and weekends on the individual units was primarily leisure oriented and acknowledged that the programming did not address the specific needs of individual patients based on their treatment goals.

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

I. Provide individualized treatment based on the presenting needs 2 of 10 sample patients (D2 and D9). These patients did not participate in most of the group modalities listed on their Master Treatment Plans and were observed to be sitting alone in the dayroom or in their bedrooms during the times their group treatments were taking place. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement. (Refer to B125-I)

II. Provide individualized active treatment for 4 of 4 (D2, D3, D9, and D11) sample patients from Ward 4 West on evenings and weekends and for 6 of 6 (A13, A24, C10, C25, G6, and G19) sample patients from other wards on weekends. No groups/activities were scheduled for evenings or weekends for 1 of 7 wards (4 West). Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion; this potentially delays their improvement. (Refer to B125-II)