HospitalInspections.org

Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, policy review, Medical Staff Rules and Regulations review, medical record reviews and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure an organized and effective, data driven quality assessment and improvement program; and failed to provide oversight of active treatment for behavioral health patients.

The findings included:

1. The facility's leadership staff failed to maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program by failing to accurately measure, analyze and track quality indicators related to restraints and seclusion; failing to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failing to monitor and track hospital readmissions

~cross refer to CFR 482.21 Condition: Quality Assurance Performance Improvement, Tag A0263

2. The facility failed to provide active treatment that was inclusive of complete cranial nerve examinations performed by a physician; Comprehensive Psychiatric Evaluations performed within 60 hours of admission; individualized comprehensive treatment plans that included medical needs; a substantiated psychiatric diagnosis that served as the primary focus for the treatment plan; specific measurable short-term and long-term patient centered goals based on individual patient problems; a focus of treatment based upon the patient's presenting symptoms; documentation of an evaluation of patients' individualized treatment plan progress toward goals; and coordination and documentation of post discharge housing, medication and appointment arrangements. The cumulative findings identified a failure to have a systemic system in place to provide active treatment to behavioral health patients.

~cross refer to 482.61 Condition: Special Medical Record Provisions for Psychiatriac Hospitals, tag B0103

Based on policy review, grievance file review and staff interview, the facility staff failed to provide a written response to grievances for 2 of 2 grievance files reviewed (#10 and #1).

The findings included:

Review of the facility's "General Grievances and Patient Advocacy" policy effective 2/2018 revealed "... Patient grievance is defined as a written or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, or issues related to the Hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489. ... Patient complaints typically involve minor issues, such as but not limited to, housekeeping or food preferences, which do not require an investigation or involve a restriction of patient's rights. Any complaint submitted in writing is always considered a grievance and will be handled as such. ... Staff present includes any staff present at the time of the complaint or who can quickly be at the patient's location to resolve the patient's complaint. If that individual comes and resolves the complaint, it is no longer considered a patient grievance. ... Social Services/Nursing Staff ... Assists the patient with completion of the patient's complaint form for any complaint issues. The complaint form is given to the nurse on the unit and either the nurse or the staff designee talks with the patient and tries to resolve the complaint. If the complaint cannot be resolved, it is passed to the Nursing Manager or therapist, whichever is appropriate to try to resolve. If the complaint has not been resolved, it will be passed to the Patient Advocate to address. When resolved at any level, it will be signed by the Director of Nursing, Director of Clinical Services and the CEO and returned to the Patient Advocate within 48 hours. The patient and/or family member will be notified in writing of the results no longer than 20 business days from when the complaint was received. ..."

1. Review of Patient #10's medical record revealed a 52 year-old female admitted on 04/23/2019 with schizoaffective disorder, bipolar type. Review of the record revealed the patient had chronic pain syndrome, hypertension and gastroesophageal reflux disease. Review of notes recorded by Therapist #3 on 04/26/2019 at 1843 revealed the therapist met with the patient to complete the intake information and the patient reported wanting assisted living or independent living housing. Review revealed the patient repeatedly identified her housing as a stressor and requested assistance with placement after discharge. Review revealed the patient had no support system and lived alone. Review of notes recorded by the patient from a "Mental Wellness: Coping" group meeting revealed the patient requested information regarding "Independent Housing Management." Review of notes recorded by the patient on 05/01/2019 revealed she wanted information from the therapist on independent housing regarding a clean and safe environment. Review of notes documented by the patient on 05/02/2019 recorded the patient continued to request information regarding housing after discharge. Review of the Discharge Plan documented by Therapist #3 revealed the patient left ambulatory via Uber transportation to go to a shelter. Review revealed no name of the facility where the patient was sent. Review of the record revealed the patient was discharged to a shelter on 05/02/2019.

Review of a written grievance filed by Patient #10 on 05/01/2019 revealed "My problem with the therapist is that they are trying to send me to a house or assistant facility without checking out the place itself. Last time the independent house was freezing and cold and there was sewage backing up in the toilet, bathtub and even unto the floor and there were broken pipes in the kitchen. ... I've not had a one on one yet to discuss my problem. I am physically handicapped, disabled and require certain things." Review of the grievance revealed a patient advocate documented that she talked with the patient's therapist and they had researched and found two boarding homes and provided the owners contact name and phone numbers to assist the patient. Review revealed the advocate visited the patient around 1400 on 05/01/2019 and the patient was calling the homes to determine which home she would be living in. Further review of the grievance revealed the patient was requesting assistance with transportation to appointments and obtaining groceries. Review revealed no evidence which housing was selected or if the patient was provided assistance to determine her needs would be met. Review of the medical record revealed the patient continued to request assistance with finding housing on 05/02/2019. Review of the grievance revealed no written response to the patient's grievance was completed.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she was the therapist working with Patient #10. Interview revealed she sent the patient to a shelter and failed to document the name or address of the shelter. Interview revealed the therapist was unable to remember the name of the shelter where the patient was sent. Interview revealed the patient was not satisfied with going to a shelter, but she was out of resources.

Interview on 07/11/2019 at 14254 with Patient Advocate #4 revealed she had talked with Patient #10 regarding her grievance. Interview revealed the patient continued to have the same issue with housing until her discharge. Interview revealed the grievance was not resolved. The staff member stated she did not provide a written response to the grievance. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. The staff member reported that no grievance letters had been sent to patients or family members since she started in January 2019.



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2. Review of Patient's #1's medical record revalued a 42 year old female admitted on 04/08/2019 at 2023 for Major Depressive Disorder and Post Traumatic Stress Disorder after ingesting 5-10 Ambiens, (sleeping agent), 2 Wellbutrins (antidepressant) and 1 Cymbalta (antidepressant and antianxiety) in a suicide attempt. Review of the MD #1's History and Physical dated 04/09/2019 at 0700 revealed Ablation (cardiac procedure for decreasing heart rate) for SVT (Supraventricular Tachycardia--Rapid heart rate) and GERD (Gastrointestinal reflux disease).

Review of a "Patient Advocate: Report and Follow-up" dated 04/09/2019 revealed "Pt. (patient) reports that upon arrival she was assured that she would be admitted onto (named patient care floor) but was sent to (named patient care unit) instead. Pt. stated that the team lied to her by telling her that she was on (named patient care unit) when she really wasn't. She feels that trust has been broken. Also, pt reports that she was asked to undress in front of a nurse and PCA (Patient care assistant) and expressed that she was very uncomfortable....Pt states that the nurse brushed her off in a rude manner. She is also unable to bathe/shower due to no one being able to locate her belongings. Pt has not slept all day and appears very emotional. ACTIONS TAKEN THUS FAR: Pt. advocate has checked every unit and front desk for pt. belongings. Checked with patient and found out that belongings are w/ pts mother who will be bringing them on 04/09. Informed DON and CEO of patients concerns. FOLLOW-UP REQUESTED BY PATIENT: Pt. wants leadership to be aware of incidents and report that she does not trust any staff members. RESOLUTION: Pt. was moved to a new unit (named patient care unit) w/ a small group in order to give pt. opportunity to rest and feel safe during the remainder of her stay. This pt. advocate visited the pt. on (named patient care unit) on 04/11 to ensure that the pt was doing well. Pt informed me that she was feeling well and much happier." Review revealed the form was dated 04/11/2019 at 1:15 pm by Patient Advocate #4. Review of the advocate's report failed to reveal a letter of grievance response to the patient.

Review of an email written by Patient Advocate #4 dated 04/09/2019 at 3:22 pm revealed "Hi (CNO and CEO), I really hate to write this type of information to you in an email but, it has been a very busy day for everyone. I spoke with (Patient #1), who wanted to speak with me to report that upon arrival last night that she lost trust in the staff when she was told that she was being admitted onto (Patient care unit) and not (Patient care unit) as she previously requested. She stated that when she asked if she was on (patient care unit) that one of the staff members lied to her and told her yes. Since then the patient has been moved to the correct unit. She also reports that when she was in intake she was asked to undress in front of an African Nurse and a skinny light skinned PCA, which she understood she would have to do but, informed the nurse that her cycle was on and that she didn't feel very comfortable. She stated that the nurse made a very rude comment and brushed her off and insisted that she get undressed...I have filled out a Patient Advocated Report and Follow-up form if you would like to keep this email in rotation until we come up with a resolution...."

Interview on 07/10/2019 at 1440 with RN #5 revealed an investigation was done. "I asked the supervisor" about the incident. Interview revealed no documentation of the investigation was available. Interview revealed no letter was sent to the patient after the investigation.

Interview on 07/10/2019 at 0930 with Patient Advocate #4 revealed patient #1 was "upset about the unit she was placed on" Interview revealed the Director of Nursing is responsible for investing complaints. Interview revealed no letter was sent to the patient after the investigation. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. Patient Advocate #4 reported that no grievance letters had been sent to patients or family members since she started in January 2019. Interview revealed the patient should have been notified by a letter of the investigation. Interview revealed the patient has a right to know of the investigation and the outcome.

Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, and staff interviews, the facility's leadership staff failed to maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program.

The findings included:

The hospital staff failed to accurately measure, analyze and track quality indicators related to restraints and seclusion; failed to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failed to monitor and track hospital readmissions.

~cross refer to CFR 482.21(a)(b)(1)(b)(2) (i)(b)(3) Standard: Qapi Data Collection and Analysis, Tag A0273

Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, and staff interviews, the hospital staff failed to accurately measure, analyze and track quality indicators related to restraints and seclusion; failed to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failed to monitor and track hospital readmissions.

The findings included:

Review of the "Organizational Quality Improvement Plan" approved August 2018 revealed the purpose was to " ... ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk. ... The primary goals of the Organizational Quality Improvement Plan are to continually and systematically plan, design, measure, access and improve performance or critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors. ...The status of identified problems and action plans is tracked to assure improvement or problem resolution. ... The scope of the organizational quality improvement program includes an overall assessment of the efficacy of quality improvement activities with a focus on continually improving care provided, and patient safety practices conducted, throughout the hospital. ... Collaborative and specific indicators of both processes and outcomes of care are designed, measured and assessed by all appropriate departments/services and disciplines of the hospital in an effort to improve patient safety and organizational performance. These indicators are objective, measurable, based on current knowledge and experience and are structured to produce statistically valid, data driven, performance measures of care provided. This mechanism also provides for evaluation of improvements and the stability of the improvement over time. ..."

1. Review of the restraint and seclusion aggregated data collection for April and May 2019 revealed a target of 90% compliance with this quality indicator, with a sample size of "All." Review of the data for April 2019 revealed there were zero (0) restraints or seclusion. Review of the data results for May 2019 revealed there were zero (0) restraints or seclusion.

Review of the restraint and seclusion log for April 2019 revealed a total of five (5) restraint episodes and one (1) seclusion had occurred (total of six (6) interventions). Review of the restraint and seclusion log for May 2019 revealed a total of two (2) restraints and one (1) seclusion had occurred (total of three (3) interventions).

Review of the restraint and seclusion log data failed to match the restraint and seclusion data collection that was presented on the quality improvement log.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the restraint and seclusion data was collected by nursing staff and submitted to the Director of Nursing (DON) or designee for review. Interview revealed the DON or designee aggregated and submitted the data to the Director of Quality. The Director of Quality formulated the data into a report that was presented to the Quality Committee and Governing Body for review and suggested actions. Interview revealed the restraint data collection was not done correctly for January through May 2019. Interview revealed the sample size of "all" referenced 100% of restraints or seclusion episodes conducted. Interview revealed nursing staff had instead reviewed thirty (30) random patient records and found no restraints or seclusion episodes. Interview revealed the data collection had been collected incorrectly since January 2019 and was inaccurate.

2. Review of a quality indicator regarding written response within seven days to a grievance revealed there were zero (0) letters sent for a total of six (6) grievances received in April 2019. Review revealed there were zero (0) letters sent for a total of six (6) grievances received in May 2019, showing 0% compliance.

Interview on 07/11/2019 at 14254 with Patient Advocate #4 revealed she was responsible for sending written response letters to complainants. The staff member stated she did not provide a written response to grievances when the patient was still in the facility. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. The staff member reported that no grievance letters had been sent to patients or family members since she started in January 2019.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the facility had been tracking the number of grievances and the number of written responses. Interview revealed the failure to provide a written response to a grievance was not compliant with facility policy. Interview revealed there had been no action plan identified to make improvements to the ongoing lack of compliance with providing a written response to a grievance.

3. Review of quality indicators revealed an indicator regarding monitoring of patient treatment plans for weekly updates. Review revealed a goal of 90% compliance was targeted. Review of April 2019 data revealed a 36% compliance rate for the week of 04/22/2019 through 04/26/2019. Review of the May 2019 data revealed 0% compliance for the week of 05/01/2019 through 05/03/2019; 0% compliance for the week of 05/06/2019 through 05/10/2019; 11% compliance for the week of 05/11/2019 through 05/17/2019; 0% compliance for the week of 05/20/2019 through 05/24/2019; and 50% compliance for the week of 05/27/2019 through 05/31/2019. Review of the June 2019 data revealed a 40% compliance for the week of 06/03/2019 through 06/07/2019; 24% compliance for the week of 06/10/2019 through 06/14/2019; 60% compliance for the week of 06/17/2019 through 06/21/2019; and 75% compliance for the week of 06/24/2019 through 06/28/2019.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the facility had been tracking the number of treatment plan weekly updates for compliance. Interview revealed the failure to provide a written treatment plan update was not consistent with facility policy. Interview revealed there was minimal improvement to the ongoing lack of compliance with ensuring weekly treatment plan updates occurred.

4. Review of hospital's discharge planning quality improvement data from January 2019 through May 2019 failed to reveal documentation of tracking and analysis of patients readmitted to the hospital within thirty (30) days of previous discharge.

Interview on 07/10/2019 at 1430 with the Director of Clinical Services revealed the hospital did not monitor data of patients that readmitted within 30 days of previous discharge for assessment and evaluation of the discharge planning process. Interview revealed there was no process in place to identify preventable readmissions in order to reassess the discharge planning process.

Based on observations, reviews of medical records, and interviews with staff and patients, the facility failed to ensure a correct diet was served to a patient with diet restrictions in 1 of 1 patients observed. (#5).

The findings included:

Observation on 07/10/2019 at 1200 of the cafeteria serving line revealed Patient #5 receiving her lunch consisting of only a ham and cheese sandwich. Observation revealed no food substitutions were given to Patient #5. Observation revealed no substitutions were offered to Patient #5. Observation revealed Patient #5 walked to the dietary table and began eating the ham and cheese from the bread. Observation revealed no dietary staff approached the table to speak to Patient #5 to offer any other food items.

Interview on 07/10/2019 at 1201 of Patient #5 revealed the patient had spoken to the Dietary manager this morning about the lunch menu of ham and cheese sandwich. Interview revealed the dietary manager informed Patient #5 of the lunch choices. Patient #5 informed the dietary manager of the bread restriction. Interview revealed the dietary manager would have something else prepared for lunch for Patient #5. Interview revealed Patient #5 was instructed by the surgeon to avoid eating bread due to the swelling of the bread in her stomach, possibly requiring surgery to remove it.

Review of closed medical record of Patient #5 revealed a 20 year old female admitted on 07/07/2019 for Major Depressive Disorder with a Suicide plan. Past medical history is significant for recent gastric bypass surgery requiring a special diet. Review of a Nutritional Assessment dated 07/08/2019 revealed "ASSESSMENT SUMMARY: Reasons for consult: BMI > 30, gastric bypass, poor po (oral) intake....Met with Pt (Patient) in consult room. Pt reported she is 7 weeks s/p (status post) gastric bypass. She reported she is on the soft foods part of the diet. Discussed high protein snacks....Discussed pt with dietary....Interventions: 1) High protein snacks tid (three times daily) r/t (related to) gastric bypass surgery..." Review of physician's diet order written on 07/07/2019 at 1157 revealed "Regular diet: No bulk forming foods, No crispy, crunchy, sticky."

Interview on 07/10/2019 at 1215 with RN #5 revealed the dietary staff member serving the food had been off work for 3 days and was unaware of the diet that the patient was ordered. Interview confirmed of dietary staff was not informed of the special diet ordered for the patient.

Interview on 07/10/2019 at 1555 with Dietary manager revealed the dietary staff member was not told this morning (07/10/2019) before preparing trays of the special diet. Interview confirmed the manager is responsible for informing the dietary staff of the special diets before trays are prepared in the morning. Interview revealed the lunch served of the ham and cheese sandwich did not meet the requirements of the ordered diet.

Interview on 07/11/2019 at 1140 with Director of Psychiatric Services revealed Patient #5 was on restrictive diet due to recent gastric bypass surgery. Interview revealed the patient should not ingest certain foods due to a very small stomach due to surgery. Interview revealed ingesting restricted foods, such as bread could be harmful to the patient. Interview revealed the diet served of ham and cheese sandwich did not meet the requirements of the ordered diet.

Based on policy review, medical record review, outside document review and staff interviews, the facility staff failed to make appropriate discharge arrangements for 1 of 3 sampled patients discharged to a community setting (#4).

The findings included:

Review of the facility's "Discharge and Transition Planning" policy revised 03/2019 revealed "... The Facility engages in ongoing transition planning at the start of services, throughout the course of treatment and at the time of discharge. This information will be facilitated by using the Discharge Planning Form. ... The form will be initiated at admission and indicate when and where a; discharge information is documented in the chart. It is very important that all steps of discharge are documented. Information that will be documented in the chart minimally includes: ... Information of living arrangements; Transportation information and needs; ... Aftercare plans to include provider and therapy appointments. ... The patient's discharge plan should include the following information: ... Next provider of care to include name, address, phone and appointment time; ... Medical appointments if needed; ... Type of place patient was discharged to ..."

Review of Patient #4's medical record revealed a 63 year-old female admitted on 05/16/2019 with schizoaffective disorder, bipolar type, auditory hallucinations, and self-harm intent. Review of the record from the transferring emergency department (ED) revealed the patient had nine previous admissions since the beginning of the year for psychosis, multi-substance abuse that included alcohol, tobacco, marijuana, and "severe" cocaine dependence, she was homeless, and supported herself through prostitution. Her medical history included coronary artery disease with vascular stenting, hypertension, and chronic obstructive pulmonary disease. Review of the provider note recommended admission to a (Named) Alcohol and Drug Abuse Treatment Center in the area. Review revealed Patient #4 was admitted to an acute care behavioral hospital with mental health and substance abuse treatment programs. Review of a psychosocial assessment dated 05/16/2019 at 1130 indicated the patient had two recent behavioral health hospitalizations which had resulted in her seeking help related to drug abuse, housing, and financial instability. Review of a "Screening Assessment" recorded by a therapist on 05/16/2019 at 1535 listed Patient 4's address as "homeless" and the patient stated, " I'm here to seek help for drugs and everything." Review revealed the patient reported she smoked cigarettes and $100 of cocaine daily but had refused to answer many of the screening questions. Review of Patient #4's "Multidisciplinary Treatment Plan" dated 05/16/2019 at 1630 revealed "Reason for Admission: Cocaine use disorder, severe - Pt was admitted due to AH (auditory hallucinations) commanding Pt to commit suicide ...Diagnoses: cocaine use disorder, severe and Bipolar I disorder, manic." Further review of the multidisciplinary treatment plan listed "Liabilities" as "Housing, drugs and finances," and "Pt will be linked to a long term substance program. Pt will be linked to a safe living environment." Review of notes recorded by weekend Therapist #4 on 05/19/2019 at 1355 revealed the therapist met with the patient to complete the intake information and the patient reported wanting "to go to a long term substance use rehab. Patient is motivated to continue sobriety once DC (discharged)." Review of notes recorded by primary Therapist #3 on 05/20/2019 at 1000 and 1100 revealed Patient #4 wanted to go to an unidentified homeless shelter in her local area and a Psychiatrist/Therapist appointment at a (Named) local area community health center had been scheduled for 06/03/2019 at 1430. Review revealed the patient repeatedly identified homelessness as a stressor and requested assistance with long term placement at discharge. Review revealed despite having children and an ex-spouse, the patient had no support system. Review of the Inpatient Discharge Plan signed by Therapist #3 (date and time not entered) and signed by the patient and a staff nurse on 05/22/2019 at 1045 revealed the patient left ambulatory to "Home." "Continued Treatment Needs" included AA/NA (alcoholics anonymous/narcotics anonymous)" and "intensive outpatient therapy." The mode of transportation, and name of the provider were not indicated on the plan. Review of a "Discharge Summary" dated 05/22/2019 and signed 05/27/2019 at 1000 by MD #1 revealed "Patient will be discharged to a shelter." (and) "Patient will be followed up by (blank) Community Center on June 3, 2019 at 1430." Review of the record revealed no name or address of the shelter where the patient was reportedly sent had been documented.

Review of outside public information revealed the community health center provider name provided by Therapist #3 during interview was a primary care physician. Review revealed the homeless shelter at the address identified by Therapist #3 during interview provided safe house services to victims of domestic abuse.

Request for interview with MD #1 revealed he was not available.

Telephone interview on 07/11/2019 at 1830 with Therapist #4 revealed she had worked with Patient #4 on the weekend of May 18-19, 2019 but was not involved in the discharge plan. Interview revealed Patient #4 had expressed a desire for treatment in a long term treatment facility and had mentioned specific facilities that were of interest to her. Therapist #4 stated "The last thing she wanted, was to go to a shelter" but did not know where Patient #4 had gone at discharge.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she had worked with Patient #4. Interview revealed Patient #4 was "homeless and she wanted to stay here until her disability check came, but she was clinically stable, and we couldn't keep her." Interview revealed Patient #4's ex-spouse had indicated he would provide transportation from the facility but that "fell through" and "I had to get an Uber for her." Therapist #3 stated she had documented the information in the record, but on review, she confirmed there was not documentation of the name of the shelter, its location, or the staff with whom she had communicated to secure discharge arrangements. Interview confirmed the name of the post discharge mental health provider was also not in the record.

Interview on 07/10/2019 at 1110 with Therapist #2 (Director of Clinical Services) revealed there should have documentation in the medical record to identify the name and address of the location of the shelter where Patient #4 was directed to at the time of discharge as well as the name of the shelter staff who had participated in the arrangements. Interview revealed the lack of documentation was not consistent with the facility policy.

Telephone interview on 07/11/2019 with shelter director at the facility identified by Therapist #3 revealed the shelter's mission was providing safe house services for female victims of domestic abuse and their children. Interview revealed Patient #4 had arrived unexpectedly at the facility on 05/22/2019, and the shelter had arranged for a night's hotel lodging for her. Interview revealed the shelter provided homeless services for women, "rarely," and only if space was available. Interview revealed communication between facilities, and approval of services by the shelter were required before an individual could receive homeless services from them. Interview revealed shelter staff had contacted the facility to obtain information about Patient #4's needs but had been unsuccessful.

NC00150557; NC00150595; NC00151265; NC00151779; NC00152889

Based on policy review, Medical Staff Rules and Regulations review, medical record reviews and staff interview, the facility failed to provide active treatment that was inclusive of complete cranial nerve examinations performed by a physician; Comprehensive Psychiatric Evaluations performed within 60 hours of admission; individualized comprehensive treatment plans that included medical needs; a substantiated psychiatric diagnosis that served as the primary focus for the treatment plan; specific measurable short-term and long-term patient centered goals based on individual patient problems; a focus of treatment based upon the patient's presenting symptoms; documentation of an evaluation of patients' individualized treatment plan progress toward goals; and coordination and documentation of post discharge housing, medication and appointment arrangements. The cumulative findings identified a failure to have a systemic system in place to provide active treatment to behavioral health patients.

The findings included:

1. The facility failed to ensure that a complete neurological screening examination was performed by a physician on admission for 11 of 12 sampled patients (#15, #16, #10, #2, #14, #4, #6, #3, #1, #17, #5).

~cross refer to 482.61(a)(5) Standard tag B0109

2. The facility failed to ensure a complete Comprehensive Psychiatric Evaluation was performed within 60 hours of admission for 2 of 12 sampled patients. (Patient #14 and #6).

~cross refer to 482.61(b)(1) Standard tag B0111

3. The facility staff failed to ensure an individualized comprehensive treatment plan that included medical needs for 2 of 12 sampled patients. (#16, #5).

~cross refer to 482.61(c)(1) Standard tag B0118

4. The facility failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan of 1 of 12 sampled patients (Patient #14).

~cross refer to 482.61(c)(1)(i) Standard tag B0120

5. The treatment team failed to delineate specific measurable short-term and long-term patient centered goals based on individual patient problems for 1 of 12 sample patients reviewed (#10). This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions.

~cross refer to 482.61(c)(1)(iii) Standard tag B0121

6. The facility failed to provide Master Treatment Plans (MTPs) for 9 of 12 sampled patients (#15, #16, #10, #2, #14, #4, #3, #6, #1) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. Specifically, MTPs failed to include a focus of treatment based on each patient's unique presenting symptoms.

~cross refer to 482.61(c)(1)(ii) Standard tag B0122

7. The facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 5 of 12 sampled patients (#10, #15, #2, #3, #1).

~cross refer to 482.61(d) Standard tag B0132

8. The facility staff failed to coordinate and document post discharge housing, medication and appointment arrangements for 3 of 3 patients that were discharged to a shelter (#4, #10, #1).

~cross refer to 482.61(e) Standard tag B0134

Based on review of the facility's policy, Medical Staff Rules and Regulations, medical record review and staff interview, the facility failed to ensure that a complete neurological screening examination was performed by a physician on admission for 11 of 12 sampled patients (#15, #16, #10, #2, #14, #4, #6, #3, #1, #17, #5).

The findings included:

Review of the facility's "Medical Consultation/History and Physical" policy revised August 2018 revealed "... Every patient admitted to the Hospital will receive a medical consultation/H&P (History and Physical) within 24 hours of admission. ... The history and physical will include, but is not limited to ... examination of cranial nerves 2 - 12 ..."

Review of Medical Staff Rules and Regulations last revised October 2018 revealed "... The attending Physician is responsible for the preparation of a complete, accurate, and legible medical record for each patient ... The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and to document the results accurately including, but not limited to the following: ... History and Physical examination, including past medical history, a review of psychological systems, and findings of assessment; evaluation of the Cranial Nerves. ... As permitted by State law and policy, the performance and reporting of a history and physical examination may be assigned by the attending Physician to another qualified Practitioner. This assignment, however, does not relieve the attending Physician from the ultimate responsibility for the report. A history and physical exam performed in part or all by a Nurse Practitioner must be reviewed and signed by the attending Physician. ..."

1. Review on 07/10/2019 of an open medical record for Patient #15 revealed a 66 year-old male admitted on 06/25/2019 with schizophrenia. Record review revealed an History and Physical (H&P) Examination had been conducted by a Nurse Practitioner on 06/26/2019 at 0830 and co-signed by a physician on the same day. Review of the H&P Examination revealed no documented evidence that this patient's "CN (cranial nerve) #II Able to read a printed page", "CN #V Able to clench teeth and feels touch on front of head", "CN VIII Able to hear finger rubs in both ears", "CN IX Gag reflex tested and present" had been evaluated. Review of the History and Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete.

2. Review on 07/10/2019 of an open medical record for Patient #16 revealed a 47 year-old female admitted on 07/04/2019 with major depressive disorder, severe and alcohol dependant, uncomplicated. Record review revealed an History and Physical Examination had been conducted by a Nurse Practitioner on 07/05/2019 at 1140 and co-signed by a physician on 07/08/2019 at 0900. Review of the History and Physical Examination revealed no documented evidence that this patient's "CN (cranial nerve) #II Able to read a printed page", "CN #V Able to clench teeth and feels touch on front of head", "CN VIII Able to hear finger rubs in both ears", "CN IX Gag reflex tested and present" had been evaluated. Review of the History and Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete.

3. Review on 07/09/2019 of an closed medical record for Patient #10 revealed a 52 year-old female admitted on 04/23/2019 with schizophrenia, bipolar type. Record review revealed an History and Physical Examination had been conducted by a Nurse Practitioner on 04/24/2019 (not timed) and co-signed by a physician on 04/26/2019. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.



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4. Review on 07/10/2019 of a closed medical record for Patient #2 revealed a 35 year-old male admitted on 04/02/2019 with schizophrenia and paranoia. Record review revealed an History and Psychiatric Examination had been conducted by a Nurse Practitioner on 04/03/2019 at 7830 and co-signed by a physician on 04/04/2019 at 1100. Review of the H&P Examination revealed no documented evidence that this patient's "CN (cranial nerve) V (five) Able to clench teeth and feels touch on front of head", "CN VI (six) Able to move eyes to either side", "CN VII (seven) able to lift both eyebrows", "CN VIII Able to hear finger rubs in both ears", "CN IX Gag reflex tested and present" had been evaluated. Review of the History and Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam. Review revealed the Cranial Nerve assessment was incomplete and not performed by a physician.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete.

5. Review on 07/10/2019 of an open medical record for Patient #14 revealed a 35 year-old female admitted on 07/05/2019 with Depression. Record review revealed an History and Physical Examination had been conducted by a Nurse Practitioner on 07/06/2019 at 1000 and co-signed by a physician on 07/10/2019 at 1408. Review revealed the Cranial Nerve assessment was not performed by a physician.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was not completed by a physician as required.



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6. Review on 07/10/2019 of a closed medical record revealed Patient #4 was a 63 year-old female admitted on 05/16/2019 with Schizoaffective disorder, bipolar type, auditory hallucinations, and self-harm intent. Record review revealed the History and Physical (H&P) Examination had been conducted by a Physician Assistant on 05/17/2019 at 0530 and co-signed by a Physician on 05/20/2019 at 0900. Review of the H&P Examination revealed no documented evidence that the patient's "CN (cranial nerve) #II Able to read a printed page", or "CN #IX Gag reflex tested and present" had been evaluated. Review of the History and Physical Examination revealed testing of the indicated Cranial Nerves had been left blank on the neurological exam form.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete.



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7. Review on 07/10/2019 of an open medical record for Patient #6 revealed a 26 year-old female admitted on 07/08/2019 with Bipolar I disorder and Depression. Record review revealed a History and Physical (H&P) Examination had been conducted by a Physician Assistant on 07/09/2019 at 0725 and co-signed by a physician on 07/09/2019 at 0835. Review of the H&P Examination revealed no documented evidence that this patient's "CN (cranial nerve) V Able to clench teeth and feels touch on front of head", "CN IX Gag reflex tested and present" had been evaluated. Review of the History and Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete and was not completed by a physician as required.

8. Review on 07/09/2019 of a closed medical record for Patient #3 revealed a 22 year-old female admitted on 04/15/2019 with suicide ideation. Record review revealed a History and Physical (H&P) Examination had been conducted by a Nurse Practitioner on 04/16/2019 at 0700 and co-signed by a physician on 04/16/2019 at 1000. Review of the H&P Examination revealed no documented evidence that this patient's "CN (cranial nerve) III Able to move eyes upward and outward", and CN IX Gag reflex tested and present" had been evaluated. Review of the History & Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete and was not completed by a physician as required.



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9. Review on 07/10/2019 of a closed medical record for Patient #1 revealed a 42 year old female admitted on 04/08/2019 for suicide attempt after ingesting Ambien (sleeping agents), Wellbutrin (antidepressant), and Cymbalta (antidepressant and antianxiety). Record review revealed a History and Physical examination had been conducted by a Nurse Practitioner on 04/09/2019 at 0700 and co-signed by a physician on 04/09/2019 at 0800. Review of the History and Physical Examination revealed no documented evidence that this patient's CN #III Able to move eyes upward and outward, CN #VII Able to lift both eyebrows, and CN X (Able to lift palate when saying 'Ah' " has been evaluated. Review of the History and Physical Examination revealed the Cranial Nerves indicated had been left blank on the neurological exam.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete.

10. Review on 07/10/2019 of an open medical record for Patient #17 revealed a 38 year old male admitted on 07/05/2019 for Alcohol use, excessive. Record review of a History and Physical examination had been conducted by a Nurse Practitioner on 07/06/2019 at 1000 and cosigned by a physician on 07/09/2019 at 0900. Review revealed the cranial nerve assessment was not completed by a physician.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete and was not completed by a physician as required.

11. Review on 07/11/2019 of an open medical record for Patient #5 revealed a 20 year old female admitted on 07/07/2019 for Major Depressive disorder with a suicide plan. Record review of a History and Physical examination had been conducted by a Nurse Practitioner and co-signed by a physician. Review revealed the cranial nerve assessment was not completed by a physician.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the physician was not aware of the requirement that a physician was required to perform the cranial nerve examination. Interview confirmed that the cranial nerve examination was incomplete and was not completed by a physician as required.

Based on Medical Staff Rules and Regulations review, medical record reviews and staff interviews, the facility failed to ensure a complete Comprehensive Psychiatric Evaluation was performed within 60 hours of admission for 2 of 12 sampled patients. (Patient #14 and #6)

The findings included:

Review of Medical Staff Rules and Regulations last revised October 2018 revealed "... The attending Physician is responsible for the preparation of a complete, accurate, and legible medical record for each patient ... The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and to document the results accurately including, but not limited to the following: ... Comprehensive Psychiatric Evaluation ... Comprehensive Psychiatric Evaluation (will include): a. Date of service; b. Place of service; c. Identifying information; d. Chief complaint; e. History of present illness; f. Past psychiatric history; g. Past medical history; h. Allergies; i. Current medication; j. Substance use history; k. Social history; l. Family history; m. Mental status exam and Patient assessment; n, Primary diagnosis; o. Treatment plan. ..." Review of the Medical Staff Rules and Regulations failed to identify a time frame requirement for completion of the Comprehensive Psychiatric Evaluation.

1. Review on 07/10/2019 of an open medical record for Patient #14 revealed a 35 year-old female admitted on 07/05/2019 with Depression. Record review revealed a Comprehensive Psychiatric Evaluation had been conducted on 07/06/2019 at 1100. Review revealed the mental status and physical assessment portion of the Comprehensive Psychiatric Evaluation of the patient was not completed. Review revealed the assessment portions were left blank.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a Comprehensive Psychiatric Evaluation needed to be completed with in 24 hours of admission. Interview revealed all portions of the evaluation needed to be completed. Interview confirmed the Comprehensive Psychiatric Evaluation was incomplete and not completed in the required timeframe.



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2. Review on 07/10/2019 of an open medical record for Patient #6 revealed a 26 year-old female admitted on 07/08/2019 with Bipolar I depression and suicidal ideation. Record review revealed a Comprehensive Psychiatric Evaluation had been conducted on 07/09/2019 at 1141. Review revealed the mental status and physical assessment portion of the Comprehensive Psychiatric Evaluation of the patient was not completed. Review revealed the assessment portions were left blank.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed a Comprehensive Psychiatric Evaluation needed to be completed within 24 hours of admission. Interview revealed all portions of the evaluation needed to be completed. Interview confirmed the Comprehensive Evaluation was incomplete and not completed in the required timeframe.

Based on review of the Medical Staff Rules and Regulations, policy review, medical record review and staff interview, facility staff failed to ensure an individualized comprehensive treatment plan that included medical needs for 2 of 12 sampled patients. (#16, #5)

The findings included:

Review of Medical Staff Rules and Regulations revised 03/2019 revealed "... 9. Clinical Services. A. The clinical program at the Hospital emphasizes a multidisciplinary team approach to patient care. The focus of the program is on healing and restoration. The program is designed to meet the special needs of the patients with unresolved acute/chronic, catastrophic, and/or multi-system disease processes. Cases are managed on an individual basis through a strong relationship among all members of the treatment team including the Providers and the attending Physician. ..."

Review of the facility's "Treatment Planning - Philosophy and Purpose" policy revised 01/2019 revealed " ... The assurance that every patient admitted will have an individual plan specific to his/her assessed needs and that the patient's attending physician will direct and participate in all phases of the treatment planning process. ... 5. The plan of care, treatment and services includes, but may not be limited to: a. Defined problems and the evidence of those problems (symptoms per patient report or staff observation). b. Measurable goals based on the assessment needs, strengths and the patient's limitations. ... c. The frequency of care, treatment and services. d. A description of facilitating factors and possible barriers to care, treatment and services or reaching goals. ..."
1. Review on 07/10/2019 of an open medical record for Patient #16 revealed a 47 year-old female admitted on 07/04/2019 with major depressive disorder, severe and alcohol dependent, uncomplicated. Record review revealed a History and Physical Examination had been conducted by a Nurse Practitioner on 07/05/2019 at 1140 and co-signed by a psychiatrist on 07/08/2019 at 0900. Review of the History and Physical Examination revealed a past medical history of diabetes. Review listed medications as "continue home medication with sliding scale insulin. AC (before meals blood sugar check) pending. Will monitor." Review of the patient's active treatment plan dated 07/04/2019 revealed Problem #1 identified as "Depression." Review revealed another Problem #1 listed as "Pain." Review of the treatment plan revealed "Co-Morbid Medical Conditions" listed as Hypertension and GERD. Review of the treatment plan failed to include the patient's diabetes listed as an identified problem with goals or interventions.
Review revealed a treatment plan evaluation of progress towards goals was reviewed on 07/09/2019. Review revealed no new problem areas were identified or added on 07/09/2019.

Interview on 07/11/2019 at 1030 with RN #5 revealed Patient #16 was a diabetic that had problems with controlling her blood sugars while she was a patient at the facility. Interview revealed the patient was an insulin dependant diabetic on sliding scale insulin. Interview revealed the Master Treatment Plan failed to include her medical problem of diabetes and it should have been included.

An interview on 07/11/2019 at 1110 with the facility's Director of Psychiatric Services revealed Patient #16 was an insulin dependant diabetic patient who required blood sugar monitoring and insulin adjustments. Interview revealed "She should have had a problem listed on her treatment plan for diabetes and interventions included. She has been hypoglycemic, requiring sliding scale insulin." Interview confirmed there was no treatment plan problem or interventions included for the patient's identified medical problem of diabetes.



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2. Review on 07/10/2019 of an open medical record for Patient #5 revealed a 20 year old female admitted on 07/07/2019 for major depressive disorder with a suicide plan. Review of a History and Physical examination revealed the patient had medical diagnosis that included Morbid Obesity and was status post bariatric surgery. Review of the active treatment plan dated 07/09/2019 at 1429 revealed "Co-Morbid Medical Conditions--Actively Treated Medical Problems: None." Review of a treatment planning problem sheet updated on 07/09/2019 failed to reveal any documentation of recent gastric bariatric surgery with goals or interventions. Review revealed no problems were added related to the recent bariatric surgery.

Interview on 07/10/2019 at 1345 with RN #5 revealed Patient #5 was admitted after the bariatric surgery and required a special diet. Interview revealed the Master Treatment Plan failed to include her medical diagnosis of recent bariatric surgery and it should have been included.

Interview on 07/11/2019 at 1055 with Director of Psychiatric Services revealed Patient #5 had received bariatric surgery prior to admission. Interview revealed the patient's recent bariatric surgery should have been on the treatment plan. Interview confirmed there were no treatment plan problem or interventions included for the patient's identified recent bariatric surgery and restrictions.

Based on medical record review and staff interview the facility failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan of 1 of 12 sampled patients. (Patient #14)

The findings included:

Review on 07/10/2019 of an open medical record for Patient #14 revealed a 35 year-old female admitted on 07/05/2019 with Depression. Record review revealed a Multidisciplinary Treatment Plan was completed on 07/06/2019. Review revealed the Psychiatric and Medical diagnoses portions were left blank on the Multidisciplinary Treatment Plan.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed there was no documented diagnosis on the Multidisciplinary Treatment Plan for Patient #14. Interview confirmed the information needed to be documented in order to assure accurate and appropriate treatment was initiated.

Based on policy review, medical record review and staff interview, the treatment team failed to delineate specific measurable short-term and long-term patient centered goals based on individual patient problems for 1 of 12 sample patients reviewed (#10). This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions.

The findings included:

Review of the facility's "Treatment Planning - Philosophy and Purpose" policy revised 01/2019 revealed " ... The assurance that every patient admitted will have an individual plan specific to his/her assessed needs and that the patient's attending physician will direct and participate in all phases of the treatment planning process. ... 4. Care planning includes the development of measurable treatment goals. Care, treatment and services will be planned, which include patient objectives, staff interventions, services and treatments necessary to assist the patient in meeting the identified care plan goals. ...5. The plan of care, treatment and services includes, but may not be limited to: ... b. Measurable goals based on the assessment needs, strengths and the patient's limitations. ... "

Review of Patient #10's closed medical record revealed a 52 year-old female admitted on 04/23/2019 with schizoaffective disorder, bipolar type. Review of the record revealed the patient had chronic pain syndrome, hypertension and gastroesophageal reflux disease. Review of the "Treatment Planning Problem Sheet Pain" dated as initiated on 04/23/2019 listed Problem #2 as "Back Pain." Review of the "Long Term Goals (In Patient's Words) was blank with no identified goals recorded. Review of the "Patient Long Term Goals" and "Target Date" was blank with no goal or target date identified. Review of the "Patient Short Term Goals (Objectives) revealed a pre-printed section with three printed goals with boxes to check if the goals applied. Review revealed no boxes were checked and the goals were blank. Review further revealed "target date" for each short term goal was blank with no date identified. Review of the Discharge Plan documented by Therapist #3 revealed the patient left ambulatory via Uber transportation to go to a shelter on 05/02/2019 at 1330.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed long-term and short-term goals are established in treatment team for each problem identified, along with target dates for completion. Interview revealed the goals are individualized and measurable for each problem and are reevaluated to determine progress weekly. The therapist reviewed the Problem #2 listed as "Back Pain" and stated that nursing manages that goal.

Interview on 07/1/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed long-term goals, short-term goals and target dates for each problem area should be defined and recorded as a basis for measuring success toward the goal. Review of Patient #10's goals revealed they were left blank and not defined according to policy. . Interview revealed RN #5 was unable to provide a rationale as to "why" the short and long term goals were left blank no expected completion date.

Based on review of the Medical Staff Rules and Regulations, policy review, medical record review and staff interview, the facility failed to provide Master Treatment Plans (MTPs) for 9 of 12 sampled patients (#15, #16, #10, #2, #14, #4, #3, #6, #1) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. Specifically, MTPs failed to include a focus of treatment based on each patient's unique presenting symptoms.

The findings included:

Review of Medical Staff Rules and Regulations revised 03/2019 revealed "... 9. Clinical Services. A. The clinical program at the Hospital emphasizes a multidisciplinary team approach to patient care. The focus of the program is on healing and restoration. The program is designed to meet the special needs of the patients with unresolved acute/chronic, catastrophic, and/or multi-system disease processes. Cases are managed on an individual basis through a strong relationship among all members of the treatment team including the Providers and the attending Physician. ..."

Review of the facility's "Treatment Planning - Philosophy and Purpose" policy revised 01/2019 revealed " ... The assurance that every patient admitted will have an individual plan specific to his/her assessed needs and that the patient's attending physician will direct and participate in all phases of the treatment planning process. ... 5. The plan of care, treatment and services includes, but may not be limited to: a. Defined problems and the evidence of those problems (symptoms per patient report or staff observation). b. Measurable goals based on the assessment needs, strengths and the patient's limitations. ... c. The frequency of care, treatment and services. d. A description of facilitating factors and possible barriers to care, treatment and services or reaching goals. ..."

Review of Master Treatment Plans for 9 of 12 sampled patients revealed interventions for pain management were not individualized. Review revealed modalities were not individualized or stated as measurable behavioral patient outcomes based on unique information from clinical assessments. Several pain goals for different patients were identical or similarly worded.

1. Review of Patient #15's open medical record revealed a 66 year-old male admitted on 06/25/2019 with schizophrenia and unspecified psychosis. Review of the record revealed the patient had chronic hip pain. Review of the "Treatment Planning Problem Sheet Pain" (not dated) listed Problem (left blank) as "blank." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: hot/cold packs; stretching. Nursing will assess patient (every shift) for decrease impact of pain, (comfort level), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (daily) to educate patient re: (symptoms), course of illness, and assess medication effects, including side effects.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #15's goals revealed they were pre-printed and not individualized according to policy.

2. Review on 07/10/2019 of an open medical record for Patient #16 revealed a 47 year-old female admitted on 07/04/2019 with major depressive disorder, severe and alcohol dependent, uncomplicated. Review of the "Treatment Planning Problem Sheet Pain" dated 07/05/2019 listed Problem #1 with a long-term goal "to be pain free." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: hot/cold packs; stretching. Nursing will assess patient (every shift) for decrease impact of pain, (meds regimen), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (daily) to educate patient re: (disease process), course of illness, and assess medication effects, including side effects. Therapy staff will provide non-pharmacological interventions for pain such as: Guided Imagery/Relaxation; Mindful Exercises; Positive Distraction."

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #15's goals revealed they were pre-printed and not individualized according to policy.

3. Review of Patient #10's closed medical record revealed a 52 year-old female admitted on 04/23/2019 with schizoaffective disorder, bipolar type. Review of the record revealed the patient had chronic pain syndrome, hypertension and gastroesophageal reflux disease. Review of the "Treatment Planning Problem Sheet Pain" dated as initiated on 04/23/2019 listed Problem #2 as "Back Pain." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: scheduled sleep techniques; hot/cold packs; low impact exercise; stretching. Nursing will assess patient (every shift) for decrease impact of pain. Medical Provider will meet with patient (q [every] day) to educate patient re: (monitor pain medication) course of illness, and assess medication effects, including side effects. Therapy staff will provide non-pharmacological interventions for pain such as: Guided Imagery/Relaxation; PMR (progressive muscle relaxation); Positive Distraction." Review of the Discharge Plan documented by Therapist #3 revealed the patient left ambulatory via Uber transportation to go to a shelter on 05/02/2019 at 1330.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #10's goals revealed they were pre-printed and not individualized according to policy.



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4. Review on 07/10/2019 of a closed medical record for Patient #2 revealed a 35 year-old male admitted on 04/02/2019 with schizophrenia and paranoia. Review of the "Multidisciplinary Treatment Plan" dated 04/03/2019 revealed the plan included three (3) identified problems with long term and short term goals with target dates for completion recorded. Review revealed "Pain" as an identified problem. Review of the patient's CPE (Comprehensive Psychiatric Evaluation) and history and physical did not identify pain as a current problem. Review of the record revealed the patient did not have any issues regarding pain control.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

5. Review on 07/10/2019 of an open medical record for Patient #14 revealed a 35 year-old female admitted on 07/05/2019 with Depression. Review of the "Treatment Planning Problem Sheet Pain" dated 07/05/19 listed Problem Number 5 as " Problem Statement Related to Pain: Generalized Pain." Review revealed "Long Term Goal (In Patient's Words)" left blank. Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: (left blank). Nursing will assess patient (every shift) for decrease impact of pain, (comfort level), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (daily) to educate patient re: (symptoms), course of illness, and assess medication effects, including side effects.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.



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6. Review of Patient #4's closed medical record revealed a 63 year-old female admitted on 05/16/2019 with Schizoaffective disorder, bipolar type, auditory hallucinations, and self-harm intent. Review of the record revealed the patient had chronic back pain. Review of the "Treatment Planning Problem Sheet Pain" dated 05/16/2019 listed "Problem Statement Related to Pain: I have back pain." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: low impact exercise; stretching. Nursing will assess patient (every shift) for decrease impact of pain, (back pain), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (daily) to educate patient re: (back pain), course of illness, and assess medication effects, including side effects. Therapy staff will provide non-pharmacological interventions for pain such as: (Guided Imagery/Relaxation) (PMR, progressive muscle relaxation) (Positive Distraction).

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #15's goals revealed they were pre-printed and not individualized according to policy.



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7. Review of Patient #3's closed medical record revealed a 22 year-old female admitted on 04/15/2019 with suicidal ideation. Review of the medical record revealed the patient had a diagnosis of Major Depressive Disorder and Autism Spectrum Disorder. Review of the "Treatment Planning Problem Sheet Pain" start date 04/15/2019 listed Problem (left blank) as "blank." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medications as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: hot/cold packs. Nursing will assess patient (every shift) for decrease impact of pain, (left blank), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (left blank) to educate patient re: (left blank) course of illness, and assess medication effects, including side effects. Therapy staff will provide non-pharmacological interventions for pain such as: Guided imagery/Relaxation, PMR and Positive Distraction." Review of the patient's CPE (Comprehensive Psychiatric Evaluation) and history and physical did not identify pain as a current problem. Review of the record revealed the patient did not have any issues regarding pain control.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #3's goals revealed they were pre-printed and not individualized according to policy.

8. Review of Patient #6's open medical record revealed a 26 year-old female admitted with Bipolar I disorder, Depression and suicidal ideation. Review of the "Treatment Planning Problem Sheet Pain" start date 07/09/2019 listed Problem as "General Pain, Headache." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: (left blank). Nursing will assess patient every shift for decrease impact of pain level, behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient daily to educate patient re: pain course of illness, and assess medication effects, including side effects." Review of the patient's CPE (Comprehensive Psychiatric Evaluation) and history and physical did not identify pain as a current problem. Review of the record revealed the patient did not have any issues regarding pain control.

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Interview on 07/11/2019 at 1030 with RN #5 revealed she was the nursing manager. Interview revealed treatment modalities should be individualized and measurable. Review of Patient #6's goals revealed they were pre-printed and not individualized according to policy.



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9. Review on 07/10/2019 of a closed medical record for Patient #1 revealed a 42 year-old female admitted on 07/04/2019 with major depressive disorder with suicide attempt after ingesting multiple pills. Review of the "Treatment Planning Problem Sheet Pain" dated 04/08/2019 listed Problem #1 with a long-term goal "Remain pain free." Review of the "Multidisciplinary Interventions" revealed a pre-printed section with six printed goals with boxes to check if the goals applied. Review revealed the following boxes checked: "Medical provider will evaluate patient's pain complaints and will consider non-opiate medication as a first choice. Nurse will provide medication for pain management. Nursing staff will provide non-pharmacological interventions for pain such as: hot/cold packs; stretching. Nursing will assess patient (every shift) for decrease impact of pain, (symptoms), behavior, effectiveness of medication and/or impact of pain. Medical Provider will meet with patient (daily) to educate patient re: (pain symptoms), course of illness, and assess medication effects, including side effects. Therapy staff will provide non-pharmacological interventions for pain such as: Guided Imagery/Relaxation; Mindful Exercises; Positive Distraction."

Interview with Therapist #1 on 07/10/2019 at 1415 revealed she participates in the process of completing treatment plans for patients. Interview revealed the treatment plans are created based on the individual patient problems and diagnoses. Interview revealed the treatment team meets daily to discuss patient progress. Interview confirmed accurate information needed to be documented in order to assure accurate and appropriate treatment is initiated. Interview revealed medical issues identified are the responsibility of the nursing and medical members of the treatment team.

Based on the facility's policy, medical record review and staff interview, the facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 5 of 12 sampled patients (#10, #15, #2, #3, #1).

The findings included:

Review of the facility's "Treatment Planning - Philosophy and Purpose" policy revised 03/2019 revealed "... A Treatment Plan review/update that evaluates patient response to goals and interventions will be revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services. If there is no appreciable change in the patient's condition, goals and objectives will be reevaluated and revised on a weekly basis at a minimum for inpatient ..."

1. Review on 07/09/2019 of a closed medical record for Patient #10 revealed a 52 year-old female admitted on 04/23/2019 with schizophrenia disorder, bipolar type. Review of the "Multidisciplinary Treatment Plan" dated 04/24/2019 revealed the plan included two identified problems. Review revealed interventions were identified for each of the problem areas that included the type of intervention, frequency and responsible individual. Review of Problem #1 revealed a long-term goal of "The patient will verbalize the desire to live" with a target date of 04/30/2019. Review of the record revealed a treatment plan review was conducted on 05/01/2019 (eight days after admission). Review of the progress toward Problem #1 dated 05/01/2019 revealed "Patient has not made any progress toward her goals." Review of the "Changes/revisions to Treatment Plan" recorded "No changes. Patient will continue the treatment plan."

Interview on 07/10/2019 at 0845 with Therapist #3 revealed an evaluation of the treatment plan intervention and progress toward goals was completed every seven days and more frequently as needed. The staff member reviewed Patient #10's medical record and stated "She was not making progress. The patient was angry. She was focused on housing. She is her frequently. We switch out (therapists) frequently with her. She came to group two days and never came back. She would not come to group." Interview revealed the interventions had not resulted in progress toward goals and no changes were made to the treatment plan. The therapist reported the facility policy was not followed.

2. Review on 07/10/2019 of an open medical record for Patient #15 revealed a 66 year-old male admitted on 06/25/2019 with schizophrenia and unspecified psychosis. Review of the "Multidisciplinary Treatment Plan" dated 06/25/2019 revealed the plan included one identified problem. Review revealed interventions were identified for the problem area that included the type of intervention, frequency and responsible individual. Review of Problem #1 revealed a long-term goal of "The patient will report less psychotic symptoms" with a target date of 07/01/2019. Review of the record revealed a treatment plan review was conducted on 07/01/2019 (six days after admission). Review of the progress toward Problem #1 dated 07/01/2019 revealed "Patient making no progress towards decrease in psychotic symptoms" with "Changes" listed as "continue to check in with thought process." Review revealed "Patient making no progress towards goal of identifying supportive person in crisis" with "changes" listed as "continue to educate on social support. Review revealed "Patient making no progress towards identifying coping skills" with "Changes" listed as "continue to educate pt (patient) on the importance of knowing coping skills." Review of the record revealed a treatment plan review was conducted on 07/03/2019 (two days after the prior review). Review of the progress toward Problem #1 dated 07/03/2019 revealed "Patient making no progress towards goal of decreasing psychotic symptoms" with "Changes" listed as "continue to check with thought process and psychosis." Review revealed "Patient making no progress towards verbalizing coping skills for psychosis" with "Changes" listed as "continue to educate on coping skills." Review of the record revealed a treatment plan review was conducted on 07/09/2019 (six days after the prior review). Review of the progress toward Problem #1 dated 07/08/2019 revealed "Patient making no progress towards goal of reporting decrease in psychotic symptoms" with "Changes" listed as "continue to check in pt monitoring psychosis thought process." Review revealed "Patient making no progress towards goal of verbalizing coping skills for psychosis" with "Changes" listed as "attempt to educate pt on coping skills to utilize." Review of the treatment plan revealed a "Pain Problem was added the the patient treatment plan (not dated) with a long-term goal to report increased comfort. Review revealed no evaluation of progress was documented on the treatment plan reviews conducted on 07/01/2019; 07/03/2019; or 07/09/2019.

Interview on 07/11/2019 at 1210 with Therapist #1 revealed an evaluation of the treatment plan intervention and progress toward goals was completed every seven days and more frequently as needed. The staff member reviewed Patient #15's active treatment plan and revealed the patient was making limited to no progress towards goals. The staff member stated "Adjustments in the modalities should be made when limited or no progress is made towards goals." Interview confirmed no changes were made to the treatment plan when reviewed and it was identified that no or limited progress was made. The therapist reported the facility policy was not followed.



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3. Review on 07/10/2019 of a closed medical record for Patient #2 revealed a 35 year-old male admitted on 04/02/2019 with schizophrenia and paranoia. Review of the "Multidisciplinary Treatment Plan" dated 04/03/2019 revealed the plan included three (3) identified problems with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for each of the problem areas that included the type of intervention, frequency and responsible individual. Review revealed an additional problem was identified on 04/09/2019 related to physical aggression. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals. Review revealed the patient discharged home on 04/20/2019 (18 days after admission).

Interview on 07/11/2019 at 1140 with Therapist #2 revealed the treatment team meets daily and an evaluation of the treatment plans and progress are discussed and updated as needed.. Therapist #2 reviewed the medical record of Patient #2 and the treatment plan did not reflect progress toward the goals.




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4. Review on 07/09/2019 of a closed medical record for Patient #3 revealed a 22 year-old female admitted on 04/15/2019 with suicidal ideation, anxiety and Autism Spectrum Disorder. Review of the "Multidisciplinary Treatment Plan" dated 04/15/2019 revealed the plan included one identified problem. Review revealed interventions were identified for the problem area that included the type of intervention, frequency and responsible individual. Review of Problem #1 revealed a long-term goal of "Patient will report decreased depression and anxiety as evidenced by daily report of 3 or below out of 10 over the next seven days." and "Patient will report zero suicidal thoughts over the next seven days." with a target date of 04/22/2019. Review of the record revealed a treatment plan review was conducted on 04/22/2019 (seven days after admission). Review of the progress toward Problem #1 dated 04/22/2019 revealed no documented progress towards patient's goals. Review of the "Changes/revisions to Treatment Plan" recorded "No changes have been made." Record review revealed Patient #3 discharged home on 04/24/2019.

Interview on 07/11/2019 at 1140 with Therapist #2 revealed the treatment team meets daily and an evaluation of the treatment plans and progress are discussed and updated as needed.. Therapist #2 reviewed the medical record of Patient #3 and the treatment plan did not reflect progress toward the goals.


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5. Medical reccord review on 07/10/2019 revealed a 42 year old female (Patient #1) admitted on 04/08/2019 for Major Depressive Disorder after ingesting multiple medications in a suicide attempt. Review of the Multidisciplinary Treatment Plan dated 04/09/2019 at 0317 revealed "Discharge Criteria--Patient will verbalize desire to live, develop a safety plan, commit to follow-up aftercare appointments. Discharge Plan: Patient will discharge home and be referred to PHP (Partial Hospitalization Program--Outpatient program). Review revealed no documentation of a Multidisciplinary Treatment Plan Review. Review revealed Patient #1 was discharged on 04/16/2019 (eight days after admission) at 1055 to home.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed an evaluation of the treatment plan intervention and progress toward goals was completed every seven days and more frequently as needed. The therapist reported the facility policy was not followed.

Interview on 07/10/2019 at 1100 with RN #5 revealed the all patients should have a Multidisciplinary Treatment Plan Review.

Based on policy review, medical record review and staff interview, the facility staff failed to coordinate and document post discharge housing, medication and appointment arrangements for 3 of 3 patients that were discharged to a shelter (#4, #10, #1).

The findings included:

Review of the facility's "Discharge and Transition Planning" policy revised 03/2019 revealed "... The Facility engages in ongoing transition planning at the start of services, throughout the course of treatment and at the time of discharge. This information will be facilitated by using the Discharge Planning Form. ... The form will be initiated at admission and indicate when and where a. discharge information is documented in the chart. It is very important that all steps of discharge are documented. Information that will be documented in the chart minimally includes: ... Information of living arrangements; Transportation information and needs; ... Aftercare plans to include provider and therapy appointments. ... The patient's discharge plan should include the following information: ... Next provider of care to include name, address, phone and appointment time; ... Medical appointments if needed; ... Type of place patient was discharged to ..."

1. Review of Patient #4's medical record revealed a 63 year-old female admitted on 05/16/2019 with schizoaffective disorder, bipolar type, auditory hallucinations, and self-harm intent. Review of the record from the transferring emergency department (ED) revealed the patient had nine previous admissions since the beginning of the year for psychosis, multi-substance abuse that included alcohol, tobacco, marijuana, and "severe" cocaine dependence, she was homeless, and supported herself through prostitution. Her medical history included coronary artery disease with vascular stenting, hypertension, and chronic obstructive pulmonary disease. Review of a "Screening Assessment" recorded by a therapist on 05/16/2019 at 1535 listed her address as "homeless" and revealed " I'm here to seek help for drugs and everything." The patient reported she smoked cigarettes and $100 of cocaine daily but had refused to answer many of the screening questions. Review of the psychosocial assessment indicated the patient had two recent behavioral health hospitalizations which had resulted in her seeking help related to drug abuse, housing, and financial instability. Review of the patient's "Multidisciplinary Treatment Plan" dated 05/16/2019 at 1630 revealed "Reason for Admission: Cocaine use disorder, severe - Pt was admitted due to AH (auditory hallucinations) commanding Pt to commit suicide ...Diagnoses: cocaine use disorder, severe and Bipolar I disorder, manic." Review of the treatment plan listed "Liabilities" as "Housing, drugs and finances." Review of the discharge plan revealed "Pt will be linked to a long term substance program. Pt will be linked to a safe living environment." Review of notes recorded by Therapist #4 on 05/19/2019 at 1355 revealed the therapist met with the patient to complete the intake information and the patient reported wanting "to go to a long term substance use rehab. Patient is motivated to continue sobriety once DC (discharged)." Review of notes recorded by Therapist #3 on 05/20/2019 at 1000 and 1100 revealed Patient #4 wanted to go to an unidentified homeless shelter in her local area and a Psychiatrist/Therapist appointment at a (Named) local area community health center had been scheduled for 06/03/2019 at 1430. Review revealed the patient repeatedly identified homelessness as a stressor and requested assistance with long term placement at discharge. Review revealed despite having two children and an ex-spouse, the patient had no support system. Review of the Inpatient Discharge Plan signed by Therapist #3 (date and time not entered) and signed by the patient and a staff nurse on 05/22/2019 at 1045 revealed the patient left ambulatory to "Home." "Continued Treatment Needs" included AA/NA (alcoholics anonymous/narcotics anonymous)" and "intensive outpatient therapy." The mode of transportation, and name of the provider were not indicated on the plan. Review of the physician "Discharge Summary" dated 05/22/2019 and signed 05/27/2019 at 1000 revealed "Patient will be discharged to a shelter." (and) "Patient will be followed up by (blank) Community Center on June 3, 2019 at 1430." Review of the record revealed discharge prescriptions were electronically sent to a retail pharmacy chain. No name of a mental health provider Patient #4 was scheduled to see was indicated on the discharge paperwork and no name, address or contact number for the shelter where the patient was reportedly sent, had been documented in the record.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she had worked with Patient #4. Interview revealed Patient #4 was "homeless and she wanted to stay here until her disability check came, but she was clinically stable, and we couldn't keep her." Interview revealed Patient #4 "was not attending groups. I talked with her about attending groups. She did not want to come. The next step was how to safely discharge her." Interview revealed Patient #4's ex-spouse had indicated he would provide transportation from the facility but that "fell through" and "I had to get an Uber for her." Therapist #3 stated she had documented the information in the record, but on review, confirmed there was not documentation of the name of the shelter, its location, or the staff with whom she had communicated. Interview confirmed the name of the post discharge mental health provider was also not in the record. During interview, Therapist #3 offered to provide the name of the therapist at the community health center, and name and address of the homeless shelter where Patient #4 was transported. Review of the information provided by Therapist #3 on a publicly available website revealed the named physician did not provide mental health services and was a primary care physician, and the facility identified as a homeless shelter did not provide homeless care services.

Telephone interview on 07/11/2019 at 1830 with Therapist #4 revealed she had worked with Patient #4 over the weekend but was not involved in the discharge plan. Interview revealed Patient #4 had expressed a desire for treatment in a long term treatment facility and had mentioned specific facilities that were of interest to her. Therapist #4 stated "The last thing she wanted, was to go to a shelter" but did not know where Patient #4 had gone at discharge.

Interview on 07/10/2019 at 1110 with Therapist #2 (Director of Clinical Services) revealed there should have documentation in the medical record to identify the name and address of the location of the shelter where Patient #4 was directed to at the time of discharge as well as the name of the shelter staff who had participated in the arrangements. Interview revealed the lack of documentation was not consistent with the facility policy.



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2. Review of Patient #10's medical record revealed a 52 year-old female admitted on 04/23/2019 with schizoaffective disorder, bipolar type. Review of the record revealed the patient had chronic pain syndrome, hypertension and gastroesophageal reflux disease. Review of a "Screening Assessment" recorded by a therapist on 04/23/2019 at 1836 revealed "The patient reported she became 'severely depressed' since her homes' pipes burst. Pt (patient) endorsed feeling 'worthless' and having suicidal thoughts. ..." Review of the psychosocial assessment recorded the patient was having "panic attacks" associated with her living situation. Review revealed the patient's expected treatment included findings a "safe dwelling place." Review of the patient's "Multidisciplinary Treatment Plan" dated 04/23/2019 at 0030 revealed "Reason for Admission: Major Depressive Disorder Severe w/ (with) psychosis. Patient reports increased depression since the pipes burst in the group home she was living in, with thoughts of cutting self or overdosing with medications." Review of the treatment plan listed "Liabilities" as "History of trauma, housing insecurities." Review of the plan revealed the discharge plan included "Therapist will facilitate a safe place for therapy and medication management." Review of notes recorded by Therapist #3 on 04/26/2019 at 1843 revealed the therapist met with the patient to complete the intake information and the patient reported wanting assisted living or independent living housing. Review revealed the patient repeatedly identified her housing as a stressor and requested assistance with placement after discharge. Review revealed the patient had no support system and lived alone. Review the Therapist #3 progress notes recorded on 04/30/2019 at 1257 recorded the therapist contacted a group home and there was not a bed available until Friday (05/04/2019). Review of the therapy note dated 04/30/2019 at 1258 recorded the therapist contacted a home for placement, but there were no available beds. Review of a therapy note recorded on 04/30/2019 at 1311 revealed Therapist #3 contacted another home care that had availability, but the facility needed an FL2 form. Documentation revealed the therapist was gathering the information. Review of notes recorded by the patient from a "Mental Wellness: Coping" group meeting revealed the patient requested information regarding "Independent Housing Management." Review of notes recorded by the patient on 05/01/2019 revealed she wanted information from the therapist on independent housing regarding a clean and safe environment. Review of notes documented by the patient on 05/02/2019 recorded the patient continued to request information regarding housing after discharge. Review of the Discharge Plan documented by Therapist #3 revealed the patient left ambulatory via Uber transportation to go to a shelter on 05/02/2019 at 1330. Review revealed no name or address of the facility where the patient was sent.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she was the therapist that worked with Patient #10. Interview revealed the patient came to the hospital from an assisted living home after the home had a flood. Interview revealed the patient needed housing arrangements upon discharge and she was anxious about her housing. The therapist stated the patient had provided her with a list of places that she was interested in going to after discharge and she called the places on 04/30/2019. Interview revealed the patient was in a wheelchair and she was unable to go to a place with stairs. Interview revealed the home that could take her needed an FL2 form and the patient was unwilling to go there. The therapist reported her last resort was to send the patient to a shelter. Interview revealed she sent the patient to a shelter and failed to document the name or address of the shelter. Interview revealed the therapist was unable to remember the name of the shelter where the patient was sent. Interview revealed the patient was not satisfied with going to a shelter, but she was out of resources.

Interview on 07/10/2019 at 1110 with Therapist #2 (Director of Clinical Services) revealed there should have documentation in the medical record to identify the name and address of the location of the shelter when Patient #10 was referred to at the time of discharge. Interview revealed the lack of documentation was not consistent with the facility policy.



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3. Review of medical record on 07/09/2019 of Patient #1 revealed a 42 year old female admitted on 04/08/2019 for Major Depressive Mood Disorder after ingesting multiple medications in a suicide attempt. Review revealed husband choked patient to an unconscious state before admission. Review of the NP #1's discharge summary dated 04/26/2019 at 0900 revealed "Patient reports recently patient has been having conflict with husband and patient's mother, all living at the same house. The patient reports that she has to leave the house as patient is not getting along with her husband and also having some difficulties commuicating with the patient's mother.....The patient was able to attend group and participate in treatment team, worked together to find best aftercare plan....Disposition: For patient to go to a women's shelter..." Review of a Clinical Discharge Plan dated 04/16/2019 at 1040 revealed "Discharged Ambulatory. Discharge to: Home." Review of the Multidisciplinary Treatment Plan dated 04/09/2019 at 0317 revealed "Discharge Criteria--Patient will verbalize desire to live, develop a safety plan, commit to follow-up aftercare appointments." Review revealed no documented conversations between staff and patient regarding shelter choices or after care. Review revealed Patient #1 was discharged to home on 04/16/2019 at 1055.

Interview with the involved discharge nurse was not obtained due to nurse was not available.

Interview on 07/09/2019 at 1400 with NP #1 revealed Patient #1 did not want to return home and was requesting shelter placement.

Interview on 07/11/2019 at 1055 with Director of Psychiatric Services revealed remembering patient, patient did not want to return home. Interview confirmed the patient was sent to a shelter instead of home. Interview confirmed a mistake in discharge documentation, adding the patient did not return home and was discharged to a shelter instead of home.

NC00150557; NC00150595; NC00151265; NC00151779; NC00152889