HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure that the patient plan of care is implemented.

Findings include:

1. The medical record of Patient #8 indicated an admission date of 4/3/18. The Attending Assessment note, dated 4/4/18, indicated that the patient has a history of a herniated disc and chronic back pain managed by a pain management doctor. The Attending Assessment note, dated 4/5/18, indicated in the Progress Note section of the assessment " ... Agrees to PT [physical therapy] consult; and in the plan section of the assessment "Physical Therapy consult ordered for back pain."

a. There was no evidence that an order for physical therapy was written. The patient was discharged on 4/10/18.

b. There was no evidence that the patient received physical therapy or that he/she refused physical therapy by the time of discharge.

c. The above was confirmed by Staff #23.

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure patients receive care in a safe setting.
Findings include:

1. During a tour on 5/21/18 in the presence of Staff #41, throughout the patient sleeping rooms, non-tamper proof screws were found on the following:

a. Door hardware, including strike plates.

b. Screws holding wardrobes to the walls.

2. During a review of a spread sheet identifying and providing a timeline for corrective action related to "Patient Safety Items," tamper proof screws were not identified as risk to be corrected.

3. During interview, Staff #41 confirmed that maintenance had not gone room by room to ensure all screws are tamper-proof.

A. Based on a review of the medical record of one patient who was placed in seclusion continuously for more than 24 hours, review of hospital policy and procedure, and interview with administrative staff, it was determined that the use of seclusion was not implemented in accordance with hospital policy and procedure.

Findings include:

Reference: Policy and procedure titled "Seclusion" stated:
"POLICY
* Each patient has the right to be free from seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Seclusion may not be used unless the use of seclusion is necessary to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. .....
* Seclusion is used only as temporary therapeutic interventions [sic] when all other less restrictive measures have failed and when the patient displays violent and/or self-destructive behaviors. Least restrictive measures include de-escalation techniques, medications, and therapeutic communications. These are utilized in efforts to avoid seclusion and to lessen the time in seclusion if seclusion proves to be necessary.
PURPOSE:
* To assure a hospital wide approach to the safe and appropriate use of seclusion. Leadership promotes an environment that supports only limited and justified clinical use of seclusion with the goal of prevention, reduction, and elimination of seclusion.
.....
INDICATIONS FOR USE OF SECLUSION:
.....
All patients in seclusion are on a one to one level of observation.
.....
LIP ASSESSMENT AND ORDER
A patient shall be placed in seclusion on the written order of the LIP (Licensed Independent Practitioner). A written order must be obtained for each seclusion event. "PRN" (as needed) orders for seclusion are not acceptable.
* When there is extreme imminent danger and all other de-escalation options have failed, the Senior Nurse or designee should contact the Attending LIP or OCP (on Call Physician) immediately, and may authorize seclusion or the patient on an emergency basis to receiving the LIP's order. The Senior Nurse or designee is responsible for assessing the patient and his/her circumstances, and shall document in the patient's EMR the observations which led to the decision to seclude the patient. The LIP must conduct a face-to-face assessment within one (1) hour. An electronic order by the LIP in charge shall be required no more than one hour after the patient has been secluded.
* Seclusion orders must not exceed four (4) hours for adults; ..... All orders must be time limited i.e. (that is) 4 hours (9 am - 1 pm); ..... and define criteria to be used to discontinue seclusion.
* After the original time limited LIP order expires, the LIP must visually assess the patient and enter a new order in the EMR for an additional four (4) hours for adults; ..... . In addition, the LIP must also document his/her assessment and the justification for seclusion of the patient in the progress note. The reordering of seclusion must be for continued immediate dangerousness and the immediate protection of self and others.
.....
ORDERING CONTINUED SECLUSION FOR EXCEPTIONAL PATIENTS WHO MIGHT BE CALM AND COOPERATIVE
The initial use of seclusion can only take place in an emergency when imminent harm is evident. If the patient is no longer threatening, is calm and cooperative, can work with staff to prevent a recurrence of the dangerousness that initiated the seclusion, then in general, the patient's order should not be renewed.
However, some patients may continue to represent imminent harm even if they are calm and cooperative if their destructive behavior and violence toward others is severe, ongoing, unpredictable, and/or repetitive and associated with their psychiatric symptoms that have not yet responded to clinical interventions. The behavior of these patients in the previous 4 hours may not be indicative of their risk to self and others in cases where patients have:
* Severely assaulted another person causing sufficient injury that medical intervention is required.
* Repeatedly assaulted, provoked and/or threatened individuals or destroyed property or is otherwise a danger to themselves or others.
Then the assessment of dangerousness and criteria for renewal of the seclusion order must also consider additional aspects of the examination that may include:
1. The patient's insight into the danger their behavior represented and their risk of injuring self or others in the future.
2. An assessment of their desire to control the dangerous behavior.
3. The patient's ability to identify controllable triggers/cues, warn of pending loss of control, utilize strategies instead of violence to get needs met.
4. Adherence to the treatment of their psychiatric condition.
5. The presence of psychiatric symptoms can directly impact risk to self or others such as active and aggressive suicidal ideation, homicidal ideation, command hallucinations to hurt self or others, paranoid delusions that identify staff and patients as immediate threats, or are sexually promiscuous.
The findings that justify an order for seclusion despite recent observations of calm, cooperative behavior and the indications for discontinuation must be clearly documented on the LIP Seclusion and Restraint Order form.

ORDERING CONTINUED SECLUSION WHEN PATIENTS ARE SLEEPING
Some patients may be asleep at the time of the order renewal and so cannot be fully evaluated. Many of these patients can be released from seclusion as sleeping may be evidence of improved overall calm and progress toward treatment goals. However, some patients may continue to represent imminent harm even if they are sleeping if their dangerousness toward self and others has been severe, ongoing, unpredictable, and/or repetitive and associated with their psychiatric symptoms that have not yet responded to clinical interventions. Because sleeping may be essential for the patient's treatment, waking a patient may be contraindicated.
If a patient is asleep at the time a renewal evaluation is to be completed, the order can be renewed. Documentation of the ongoing dangerousness and indications for discontinuation as noted above for patients who are calm and cooperative is required. A face to face LIP evaluation must take place and the seclusion order confirmed as soon after the patient awakes as possible (no more than 60 minutes). While recognizing the therapeutic value of sleep, no patient shall be permitted to sleep through more than two LIP evaluations.
.....
PATIENTS' RIGHTS, DIGNITY AND WELL BEING MUST BE PROTECTED DURING SECLUSION
NURSING ASSESSMENTS/MONITORS
* A nursing staff member will monitor patients continuously and document patient's behavior q 15 minutes in the EMR.
.....
* A registered nurse shall assess the patient every hour, visually observe patient, review patient behaviors, response to medication and consider whether seclusion may be discontinued.
* Care of the patient in seclusion will also include the following checks every 15 minutes or as appropriate to the current clinical condition aimed at achieving safety and comfort:
.....
7. Physical and psychological status and comfort
8. Readiness for discontinuation of seclusion
* All interventions are to be documented on the flow sheet in both the check-off boxes and narrative comment sections in the EMR.
DISCONTINUATION OF SECLUSION
The discontinuation of seclusion must be at the earliest possible time.
* Assessment of early discontinuation of seclusion:
- With each monitoring, the patient is reassessed to determine the continuation of seclusion is necessary.
- When patients meet criteria specified in the LIP order, seclusion may be discontinued.
....."

1. Review of the medical record of Patient #13 revealed:

a. An RN note dated 10/24/17 at 10:45 stated: "pt (patient) stated to MHT (Mental Health Technician) "Put me in restraints, everybody knows I'm a homicidal maniac," prior to lunging at staff member in QA (Quiet Area). Pt secluded at this time for pt and staff safety, order obtained for Ativan 2 mg (milligrams) IM (intramuscular), very unpredictable at his time, will maintain in QA at this time and provide support as needed, [sic]." The patient was documented to have remained in seclusion until 11:10 AM on 10/25/17. An initial order for seclusion was documented as having been entered in the EMR at 10:45 AM on 10/24/17.

(i) Staff #42 and Staff #43 stated during interview that the orders for seclusion were entered by registered nurses, not licensed independent practitioners (LIPs). The orders are then cosigned by the LIP. Facility policy requires the LIP to enter the orders.

(ii) The order, time limited to 4 hours, did not define the criteria to be used to discontinue seclusion.

b. The next order for seclusion, time limited to 4 hours, was dated 10/24/17 at 2:45 PM. The face to face evaluation of the patient by the LIP was not done until 3:24 PM - 39 minutes after the order had expired. The 2:45 PM order was not documented as having been signed by the LIP until 3:25 PM - 40 minutes after the 2:45 PM order had expired.

(i) The patient did not receive a face to face evaluation by an LIP every 4 hours as required by policy.

(ii) The patient was in seclusion for 40 minutes without a written order signed by an LIP.

c. The next order for seclusion, time limited to 4 hours, was dated 10/24/17 at 6:45 PM. The face to face evaluation of the patient was documented to have occurred at 6:40 PM and the order signed by the LIP at 4:11 AM on 10/25/17.

(i) The physician did not authenticate an order entered by an RN until 9 hours and 26 minutes after the expiration of the previous order. The patient was in seclusion for that 4 hour period of time without an order.

d. The next order for seclusion, time limited to 4 hours, was dated 10/24/17 at 10:45 PM. There was no attempt at a face to face evaluation of the patient.

(i) This order was not authenticated by an LIP. The patient was in seclusion without a written order.

(ii) The patient did not receive a face to face evaluation by an LIP every 4 hours as required by policy.

e. The next order for seclusion, time limited to 4 hours, was dated 10/25/17 at 2:45 AM. The "Seclusion Progress Note - Face to Face Assessment" section of the medical record, dated 10/25/17 at 3:00 PM, stated: "..... pt asleep and does not want to communicate" The order was not authenticated by the LIP until 4:11 AM on 10/25/17.

(i) The patient was in seclusion without a written order for an hour and 26 minutes.

f. The next order for seclusion, time limited to 4 hours, was dated 10/25/17 at 6:45 AM. The "Seclusion Progress Note - Face to Face Assessment" section of the medical record, dated 10/25/17 at 7:53 AM stated: "..... pt asleep but at ti mes (times) [sic] restless. ....." The order was documented as having been authenticated at 7:55 AM on 10/25/17 - an hour and 10 minutes after the expiration of the previous order.

(i) There was no documentation that the LIP awakened the patient who had been documented as having been asleep for two consecutive face to face evaluations, as per policy.

(ii) The patient was in seclusion without a written order for an hour and 10 minutes.

g. The "Pt verbalizing insight & appears calm. RN notified - 'Yes'" section of the seclusion flowsheet included entries made by MHTs indicating that the patient was calm and verbalizing insight on 10/24/17 at 12:29 PM, 12:50 PM, 1:00 PM, 1:10 PM, 3:40 PM, 9:10 PM, 9:20 PM, 11:30 PM, 11:50 PM, and 11:59 PM. Similar entries were made on 10/25/17 at 12:20 AM, 1:40 AM, 1:50 AM, 2:00 AM, 2:20 AM, 4:10 AM, 4:40 AM, and 5:00 AM. There was no documentation that an RN reassessed the patient for release from seclusion at any of these time after being informed by the MHTs.

B. Based on review of facility policy and procedure, review of the medical records of 2 of 2 patients who were physically restrained with a physical hold, and interview with administrative staff, it was determined that use of physical restraint is not implemented in accordance with hospital policy and procedure.

Findings include:

Reference: The section of policy and procedure titled "Restraints" stated: ".....
.....
Physical Holds are the use of hospital instructed, approved manual holds that prevent free choice of bodily movements in an emergent situation in order to prevent aggressive and/or destructive behavior towards self or others. Any physical hold is a restraint. "Physically holding a patient during forced psychotropic medication procedure is considered a restraint." Physical holds should not exceed 10 minutes.
.....
LIP (Licensed Independent Practitioner) ASSESSMENT AND ORDER
A patient shall be placed in restraints on the electronic order of the LIP. An order must be obtained for each restraint event. .....
.....
- All orders must be time limited and define criteria to be used to discontinue restraints.
....."

1. Review of the medical records of Patient #5 and Patient #27 indicated that both patients were physically restrained using a physical hold. Neither of the written orders were time limited.

2. Staff #42 and Staff #43 agreed with the findings.

Based on document review and interviews, it was determined that the facility failed to ensure that the process of testing the patient for pregnancy is implemented in accordance with physician orders and its policies.

Findings include:

Reference #1: Facility policy "LIP [licensed independent practitioner] Orders" states,
" ... Pregnancy Medications will be used with caution in pregnant patients, especially in the first trimester. We test all patients of child bearing age upon admission."

Reference #2: Facility policy "Laboratory Studies-Operational Protocols" states, " ... Urine Collection Pregnancy Tests: To be done on all women up to and through age 50, unless canceled by the LIP ... -- Al urine pregnancy testing should be performed on the first morning specimen, although in rare cases specimens can be collected at any time. If that is the case, the Clinical Services department must be notified - Make sure the specimen is labeled and then document the time and date collected on the requisition and sign. Urine specimens for pregnancy should be a fresh specimen, therefore any specimen received in the laboratory older than 24 hours will be discarded and be required to be reordered and recollected.""

1. Review of 4 patients medical records who are of childbearing age revealed the following:

a. Patient #25, age 26, admitted on 5/16/17, had a physician order upon admission for a pregnancy test. Upon review of the medical record on 5/22/18, there was no evidence that a pregnancy test was done. There was no evidence that the test was canceled by the LIP.

b. Patient #28, age 37, admitted on 5/14/18 had a physician order upon admission for a pregnancy test. Upon review of the medical record on 5/22/18, there was no evidence that the test was performed. There was no evidence that the test was canceled by the LIP.

c. The above was confirmed by Staff #23 and Staff #43.

d. Patient #21 had a urine for pregnancy ordered on 5/21/18 and collected on 5/21/18 at 1715 (5:15 PM) as per the requisition slip. The urine specimen was not a first morning specimen.

e. Patient #22 had an order for urine pregnancy on 4/24/18. The requisition slip lacked the signature, the date and the time the specimen was collected. The test was performed on 4/25/18 without knowing if the specimen was past the 24 hours of collection.

Based on review of 3 medical records and staff interview, it was determined that the facility failed to ensure that physicians orders are followed for one patient (Patient #7).

Findings include:

1. In Medical Record #7, a physician order dated 3/25/18 stated, "Librium Alcohol Detox Orders Chlordiazepoxide [Librium] Dose Dependent on CIWA (Clinical Institute Withdrawal Assessment for Alcohol) Score ...
For CIWA 5-10 give Chlordiazepoxide PO [by mouth] 25 mg [milligram]
For CIWA 11-20 give Chlordiazepoxide PO 50 mg ...
CIWA is done every 4 hours while aware."

a. The eMAR (electronic medication administration record) Documentation sheet revealed the following:

(i) On 3/26/18 at 1:14 AM, Librium 50 mg. was administered for a score of 10 instead of Librium 25 mg.

(ii) On 3/26/18 at 5:30 AM, Librium was not administered due to nausea. There was no evidence that a CIWA assessment was performed.

(iii) On 3/26/18 at 21:19 (9:19 PM), Librium 25 mg. was administered, however, there was no evidence that a CIWA assessment was performed.

2. The above was confirmed by Staff #23.

Based on document review and staff interview, it was determined that the facility failed to ensure that entries in the medical record are dated, timed, and authenticated.

Findings include:

Reference #1: Facility policy "Medical Staff Documentation" states, " ... Medical Records 1. A medical record shall be created for each inpatient upon admission. Documentation shall be done in the electronic medical record and on preprinted approved forms only ... 3. History and Physical (H&P)-("Medical Evaluation") - a patient must have a completed H&P relevant to the care episode ... 4. Content ... b. iv. The ordering and review of all labs tests and clinical data as available in the available medical record will be completed as appropriate ..."

1. On 5/23/18, review of 2 of 2 medical records (#22 and #26) of patients who had a pregnancy test ordered and completed revealed that the results were available in an approved form (lab slip). There was no evidence that the test results were reviewed/acknowledged by a LIP on paper or in the eMAR (electronic medication administration record).

2. Review of Patient #1's EKG (electrocardiogram) results, dated 2/2/2017, revealed a physician initials, however, it lacked the date and time of when it was authenticated.

3. The above was confirmed with Staff #23. Interview with Staff #23 and Staff #43 revealed that pregnancy testing is performed in the on-site lab (laboratory) area and not sent out to an outside laboratory, therefore, the results are not a part of the electronic medical record.

Based on observation, staff interview and document review, it was determined that the facility failed to ensure the implementation of policies and procedures that address the storage of emergency medications for the treatment of malignant hyperthermia.

Findings include:

Reference: Facility policy titled Emergency Medication and Medical Equipment states," Contents of the ECT Code Cart: Drawer #2: Dantrium 20mg vials..."

1. On 5/22/18 at 11:00 AM in the ECT (Electroconvulsive Therapy) unit, Dantrium (Dantrolene) vials and other supplies needed to treat malignant hyperthermia were stored in a locked cabinet inside the locked medication room, and not immediately available in an emergency.

a. This was confirmed by Staff #11 and Staff #36, and Staff #38.

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure the implementation of policies and procedures addressing medication administration.

Findings include:

Reference: Facility policy titled "Medication Administration" states,"Medications may not be removed from the patient's cassette until the time of administration."

1. On 5/22/18 at 11:40 AM, on the Older Adult Unit, there were drawers labeled with patient names and room numbers in the WOW (Workstation on Wheels) that contained patient medication. The patient cassettes that had been delivered by the pharmacy were located in the unit's Medication Room.

a. Staff #37 stated that the nurses transfer medications from the patient cassettes to the WOWs in order to administer medications to patients who had difficulty ambulating to the nurse's station.

b. Staff #38 stated that the pharmacy staff does not maintain the WOWs.

2. Staff #38 confirmed that this practice did not follow facility policy.

Based on document review and staff interview, it was determined that the facility failed to ensure that at least two independent physicians on the Utilization Review (UR) committee are regularly attending the UR committee meetings.

Findings include:

Reference: Facility "Utilization Management Plan Policy" states, " ... The Utilization Review Committee is a standing committee of Carrier Clinic (Medical Staff) comprised of the following staff members: Medical Director of Carrier Clinic, Deputy Chief Medical Officer, Chief of Addiction Psychiatry, Chief of Adult Psychiatry ... The UR Committee will convene quarterly ..."

1. Upon review of the quarterly Utilization Review Committee (URC) meeting minutes for the past 5 quarters beginning 2017, the following was revealed:

a. On 5/12/17 and 7/20/17, only one physician instead of two attended the URC meetings.

b. On 10/19/18, no physician attended the URC meeting.

2. This was confirmed by Staff #11.

Based on observation, it was determined that the facility failed to ensure the safety of the patient.

Finding include:

The facility failed to ensure compliance with the 2012 edition of the National Fire Protection Association's Life Safety Code. (Cross refer to Tag A 0710).

Based on observation, it was determined that the facility failed to ensure compliance with the 2012 edition of the National Fire Protections Association's Life Safety Code.

Findings include:

1. On 5/22/18 at 12:15 PM, in the presence of Staff # 41, the door to the Chapel lacked a self closing device creating an area open to the corridor without smoke detection.

2. On 5/21/18 at 1:45 PM, in the presence of Staff #41, the Storage Room off the Main Gym was equipped with pendent sprinkler heads connected to an automatic sprinkler system but lacked the ceiling required to collect heat.

3. On 5/21/18 at 11:25 AM, in the presence of Staff #41, the door to the Laundry Room was held open with a magnet not connected the the fire alarm system preventing the door from automatically closing upon fire or sprinkler alarm activations.

Based on observation and staff interview, it was determined the facility failed to ensure that the overall hospital environment is maintained in an acceptable level of safety and quality.

Findings include:

1. During a tour of the Adult Psychiatric Unit (APU), on 5/21/18, the following was observed:

a. In Patient Room #713, the shower walls had a build up of an orange substance.

b. In Patient Room #730, the bathroom walls had a build up of a black substance.

c. Outside of Patient Room #730, the corridor wall had an area of wallpaper that was torn and frayed, creating an uncleanable surface area.

2. The above were confirmed by Staff #10 and Staff #26.

3. During a tour of the Older Adult Unit (OAU), on 5/21/18, the following was observed:

a. In Patient Room #806, the shower walls contained two (2) holes in the wall and a thick buildup of orange/brown corrosion on the under sides of two (2) shower grab bars.

b. In Patient Room #807, the shower contained four (4) small holes in the wall and a thick buildup of orange/brown corrosion on the under side of the shower grab bar.

c. In Patient Room #808, the shower contained four (4) small holes in the wall.

4. The above were confirmed by Staff #10 and Staff #17.




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5. A tour of the West Wing of the Adolescent Unit revealed:

a. Lounge: There were cereal pieces, candy pieces, paper scraps, and grit between the cushions of a chair.

b. Room #912: The storage area had water damage above and behind the kick moulding, including chipping and peeling paint.

c. Adolescent Pantry:

(i) The refrigerator contained three (3) slices of Rockland Bakery individually wrapped white bread slices. Two (2) of the slices expired on 5/19/18 and one slice was undated.

(ii) The bottom of the refrigerator, beneath and inside of the plastic drawers, had tacky stains, raised stains, grit, plastic scraps, sprinkles, and other food particles.

(iii) Atop the refrigerator was a coat of dust. Beneath and behind the refrigerator was dust, dried spillage, grit, and food particles.

d. Nurses Station:

(i) A wooden cabinet containing personal care items had chads, heavy dust, pens, candy pieces, grit, shoe laces, plastic wrappers and other refuse beneath and behind it.

(ii) A wooden cabinet containing restraints had heavy dust, paper clips, pens, chads, grit, and other refuse beneath and behind it.

(iii) A Shred-It box had heavy dust, grit, pens, paper scraps, and other refuse beneath and behind it.

6. A tour of the North Wing Adolescent Unit revealed:

a. Room #917: A black mold-like substance was on the grout around the base of the tiled walls.

b. Lounge:

(i) Three (3) chairs had tears in the seat covers.

(ii) There was chipping paint on the wall and paint chips on the floor behind and beneath one couch.

(iii) Between the cushions of the chairs was sticky substances, cereal pieces, candy pieces, dust, grit, wrappers, and other refuse.

7. South Wing Adolescent Unit:

a. Room #905 (Quiet Area bathroom): There was broken/worn away grout in areas of the shower floor tiles.

b. Nurses Station: There was grit, dust, cereal pieces, paper scraps, and other refuse beneath and behind the refrigerator.

c. Medication Room: The edge of a wooden shelf was unpainted/unfinished making it an uncleanable surface.

d. Lounge:

(i) A metal floor cabinet had tacky spillage, dried white stains, cellophane, cereal pieces, grit, dust, a dried orange peel, food particles, pencils, a dead insect, and hair behind and beneath it. The wall behind the cabinet had raised stains and food particles on it.

(ii) There were three (3) stained ceiling tiles.

(iii) Between the couch cushions was dried food, grit, hair, melted candy pieces, paper scraps, and sticky substances.

(iv) A tan metal cabinet was stuck to the floor with spillage. There was dried orange peel, grit, dust candy pieces, and stains beneath it.

(v) There were stains and raised stains, as well as chipping paint, on the walls and floor behind the couches.

8. Older Adult Unit (OAU):

a. Laundry Room: There were 2 stained ceiling tiles.

b. Women's Bathroom:

(i) The grout around the shower dial was broken/missing.

(ii) The caulking at the outer edge of the shower floor surface was cracked/missing.

(iii) The kick moulding around the shower wall was separated from the wall.

(iv) A particle board cabinet in front of the shower was crumbling at the bottom from water damage. There was a black mold-like substance on the crumbling particle board. The paint was peeling from the cabinet and two live beetle-like insects were observed.

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure the implementation of policies and procedures addressing the security of medical waste according to OSHA guidelines.

Findings include:

Reference #1: Facility policy titled Hazardous Materials and Waste Management Plan states, "The purpose of the HAZMAT Plan is to: Establish written criteria consistent with all applicable laws and regulations, including EPA, OSHA..."

Reference #2: https: OSHA (Occupational Safety and Health Standards) www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051, states," Moving containers of contaminated sharps from the area of use, the containers shall be...Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping..."

1. On 5/22/18 at 11:30 AM, the sharps container stored inside the Emergency Response Bag, located on the Older Adult Unit, did not have the lid on. The lid was found inside the bag. Used needles and syringes were found inside the open container.

2. This finding was confirmed by Staff #11 and Staff #38.

A. Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure a hand hygiene in-service program is implemented after the identification of a drop in hand hygiene compliance.

Finding include:

Reference: Facility Summary of the 2017 Infection Prevention Risks & Goals as of December 31, 2017 indicate, "Goal 1: " ...Hand Hygiene: Our goal was to maintain compliance at 90% or increase to greater than 91%. YTD [Year to Date] 87.5 [%] This goal was not met especially decreasing in the last six months of 2017 ...monitoring will continue."

1. Review of the Infection Control Committee minutes indicate the following:

a. Date: 11/20/17- Bi-Monthly Summary: "Hand washing has gone down ..."

b. Date: 1/15/18 - Miscellaneous: " ...We're going down in this [hand hygiene] ...It was 85% in the last quarter. Dr. (name of) said that's low, historically we're in the 90s-that's a problem."

2. Review of the Health Associated Infection Prevention Plan 2018, dated 1/15/18, indicated the following:

a. "The following infection prevention goals have been established to be monitored during 2018: ...6. To maintain or exceed a goal of 90% hand hygiene compliance ..."

b. "System wide hand hygiene program that complies with current CDC guideline ..."

c. "Evaluation of Interventional Effectiveness: This program and goals are evaluated at least annually (or whenever risks scientifically change) and are revised as necessary."

3. Upon interview Staff #44, the Staff Educator stated he/she was aware of the drop in hand hygiene compliance. Furthermore, he/she confirmed that additional in-services to staff have not been implemented. The only hand hygiene in-services that staff receive are the annual mandatory in-services.

4. Upon interview, Staff #3 stated that the system wide hand hygiene program includes monitoring of hand washing and confirmed that the only hand hygiene in-services that staff receive are the annual mandatory in-services for hand hygiene. He/She stated that there has been no additional in-services since the drop of hand hygiene compliance.



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B. Based on observation and interview, it was determined that the facility failed to ensure implementation of hand hygiene in accordance with nationally recognized guidelines.

Findings include:

Reference: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states,
"Recommendations:
1. Indications for Handwashing and Hand antisepsis ...
C. Decontaminate hands before having direct contact with patients ...
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ..."

1. During a tour of the facility on 5/21/18, the following was determined:

a. Staff #15 entered the Medication Room with gloves donned, drew up medications, exited the room and then proceeded to provide patient care. Staff #15 failed to doff gloves or perform hand hygiene prior to performing patient care.

2. The above was confirmed by Staff #10.

Based on review of facility policy and procedure, review of the medical record of one patient who expired at the facility, and interview with administrative staff, it was determined that the facility failed to notify the OPO (Organ Procurement Organization) of a patient's death in the hospital.

Findings include:

Reference: Facility policy and procedure titled "Organ and Tissue Donor Protocol" stated: "... B. The Hospital shall contact NJ Sharing Network within one (1) hour of the death of an individual while at Carrier Clinic or when death is imminent in order to facilitate the preliminary determination of suitability for organ, tissue or eye donation.
[Bullet] The LIP/On-Call Physician or nursing supervisor shall call the NJ Sharing Network at __ [phone number] and refer the patient and perform a telephone screening to determine the medical suitability of the patient for organ/tissue/eye donation ...
E. The LIP/On-Call Physician and/or Nursing Supervisor shall notify the Office of the Medical Director or designee (AOC) of any death promptly after the event and state when the OPO was notified ...
J. The Potential Organ/Tissue Donor Referral Form #953 should be completed as documentation of communication with the Network. The form becomes a permanent part of the medical record.
K. If a call is made to the Network and it is determined by The Network that the patient is not a suitable candidate for organ donation, documentation must be made in the chart.

1. Review of the medical record of Patient #1 revealed the following entries:

a. The LIP (Licensed Independent Practitioner)/Discharge Summary dated 2/3/17 stated "... Course of Treatment:
On arrival at 745 am in hospital this writer noted that code blue was called and cpr was in progress until she was pronounced dead by MICU at 818 am I was present as witness. I called pt's daughter __ [name of daughter] to inform her mother's passing. Call was also made to medical examiner ..."

(i) There was no documentation in the medical record that the LIP/On-Call Physician or nursing supervisor called the NJ Sharing Network within 1 hour of the patient's death or when death is imminent in order to facilitate the preliminary determination of suitability for organ, tissue or eye donation.

(ii) There was not a Potential Organ/Tissue Referral Form in the patient's medical record.

2. Staff #2 and Staff #23 agreed with the findings.

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

I. Ensure that the psychiatric diagnosis was provided in the Psychiatric Evaluations for five (5) of twelve (12) active sample patients (Patients 1, 6, 7, 8 and 9). This failure interfered with timely planning and focused treatment to the patients (Refer to B110).

II. Plan and develop coordinated and comprehensive interdisciplinary Master Treatment Plans (MTPs) for 12 of 12 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). Instead, treatment plans were not based on collaboration regarding target problems and treatment goals. Specifically, (1) Many interventions were not directly related to the identified problems (Refer to B122), (2) There was a limited relationship between the interventions on the MTPs and the assigned active treatment group schedules, (3) Patients were not assigned to specific groups based on identified psychiatric problems or needs. Instead, all patients were expected to attend all groups offered on units, and (4) There was a separate treatment plan used for psychiatrist or Licensed Independent Practitioner (LIP) leading to a disconnection between the "Master Care Plan" or "Care Plan" and the separate care plan titled "LIP Care Plan" (See also B122). These practices failed to demonstrate a coordinated and collaborative treatment planning process. This failure resulted in the potential to compromise patients' opportunity to receive appropriate active treatment measures. Refer to B118-II.

III. Provide comprehensive Master Treatment Plans (MTPs) that were cohesive, understandable and individualized with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:

A. An inventory of strength to be used as the basis for developing the Treatment Plans for 12 of 12 sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) and behaviorally descriptive disability statements to be used as the basis for developing Treatment Plans for four (4) of 12 active sample patients (Patients 2, 5, 6 and 9). Refer to B119.

B. Short-term goals and objectives written in observable, measurable, and behavioral terms for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Refer to B121.

C. Individualized and specific active treatment interventions for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Refer to B122 - I & II.

D. The names of discipline staff responsible and accountable for each intervention for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Refer to B123.

Failure to develop a cogent and understandable Master Treatment Plan with all the necessary components impeded the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

Based on record review and interview, the facility failed to ensure that the psychiatric diagnosis was provided in the Psychiatric Evaluations for five (5) of twelve (12) active sample patients (Patients 1, 6, 7, 8 and 9). Such failure interfered with timely planning and providing of focused treatment to the patients.

Findings include:

A. Record Review
The following Psychiatric Evaluations, dates of evaluations in parenthesis, do not have a diagnosis for Patient 1 (5/15/18), Patient 6 (4/25/18), Patient 7 (5/18/18), Patient 8 (4/16/18) and Patient 9 (4/26/18).

B. Staff Interview

On 5/22/18 around 2:30 p.m., in the interview with the Medical Director, he validated the following----: (1.) MD interventions were missing on all the sample Treatment Plans. (2.) In Treatment Plan review all the treatment team members' signatures 'may not be there.' and (3.) MD interventions listed were generic discipline functions.

I. Based on record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were cohesive, understandable and individualized with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:

A. An inventory of strength to be used as the basis for developing the Treatment Plans for 12 of 12 sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) and behaviorally descriptive disability statements to be used as the basis for developing Treatment Plans for four (4) of 12 active sample patients (Patients 2, 5, 6 and 9). Refer to B119.

B. Short-term goals and objectives written in observable, measurable, and behavioral terms for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). (Refer to B121).

C. Individualized and specific active treatment interventions for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Refer to B122.

D. The names of discipline staff responsible and accountable for each intervention for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Refer to B123.

Failure to develop a cogent and understandable Master Treatment Plan with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

II. Based on record review, observation and interview, the facility failed to plan and develop coordinated and comprehensive interdisciplinary Master Treatment Plans (MTPs) for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Instead, Treatment Plans were not based on collaboration regarding target problems and treatment goals. Specifically,

(1) Many interventions were not directly related to the identified problems (Refer to B122),

(2) There was a limited relationship between the interventions on the MTPs and the assigned active treatment group schedules,

(3) Patients were not assigned to specific groups based on identified psychiatric problems or needs. Instead, all patients were expected to attend all groups offered on units, and

(4) There was a separate Treatment Plan used by psychiatrist or Licensed Independent Practitioner (LIP) leading to a disconnection between the "Master Care Plan" or "Care Plan" and the separate care plan titled "LIP Care Plan" (See also B122).

These practices failed to demonstrate a coordinated and collaborative treatment planning process and resulted in the potential to compromise patients' opportunity to receive appropriate active treatment measures.

Findings include:

A Record Review:

1. The facility's policy titled "Treatment Planning" last revised "7/15," stipulated under "Treatment Planning Conference (TPC)" that: "The TPC is completed by the third day of the patient's hospitalization. Members of the interdisciplinary treatment team who meet with the patient at the TPC, or provide feedback, include the LIP, Social Worker/Counselor, Registered Nurse, Group Counselor ... Attending team members review the results of their assessment with the patients. The TPC is a collaborative process based on the patient's goals." It was difficult to discern whether these conferences occurred consistently. Based on a review of the signatures on the paper titled "Plan of Care Outcome Goals," staff signatures were not entered on the same day for eight (8) of the 12 active sample patients (Patients 4, 5, 6, 7, 9, 10, 11 and 12). In addition, some MTPs had missing staff signatures or had a signature but not dated. It was difficult to discern if the psychiatrist or LIP consistently attended the TPC for all patients. The LIP signature was missing or had a different date on the signature sheets for Patients 10, 11 and 12.

B. Observations:

Observation of the treatment team meeting that occurred on 5/22/18 at 9:10 a.m. for the General Adult Unit (GAU) and at 9:50 a.m. for the Adult Psychiatric & Addiction Unit (APA).
The GAU meeting was scheduled to start at 9:00 a.m. There was no LIP (APRN) present at the GAU until approximately 9:25 a.m. and left before the meeting ended.
The process of both meetings was primarily a rounding report of each patient with a discussion of behavior and/or disposition of existing and presenting symptoms of new patients. There was no evidence of a discussion or collaboration regarding the development of the targeted problems to be addressed for current or new patients, the goals for the treatment to be provided, the treatment modalities to be implemented, or the role of specific disciplines in carrying out the MTP for these patients.

C. Interviews:

1. In a discussion on 5/21/18 at 10:50 a.m., with Director of Social Work the group schedule on GAU was discussed. The Director of Social Work stated, "Patients are not assigned to groups. They select the groups they want to attend."

2. During an interview on 5/21/18 at 12:48 p.m., Patient 9 stated, "I like to stay in the quiet room instead of going to group."

3. During an interview on 5/22/18 at 10:41 a.m., Patient 11 stated, "I don't like groups, so I don't go."

4. During an interview on 5/22/8 at 10:45 a.m., Patient 5 stated, "Some groups are not constructive. Like the Art Group, not as helpful. I don't like coloring."

In an interview on 5/22/18 at 2:30 p.m., the treatment planning process was discussed with the Director of Social Work, Registered Nurse #4, Registered Nurse #5, Social Worker #2, and Group Counselor #2. They did not dispute the findings that patients were not assigned to groups on the schedule for units. They, also, agreed that there was not a consistent or direct relationship to groups on the MTPs and those attended by patients. Social Worker #2 stated, "We need to rethink this."

In an interview on 5/22/18 at around 2:30 p.m. with the Medical Director, the Director validated that LIP interventions were not incorporated on the "Master Care Plan" along with other disciplines.

Based on record review and interview, the facility failed to provide the patient's strengths in the Master Treatment Plan (MTP) for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Furthermore, the facility failed to provide the problem statement that identified and described the patient's problems specifically in the Master Treatment Plan (MTP) of four (4) of 12 active sample patients (Patients 2, 5, 6 and 9). The problem statement was broad and a general description of the patient's state of mind. Failure to identify and incorporate the patient's strengths in the Master Treatment Plan diminishes the effectiveness of treatment interventions and can hamper patient's achievement of treatment goals. Failure to specifically identify and individualize patient's problem in the MTP compromises the treatment team ability to formulate appropriate treatment goals and plan targeted interventions to the patient's specific needs.

Findings include:

A. Record Review

1. Master Treatment Plan (MTP) of all twelve (12) active patients reviewed, lacked a description of patient strengths. (Date of MTP in parenthesis): Patient 1 (5/21/18), Patient 2 (5/19/18), Patient 3 (5/19/18), Patient 4 (5/19/18), Patient 5 updated (5/19/18), Patient 6 updated (5/17/18), Patient 7 (5/19/18), Patient 8 (5/20/18), Patient 9 (4/26/18), Patient 10 (4/9/18), Patient 11 (5/9/18), and Patient 12 (3/30/18).

2. For Patient 2, in the MTP, dated 5/19/18, the problem statement noted:
"Dangerous / Aggressive Behavior ... As evidenced by dangerous or aggressive behavior that requires PRT (sis PRN), Seclusion and / or Restraint." For the problem of "Alteration in Thought," it noted: "As manifested by Pt (Patient) presents to treatment due to psychiatric decompensation, illogical thinking, paranoid thinking and mania."

3. For Patient 5, in the MTP dated 5/21/18, the problem statement noted: "Alteration in Thought as Manifested By: Command auditory and visual hallucinations."

4. For Patient 6, in the MTP dated 5/17/19, the problem statement noted: "Alteration in Mood As manifested by depressed, sad, SI and HI (and recent SA as well as abuse of marijuana and cocaine.)"

5. For Patient 9, in the MTP dated 4/26/18, the problem statement noted: "Alteration in Mood as Manifested By: S1, urges to self-harm, increase in depression/anxiety- hopeless, sad and anxious."

6. The facility's policy titled "Treatment Planning" last revised "7/15," stipulated under "Patient Strengths/Assets that: " ...The treatment plan applies the patient strengths identified from multi-disciplinary assessment in formulating the patient's desired treatment objectives/goals ..." The MTPs did not show evidence that facility followed this policy requirement.

B. Interview

On 5/22/18 around 2:30 p.m., the Medical Director in the interview acknowledged that the patient strengths were missing on the Master Treatment Plans of all 12 active sample patients. He, further, validated that four (4) out of 12 active sample patients had generalized problem statements on their Master Treatment Plans.

Based on record review, hospital policy review and staff interview, it was determined that the facility failed to develop Master Treatment Plans (MTPs) that identified patient-centered long-term goals and short-term goals stated in observable measurable, behavioral terms for 12 out of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Several identified goals were generic staff expectations instead of patient outcomes related to improving the identified psychiatric symptoms. Also, active sample patients did not have treatment goals at all on the separate form used by psychiatrists and Licensed Independent Practitioners. The lack of patient-specific goals hampers the treatment team's ability to assess changes and progress in each patient's condition.

Findings include:

A. Record review

The MTPs for the following patients were reviewed (dates of plans in parentheses): Patient 1 (5/21/18), Patient 2 (5/19/18), Patient 3 (5/19/18), Patient 4 (5/19/18), Patient 5 updated (5/19/18), Patient 6 (updated 5/17/18), Patient 7 (5/19/18), Patient 8 (5/20/18), Patient 9 (4/26/18) updated (5/20/18, Patient 10 (4/9/18), Patient 11 (5/9/18) and Patient 12 (3/30/18). This review revealed that MTPs included short-term and behavioral objectives that were not written in measurable, observable, and behavioral terms or were staff expectations or treatment compliance issues.

1. Patient 1's MTP included the following problem: "Alteration in thought - As Manifested by: ... increased auditory hallucinations. Pt [Patient] reports AH of a woman telling her 'You are not a good person, kill yourself ...' Pt reports experiencing intense urges to cut herself and has hx of self-harm ..." The deficient behavioral objectives included:

"Pt will attend 5 daily coping skills groups to use when auditory hallucination increase." This intervention statement was a treatment compliance expectation, not a patient outcome statement reflecting what the patient would be doing or saying to show improvement in presenting psychiatric symptoms. "Pt will positively respond to at least 2 different relaxation techniques implemented by staff (music, sensory-specific activities, walking)." This behavior objective was identical or similarly worded on the MTPs of Patient 1, 2, 3, and 4. Therefore, the objective was not individualized to reflect each patient's assessed needs.

2. Patient 2 's MTP included the following problem: "Harm to Others - As Manifested by: assaultive behavior. Towards police, VA staff." The deficient behavioral objectives included:

"Will attend groups to learn and develop two or more coping skills to manage unsafe thoughts", "Will take prescribed medications [sic] to help manage symptoms", "Will progress to no status through safe behaviors." These objectives were primarily treatment compliance issues, not a patient outcome statement reflecting what the patient would be doing or saying to show improvement in presenting psychiatric symptoms.

For the problem of "Alteration in Thought - As Manifested by: Pt presents to treatment due to psychiatric decompensation, illogical thinking, paranoia, and mania," the following identical or similarly worded objective was included for both Patients 2 and 3: "[Patient name] will display good behavioral control (no verbal threats or attacking staff, compliance with medications x 3 consecutive days." Therefore, the objective was not individualized to reflect each patient's assessed needs. Additionally, there was no information in the problem statement regarding lack of behavioral control or non-compliance with medications.

3. Patient 3's MTP included the following problem: "Alteration in thought - As Manifested by: psychotic features ... Per records, pt. stated [s/he] met God and can solve all of [his/her] problems ..." The deficient short-term goals or behavioral objectives included:

"[Patient name] will display good behavioral control (no verbal threats or attacking staff, compliance with medications x 3 consecutive days." Therefore, the objective was not individualized to reflect each patient's assessed needs. Additionally, the objective was not directly related to information in the problem statement. "Pt will positively respond to at least 2 different relaxation techniques implemented by staff (music, sensory-specific activities, walking)." This behavior objective was identical or similarly worded on the MTPs and was not individualized to reflect this patient's assessed needs.

4. Patient 4's MTP included the following problem: "Alteration in thought - As Manifested by: ... paranoia that [his/her] mother and aunt are stealing [his/her] disability checks ...." The deficient short-term goals or behavioral objectives included:

"[Patient name] will display good behavioral control (no verbal threats or attacking staff, compliance with medications x 3 consecutive days." Therefore, the objective was not individualized to reflect each patient's assessed needs. Additionally, the objective was not directly related to information in the problem statement. "Pt will positively respond to at least 2 different relaxation techniques implemented by staff (music, sensory-specific activities, walking)." This behavior objective was identical or similarly worded on the MTPs and was not individualized to reflect this patient's assessed needs.

5. Patient 5's MTP included the following problem: "Alteration in thought - As Manifested by: ... SI [Suicidal Ideation] with Command auditory and visual hallucinations." The deficient short-term goals and behavioral objectives included:

Short-term goal: "[Patient name] will demonstrate an understanding of the role of medication in symptom management." Behavioral objective: "[Patient name] will display good behavioral control for multiple days on the unit." "[Patient name] will exhibit a reduction in A/VH [auditory/visual hallucinations] x3 consecutive days. These goals/objectives were not stated in measurable, observable or behavioral terms.

6. Patient 6's MTP included the following problem: "Alteration in Mood - As Manifested by: depressed, sad, SI, and HI (had recent SA ...)" The deficient short-term goals or behavioral objectives included:

Short-term goal: [Patient name] will a decrease in suicidal and homicidal ideation and depressive symptoms." Behavioral Objectives: [Patient name] will attend 5 coping skills groups ... to learn ways to manage depression & anxiety." [Patient name] will discuss 2 triggers that led to hospitalization in family mtg [meeting] [with] mother." These goals/objectives were not stated in measurable, observable or behavioral terms. The objective regarding attending groups was a staff expectation and failed to describe what the patient would be saying or doing in observable and behavioral terms to show improvement. The objective regarding identifying triggers failed to include what the patient would do to manage triggers once identified.

7. Patient 7's MTP included the following problem: "Alteration in Mood - As Manifested by: Pt reports depression, SI with plan to cut [his/her] wrist and PTSD symptoms since [his/her] friend died last year next to [him/her]." The deficient short-term goals or behavioral objectives included:

"[Patient name] will attend coping skills groups to identify coping skills to use for [his/her] depression and SI." "[Patient name] will attend grief recovery group to receive grief recovery education." These objectives were not written in behavioral terms and were staff expectations or treatment compliance issues.

8. Patient 8's MTP included the following problem: Alteration in Mood - As Manifested by: suicide attempt via cutting neck with a sharpened can lid ... history of multiple suicide attempts ... noncompliance with medications/treatment." The deficient behavioral objectives were: "Patient will verbalize an improvement in mood on 3 consecutive days." "Patient will verbalize 3 symptoms of depression/anxiety pt. was experiencing prior to hospitalization." These objectives were not written in observable, measurable, and behavioral terms. The objective regarding identifying symptoms of depression failed to include what the patient would do to manage these symptoms once identified.

9. Patient 9's MTP included the following problem: "Alteration in mood - As Manifested by: SI [Suicidal Ideation], urges to self-harm, increase in depression/anxiety, hopeless, and anxious." The deficient behavioral objectives included:
"attend 2-3 groups per day, comply with medication management and therapeutic activities." "Identify coping skills for feelings associated with increase in depression and anxiety, as well as suicidal ideation and urges to self-harm." Identify resources for psychosocial stressors." "Attend family meetings to discuss aftercare plans, determine/contribute to safe/stable discharge plan ..." These objectives were very broad and not written in measurable, observable, and behavioral terms. Objective regarding attending family meetings was a staff expectation or treatment compliance issue.

10. Patient 10's MTP included the following problem: "Alteration in mood- As Manifested by: suicide attempt via hanging, hx [history] of multiple attempts (hanging, OD), self-harm, swallowing sharp objects, AH (Auditory Hallucination), aggression, depression." The deficient short-term goals or behavioral objectives included:

"attending coping skills groups in order to identify additional skills for depressions." "display safe bx [behavior] and not engage in swallowing objects." "identify triggers leading up to hospitalization and share these with [his/her] family." These objectives were not written in measurable, observable, and behavioral terms. Objective regarding attending coping skills was a staff expectation and treatment compliance issue, not what the patient would be doing or saying to show measurable, observable and behavioral improvement in presenting psychiatric symptoms.

11. Patient 11's MTP included the following problem: "Alteration in Thought - As Manifested By: lack of sleep and reduced food intake due to paranoid thoughts about being poisoned, medication noncompliance ..." The deficient short-term goals and behavioral objectives included:

Short-term goal: "[Patient name] will identify [his/her] insight into change in mental status and mood by discharge." Behavior objectives: "Pt [Patient] will attend 5 daily coping skills groups during inpatient stay to help identify 3 coping skills to cope when feeling depressed and anxious." "Patient will verbalize an improvement in mood on 3 consecutive days." "Patient will verbalize 3 symptoms of (depression/mania/anxiety) pt. was experiencing prior to hospitalization." The short goal and behavioral objectives were not written in measurable, observable, and behavioral terms. The objectives regarding attending groups was a staff expectation and treatment compliance, not a patient outcome statement reflecting what the patient would be doing or saying to show measurable, observable, and behavioral improvement in presenting psychiatric symptoms.

12. Patient12's MTP included the following problem: "Alteration in Thought - As Manifested By: lack of sleep and reduced food intake due to paranoid thoughts about being poisoned, medication noncompliance ..." The deficient short-term goal and behavioral objectives included:

Short-term goal: "[Patient name] will exhibit or report a reduction in psychotic sx [symptoms]." Behavioral Objective: "[Patient name] will exhibit or report a reduced preoccupation with grandiose delusions." The short goal and behavioral objectives were not written in measurable, observable, and behavioral terms.

B. Hospital Policy Review:

The facility's policy titled "Treatment Planning" last revised "7/15," stipulated that: "Problems are addressed with specific objectives/goals and anticipated target dates for projected achievement ... Goals and objectives are related to the problem/need and documented by the appropriate discipline - Be written in specific, time framed measurable terms. Statement of patient's desired behavioral change. What the patient will do, or will refrain from doing, or expected status of the patient's condition/situation ..." The clinical staff failed to follow the requirements in this policy.

C Staff Interviews:

1. In an interview on 5/22/18 at 10:33 a.m. with RN #1, the generic interventions were discussed. She did not dispute the findings.

2. In an interview on 5/22/18 at 2:30 p.m., the treatment planning process was discussed with the Director of Social Work, Registered Nurse #4, Registered Nurse #5, Social Worker #2 and Group Counselor #2. They did not dispute the findings that patients were not assigned to groups on the schedule for units. They also agreed that there was not a consistent or direct relationship to groups on the MTPs and those attended by patients.

Based on observation, record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of active treatment interventions with specific focus based on unique psychiatric problems and needs of 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Specifically, interventions were stated as generic and routine discipline functions written as active treatment interventions. MTPs also failed to state the specific focus for interventions consistently and whether interventions would be delivered in group or individual sessions. The interventions for MDs and Advanced Practice Registered Nurses (APRNs) were included on a separate form titled "LIP Care Plan" that failed to include all the components of a comprehensive Master Treatment Plan. In addition, the MTPs did not include a "Nurse Education Group" attended by patients and included in the Adult Psychiatry and Addiction Unit's (APA) schedule. These deficiencies result in Treatment Plans that failed to reflect an individualized approach to interdisciplinary treatment and failed to guide staff regarding the specific interventions and purpose for each. These failures, also, potentially result in inconsistent or ineffective treatment.

Findings include:

I. Lack of Individualized MTPs

A. Record Review

1. The facility's policy titled "Treatment Planning" last revised "7/15," stipulated that: "The interdisciplinary team shall identify the treatment interventions to be utilized to achieve the corresponding objectives for each problem. Each intervention corresponds to the problem and objective ..." This policy did not have sufficient information available to guide clinical staff when writing treatment intervention statements. In addition, the policy had not been updated to reflect the electronic medical record template for the Master Treatment Plan.

2. The MTPs for the following patients were reviewed (dates of Plans in parentheses): Patient 1 (5/21/18), Patient 2 (5/19/18), Patient 3 (5/19/18), Patient 4 (5/19/18), Patient 5 updated (5/19/18), Patient 6 (updated 5/17/18), Patient 7 (5/19/18), Patient 8 (5/20/18), Patient 9 (4/26/18) updated (5/20/18, Patient 10 (4/9/18), Patient 11 (5/9/18) and Patient 12 (3/30/18).
This review revealed that MTPs contained interventions that were not individualized and were non-specific. Many Treatment Plans did not include: 1) how the intervention would be delivered (individual or group sessions), 2) the frequency of contact, or 3) the focus or purpose of treatment related to the patient's presenting psychiatric symptoms.
The interventions assigned to the psychiatric and APRN were not included on the document titled "Master Treatment Plan." A separate form in the electronic medical record titled "LIP [Licensed Independent Practitioner] Care Plan" was used by LIPs.

3. Active sample Patient 1 had the problem of "Alteration in thought - As Manifested by: ... increased auditory hallucinations. Pt [Patient] reports AH of a woman telling her 'You are not a good person, kill yourself ...' Pt reports experiencing intense urges to cut herself and has hx of self-harm ..."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed two (2) problem statements with no descriptive information and there were no long-term or short-term goals related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress" and "Discuss Medication Management/Changes." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications to be addressed.

Registered Nurse Interventions: "RN will observe [Patient name] for verbal and nonverbal behaviors associated with auditory and visual hallucination q[i.e.each] shift." "RN will encourage [Patient name] to attend at least 3 therapeutic groups each day." These two (2) interventions were generic and routine nursing job duties of observing and encouraging patients. These intervention statements were not active treatment interventions reflecting the RN's meeting with the patient to provide information and assist him/her to manage unique presenting psychiatric symptoms or needs. "RN will educate on the uses and benefits of [his/her] medication, providing verbal and written info as needed, qshift. (Haldol and Zyprexa)." "RN will assist [Patient name] in identifying coping skills that help reduce disturbance in thought." These interventions failed to include a delivery method (individual or group sessions), a planned frequency of contact instead of "as needed."

Social Worker Interventions: "LSW ... will meet with pt. [patient] x10 minutes, 2-3x per week and provide validation therapy to help patient maintain good behavioral control." This intervention was very broad and non-specific. Also, interventions were not directly related to the behavioral objectives and long-term goals which identified issues related to managing auditory hallucinations and coping skills.

Group Counselor Staff (GCS): " ... will offer daily reorientation groups for 45 minutes to assist [Patient name] with decreasing confusion and establishing routines." " ... will provide cognitive and sensory stimulation groups daily for 45 minutes provide [Patient name] with a focus on decreasing agitation." These intervention statements failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific. The statements were not directly related to the behavioral objectives and long-term goals which identified issues related to managing auditory hallucinations. There was no information in the problem statement or objectives regarding cognitive functions or agitation.

3. Active sample Patient 2 included the problem of "Alteration in thought - As Manifested by: Pt presents to treatment due to psychiatric decompensation, illogical thinking, paranoia, and mania."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed two (2) problem statements with no descriptive information and there were no long-term or short-term goals related to these problems. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress" and "Discuss Medication Management/Changes." The interventions regarding educating the patients failed to include a frequency of contact and a focus of treatment based on this patient unique psychiatric symptoms or the names of medications to be addressed.

Registered Nurse Interventions: "RN will monitor [Patient name] delusion and thought process qshift and notify LIP when patient exhibits a decrease in [his/her] symptoms by time of discharge." "RN will administer Zyprexa (QHS) daily and elicit an understanding from [Patient name] of the importance of medication adherence by time of discharge." These two (2) interventions were generic and routine nursing job duties of monitoring patients and administering medications. These intervention statements were not active treatment interventions reflecting the RN's meeting with the patient to provide information and assist him/her to manage unique presenting psychiatric symptoms or needs.

Group Counselor Staff (GCS): " ... will offer daily reorientation groups for 45 minutes to assist [Patient name] with decreasing confusion and establishing routines" and " ... will provide cognitive and sensory stimulation groups daily for 45 minutes provide [Patient name] with a focus on decreasing agitation." These intervention statements were not individualized and were identical or similarly worded for Patient 1. The statements failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific. The statements were not directly related to the behavioral objectives which identified issues related to behavioral control, preoccupation with police, and compliance with medications. There was no information in the problem statement or objectives regarding cognitive functions, confusion or agitation.

4. Active sample Patient 3 included the problem of "Alteration in thought - As Manifested by: psychotic features ... Per records, pt. stated [s/he] met God and can solve all of [his/her] problems ..."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed two (2) problem statements with no descriptive information and there were no long-term or short-term goals related to these problems. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily." "Meet Daily to Discuss Progress." "Discuss Medication Management/Changes." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications to be addressed.

Registered Nurse Interventions: "RN will educate [Patient name] on the use of Risperdal for alteration in thought x5 minutes prior to administration. [Patient name] will be able to identify the benefits of medications, and side effects via the teach-back method." This intervention failed to include a delivery method (individual or group sessions), a frequency of contact, and a focus of treatment based on this patient's unique needs for education such as first dose, lack of knowledge, non-compliance issues, etc.

Social Worker Interventions: "LSW will meet with pt. [patient] x10 minutes, 2-3x per week and provide validation therapy to help patient maintain good behavioral control." "LSW will meet with pt. x10 minutes 2-3x per week to assist pt. in establishing a routine pattern of daily activities such as sleeping, eating, social activities and exercise." These intervention statements were very broad and non-specific. They were not individualized and were also identical or similarly worded for Patient 1. There was no information in the problem statement or patient objectives regarding daily activities.

Group Counselor Staff (GCS): " ... will offer daily reorientation groups for 45 minutes to assist [Patient name] with decreasing confusion and establishing routines", " ... will provide cognitive and sensory stimulation groups daily for 45 minutes provide [Patient name] with a focus on decreasing agitation." These intervention statements were not individualized and were identical or similarly worded for Patients 1 and 2. The statements failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific. The statements were not directly related to the behavioral objectives and/or which identified issues related to behavioral control regarding "verbal threats or attacking staff." There was no information in the problem statement or patient objectives regarding cognitive functions, confusion, or agitation.

5. Active sample Patient 4 included the problem of "Alteration in thought - As Manifested by: ... paranoia that [his/her] mother and aunt are stealing [his/her] disability checks ...."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed two (2) problem statements with no descriptive information and there were no long-term, and/or short-term goals, or behavioral objectives related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress" and "Discuss Medication Management/Changes." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications that might be utilized.

Registered Nurse Interventions: "RN will observe for verbal and nonverbal behaviors associated with hallucinations/delusions q shift." "RN will spend 1:1 time with [Patient name] qshift to (x10 mins) to assess for paranoid thoughts." These two interventions were generic and routine nursing job duties, not active treatment interventions reflecting the RN's meeting with the patient to provide information regarding his/her unique presenting psychiatric symptoms or needs. "RN will educate [Patient name] on the uses and benefits of [his/her] medication, providing verbal and written info as needed, qshift." This intervention failed to include a delivery method (individual or group sessions), a planned frequency of contact rather than "as needed." Also, there was no specific focus of treatment based on this patient's unique needs for education regarding a medication and whether there were education needs such as first dose, lack of knowledge, non-compliance issues, etc.

Social Worker Interventions: "LSW will meet with pt. [patient] x10 minutes, 2-3x per week and provide validation therapy to help patient maintain good behavioral control." This intervention statement was very broad and non-specific. The statement was not individualized and was also identical or similarly worded for Patients 1, 2 and 3.

Group Counselor Staff (GCS): " ... will offer daily reorientation groups for 45 minutes to assist [Patient name] with decreasing confusion and establishing routines." " ... will provide cognitive and sensory stimulation groups daily for 45 minutes provide [Patient name] with a focus on decreasing agitation." These intervention statements were not individualized and were identical or similarly worded for Patients 1, 2 and 3. The statements failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific. The statements were not directly related to behavioral objectives and identified issues related to behavioral control regarding "verbal threats or attacking staff." There was no information in the problem statement or objectives regarding cognitive functions, confusion or agitation.

6. Active sample Patient 5 included the problem of "Alteration in thought - As Manifested by: ... SI with Command auditory and visual hallucinations."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed two (2) problem statements with no descriptive information and there were no long-term, short-term goals, or behavioral objectives related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress" and "Discuss Medication Management/Changes." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications to be addressed.

"RN will assess [Patient name] for presence of SI, HI, AVH, delusions, & paranoid thoughts processes & will update LIP of changes in progress." "RN will encourage [Patient name] to attend/participate in therapeutic groups to aid with coping skill development." These two (2) interventions were generic and routine nursing job duties of "assessing and encouraging" the patient, not active treatment interventions reflecting the RN's meeting with the patient to provide information regarding his/her unique presenting psychiatric symptoms or needs.

Group Counselor Staff (GCS): " ...will offer groups such as DBT and CBT to assist [Patient name] in developing three (3) skills to address distorted thinking into a more logical processing." This intervention statement was not individualized and non-specific. The statements failed to list the group techniques that would be appropriate for this patient.

7. Active sample Patient 6 included the problem of "Alteration in Mood - As Manifested by: depressed, sad, SI, and HI (had recent SA ..."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed three problem statements with no descriptive information and there were no long-term, short-term goals, or behavioral objectives related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily." "Meet Daily to Discuss Progress." "Discuss Medication Management/Changes." "Discuss Maintenance." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications to be addressed.

"RN will provide education to [Patient name] on uses and side effects of Zoloft, Risperdal (prn) x5 mins prior to each administration with focus on managing mood." This intervention statement included a prn frequency instead of a planned frequency of contact to ensure intensive active treatment. "[sic] provide psychoeducation to [Patient name] on the use of alternative coping skills when stressed and angry to decrease stimulus every shift." This intervention was non-specific and failed to identify a method of delivery (individual or group sessions). Also, the intervention reflected psychoeducation every shift which included the night shift.

Group Counselor Staff (GCS): " ...will use CBT techniques (education, modeling, corrective feedback, and role playing) to assist [Patient name] in learning three (3) ways to communicate how [s/he] is feeling before resorting to self-harm." These intervention statements were not individualized and were non-specific. The statements failed to list the group techniques that would be appropriate for this patient. This identical or similarly worded intervention statement was also included on the MTP of Patient 5 under the problem statement related to "Alteration in Mood."

8. Active sample Patient 7 included the problem of "Alteration in Mood - As Manifested by: Pt reports depression, SI with plan to cut [his/her] wrist and PTSD symptoms since [his/her] friend died last year next to [him/her]."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed three (3) problem statements with no descriptive information and there were no long-term, short-term goals, or behavioral objectives related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress", "Discuss Medication Management/Changes" and "Monitor Detox-Review CIWA." The interventions regarding educating the patients failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms or the names of medications to be addressed.

"Nurse will provide medication education on the uses and side effects of Praxil, and Rexulti with focus on the management of depression and anxiety x 5 minutes prior to each administration until discharge." to [Patient name] on uses and side effects of Zoloft, Risperdal (prn) x5 mins prior to each administration with focus on managing mood." This intervention statement did not include a focus of treatment based on this patient's unique needs for education such as lack of knowledge, reinforcement, non-compliance issues, etc. "Nurse will provide psychoeducation x 10 minutes daily on the benefits of using coping skills (such as music, walking, meditation) for depression and anxiety until discharge." This intervention was non-specific and failed to identify a method of delivery (individual or group sessions).

Group Counselor Staff (GCS): " ...will offer daily coping skills groups (x 45 minutes) to assist [Patient name] with identifying alternative ways to manage feelings of sadness and anxiety, while identifying reasons to live." " ... will offer a daily psychoeducation and coping skills groups as well as "Healing Arts groups 2-3 times per week on factors related to the development and maintenance of [Patient's] mood ..." These intervention statements failed to list the groups that would be appropriate for this patient and did not include appropriate or anticipated coping skills that the patient could use based on clinical assessments and patient need.

9. Active sample Patient 8's MTP included the problem of "Alteration in Mood - As Manifested by: suicide attempt via cutting neck with a sharpened can lid ... history of multiple suicide attempts ... noncompliance with medications/treatment."

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. The separate form in the electronic medical record titled "LIP Care Plan" also did not include any problem statements with no descriptive information, long-term, and/or short-term goals, behavioral objectives or intervention statements.

"Nurse will provide medication education on the uses and side effects of Invega and Neurontin with a focus on the management of depression and anxiety x 5 minutes prior to each administration until discharge." This intervention statement did not include a focus of treatment based on this patient's unique needs for education such as lack of knowledge, reinforcement, non-compliance issues, etc. "Nurse will provide psychoeducation x 10 minutes daily on the benefits of using coping skills (such as music, walking, meditation) for depression and anxiety until discharge." This intervention was non-specific and failed to identify a method of delivery (individual or group sessions). These two interventions were not individualized and were identical or similarly worded for those interventions identified for Patient 7.

Group Counselor Staff (GCS): " ...will offer daily coping skills groups (x 45 minutes) to assist [Patient name] with identifying alternative ways to manage feelings of sadness and anxiety, while identifying reasons to live." " ... will offer a daily psychoeducation and coping skills groups as well as "Healing Arts groups (x 45 minutes) 2-3 times per week to assist [Patient name] with managing symptoms of mental health disorders." These intervention statements failed to list the groups that would be appropriate for this patient and did not include appropriate or anticipated coping skills that the patient could use based on clinical assessments and patient need. Additionally, the intervention was very broad and non-specific failing to specify unique psychiatric symptoms that would be addressed. These were also identical or similarly worded intervention statements included on the MTP of Patient 7.

10. Active sample Patient 9 had the problem of "Alteration in mood - As Manifested by: SI [Suicidal Ideation], urges to self-harm, increase in depression/anxiety, hopeless, and anxious."

Psychiatric Interventions: There were LIP interventions on the Master Treatment Plan for the problem regarding "Dangerous/Aggressive. A separate form in the electronic medical record titled "LIP Care Plan" listed one (1) problem statement with no descriptive information and there were no long-term or short-term goals related to this problem. The interventions listed included routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily", "Meet Daily to Discuss Progress" and "Discuss Medication Management/Changes." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms and needs and the names of medications to be addressed.

Registered Nurse Interventions: "RN will encourage [Patient name] to use identified coping skills and attend assigned groups daily." "RN will inform LIP of the patient's progress." These two (2) interventions were generic and routine nursing job duties, not active treatment interventions reflecting the RN's meeting with the patient to provide information regarding his/her unique presenting psychiatric symptoms or needs. "RN will educate [Patient name] on medication regime to include Abilify and Prozac, such as uses, benefits and potential side effects by using the Teach-Back Method and using Care Notes and documenting accordingly." This intervention failed to include a delivery method (individual or group sessions), a frequency of contact, and a focus of treatment based on this patient's unique needs for education such as first dose, lack of knowledge, non-compliance issues, etc.

Social Worker Interventions: "LSW to hold family meetings, discharge plan, provide 1:1 support as needed and update social support as authorized." This intervention was very broad and non-specific. Also, it failed to identify a frequency of contact and a focus on appropriate coping skills that the patient could use based on the psychosocial assessment or this patient's psychiatric needs.

Group Counselor Staff (GCS): " ... will offer [Patient name] daily coping skills (x 45 min) to assist [Patient name] with identifying alternative ways to manage feelings of sadness and anxiety while identifying reasons to live." This intervention failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific failing to specify unique psychiatric symptoms that would be addressed.

11. Active sample Patient 10 had the problem of "Alteration in mood- As Manifested by: suicide attempt via hanging, hx [history] of multiple attempts (hanging, OD), self-harm, swallowing sharp objects, AH (Auditory Hallucination), aggression, depression." The deficient interventions were:

Psychiatric Interventions: There were no MD interventions on the Master Treatment Plan. A separate form in the electronic medical record titled "LIP Care Plan" listed three (3) problem statement with no descriptive information and there were no long-term or short-term goals. The interventions listed were routine and generic MD job duties such as "Assess Psychiatric Symptoms Daily" and "Meet Daily to Discuss Progress." The interventions regarding educating the patient failed to include a frequency of contact and a focus of treatment based on this patient's unique psychiatric symptoms and needs.

Registered Nurse Interventions: "RN will educate [Patient name] on medication regime such as uses, benefits, side effects by using teach-back method." This intervention failed to include a frequency of contact and a focus of treatment based on this patient's psychiatric symptoms and needs. "RN will continue to encourage positive behavior and acknowledge the patient for staying out of the quiet area and not self-harming" and "Encourage patient to talk to staff and utilize positive coping skills." These two (2) interventions were generic and routine nursing job duties, not active treatment interventions reflecting the RN's meeting with the patient to provide information regarding his/her unique presenting psychiatric symptoms or needs.

Social Worker Interventions: "LCSW will meet with Pt [patient] 1:1 2-3x's a week (x 15 min) to discuss coping skills and reasons to live." This intervention was non-specific and failed to identify appropriate coping skills based on this patient's psychiatric needs.

Group Counselor Staff (GCS): " ... will offer [Patient name] daily psychoeducational groups to help identify new ways to cope with stressful emotions and situations providing improved ability to implement problem solving skills." This intervention failed to list the groups that would be appropriate for this patient. Additionally, the intervention was very broad and non-specific failing to specify unique psychiatric symptoms that would be addressed.

12. Active sample Patient 11 had a problem of "Alteration in mood - As Manifested By: [Patient name} presents with a change in mental status in regards [sic] to irritability, expansive mood, paranoia and suicidal thoughts ..." The deficient interventions were:

"Psychiatrist: There no MD interventions included on the MTP. A separate plan titled "LIP Care Plan" did not correlate to short-term goals and behavioral objectives of the MTP.

Registered Nurse: "RN will assess the patient's mood qshift and intervene per protocol to maintain patient's safety. "This intervention was a routine nursing job duty and not an active treatment intervention that reflected a scheduled meeting with the patient in individual or group sessions to provide information related to his/her presenting psychiatric symptoms.

Social Work: "LCSW will meet with [Patient's name] 2-3x per week (15 min.) to help the patient identify symptoms of depression/mania/anxiety that led to hospitalization. "This interventions was non-specific and not individualized to, also, reflect how the staff would assist the patient with actions that could be used to manage or lessen the magnitude of symptoms that resulted in hospitalization.

Therapeutic activities/Group Counseling Staff (GCS): "GCS will provide 4-5 daily group sessions (x 45 minutes) to assist [Patient] with decreasing isolation and establishing routines." "(Patient's name) will attend at least two groups/day." These intervention statements were non-specific and failed to identify particular groups that would be appropriate to address the patient's unique psychiatric problems and needs.

13. Active sample Patient 12 had the problem of "Alteration in Thought - As Manifested By: lack of sleep and reduced food intake due to paranoid thoughts about being poisoned, medication noncompliance ..." The deficient interventions were:

Psychiatrist: There were no MD interventions included on the MTP. A separate plan titled "LIP Care Plan" did not correlate to short-term goals and behavioral objectives of the MTP.

Registered Nurse: "RN will educate patient on uses and benefits of Klonopin and Haldol x 5min prior to administration." "RN will offer reality based feedback and provide psychoeducational on how to reframe negative thinking x qshift ..." These two (2) interventions failed to include the method of delivery and the focus of treatment based on the patient's unique need for medication education such as "medication non-compliance issues and learning how to manage paranoid thinking regarding being poisoned. "RN will assess patient thoughts qshift and intervene per protocol. This intervention was a routine nursing job duty and not an active treatment intervention that reflected meeting with the patient in individual or group sessions to provide information related to his/her presenting psychiatric symptoms.

Social Work: "LCSW will meet with [Patient's name] 2-3x per week (15 min.) to engage [Patient] in reality testing in an effort to increase a logical thought process." "Will meet with [Patient] to help [Patient] ID [identify] a benefit to remaining mediation compliant." These interventions were non-specific and not individualized to reflect how the staff would assist the patient with actions that could be used to manage or lessen the magnitude of symptoms that resulted in hospitalization.

Therapeutic activities/Group Counseling Staff (GCS): "GCS will provide 4-5 daily group sessions (x 45 minutes) to assist [Patient] with decreasing isolation and establishing routines." "David will attend at least two groups/day." These intervention statements were non-specific and failed to identify particular groups that would be appropriate to address the patient's unique psychiatric problems and needs.

C. Interviews

1. In an interview on 5/22/18 at 10:33 a.m. with RN #1, the generic interventions were discussed. RN #1 did not dispute the findings that several nursing interventions were generic or routine job duties.

2. In an interview on 5/22/18 at 2:30 p.m., the treatment planning process was discussed with the Director of Social Work, Registered Nurse #4, Registered Nurse #5, Social Worker #2 and Group Counselor #2. They did not dispute the findings that patients were not assigned to groups on the schedule for units. They, also, agreed that there were not a consistent or a direct relationship to the groups on the MTPs and to those attended by patients.

II. Failure to in

Based on record review and interview, the facility failed to ensure that the staff member responsible for each intervention was specifically identified in the Master Treatment Plans for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Findings include:

A. Record review

1. The facility's policy titled "Treatment Planning" last revised "7/15," stipulated that: "The interdisciplinary team shall identify the treatment interventions to be utilized to achieve the corresponding objectives for each problem ... The responsible discipline and frequency of treatment approach should be noted for each 'Staff Intervention' ..." This policy did not include the CMS requirement for both the name and discipline to be designated for each intervention.

2. The MTPs for the following patients were reviewed (dates of plans in parentheses): Patient 1 (5/21/18), Patient 2 (5/19/18), Patient 3 (5/19/18), Patient 4 (5/19/18), Patient 5 updated (5/19/18), Patient 6 (updated 5/17/18), Patient 7 (5/19/18), Patient 8 (5/20/18), Patient 9 (4/26/18) updated (5/20/18, Patient 10 (4/9/18), Patient 11 (5/9/18) and Patient 12 (3/30/18). This review revealed that each intervention did not identify either the name or the discipline responsible for ensuring implementation of the assigned interventions.

1. Patient 1 had no specific designation that included the name of the person responsible and accountable for any of the interventions assigned to the registered nurse.

2. Seven (7) active patients (2, 3, 4, 5, 6, 8 and 12) had no designation that included the designation of the clinical discipline responsible for each intervention. Several treatment team members signed the signature page for the Treatment Plan, but many signatures were illegible, and no specific designation of responsibility was noted.

3. Patient 7 had no specific designation that included the name of the person responsible and accountable for any of the medical interventions assigned to the registered nurse.

4. Patient 9 had no specific designation that included the name of the person responsible and accountable for the interventions assigned to the social worker. Some of the interventions assigned to registered nurses did not include the name of the responsible person.

5. Patient 10 had no specific designation that included the name of the person responsible and accountable for any of the interventions assigned to the social worker and registered nurse.

6. Patient 11 had no specific designation that included the name of the person responsible and accountable for any of the interventions assigned to the registered nurse.

C. Interviews

1. In an interview on 5/22/18 at 12:04 p.m., the problem of staff using just the discipline or initials to define the responsible person was discussed with RN #2. RN #2 agreed with the findings.

2. In a discussion on 5/22/18 at 3:40 p.m., the failure to include the name of the staff responsible for interventions was discussed with the Director of Social Work. Although a printout of staff names was submitted so that staff initials on the treatment plans could be identified, she did not dispute that determining staff responsible was difficult.

Based on record review and interview, the facility failed to ensure that treatment notes for interventions listed on the Master Treatment Plans (MTPs) were documented by clinical staff for four (4) of 12 active sample patients (Patients 5, 6, 7 and 8). Specifically, there was no evidence to show consistent documentation of interventions reflecting the topics discussed or information provided during one-to-one or group sessions. There was no or limited documentation to show the patient's response (level of participation, level of understanding, and behaviors exhibited during intervention sessions). These deficiencies hamper the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the Treatment Plan if or when needed.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): Patient 1 (5\, Patient 5 updated (5/19/18), Patient 6 (updated 5/17/18), Patient 7 (5/19/18), Patient 8 (5/20/18), Patient 9 (4/26/18) updated (5/20/18, Patient 10 (4/9/18), Patient 11 (5/9/18) and Patient 12 (3/30/18). This review revealed that there were either no or limited focused information that addressed each intervention and did not identify both the name and discipline responsible for ensuring implementation of the assigned interventions.

1. Patient 5 (admitted 5/17/18, MTP dated 5/19/18): Based on a review of the electronic medical record from 5/19/18 through 5/21/18, there were limited or no treatment notes for the following interventions that included the specific topic discussed and the patient's response to the intervention reflecting level of participation, level of understanding, behaviors exhibited, and any specific comments made during intervention sessions.

a. Registered Nurse: "RN will spend ten minutes q shift with pt. to discuss positive coping skills to cope with auditory hallucinations." Registered Nurse Interventions: RN will provide pt. with teaching that continued med compliance [sic] will assist in mood management care notes to be provided on Lamictal on pt.'s request."

b. Group Counselor Staff: " ...will offer groups such as DBT and CBT to assist [Patient name] in developing three skills to address distorted thinking into a more logical processing."

2. Patient 6 (admitted 4/24/18, MTP updated 5/17/18): Based on a review of the electronic medical record from 5/13/18 through 5/21/18, there were limited or no treatment notes for the following interventions that included the specific topic discussed and the patient's response to the intervention reflecting level of participation, level of understanding, behaviors exhibited, and any specific comments made during intervention sessions.

a. Registered nurse: "[sic] provide psychoeducation to [Patient name] on the use of alternative coping skills when stress and angry to decrease stimulus every shift." This intervention was non-specific and failed to identify a method of delivery (individual or group sessions). Also, the intervention reflected psychoeducation every shift which included the night shift.

b. Group Counselor Staff (GCS): " ...will use CBT techniques (education, modeling, corrective feedback, and role playing) to assist [Patient name] in learning three ways to communicate how [s/he] is feeling before resorting to self-harm."

3. Patient 7 (admitted 5/17/18, MTP updated 5/19/18): Based on a review of the electronic medical record from 5/19/18 through 5/21/18, there were limited or no treatment notes for the following interventions that included the specific topic discussed and the patient's response to the intervention reflecting level of participation, level of understanding, behaviors exhibited, and any specific comments made during intervention sessions.

a. "Nurse will provide psychoeducation x 10 minutes daily on the benefits of using coping skills (such as music, walking, meditation) for depression and anxiety until discharge."

b. Group Counselor Staff (GCS): " ...will offer daily coping skills groups (x 45 minutes) to assist [Patient name] with identifying alternative ways to manage feelings of sadness and anxiety, while identifying reasons to live." " ... will offer a daily psychoeducation and coping skills groups as well as "Healing Arts groups 2-3 times per week on factors related to the development and maintenance of [Patient's] mood."

4. Patient 8 (admitted 4/13/17, MTP updated 5/20/18): Based on a review of the electronic medical record from 5/13/18 through 5/21/18, there were limited or no treatment notes for identified interventions that included the specific topic discussed and the patient's response to the intervention reflecting level of participation, level of understanding, behaviors exhibited, and any specific comments made during intervention sessions.

B. Interviews

1. In an interview on 5/22/18 at 11:10 a.m. with RN #3, treatment notes for the nursing interventions on the MTP for Patient 7 were discussed. After attempts to locate nursing treatment notes, RN#3 did not dispute the findings that nursing interventions were not documented to include the topic discussed and the patient's response to the interventions. In addition, although interventions included the duration of contact, the amount of time spent with patient was not included in the treatment notes.

2. During an interview on 5/22/18 at 3:30 p.m. with the Director of Nursing (DON), treatment notes for the interventions listed on Master Treatment Plans were discussed. The DON did not dispute the findings that treatment notes were not consistently documented by registered nurses.

3. In an interview on 5/23/18 at approximately 9:30 a.m. with RN #6, the documentation of treatment notes on the electronic medical records was reviewed for active sample patients 5, 6, 7 and 8. This review revealed that treatment notes were not consistently documented by registered nurses and group counselors reflecting the topics discussed and the patient's response to interventions (level of participation, level of understand, behavior exhibited during intervention sessions). RN #6 did not dispute these findings and acknowledged that the documentation was not always directly related to interventions listed on the patient's Treatment Plan.

Based on observation, record review, document review, and interview, the Medical Director failed to monitor and provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure that the psychiatric diagnosis was provided in the Psychiatric Evaluations for five (5) of twelve (12) active sample patients (Patients 1, 6, 7, 8 and 9). This failure interfered with timely planning and focused treatment to patients. (Refer to B110)

II. Plan and develop coordinated and comprehensive interdisciplinary Master Treatments Plans (MTPs) for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Instead, Treatment Plans were not based on collaboration regarding target problems and treatment goals. Specifically, (1) Many interventions were not directly related to the identified problems (Refer to B122), (2) There was a limited relationship between the interventions on the MTPs and the assigned active treatment group schedules, (3) Patients were not assigned to specific groups based on identified psychiatric problems or needs. Instead, all patients were expected to attend all groups offered on units, and (4) There was a separate Treatment Plan used for psychiatrist or Licensed Independent Practitioner (LIP) leading to a disconnection between the "Master Care Plan" or "Care Plan" and the separate care plan titled "LIP Care Plan" (See also B122). These practices failed to demonstrate a coordinated and collaborative treatment planning process resulting in the potential to compromise patient's opportunity to receive appropriate active treatment measures. (Refer to B118-II)

III. Provide comprehensive Master Treatment Plans (MTPs) that were cohesive, understandable and individualized with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components----

1.. An inventory of strengths to be used as the basis for developing the Treatment Plans for 12 of 12 sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) and behaviorally descriptive disability statements to be used as the basis for developing Treatment Plans for four (4) of 12 active sample patients (Patients 2, 5, 6 and 9). (Refer to B119.)

2. Short-term goals and behavioral objectives written in observable, measurable, and behavioral terms for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). (Refer to B121).

3. Individualized and specific active treatment interventions to be delivered by the psychiatrist and/or Advanced Practice Registered Nurse for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). The interventions for MDs and Advanced Practice Registered Nurses (APRNs) were included on a separate form titled "LIP Care Plan" that failed to include all the components of a comprehensive Master Treatment Plan. (Refer to B122-I).

4. The names of discipline staff responsible and accountable for each intervention for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). (Refer to B123).

Failure to develop a cogent and understandable Master Treatment Plan with all the necessary components impeded the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

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

I. Develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of active treatment interventions with specific focus based on unique psychiatric problems and needs of 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). Specifically, nursing interventions were stated as generic and routine discipline functions written as active treatment interventions. MTPs also failed to state the specific focus for nursing interventions consistently and whether these interventions would be delivered in group or individual sessions. In addition, the MTPs did not include a "Nurse Education Group" attended by patients and included in the Adult Psychiatry and Addiction Unit's (APA) schedule. These deficiencies resulted in Treatment Plans that failed to reflect an individualized approach to interdisciplinary treatment and failed to guide staff regarding the specific interventions and purpose for each. These failures, also, potentially result in inconsistent or ineffective treatment. (Refer to B122 I & II).

II. Ensure that the name of the registered nurse responsible for each intervention was specifically identified in the Master Treatment Plans for 12 of 12 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented. (Refer to B123).

III. Ensure that treatment notes for nursing interventions listed on the Master Treatment Plans (MTPs) were documented for four (4) of 12 active sample patients (Patients 5, 6, 7, and 8). Specifically, there was no evidence to show consistent documentation of interventions reflecting the topics discussed or information provided during one-to-one or group sessions. There was no or limited documentation to show the patient's response (level of participation, level of understanding, and behaviors exhibited during intervention sessions). These deficiencies potentially hamper the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the Treatment Plan if needed. (Refer to B124).

Based on record review and interview, the Director of Social Work failed to ensure that Master Treatment Plans (MTPs) for seven (7) of 12 active sample patients (Patients 1, 3, 4, 9, 10 11 and 12) included individualized and specific social work interventions based on the unique psychiatric symptoms of each patient. Specifically, some social work intervention statements were identical or similarly worded despite the different clinical presentations of patients. Also, social work interventions were not always directly related to the behavioral objectives and long-term goals identified on the MTPs. These deficiencies resulted in Treatment Plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment. (Refer to B122-I).

II. Ensure that the social worker responsible for the social service intervention was specifically identified in the Master Treatment Plans for nine (9) of 12 active sample patients (Patients 2, 3, 4, 5, 6, 8, 9, 10 and 12). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Based on record review and interview, the facility failed to provide activity therapy groups by occupational therapy (OT) staff or unit group counselors seven (7) days per week on evenings and weekends for four (4) of six (6) patient units (Adolescent, Acute Care Unit East, Acute Care Unit West and General Adult Unit). This failure results in patients not receiving a full complement of therapies and not receiving individualized and goal-directed active treatment.

Findings include:

A. Record Review

The four (4) patient units listed above did not have any O.T. staff and unit counselor groups on evenings and weekends included on the unit activity schedules of the 4 patient units listed.

B. Interview

In an interview on 5/22/18 at 10:51 a.m. with the Social Work Director who was responsible for O.T. staff and counselors, the lack of evening and weekend therapeutic activities was discussed. The Director did not dispute the findings.