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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure the development and implementation of policies and procedures for the administration of compelled medications for the refusal of antipsychotic medications, including the identification of medications to be compelled (antipsychotics), and obtaining a 2nd medical opinion, as demonstrated by 2 of 4 records reviewed (Patient #1501 and #1506).

Failure to develop and implement policies and procedures for the administration of compelled medications for the refusal of antipsychotic medications, including identification of the medications able to be compelled (antipsychotics), and obtaining a 2nd medical opinion, puts patients at risk for violation of their rights, risk of psychological harm, and loss of personal dignity.

Reference:

Revised Code of Washington (RCW) 71.05.215 Right to refuse antipsychotic medicine - Rules.

(1) A person found to be gravely disabled or to present a likelihood of serious harm as a result of a behavioral health disorder has a right to refuse antipsychotic medication unless it is determined that the failure to medicate may result in a likelihood of serious harm or substantial deterioration or substantially prolong the length of involuntary commitment and there is no less intrusive course of treatment than medication in the best interest of that person.

(2) The authority shall adopt rules to carry out the purpose of this chapter. These rules shall include:

(a) Administration of antipsychotic medication in an emergency and review of this decision within twenty-four hours. An emergency exists if the person presents an imminent likelihood of serious harm, and medically acceptable alternatives to administration of antipsychotic medications are not available or are unlikely to be successful; and in the opinion of the physician, physician assistant, or psychiatric registered nurse practitioner, the person's condition constitutes an emergency requiring the treatment be instituted prior to obtaining a second medical opinion.

(b) Documentation in the medical record of the attempt by the physician, physician assistant, or psychiatric advanced registered nurse practitioner to obtain informed consent and the reasons why antipsychotic medication is being administered over the person's objection or lack of consent.

Findings included:

1. Document review of the hospital's policy titled, "Informed Consent, Psychotropic Medications," policy number ICPM.100, last reviewed 08/21, showed that for short-term treatment, up to 30 days, the patient has the right to refuse medications, unless the prescribing practitioner obtains a concurring medical opinion (2nd opinion) by a psychiatrist, physician assistant working with a supervising psychiatrist, psychiatric advanced nurse practitioner, who has examined the patient. Once the concurring medical opinion (2nd opinion) has been obtained the order will be reviewed by the Chief Medical Officer for final approval. The practitioners will use the "Order to Compel Medication Form" along with a detailed progress note documenting the reasons why medication is being administered over the patient's objections or lack of consent.

Patient #1501

2. On 08/11/21, Investigator #15 and the Director of Risk (Staff #1501), reviewed the medical records for Patient #1501, a 27-year-old male admitted on 07/24/21, on an involuntary detainment with a psychiatric diagnosis of Psychosis. Review of the Patient's medical record showed the following:

a. On 07/28/21 at 8:00 PM, an order was written by the provider to "start Ativan IM (intramuscular) every 4 hours, as needed. May use only if patient refuses oral Ativan." Review of the Patient's record found that the Patient had not been given the medication.

b. Investigator #15 noted that Ativan (lorazepam) belongs to the drug class anxiolytics and is not considered an antipsychotic drug and therefore cannot be compelled or forced for refusal, as directed by hospital policy and state regulations.

c. Investigator #15's review of the Patient's Medication Administration Record (MAR), dated 07/25/21 to 08/09/21, found that Patient #1501 had a standing (continuous) order for Cogentin injection IM 2 mg/2 ml (intramuscular) every 4 hours if oral medication is refused.

d. Investigator #15 noted that Cogentin (benztropine) belongs to the drug class anticholinergics and is not considered an antipsychotic drug and therefore cannot be compelled or forced for refusal, as directed by hospital policy and state regulations.

Patient #1506

3. On 08/11/21, Investigator #15 and the Director of Risk (Staff #1501), reviewed the medical records for Patient #1506, a 22-year-old male admitted on 07/03/21, on an involuntary detainment with a psychiatric diagnosis of Schizophrenia. Review of the Patient's medical records showed the following:

a. On 07/03/21 at 2:25 PM, an order was written by the provider to "give Zyprexa 10 mg (oral) now. Give Zyprexa 10 mg IM (intramuscular) if oral Zyprexa refused." Investigator #15's review of the medical record found that the medication was given to the Patient without his consent and without the required second medical opinion.

b. Investigator #15 noted that Zyprexa (olanzapine) belong to the drug class antipsychotics, however, Investigator #15 found no evidence in Patient #1506's medical record documenting an attempt to obtain a concurring second medical opinion and review by the Chief Medical Officer prior to the administration of the medication, as directed by hospital policy.

4. On 08/12/21 at 3:25 PM, during an interview with Investigator #15, the Director of Risk (Staff #1501), the Chief Nursing Officer (Staff #1507) and the Director of Quality (Staff #1502) verified that the medical records did not have a 2nd opinion prior to the administration of compelled medications. Staff #1501 verified that Patient #1506 did receive the medication Zyprexa, documented as a compelled medication without the concurring 2nd opinion. Staff #1507 verified that the medical records reviewed contained orders for compelled medications that were not considered antipsychotic medications and should not be compelled for refusal. Staff #1507 stated that the Chief Medical Officer and the Medical Executive Committee had addressed these discrepancies and new policies were being initiated. Staff #1501 stated that the facility practice was to require a 2nd Opinion for forced/compelled medication and there was a form already initiated to capture the 2nd signature. Staff #1501 stated that the current policies would reflect the changes to ensure the hospital's compliance with the state regulations.

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Based on record review and review of hospital policy and procedures, the hospital failed to modify the patient's treatment plan after placing patients in restraints or seclusion for 3 of 4 records reviewed (Patient #1403, #1405, #1406).

Failure to modify treatment plans for patients in restraints or seclusion places patients at risk of harm by not meeting their physical and emotional needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint," policy number POC.01.90, revised 08/21, showed that a treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent reoccurance. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion.

2. On 08/26/21, Investigator #14 conducted a medical record review of 4 patients who were placed in seclusion or restraints. In 3 of 4 patient medical records reviewed (Patient #1403, #1405, #1406), staff failed to update the patient's treatment plan to reflect seclusion or restraint interventions.

3. During an interview with the Director of Risk Management (Staff #1401) on 08/26/21 at 4:20 PM, the restraint and seclusion medical record review was discussed. Staff #1401 verified that updates to the treatment plans after restraint or seclusion could not be found.

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Item #1 - Emergency Medications - Chemical Restraints

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure the development and implementation of policies and procedures for the administration of emergency medications, including obtaining a 2nd medical opinion, when used as chemical restraints, as demonstrated by 2 of 4 records reviewed (Patient #1501, and #1505).

Failure to develop and implement policies and procedures for the administration of emergency medications, including obtaining a 2nd medical opinion, puts patients at risk for violation of their rights, risk of psychological harm, and loss of personal dignity.

Reference:

Revised Code of Washington (RCW) 71.05.215 Right to refuse antipsychotic medicine - Rules.

(1) A person found to be gravely disabled or to present a likelihood of serious harm as a result of a behavioral health disorder has a right to refuse antipsychotic medication unless it is determined that the failure to medicate may result in a likelihood of serious harm or substantial deterioration or substantially prolong the length of involuntary commitment and there is no less intrusive course of treatment than medication in the best interest of that person.

(2) The authority shall adopt rules to carry out the purpose of this chapter. These rules shall include:

(a) Administration of antipsychotic medication in an emergency and review of this decision within twenty-four hours. An emergency exists if the person presents an imminent likelihood of serious harm, and medically acceptable alternatives to administration of antipsychotic medications are not available or are unlikely to be successful; and in the opinion of the physician, physician assistant, or psychiatric registered nurse practitioner, the person's condition constitutes an emergency requiring the treatment be instituted prior to obtaining a second medical opinion.

(b) Documentation in the medical record of the attempt by the physician, physician assistant, or psychiatric advanced registered nurse practitioner to obtain informed consent and the reasons why antipsychotic medication is being administered over the person's objection or lack of consent.

Findings included:

1. Document review of the hospital's policy titled, "Informed Consent, Psychotropic Medications," policy number ICPM.100, last reviewed 08/21, showed the following:

a. During an emergency which requires the use of medication, staff will follow the "Restraint" policy and utilize the Seclusion and Restraint packet to document. An emergent situation is defined as:

i. Patient constitutes a danger to self.

ii. Patient constitutes a danger to others.

iii. Patient is gravely disabled, incompetent, and does not have a legal representative.

b. If emergent medications are provided to an involuntary patient, the attending practitioner must direct the staff to contact the Department of Crisis and Commitment to evaluate the patient for involuntary treatment.

2. Document review of the hospital's policy titled, "Restraint," policy number POC.01.90, last reviewed 08/21, showed the following:

a. Chemical restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency.

b. Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled-out.

c. Restraint may only be ordered by a psychiatrist, physician assistant practicing under supervision of a psychiatrist, or a psychiatric advanced nurse practitioner. Orders for restraint shall never be written as a standing order or on as needed basis (PRN).

d. Administration of an antipsychotic medication in an emergency, requires review of the decision within 24 hours by a psychiatrist, physician assistant practicing under supervision of a psychiatrist, or a psychiatric advanced nurse practitioner.

Patient #1501

3. On 08/11/21, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical records for Patient #1501, a 27-year-old male admitted on 07/24/21, on an involuntary detainment with a psychiatric diagnosis of Psychosis. Review of the Patient's medical record showed the following:

a. On 07/28/21 at 8:05 AM, a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "agitation." Investigator #15 found no evidence in Patient #1501's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

b. On 08/02/21 at 3:00 AM, the provider signed a telephone order for a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 10 mg to be administered via intramuscular injection (IM). Investigator #15 found no evidence in Patient #1501's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

c. On 08/02/21 at 4:15 PM, a chemical restraint of Ativan 4 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "anxiety and psychosis." Investigator #15 found no evidence in Patient #1501's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

d. On 08/08/21 at 9:50 AM, a chemical restraint of Ativan 4 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "aggressive behavior-refusal of all medications." Investigator #15 found no evidence in Patient #1501's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

Patient #1505

4. On 08/11/21, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical records for Patient #1505, a 31-year-old male admitted on 06/08/21, on an involuntary detainment with a psychiatric diagnosis of Schizoaffective Disorder. Review of the Patient's medical record showed the following:

a. On 06/09/21 at 8:30 AM, a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 5 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "agitation-aggression." Investigator #15 found no evidence in Patient #1505's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

b. On 06/09/21 at 10:30 PM, a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "severe agitation." Investigator #15 found no evidence in Patient #1505's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

c. On 06/10/21 at 10:39 AM, a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "agitation and psychosis." Investigator #15 found no evidence in Patient #1505's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

d. On 06/11/21 at 5:20 PM, a chemical restraint of Ativan 2 mg, Benadryl 50 mg, and Haldol 10 mg was ordered and administered via intramuscular injection (IM). The indication for the chemical restraint is documented by the provider as "agitation - assaultive behavior." Investigator #15 found no evidence in Patient #1505's medical record documenting an attempt to obtain a second medical opinion and review within 24 hours.

5. On 08/12/21 at 3:25 PM, during an interview with Investigator #15, the Director of Risk (Staff #1501), the Chief Nursing Officer (Staff #1507) and the Director of Quality (Staff #1502) verified that the medical records did not have a 2nd opinion for the emergency medication administration. Staff #1507 stated that the Chief Medical Officer and the Medical Executive Committee had addressed these medication administration discrepancies and new policies were being initiated to ensure that the 2nd signature is obtained for emergency medications. Staff #1501 stated that the new policies would reflect changes to ensure the hospital's compliance with the state regulations.

Item #2 Seclusion and Restraint - Follow Policies and Procedures for Safe, Appropriate Intervention

Based on interview, record review and review of hospital policy and procedures, the hospital failed to follow its policy and procedure for implementation, monitoring, evaluation, and documentation of patient's placed in restraint and seclusion, in accordance with safe and appropriate techniques for 4 of 4 patient's reviewed (Patient #1403, #1404, #1405, #1406).

Failure to follow established procedures for restraints and seclusion risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint," policy number POC.01.90, revised 08/21, showed the following:

a. Restraint means the use of manual, physical, material, equipment, OR a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

b. A chemical restraint is a drug used to restrict or manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

c. Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others, after less restrictive interventions are ineffective or ruled out.

2. Document review of the hospital's policy and procedure titled, "Informed Consent, Psychotropic Medications," policy number ICPM.100, last reviewed 08/21, showed the following:

a. During an emergency, when the patient constitutes a danger to self or others, and requires the use of medication:

i. Staff will follow the Restraint Policy.

ii. Staff will utilize the Seclusion and Restraint packet.

3. Document review of the hospital's documentation record titled, "Seclusion/Restraint Packet," showed the following as required documentation components:

a. Restraint/Seclusion Order: Completed practitioner order with rationale for intervention, least restrictive alternatives used prior to restraint/seclusion, criteria for release, and in person evaluation by practitioner or qualified registered nurse (RN).

b. Restraint/Seclusion Flowsheet: Documented continuous observation, including date/time initiated and date/time patient released.

c. Restraint/Seclusion Face-to-Face Evaluation: Completed by qualified RN within one hour of initiation of seclusion and/or restraint.

d. Aggression/Assault Individual Treatment Plan: To be completed and added to the Patient's treatment plan.

e. Restraint/Seclusion Staff Team Debriefing: To be completed by staff after incident. Not filed in medical record.

f. Restraint/Seclusion Patient Debriefing: To be filed in the medical record.

4. Investigator #14 reviewed the medical records of 4 patients placed in restraints. Of the 4 medical records reviewed, 3 of 4 did not have completed restraint and seclusion documentation per hospital policy (Patient #1403, #1405, #1406):

a. On 03/02/21, Patient #1403 was admitted to the hospital with a psychiatric diagnosis of schizophrenia. Review of Patient #1403's medical record showed the following:

i. On 08/25/21, Patient #1403 was placed in physical restraints. An order for physical restraints could not be found.

ii. On 08/25/21, Patient #1403 was given chemical restraint medications. An order for chemical restraint medication administration could not be found.

b. Patient #1405 was admitted to the hospital with a psychiatric diagnosis of acute psychosis. Review of Patient #1405's medical record showed the following:

i. On 08/02/21 at 3:00 AM, an order for 5-point physical restraint and chemical restraint medications was written. Due to an indication of agitation, the provider ordered Benadryl 30mg, Haldol 10mg, and Ativan 2mg to be administered intramuscularly (IM). Investigator #14's review of the medical record found the following seclusion and restraint documents missing: practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation.

ii. On 08/02/21 at 4:15 PM, an order for physical seclusion and restraint, including an order for chemical restraint medications was written. No indication was documented as an indication for the order. The provider ordered Benadryl 50mg, Haldol 10mg, and Ativan 4mg to be administered IM. Investigator #14's review of the medical record failed to find evidence of the seclusion and restraint packet documents, including: a practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation, and patient debrief.

iii. On 08/08/21, an order was written for seclusion and restraint, including an order for chemical restraint medications. The provider signature, date, and time were missing from the telephone order. Investigator #14's review of the restraint and seclusion packet documents found that staff failed to complete the required seclusion and restraint documentation, including: practitioner order for seclusion and restraint (missing practitioner signature), seclusion and restraint flowsheet (incomplete), and patient debrief.

c. Investigator #14 reviewed the medical record of Patient #1406. Patient #1406 was admitted to the hospital with a psychiatric diagnosis of acute psychosis. Review of Patient #1406's medical record showed the following:

i. On 03/26/21, a chemical restraint medication order was written for Geodon 20mg and Ativan 2mg IM. Investigator #14's review of the medical record failed to find evidence of the seclusion and restraint packet documents, including: a practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation, and patient debrief.

ii. On 04/05/21, a chemical restraint medication order was written for Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM. Provider signatures, dates, and times were missing from the medication order. Investigator #14's review of the medical record failed to find evidence of the seclusion and restraint packet documents, including: a practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation, and patient debrief.

iii. On 04/20/21, a chemical restraint medication order was written for Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM. Investigator #14's review of the medical record failed to find evidence of the seclusion and restraint packet documents, including: a practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation, and patient debrief.

iv. On 04/27/21, a chemical restraint medication order was written for Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM. Provider signatures, dates, and times were missing from the medication order. Investigator #14's review of the medical record failed to find evidence of the seclusion and restraint packet documents, including: a practitioner order for seclusion and restraint, seclusion and restraint flowsheet with observations, and RN face to face evaluation, and patient debrief.

5. On 08/26/21 at 4:30 PM, Investigator #14 interviewed the Director of Risk Management (Staff #1401). Staff #1401 reviewed the restraint documentation and confirmed that several required components were missing. Staff #1401 confirmed that the seclusion and restraint packet need to be completed during any seclusion or restraint intervention.

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Based on interview and document review, the hospital failed to develop and implement a hospital-wide quality assessment and performance improvmenent (QAPI) plan to monitor, evaluate, and improve the quality of patient care services through systematic data collection, analysis, implementation, and monitoring of quality activities.

Failure to systematically collect and analyze hospital-wide performance data limits the hospital's ability to identify problems and formulate action plans, reducing the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Failure to develop and implement a QAPI program that measured, analyzed, and tracked quality indicators.

Cross Reference Tag A-0273

2. Failure to develop action plans when performance goals were not being met.

Cross Reference Tag A-0283

3. Failure to develop, implement, and maintain a hospital-wide QAPI program that included evaluation of patient care contracts.

Cross Reference Tag A-0308

4. Failure to ensure that all improvement actions are evaluated.

Cross Reference Tag A-0309

Based on the scope and severity of deficiencies identified under 42 CFR 482.21 the Condition of Participation for Quality Assessment and Performance Improvement was NOT MET.

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Based on interview and review of the hospital's quality program and quality documents, the hospital failed to collect and analyze data for performance measures assigned by the Governing Body and Quality Council for the year 2020 and January through July 2021.

Failure to measure, analyze and track data related to performance measures as assigned leaves the hospital unable to identify contributing factors and develop action plans to improve patient outcomes.

Findings included:

1. Review of the hospital's document titled, "Process Improvement Plan," dated 01/21, and Appendix A of that document, showed that the hospital was to collect and analyze data for 92 different performance measures. Each performance measure was assigned to a specific person for data collection and analysis, and the reporting frequency was defined. The Governing Body was to review the performance measures either monthly or quarterly, as identified in Appendix A.

2. During review of the hospital's document titled, "Quality Council Report-Quarterly Report," Investigator #13 noted that the hospital's quality indicator data was presented in a line-listed format without aggregation or analysis.

3. On 08/25/21 at 3:00 PM, Investigator #13 interviewed the Director of Quality (Staff #1302). The interview showed the following:

a. The Performance Measure titled, "Seclusion/Restraint Documentation" was to be collected and analyzed by the Chief Nursing Officer and reported to the Quality Council, Medical Executive Committee, and Governing Body monthly. The Quality Council meeting document titled, "Quality Council Report-Quarterly Report" dated 05/20/21, showed that February, March, and April 2021 contained no data, and a note documented "data entry in progress." Review of the Governing Board meeting minutes, dated 04/27/21, showed that there was no report for Quarter 1, 2021 for this indicator.

b. The Performance Measure titled, "Physical Restraint Use; Seclusion Use" was to be collected and analyzed by the Chief Nursing Officer and reported to the Quality Council, Medical Executive Committee, and Governing Body quarterly. The Quality Council meeting document titled, "Quality Council Report-Quarterly Report" dated 05/20/21, showed that February, March, and April 2021 contained no data, and a note documented "data entry in progress." The Governing Board meeting minutes dated 04/27/21, showed that there was no report for Quarter 1, 2021 for this indicator.

c. The Performance Measure titled, "Staffing Adequacy," was to be collected and analyzed by the Director of Performance Improvement/Risk Management and reported to the Quality Council, Medical Executive Committee, and Governing Body quarterly. The Quality Council meeting document titled, "Quality Council Report-Quarterly Report" dated 05/20/21, showed that February, March, and April 2021 contained no data, and a note documented "N/A." The Governing Board meeting minutes dated 04/27/21, showed that there was no report for Quarter 1, 2021 for this indicator.

d. Investigator #13 and the hospital's Director of Quality (Staff #1302) reviewed the hospital's quality program and Quality Council meeting minutes for February, April, and May 2021. Review of the Quality Council meeting minutes showed the hospital did not aggregate performance improvement indicator data or perform statistical analysis, as directed by the hospital's Quality Assurance Performance Improvement (QAPI) plan.

e. At the time of the review, Staff #1302 stated that the information regarding action plans was given verbally during the Quality Council meeting and confirmed that the information was not found in the meeting minutes.

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Based on interview, document review, and review of quality documents, the hospital failed to develop and implement performance improvement activities and action plans that support hospital quality indicators related to patient safety and quality of care.

Failure to develop projects and action plans based on results of data collection aimed at improving patient outcomes places patients at risk from harm due to substandard care.

Findings included:

1. Document review of the hospital's Quality Assurance Performance Improvement (QAPI) plan titled, "Process Improvement Plan," dated 01/21, showed that the program supports the hospital by evaluation of program effectiveness through performance measures, action plans for poor performance, development of performance targets and ongoing quality improvement projects.

2. During an interview with Investigator #13 on 08/27/21 at 11:10 AM, the Director of Quality and Performance Improvement (Staff #1302) stated that the prioritization for the chosen quality indicators is on an attachment to the Process Improvement Plan. Staff #1302 stated that:

a. The quality indicators are identified as high volume, high risk or problem prone, and the document is maintained by the Director of Quality.

b. Data collection is a joint responsibility of all leadership. All leaders are assigned chart reviews, and data collection sheets are sent back to the Quality Director when completed. Results are discussed at the Quality Council meeting where red items (indicators that are below acceptable threshold of compliance) are called out to the responsible manager or director. Group discussion includes action planning.

3. Review of the hospital's Process Improvement Plan's Attachment A showed that 11 of the 92 indicators are listed as PRIORITY, but there was no rationale as to why these are priority indicators (there is no evidence of high risk, high volume or problem prone identification of indicators).

4. During an interview with Investigator #13 on 08/25/21 at 3:00 PM, the hospital's Director of Quality and Performance Improvement (Staff #1302) verified that there were no action plans found in the Quality Council minutes reviewed for 2020 or 2021.

5. Review of the Quality Council Report to the Governing Body dated 04/27/21 showed the following:

a. There were 92 indicators listed for reporting.

b. 25 of 92 indicators were scored red, indicating the compliance threshold was not met.

c. 35 of 92 indicators were marked "N/A" for not applicable.

d. 22 of 92 indicators were without data for the first quarter and had a notation that data entry was "in progress."

e. 9 of 92 indicators had no data with no remarks or explanations in the comment's column.

f. Chart audit results for January, February, and March 2021 showed the following:

i. 35 of 36 indicators for the Nursing Documentation audits were red.

ii. 9 of 9 indicators for the Sexual Acting Out audits were red.

iii. 18 of 21 indicators for the Interdisciplinary Treatment Plan and Updates audits were red.

g. There were no documented analyses or action plans included in the minutes.

6. On 08/27/21 at 10:38 AM, Investigator #13 interviewed the hospital's Chief Executive Officer (Staff #1308) and the Corporate Director of Quality (Staff #1304). During the interview, Staff #1304 stated that there was a lot going on, but it was not captured well in minutes.

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Based on interview and document review, the hospital failed to ensure that it's Quality Assurance Performance Improvement (QAPI) processes, which fall under the responsibility of the hospital's Governing Body, included systematic review of contracted patient care services.

Failure to ensure that the hospital QAPI processes included systematic review of contracted patient care services risks provision of clinical services not meeting hospital expectations.

Findings included:

1. On 08/26/21 at 2:30 PM, during a review of contracted services documents and interview with the Director of Risk Management (Staff #1301), Investigator #13 found that the facility did not require that evaluation of contracted services was a requirement of the Quality Program. Staff #1301 confirmed this finding.

2. Investigator #13's review of the hospital's contracts for contracted services on 08/26/21, found that 5 of 5 contracts had been evaluated more than 12 months prior to date.

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Based on interview and review of the hospital's Quality Assurance Performance Improvement (QAPI) plan, the hospital's Governing Body failed to ensure that the facility developed a systematic process for evaluating performance improvement action plans on an annual basis, as directed by the quality improvement plan.

Failure to systematically develop, monitor, and evaluate action plans limits the hospital's ability to improve patient outcomes.

Findings included:

1. Document review of the hospital's QAPI plan titled, "Process Improvement Plan," revised 01/21, showed that the quality program was to be reviewed and evaluated annually. Findings of the review were to be appropriately documented and reported by the Director of Quality to the Chief Executive Officer, Governing Board, the Medical Executive Committee, and the Quality Council.

2. Document review of the Quality Committee meeting minutes and Governing Board meeting minutes for 2021 showed that there was no documentation regarding the outcome of the 2020 Quality Program.

3. During an interview with Investigator #13 on 08/26/21 at 11:25 AM, the Director of Risk Management (Staff #1301) stated that the 2020 plan evaluation had not been done.

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Based on interview, policy review, and document review, the hospital failed to ensure that staff members developed, updated, and signed an interdisciplinary treatment plan for all patients, that included behavioral and medical problems and individualized interventions, as demonstrated by 7 out of 8 treatment plans reviewed (Patient #1401, #1402, #1404, #1405, #1406, #1523, and #1526).

Failure to ensure the development and maintenance of an interdisciplinary treatment plan for behavioral and medical problems places patients at risk for inappropriate, inconsistent, and delayed care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Treatment Planning," policy number PC.T.200, reviewed 02/21, showed that within 72 hours of admission, the treatment team shall develop an interdisciplinary treatment plan. The team includes the physician, nurse, and social worker at a minimum. Each treatment plan includes a diagnosis, strengths/liabilities, problems, activated problems, goals, and interventions.

Patient #1401

2. On 08/26/21 at 2:08 PM, Investigator #14 and the Director of Risk Management (Staff #1401) reviewed the medical records for Patient #1401. Patient #1401 was a 50-year-old female, involuntarily detained patient, admitted on 08/16/21, with a psychiatric diagnosis of Bipolar with Mania and Psychosis and medical diagnoses of Hyperlipidemia (high cholesterol in the blood), Diabetes (high glucose in the blood), Gastroesophageal Reflux Disease (GERD) (acid reflux), and Headaches. Document review of the patient's medical record showed the following:

a. On 08/19/21, the Interdisciplinary Master Treatment Plan (MTP) was initiated. The staff failed to include Hyperlipidemia, GERD, and Headaches on the Active Medical Problems list.

b. On 08/26/21 at 4:30 PM, Investigator #14 interviewed Staff #1401. Staff #1401 verified that the MTP was missing several known active medical problems.

Patient #1402

3. On 08/26/21, Investigator #14 reviewed the medical record for Patient #1402. Patient #1402 was a 55-year-old female, involuntarily detained patient, admitted on 08/22/21, with a psychiatric diagnosis of Schizoaffective Disorder and medical diagnoses of Anemia (low iron in the blood), Obesity, Hyperlipidemia (high cholesterol in the blood), Diabetes (high glucose in the blood), Gastroesophageal Reflux Disease (GERD) (acid reflux), and Sleep Apnea (inconsistent breathing while sleeping). Document review of the patient's medical record showed the following:

a. Investigator #14's review of the Interdisciplinary MTP, dated 08/23/21 found no documentation of GERD on the Active Medical Problem List.

b. Investigator #14 reviewed additional medical records dated 08/24/21. The records showed that the patient was placed on 1 to 1 observation due to sexual inappropriateness. As of 08/26/21, the problem of sexual inappropriateness had not been added to the MTP or Problem List.

c. Further review of the MTP showed that the staff failed to document the initial discharge criteria, initial discharge plan, patient signature, nurse signature, and provider signature.

d. On 08/26/21 at 4:30 PM, Investigator #14 interviewed Staff #1401. Staff #1401 verified that the MTP was missing several active medical problems, initial discharge plan, and participant signatures.

Patient #1404

4. On 08/26/21 at 4:45 PM, Investigator #14 and the Director of Risk Management (Staff #1401) reviewed the medical records for Patient #1404. Patient #1404 was a 28-year-old male, involuntarily detained patient, with a psychiatric diagnosis of Schizophrenia. Document review of the patient's medical record showed the following:

a. On 07/16/21, the Interdisciplinary MTP was updated. The nurse failed to sign their updated assessment.

b. On 08/26/21 at 4:30 PM, Investigator #14 interviewed Staff #1401. Staff #1401 verified that the MTP was missing a nurse signature for the assessment on 07/16/21.

Patient #1405

5. On 08/26/21 at 4:30 PM, Investigator #14 and the Director of Risk Management (Staff #1401) reviewed the medical records for Patient #1405. Patient #1405 was a 27-year-old male, involuntarily detained patient, admitted on 07/24/21 with a psychiatric diagnosis of Acute Psychosis. Document review of the patient's medical record showed the following:

a. On 07/26/21, the Interdisciplinary MTP was initiated. The provider interventions, signatures, and dates were missing from the document. The nursing interventions, signatures, and dates were also missing from the document.

b. On 08/26/21 at 4:30 PM, Investigator #14 interviewed Staff #1401. Staff #1401 verified that the MTP was missing provider and nursing contributions.

Patient #1406

6. On 08/26/21 at 4:30 PM, Investigator #14 and the Director of Risk Management (Staff #1401) reviewed the medical records for Patient #1406. Patient #1406 was a 29-year-old male, involuntarily detained patient, admitted on 02/12/21 with a psychiatric diagnosis of Acute Psychosis. Document review of the patient's medical record showed the following:

a. On 03/15/21, the Interdisciplinary MTP was updated. The provider signatures and dates were missing from the document. The patient signature or rationale for not signing were also missing from the document.

b. On 04/22/21, the MTP was updated. The provider signatures and dates were missing from the document. The patient signature or rationale for not signing were also missing from the document.

c. On 05/14/21, the MTP was updated. The provider signatures and dates were missing from the document. The patient signature or rationale for not signing were also missing from the document.

d. On 06/11/21, the MTP was updated. The provider signatures and dates were missing from the document. The patient signature or rationale for not signing were also missing from the document.

e. On 08/26/21 at 4:30 PM, Investigator #14 interviewed Staff #1401. Staff #1401 verified that the Interdisciplinary MTP was missing provider and patient contributions for the above dates.

Patient #1523

7. On 08/26/21 at 2:20 PM, Investigator #12 and the Director of Quality (Staff #1502) reviewed the medical records for patient #1523, a 67-year-old male, involuntarily detained patient, admitted on 08/02/21 for danger to self, delusions, and psychosis. Patient #1523 had a history of Schizoaffective Disorder, Post-Traumatic Stress Disorder (PTSD), and Anxiety. Document review of the patient's medical record showed the following:

a. On 08/02/21, the Interdisciplinary MTP was initiated and a total of five problems were identified. Two problems, Problems #2 and #4, showed a Target Date of "08/07" and Updated Date "08/23." Problems #1, #3, and #5 showed a Target Date of "08/07," but there were no documented Updated or Resolved Dates at the time of the review.

b. On 08/23/21, the MTP was updated. Staff did not update the patient's progress or plan for changes in the treatment plan for either goal of Problem #1. The patient signature or rationale for not signing were also missing.

c. On the Individual Treatment Plan for Psychiatric Problem #1, staff failed to document the identified primary problem. The initiated date documentation for two short term goals, the social services update, and the activities therapy update was also missing.

Patient #1526

8. On 08/26/21 at 2:40 PM, Investigator #12 and the Director of Quality (Staff #1502) reviewed the medical records for Patient #1526, a 55-year-old male, involuntarily detained patient, admitted on 06/19/21 for treatment of Chronic Paranoid Schizophrenia. Document review of the patient's medical record showed the following:

a. On 06/22/21, the Interdisciplinary MTP Psychiatric Problem Sheet was initiated. The provider signature, intervention, and date were missing from the document.

b. On 06/28/21, staff initiated the Altered Tissue Perfusion Treatment Plan. The nurse's signature was missing from the document.

c. On 07/30/21, the MTP was updated. The treatment plan was missing documentation to show that the patient fell on 07/24/21 and that he had been identified as a fall risk.

d. On 08/06/21, the MTP was updated. The Interdisciplinary MTP Update sheet was incomplete and did not contain any information for the patient's medical problems 2, 3, 4, 5, 6, and 7, including goals, progress, or plan information. The treatment plan was missing documentation to show that the patient fell on 07/24/21 and that he was a fall risk.

e. On 08/13/21, the MTP was updated. The Interdisciplinary MTP Update sheet was incomplete and did not contain any information for the patient's medical problems 2, 3, 4, 5, 6, and 7, including goals, progress, or plan information. The treatment plan update did not show that the patient fell on 07/24/21, if he was injured from the fall, or that he was a fall risk.

f. On 08/20/21, the MTP was updated. The Interdisciplinary MTP Update sheet was incomplete and did not contain any information for the patient's medical problems 2, 3, 4, 5, 6, and 7, including goals, progress, or plan information. The treatment plan update did not reflect that the patient fell on 07/24/21, his status post-fall, or that he was a fall risk.

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Based on interview and personnel record review, the hospital failed to ensure that nurses received documented hospital orientation for 1 of 3 files reviewed (Staff #1412), and failed to complete annual performance evaluations for 2 of 3 personnel records reviewed (Staff #1406 and #1407).

Failure to ensure nursing staff receive orientation to the hospital and annual performance evaluations places patients at risk for inconsistent or inadequate care.

Findings included:

1. On 08/26/21 at 12:15 PM, Investigator #14 and the Director of Human Resources (Staff #1405) reviewed the personnel files for 3 staff members who provided patient care. Of the 3 personnel records reviewed, 2 of 3 (Staff #1406 and #1407) were missing current job evaluations. Investigator #14 found that 1 of 3 of the personnel records reviewed was missing documentation of the hospital's employee orientation (Staff #1412).

2. On 08/26/21 at 12:15 PM, Investigator #14 interviewed Staff #1405 regarding the missing job evaluations and orientation. Staff #1405 confirmed the missing orientation and evaluations and verified that it is the hospital's policy for nurses to have orientation and yearly evaluations.

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Based on interview, document review, and review of policies and procedures the hospital failed to ensure the development, implementation of an effective discharge planning process for patients that focused on the patient's individual goals and treatment preferences, included the patient's participation, and ensured an effective, safe transition to post-hospitalization care.

Failure to ensure the development and implementation of an effective discharge planning process results in ineffective clinical care, negative patient outcomes, and increases the risk for patient readmission.

Findings included:

1. Failure to develop and implement a discharge plan for the patient.

Cross Reference Tag A-0801

2. Failure to re-evaluate the patient's discharge plan and make modifications, as necessary.

Cross Reference Tag A-0802

3. Failure to ensure adequate discharge planning documentation in the medical records, as outlined in the Special Conditions of Participation - Special Medical Record Requirements for Psychiatric Hospitals.

Cross Reference Tag A-1620

Based on the scope and severity of deficiencies identified under 42 CFR 482.43 the Condition of Participation for Discharge Planning was NOT MET.

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that staff implemented the hospital's discharge and aftercare policies, including developing a discharge plan that included all professionals who will follow-up with the patient, a provider to order discharge for continuing care, communication with transfer of information to other program agencies providing continuing care, including the patient in the development of the plan, and ensuring complete and appropriate documentation on the patient's Discharge and Aftercare plan, as demonstrated by 9 of 9 records reviewed (Patients #1201, #1519, #1527, #1529, #1531, #1532, #1533, #1534, #1535, and #1536).

Failure to ensure that patients receive comprehensive discharge planning places patients at risk for receiving inappropriate or inadequate post-hospitalization follow-up and continuing care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, last reviewed 02/21, showed the following:

a. The patient's demonstrated readiness for discharge should be linked to the achievement of treatment goals. Long-term goals represent the highest level of function which the patient is expected to achieve during current hospitalization.

b. Discharge goals represent the achievements expected for the identified problem by the time of discharge.

c. Discharge planning begins at the point of admission by the physician and continues throughout treatment as an interdisciplinary effort. Discharge criteria are established by the physician during the admission process and revised as necessary during treatment. Possible discharge date and post-treatment goals are discussed as the patient moves toward achieving the criteria set for discharge.

d. The physician and therapist, with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain discharge needs may be considered for the patient, including a return to the home, outpatient therapy, community and support groups, transportation, medical follow-up, and aftercare programs.

e. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient.

f. Ongoing discharge planning takes place at least weekly during Interdisciplinary Treatment Team meetings and with the patients/families. In addition, discharge planning occurs on an individual basis and/or in group.

g. The discharge planning process should include the following:

i. Evaluation of all indicators of readiness for discharge, including psychosocial status and living situation, patient's level of care required at the time of discharge, and assessment of the patient needs for aftercare services.

ii. Address the patient's and family's concerns for instructions about continued treatment.

iii. Assist the patient/family to self-refer for appropriate community-based resources.

iv. Educate the patient/family in understanding the patient's aftercare needs and involve them in the decision-making process.
Advise the patient/family of options and assist in making effective use of community resources.

v. Delineate how progress made in the current level of care will continue after discharge.

vi. Identify problems to be addressed in the next level of care, including any ongoing health issues.

vii. Identify the responsibility for ensuring the prescribed follow-up is accomplished.

viii. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing care (i.e. primary care provider, skilled nursing facility, therapists, etc.).

h. The discharge plan should consider the continuation or completion of those treatments which were generated in the current level of care and the initiation of those treatments which are needed but deferred to another phase of treatment.

i. When developing discharge aftercare plans, staff must consider family relationships, physical and psychiatric needs, financial needs, housing or placement issues, accessibility to community resources, personal support systems, transportation problems related to aftercare treatment, potential for recidivism, a list of crisis numbers given to the patient/family, and a list of community resources specific to the patient's individual needs.

j. The discharge/aftercare plan defines the following:

i. The patient's final diagnosis.

ii. Where the patient will live following discharge.

iii. The level of care which the patient will be discharged to.

iv. All professionals who will follow-up with the patient, including medical follow-up for medication management.

v. All appropriate recommendations and specific plans to include psychiatric, medical, case management, housing, other community support needs and community resources available to meet these needs.

vi. Referrals to self-help groups, support groups, or community resources.

vii. Specific efforts to educate the family/receiving facility/agency, regarding the patient's treatment interventions, nature and management of the patient's illness, medication, and prognosis.

viii. Follow-up appointments based on the patient's clinical need.

ix. A crisis management plan when indicated.

k. Aftercare plans are communicated to the patient/family or receiving facility/agency as appropriate and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family or sent to the receiving facility/agency with the patient.

l. The treatment team will develop a discharge plan with active participation from patient/family. The post-discharge plan shall be reviewed and signed by the patient/family and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patient's inability or refusal to sign or participate in discharge planning, and the patient's reason for such, shall be documented on the plan.

m. Post-discharge services will be arranged with appropriate resources prior to discharge including appointments made for follow-up treatment, medication management and education regarding the nature and management of the patient's illness or disorder to meet the needs of the patient. If post-discharge services cannot be obtained, the inpatient facility will provide interim follow-up services, including medication management, with the patient for up to 2 weeks post discharge.

n. Discharge responsibilities include the following:

i. The physician will write an order for discharge in the patient's medical record.

ii. The registered nurse (RN) will note the physician's order, complete the nursing sections of the discharge form, review instructions with the patient/family, and provide a nurse to nurse handoff with the receiving facility, if applicable.

iii. The social worker will complete the social service portion of the discharge form.

2. Document review of the hospital's policy and procedure titled, "Treatment Planning," policy number PC.T.200, reviewed 02/21, showed that within 72 hours of admission, the treatment team shall develop an Interdisciplinary Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, and emotional and behavioral status. The treatment plan shall contain specific discharge criteria necessary for the individual patient to achieve and maintain emotional, physical, social, and recreational stability as deemed appropriate for the patient's capabilities. For patients admitted to the Detox Unit, the counselor/social worker will add appropriate goals and interventions, including discharge planning goals, to the Initial Treatment Plan within 48 hours of admission

The treatment plan shall be reviewed, updated, and/or revised within 7 days of admission, and all subsequent updates to the plan shall occur at least every seven days during hospitalization. The treatment plan reviews and updates shall include a review of progress toward goals and effectiveness of intervention for each open problem of the Problem List, modifications or additions made to goals and interventions as appropriate, and updates to the discharge plan, estimated length of stay, and justification for continued stay.

Patient #1201

3. Investigator #12 reviewed the medical record of Patient #1201, a 28-year-old patient admitted involuntarily on 07/08/21 for schizophrenia. Patient #1201 left the hospital against medical advice (AMA) on 07/19/21. The medical record review showed the following:

a. Patient #1201 was detained while in jail after refusing to leave the cell, declining medications, not engaging with, or speaking to staff, and for poor hygiene including urinating and defecating in his cell.

b. The Interdisciplinary Treatment Plan created on 07/08/21 showed a primary problem of disturbed thought with paranoia, and a short-term goal of "Improved personal hygiene and care for health needs by showering, eating, and changing clothes on a daily basis." Staff failed to identify the patient's ability to meet basic life and health needs under Initial Discharge Criteria.

c. On 07/15/21, social services updates to the Interdisciplinary Treatment Plan showed that referrals were indicated for discharge placement to assist with medication management and ability to locate community services.

d. On 07/19/21, discharge papers showed that the patient's case was dismissed by the court, and the patient chose to leave the facility against medical advice (AMA). The Discharge Form showed the following:

i. The discharge form did not include a discharge address, phone number or emergency contact information.

ii. The treatment summary information was incomplete and did not indicate the type of service or the type of discharge.

iii. The Recovery and Support section was incomplete and did not include Medical and Psychiatric Advanced Directive (MPAD) information or if medical equipment was needed.

iv. The Discharge Medications form did not indicate if the patient was discharged on a long acting injectable medication.

Patient #1519

4. Investigator #12 reviewed the medical record of Patient #1519, a 76-year-old admitted on 07/28/21 for major depression with suicide ideation (SI). Patient #1519 was discharged to a family member's home on 08/16/21. The medical record review showed the following:

a. The Treatment Summary did not include the name of the attending provider.

b. The Recovery and Support section was incomplete and did not include MPAD information. The Medical Equipment was marked "N/A," but documentation showed that the patient "lost the ability to walk" 2 to 3 years ago, and the patient uses a walker.

c. The Discharge Medications form did not indicate if the patient was discharged on a long acting injectable medication.

d. The Interdisciplinary Treatment Plan was initiated on 07/30/21, and updates from social services were documented on 08/04/21 and 08/12/21. The social services updates on 08/04/21 and 08/12/21 did not include Discharge Planning Updates.

Patient #1527

5. Investigator #12 reviewed the medical record of Patient #1527, a 65-year-old patient admitted on 06/15/21 for alcohol abuse and detox. The patient discharged on 06/19/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan was initiated on 06/15/21. The Interdisciplinary Treatment Plan Master Sheets did not include nursing or social services signatures.

b. The Discharge Form contact information was missing including the patient's discharging address and phone number, and emergency contact information.

c. There was no information instructing the patient to follow-up with her primary care provider (PCP) in 2-4 weeks and no documentation showing that the patient's information was sent to the PCP after discharge.

d. The important contact information was incomplete, and staff did not review the discharge plan with the patient. The patient and staff signatures were missing from the Discharge Form.

e. The Discharge Form Treatment Summary information did not include the patient's attending physician or information on tests or procedures performed during hospitalization.

f. The Discharge Form Recovery and Support information was missing documentation on MPAD, medical equipment needs, and self-care activities.

g. The Discharge Medications did not include long acting injectable medication information or information on any discontinued medications, if applicable.

Patient #1529

6. Investigator #12 reviewed the medical record of Patient #1529, a 51-year-old patient admitted on 05/27/21 for suicide ideation and methamphetamine abuse. Patient #1529 was discharged to an inpatient rehab facility on 06/07/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan was initiated on 05/29/21. There was no documentation of updates to the patient's Master Treatment Plan during hospitalization.

b. The Discharge Form treatment summary was incomplete and did not include the dates of admission and discharge, the type of discharge, the attending physician, or the reason for admission.

c. The Discharge Form recovery and support information was incomplete and did not include if the patient required medical equipment or assistance with self-care activities.

Patient #1531

7. Investigator #12 reviewed the medical record of Patient #1531, a 26-year-old patient admitted on 07/13/21 for suicide ideation with a suicide attempt and alcohol abuse. Patient #1531 was discharged on 07/16/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan was initiated on 07/13/21 and included primary problems of heavy daily alcohol abuse and depressed mood without psychosis. The Interdisciplinary Treatment Plan Master Sheet did not include nursing, physician, social services, or patient signatures.

b. The Interdisciplinary Treatment Plan Master Sheet did not include an admission date, anticipated discharge date, psychiatric and medical diagnoses, assessment of the patient's strengths and weaknesses, initial discharge criteria, or an initial discharge plan.

c. The Discharge Form did not include the discharge setting or transportation mode.

d. Patient #1531 had a history of hypokalemia and malnutrition and was instructed to follow up with a primary care provider (PCP). The patient did not have a PCP, but he was not provided with information on community resources available. The patient was instructed to call a different hospital in Tacoma so that they could provide him with a PCP.

e. The Discharge Plan Review was incomplete and missing a staff signature, date, and time.

f. The Discharge Form Treatment Summary was incomplete and missing information including the reason for admission and information regarding tests and procedures completed during hospitalization.

g. The Recovery and Support section was incomplete and missing MPAD information.

h. The Discharge Medications did not include information regarding long acting injectable medication, and staff failed to check "not applicable" if the patient had no medications to be discontinued.

Patient #1532

8. Investigator #12 reviewed the medical record of Patient #1532, a 33-year-old patient admitted on 07/29/21 for opioid dependence. The patient discharged AMA on 08/02/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan Master Sheet was initiated and signed by a registered nurse on 07/29/21. The physician, social worker, activities coordinator, and patient signatures, with date and time, were missing.

b. The Interdisciplinary Treatment Plan Master Sheet did not include an anticipated discharge date, a psychiatric diagnosis, patient asset and weakness information, initial discharge criteria, and initial discharge plan information.

c. The Discharge Form Contact Information did not include the patient's address.

d. There were no referrals for scheduling follow-up care appointments including mental health, addictions treatment, or primary care physician, and no documentation on the form showing that the patient refused the information.

e. The Discharge Form Treatment Summary did not include the discharge date or information regarding studies with pending results.

f. Staff did not include any diagnoses at discharge, MPAD information, or information regarding the need for medical equipment.

g. Staff did not include information regarding any discharge medications, including long acting injectable medications, or any medications that needed to be discontinued.

h. There was no patient or staff signature on the Discharge Form, and no documentation of the patient's refusal to sign or the reason for the patient's refusal to participate.

i. The Patient's Discharge Summary was incomplete and did not include information regarding the patient's clinical diagnosis or a summary of the hospitalization.

Patient # 1533

9. Investigator #12 reviewed the medical record of Patient #1533, a 55-year-old patient admitted involuntarily on 07/28/21 for SI. The patient discharged AMA on 08/10/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan Master Sheet (MTP) was initiated on 07/29/21. The physician, RN, social worker, and activities coordinator signatures with date and time, were missing.

b. The Interdisciplinary Treatment Plan was not updated after the Interdisciplinary MTP dated 07/29/21. The patient discharged on 08/10/21, yet the medical record did not contain a treatment plan update, which is required weekly after the initiation of the MTP, as directed by hospital policy.

c. The Discharge Form Contact Information did not include the patient's address or setting type.

d. There were no referrals for scheduling follow-up care appointments including mental health, addictions treatment or primary care physician and no documentation on the form showing that the patient refused the information.

e. Staff did not document if any medications needed to be discontinued.

Patient #1534

10. Investigator #12 reviewed the medical record of Patient #1534, an 87-year-old patient admitted to the Geropsych Unit on 07/31/21 for depression and SI. The patient was transferred to another medical facility on 08/06/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan was initiated on 07/31/21. Documentation of the patient's anticipated discharge date, patient strengths and weaknesses, initial discharge criteria, and initial discharge plan information was missing. The physician, RN, social worker, activities coordinator, and patient signature and date information was missing.

b. The Interdisciplinary Treatment Plan update on 08/06/21 did not include updates on discharge planning, or nursing updates, or signatures with dates from the nurse and the patient.

c. The patient was transferred to another hospital on 08/06/21, but there was no documentation of a change in the patient's condition or reason for the transfer. There is no documentation that a nurse to nurse handoff occurred with the transfer of care.

Patient #1535

11. Investigator #12 reviewed the medical record of Patient #1535, an 82-year-old patient admitted involuntarily on 06/29/21 for treatment of bipolar schizophrenia with psychosis. The patient discharged home with family on 08/13/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan Update forms showed that treatment team conferences occurred on 07/07/21, 07/15/21, 07/22/21, 07/28/21, and 8/06/21.

b. Social services staff failed to document Discharge Planning Issues for 5 of 5 Interdisciplinary Treatment Plan updates.

c. The Discharge Form Scheduled Aftercare Appointments showed the patient was scheduled for follow-up mental health therapy and psychiatric medication management appointment and provided with case management contact information. There was no documentation showing that the Discharge Care Plan was sent to the continuing care providers within 24 hours post-discharge.

d. The Discharge Form Treatment Summary did not show the patient's date of admission, attending physician, reason for admission or routine test results information.

e. The Recovery and Support section did not contain documentation of MPAD status or accurately address the patients need for assistance with self-care activities.

f. The Discharge Medications information did not include tobacco cessation or long acting injectable medication information, and patient and staff signatures, dates and time information was missing.

Patient #1536

12. Investigator #12 reviewed the medical record of Patient #1536, a 31-year-old patient admitted on 07/19/21 with psychosis, substance abuse, and possible suicide attempt. The patient discharged on 07/26/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan Master Sheet was signed by the patient and social worker on 07/20/21. The social worker interventions were initiated on 07/21/21. The physician and RN signatures, with date and time, were missing from the Master Sheet, and there was no documentation of physician or nursing interventions under the patient's primary psychiatric problem.

b. There were no social worker progress notes or Interdisciplinary Treatment Plan updates, and there was no documentation showing that discharge and aftercare planning occurred prior to the patient's discharge on 07/26/21.

c. On 07/24/21, the psychiatrist notes showed that the patient had delusional thought processes, was still in process of achieving treatment goals, and the estimated day of discharge was in "3 - 5 days." There were no psychiatrist notes for 07/25/21 and 07/26/21. There was no documentation showing that the patient's psychiatric treatment goals were achieved, and the patient met the criteria for discharge.

13. On 08/27/21 at 9:40 AM, Investigators #12 and #15 interviewed the Chief Clinical Officer (Staff #1512) and the Director of Social Services (Staff #1506). Staff #1506 stated that the patients' Interdisciplinary Treatment Plans were initiated and signed by the physician, RN, social worker, and activity therapist within 72 hours of admission. Staff #1506 stated that social workers were responsible for initiating the Treatment Plan Master Sheets, completing the treatment team conference sheets, entering social services updates, and documenting notes from any 1:1 meeting with the patient. Staff #1512 stated that when patients were discharged, the medical record documentation should show that the patient achieved the treatment goals during hospitalization and how the goals were met. Staff #1506 and #1512 discussed the hospital's audit process and confirmed Investigator #12's findings that staff were not completing the Discharge Forms according to hospital policy.

14. On 08/27/21 at 1:05 PM, Investigators #12 and #15 interviewed the Substance Use Disorder Program Manager (Staff #1516). Staff #1516 stated that a patient's readiness for discharge is determined by reviewing the information in the treatment plan updates and during treatment team meetings. Staff update the Treatment Plans on a weekly basis for rehab patients and daily for detox patients. Staff #1516 stated that discharge orders for the SUD patients are written by the medical provider, and rehab patients are not usually followed by a psychiatrist unless requested by the medical provider.

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Based on observation, interview, and document review, the hospital failed to ensure that staff implemented its policies and procedures for re-evaluating patients for changes in condition that require modification to the discharge plan and for updating the discharge plan when changes occur for 9 of 10 patient records reviewed (Patients #1201, #1519, #1529, #1531, #1532, #1533, #1534, #1535, and #1536).

Failure to re-evaluate patients for changes in condition that require modification to the discharge plan and to update the discharge plan risks patients receiving inappropriate or inadequate care during hospitalization and following discharge.

Findings included:

1. Review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, last reviewed 02/21, showed that ongoing discharge planning takes place at least weekly during Interdisciplinary Treatment Team meetings with the patient/family and may also occur in individual and group settings. The treatment team will develop a discharge plan with active participation from patient/family. The post-discharge plan shall be reviewed and signed by the patient/family and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patient's inability or refusal to sign or participate in discharge planning, and the patient's reason for such, shall be documented on the plan.

2. Review of the hospital's policy and procedure titled, "Treatment Planning," policy number PC.T.200, reviewed 02/21, showed that the treatment team shall develop an Interdisciplinary Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status within 72 hours of admission. The treatment plan shall be reviewed, updated, and/or revised within 7 days of admission, and all subsequent updates shall occur at least every seven days during hospitalization. Treatment plan reviews shall include updates to the discharge plan, estimated length of stay, and justification for continued stay.

3. On 08/25/21 at 9:30 AM, Investigators #12 and #14 observed the Interdisciplinary Treatment Team Conference on the 3 North Unit. The observation showed that Treatment Team Conference took place in a meeting room off the patient care floor. Meeting attendees included providers, a charge nurse, social workers, an activities therapist, the Chief Clinical Officer, and utilization review staff. Staff discussed patient behaviors, treatment progress, discharge goals and barriers to discharge, medication changes, and insurance issues. Investigators observed that staff brought all patient charts into the room, but nobody was assigned to document updates to the individual Treatment Plans during the meeting. Patients were not invited to participate in the Treatment Team Conference.

4. On 08/25/21 at 9:25 AM, the Investigators interviewed the charge nurse (Staff #1201) about the Treatment Team Conference process. Staff #1201 confirmed that the patients were not included in the Treatment Team meetings.

5. On 08/25/21 at 10:15 AM, Investigators interviewed the Chief Clinical Officer (Staff #1512) following the Treatment Team Conference. Staff #1512 confirmed that the hospital has no process for updating the Treatment Plans during the weekly conferences.

Patient #1201

6. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1201, a 28-year-old patient admitted involuntarily on 07/08/21 for Psychosis. Patient #1201 left the hospital against medical advice (AMA) on 07/19/21. The medical record review showed the following:

a. The patient transferred to the facility from the South Correctional Entity (SCORE) jail. The Treatment Plan Update on 07/15/21 showed that the Discharge Planning Issues included a referral to the Crisis Respite Program (CRP) was recommended, but it contained no documentation of any legal issues or pending court date related to the Patient's involuntary detainment.

b. On 07/19/21, Patient #1201 discharged against medical advice (AMA) after the court dismissed the patient's case. Patient #1201 was provided with a list of emergency shelters, homeless services, and mental health services and information on outpatient services in King and Spokane Counties. Investigator #12 found no evidence that staff arranged for aftercare services prior to the patient's AMA discharge.

Patient #1532

7. On 08/27/21, Investigator #12 reviewed the medical record of Patient #1532, a 33-year-old patient admitted on 07/29/21 for Opioid Dependence. The patient left AMA on 08/02/21. The medical record review showed that the Interdisciplinary Treatment Plan Master Sheet was not signed by the physician, social worker, activities coordinator, or patient, and it was missing discharge planning documentation including an anticipated discharge date, patient strengths and weaknesses, initial discharge criteria, and initial discharge plan information.

Patient #1533

8. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1533, a 55-year-old patient admitted involuntarily on 07/28/21 for Suicidal Ideation (SI). The patient left AMA on 08/10/21. The medical record review showed the following:

a. The Interdisciplinary Treatment Plan showed that the patient was homeless, but the initial discharge criteria did not address the need for adequate post-discharge living arrangements.

b. The Treatment Team did not review the Initial Treatment Plan within 7 days of admission or update it to include Discharge Planning Issues at any time during the patient's hospitalization.

c. On 08/03/21 between 11:00 AM to 11:02 AM, a social worker tried to meet with Patient #1533 to discuss discharge planning, but the patient was "too preoccupied with getting his clothes." The social worker ended the conversation and did not document any further attempts to discuss discharge planning with the patient.

Patient #1519

9. On 08/26/21 at 12:00 PM, Investigator #12 reviewed the medical record of Patient #1519, a 76-year-old admitted on 07/28/21 for Major Depression with Suicidal Ideation (SI). Patient #1519 was discharged to a family member's home on 08/16/21. The medical record review showed that the Interdisciplinary Treatment Plan was initiated on 07/30/21. Updates from social services were documented on 08/04/21 and 08/12/21, but they did not include Discharge Planning Updates.

Patient #1529

10. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1529, a 51-year-old patient admitted on 05/27/21 for Suicidal Ideation (SI) and Methamphetamine Abuse. Patient #1529 was discharged to an inpatient rehab facility on 06/07/21. Documentation showed the Interdisciplinary Treatment Plan was initiated on 05/29/21, but it was not reviewed or updated during the patient's hospitalization. There was no documentation to show that staff re-evaluated the patient on a regular basis for changes in condition that would require modification to the discharge plan.

Patient #1531

11. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1531, a 36-year-old patient admitted on 07/13/21 at 9:59 AM for Suicidal ideation (SI) with a suicide attempt and Alcohol Abuse. Patient #1531 was discharged on 07/16/21 at 3:35 PM. The medical record review showed that the patient was admitted to the hospital for co-occurring treatment. The investigator found no documentation showing that staff developed an initial discharge plan, reviewed the discharge plan with the patient, or re-evaluated the patient's condition and discharge readiness during hospitalization.

Patient #1534

12. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1534, an 87-year-old patient admitted to the Geropsych Unit on 07/31/21 for Depression and Suicidal Ideation (SI). The patient was transferred to an unidentified address in Auburn on 08/06/21. The medical record review showed that the initial discharge criteria and initial discharge plan was not documented on the Interdisciplinary Treatment Plan Master Sheet, and staff failed to document discharge planning updates or evidence that the patient was re-evaluated for discharge readiness during the Treatment Team conference on 08/06/21.

Patient #1535

13. On 08/27/21 at 8:30 AM, Investigator #12 reviewed the medical record of Patient #1535, an 82-year-old patient admitted involuntarily on 06/29/21 for treatment of Bipolar Schizophrenia with Psychosis. The patient discharged home with family on 08/13/21. The medical record review showed the following:

a. Interdisciplinary Treatment Team conferences occurred on 07/07/21, 07/15/21, 07/22/21, 07/28/21, and 08/06/21.

b. The Treatment Team did not meet to review the patient's initial Treatment Plan, including the initial discharge criteria and discharge plan, within 7 days of admission.

c. Social services staff failed to document Discharge Planning Issues for 5 of 5 Treatment Plan Updates.

Patient #1536

14. On 08/26/21 at 11:40 AM, Investigator #12 reviewed the medical record of Patient #1536, a 31-year-old patient admitted on 07/19/21 with Psychosis, Substance Abuse, and possible suicide attempt. The patient discharged on 07/26/21. The medical record review showed that there were no social services progress notes or Interdisciplinary Treatment Plan updates, and there was no documentation showing that discharge and aftercare planning occurred prior to the patient's discharge on 07/26/21.

15. On 08/27/21 at 9:40 AM, Investigators #12 and #15 interviewed the Chief Clinical Officer (Staff #1512) and the Director of Social Services (Staff #1506) who confirmed the Investigators' findings.

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Based on observation, interview, policy review and record review, the hospital failed to ensure that the medical record provided information that indicated the degree and intensity of the treatment provided to individuals who are furnished services at the facility.

Failure to ensure that the medical records contained documentation of the degree and intensity of the treatment provided puts the patient at risk for ineffective treatment and creates barriers to effective post hospitalization care, negatively impacting patient outcome.

Findings included:

1. Failure to develop and implement an individualized comprehensive treatment plan based on an inventory of the patient's strengths and disabilities.

Cross Reference: A1640

2. Failure to develop and implement an individualized comprehensive treatment plan that included short-term and long-range goals.

Cross Reference: A1642

3. Failure to develop and implement an individualized comprehensive treatment plan that utilized specific treatment modalities.

Cross Reference: A1643

4. Failure to ensure treatment documentation that provided adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.

Cross Reference: A1645

5. Failure to ensure that the treatment received by the patient is documented in such a way to ensure that all active therapeutic efforts are included.

Cross Reference: A1650

6. Failure to ensure that progress notes recorded by the staff responsible for the care of the patient, involved in active treatment modalities, contained recommendations for revisions in the treatment plan as indicated.

Cross Reference: A1661

7. Failure to ensure that the medical record of each patient who had been discharged had a discharge summary that included a recapitulation of the patient's hospitalization.

Cross Reference: A1670

8. Failure to ensure that the medical record of each patient who had been discharged had a discharge summary that included recommendations for appropriate services concerning follow-up or aftercare.

Cross Reference: A1671

9. Failure to ensure that the medical record of each patient who had been discharged had a discharge summary that included a summary of the patient's condition on discharge.

Cross Reference: A1672

Due to the scope and severity of deficiencies cited under 42 CFR 482.61, the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals was NOT MET.

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Based on interview, record review, and policy review, the facility failed to ensure that the Master Treatment Plans (MTPs) were based on an inventory of the patient's individualized, descriptive strengths and disabilities for 4 of 10 active sample patients (Patient #1501, #1514, #1520, and #1526). The strengths identified on the preprinted checklist were general statements and failed to describe each of the patient's personal assets that could be used to develop treatment goals and interventions. In addition, the MTPs failed to include identified medical problems, or contained problems that were generalized psychiatric jargon instead of behaviorally descriptive psychiatric problems based on the patient's assessment data.

Failure to ensure that the MTP identified the patient's strengths and their disabilities, including behaviorally descriptive and/or medical problems may negatively impact clinical decision-making when developing the MTP and creates barriers to the development of the patient's individual goals and interventions.

Findings included:

1. Document review of the hospital's document titled, "Treatment Planning," policy number PC.T.200, last reviewed 01/21, showed the following:

a. Each patient admitted to the hospital shall have a written, individualized treatment plan that is responsive and timely to the treatment needs of the patient based on information provided by the patient, patient's family, and assessments by the clinical treatment team.

b. Based on these assessments, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provisions for aftercare.

2. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patients #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that each patient had an individualized comprehensive Master Treatment Plan (MTP) that was based on an inventory of the patient's individualized strengths and disabilities. The medical record review showed the following:

a. On Patient #1501's MTP, dated 07/26/21, staff documented the following Patient Assets and Patient Liabilities:

i. Patient Assets/Strengths: "Support System, Motivated, Physical Health, Spirituality, Communication Skills, Sense of Humor, and Capable of Independent Living."

ii. Patient Liabilities/Weaknesses: "Limited Support System and Poor Family Relations."

iii. The assets identified failed to provide an accurate description of the Patient's strengths at the time of his admission and consequently failed to identify opportunities for support and interventions. Investigator #15's review of the Petition for Initial Detention, dated 07/21/21, found that the Designated Crisis Responder (DCR) documented that Patient #1501 was homeless and was detained at the home of a woman he had met during a previous psychiatric hospitalization, requiring a combination of 7 police and Emergency Medical Services (EMS) staff to get him into restraints.

On the Psychosocial Assessment, dated 07/26/21, staff documented that Patient #1501 was homeless and requested housing resources. The Patient reported having no family in Washington and stated that his support system was a "friend." Staff documented that barriers to discharge included homelessness, a limited support system, and no connection to mental health services. On the Psychiatric Evaluation, dated 07/25/21, the provider documented that Patient #1501 presented with poor judgement and insight and refused to take any medications.

b. On Patient #1514's MTP, dated 05/28/21, staff documented the following Patient Assets and Patient Liabilities:

i. Patient Assets/Strengths: There were no assets or strengths documented for Patient #1514.

ii. Patient Liabilities/Weaknesses: "Medication Non-compliance, Pathological Un-supported Environment, History of Suicidal Ideation (SI)."

iii. Failure to identify the Patient's assets and/or strengths, does not provide an accurate representation of the Patient's at the time of his admission.

iv. On 05/28/21, staff documented that Patient #1514's Active Psychiatric Problem #1 was "amotivated (a reduction in the motivation to initiate or persist in goal-directed behavior); anhedonia (inability to experience pleasure)." Staff documented on the Individual Treatment Plan that Problem #1 was "Disturbed Thought with paranoia and delusions." Investigator #15's review of the medical record found that the MTP's Problem #1 and the Individual Treatment Plan Problem #1 were incongruent and failed to include clear descriptive information about the Patient's impairments based on the clinical assessments. On the Psychiatric Evaluation, dated 05/28/21, the provider documented that prior to hospitalization, Patient #1514 "was staying at a shelter when he displayed very threatening behavior and was holding a knife to his own throat threatening to kill himself." The provider noted that the patient is also "known to have suicidal ideation in the past."

c. On Patient #1520's MTP, dated 08/23/21, staff documented the Psychiatric Diagnosis as Schizoaffective Disorder. Staff documented the Patient's Assets/Strengths and Liabilities/Weaknesses are as follows:

i. Patient Assets/Strengths: "Support System, Spirituality, Capable of Independent Living, Insightful, and Intelligent."

ii. Patient Liabilities/Weaknesses: "Physical/Medical Problems."

iii. Failure to accurately identify the Patient's Assets or Liabilities does not provide the clinical staff with the behavioral descriptions and clinical presentation used to implement plan treatment goals and active treatment interventions. On 08/23/21, staff documented that Patient #1520's Active Psychiatric Problem #1 was "Disturbed Thought." Staff documented on the Individual Treatment Plan that Problem #1 was "Disturbed Thought." None of the check boxes for symptom identifiers, such as "paranoia, delusions, auditory hallucinations, or visual hallucinations" was checked. Staff documented that the Patient was "currently mute and is on 1:1 observation due to touching peers and staff inappropriately." On the Psychiatric Evaluation, dated 08/22/21, the provider documented that the Patient reported an increase in auditory hallucination and gang stalking. Investigator #15's review of the MTP found that staff failed to include the patient's new presentation of not speaking and sexually inappropriate behavior.

d. On Patient #1526's MTP, dated 06/19/21, staff documented the admitting diagnosis as Schizophrenia, Paranoid Type. Staff documented the Patient's Assets/Strengths and Liabilities/Weaknesses are as follows:

i. Patient Assets/Strengths: "Sense of Humor and Kindness."

ii. Patient Liabilities/Weaknesses: "Lack of Friendship and Unable to Live Independently."

iii. The assets identified failed to provide an accurate description of the Patient's strengths at the time of his admission and consequently failed to identify opportunities for support and interventions. Investigator #15's review of the Psychiatric Evaluation, dated 06/19/21, found that the provider documented that Patient #1526 presented as "demanding, easily irritable, agitated and responding to internal stimuli." The Patient reported having suicidal ideation and homicidal ideation. On 08/03/21, the medical provider documented on the History and Physical Evaluation the diagnosis of Acute Psychosis with both auditory and visual hallucinations and suicidal ideation. The patient presented as "gravely disabled and exhibited hypersexual behavior."

iv. Investigator #15's review of Patient #1526's MTP found that staff documented the Active Psychiatric Problem #1 as "Medication Compliance." However, the Patient's Individual Treatment Plan for Psychiatric Problem #1 was noted as "Disturbed Thought with Auditory Hallucinations. The problem statement failed to include clear, descriptive information about the patient's suicidal and homicidal ideation, and the inability to care for self.

3. On 09/15/21 at 1:00 PM, during an interview with Investigator #15, Registered Nurse (Staff #1507) verified that the strengths and liabilities are not consistently documented accurately.
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Based on interview, record review, and policy review, the facility failed to ensure that the Master Treatment Plans (MTPs) contained measurable patient goals, both short-term and long-range for 6 of 10 active sample patients (Patient #1501, #1514, #1515, #1516, #1520, and #1523). Each identified problem was typically addressed on an Individual Treatment Plan, with preprinted goals which contained generalized statements and not consistently measurable and relevant to the identified problem. Other goals listed were staff goals for the patient to achieve, rather than goals identified by the patient.

Failure to ensure that the MTP initiated measurable, individualized, patient-specific goals, both short-term and long range, prevents the patient and staff from having a clear understanding of what goals have been agreed upon, and how progress towards the goals is measured and quantified.

Findings included:

1. Document review of the hospital's document titled, "Treatment Planning," policy number PC.T.200, last reviewed 01/21, showed the following:

a. The Initial Treatment Plan, and any subsequent revisions of the plan, shall specify goals for achieving emotional and/or physical health, as well as maximum growth and adaptive capabilities.

b. Treatment goals are based on assessment of the patient, and as appropriate, the family.

c. Treatment goals are identified by the patient and actions the patient agrees to or requests to take, and the patient's involvement in and expressed concerns about the treatment plan are documented.

d. Specify intermediate steps towards those goals in measurable terms.

e. Specific target dates or timeframes for completion of goals and steps.

2. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that each patient had an individualized comprehensive Master Treatment Plan (MTP) that included measurable, individualized, patient-specific goals, both short-term and long-range. The medical record review showed the following:

a. On Patient #1501's MTP, dated 07/26/21, staff documented for the Active Psychiatric Problem #1 "Disturbed Thought - Manic Mood with Psychosis" the long-term goal is the "absence of psychotic symptoms or delusional thinking 3 days prior to discharge." Short-term goals for the problem included "Patient will take antipsychotic medications willingly for the next 10 days as prescribed daily and express at least one benefit 3 consecutive days prior to discharge." Investigator #15's review of the medical records found that the patient was not prescribed a scheduled antipsychotic mediation upon admission.

b. On Patient #1514's MTP, dated 05/28/21, staff documented the Active Psychiatric Problem #1, listed as "Amotivated (reduction in the motivation to initiate or persist in goal-directed behavior/Anhedonia (inability to experience pleasure)" on the MTP, however staff documented on the Individual Treatment Plan for Psychiatric Problem #1 "Disturbed Thought - with Paranoia and Delusions" and that the long-term goal was "Patient will develop a crisis plan and share it with social worker. Patient will state 2-3 ways that taking meds help to keep him stable." Short-term goals for the problem included "Patient will state 3 ways self-harm has negatively impacted his life" and "Patient will state 1-2 ways that taking medications helps to keep him stable." Investigator #15 found that that short-term goal was similar to the long-range goal. For the problem "Malnutrition," the preprinted goal of "Patient will comply with medication administration, vital signs and lab monitoring as ordered," and "Patient will not experience any exacerbations related to (poor nutrition) while hospitalized." For the problem of "Impaired Skin Integrity - Skin Rash," the preprinted goals of "Patient will not experience any exacerbations related to (skin rash) while hospitalized" and "Patient will comply with medication administration, vital signs and lab monitoring as ordered," the preprinted goal is identical to Patient #1514's goals for "Malnutrition," with the exception of the identified problem. On 05/28/21, staff initiated an Individual Treatment Plan for the medical problem of "Insomnia," which was not added to the MTP Problem List. Preprinted, short-term goals for the problem included "Patient will comply with medication administration" and "Patient will sleep six hours each night by discharge."

c. On Patient #1515's MTP, signed 06/18/21 and 06/21/21, staff documented the Active Psychiatric Problem #1 as "Disturbed Thought - with Confusion" as evidenced by agitation and responding to internal stimuli. The long-range goal established for Patient #1515 was "Patient will be euthymic without any aggressive thoughts or behaviors for 3 days prior to discharge." Investigator #15 failed to find a method to measure the Patient's progress for this goal. Staff documented the short-term goals as "Patient will attend 2 groups a day for 2 weeks to increase social interaction." The focus of the groups, treatment modalities, or correlation to the Patient's treatment plan was not specified. On 06/16/21, staff initiated an Individual Treatment Plan for the medical problem of "Insomnia." Preprinted, short-term goals for the problem included "Patient will comply with medication administration" and "Patient will sleep six hours each night by discharge." The preprinted goals were identical to those for Patient #1514. On 06/16/21, staff initiated an Individual Treatment Plan for the medical problem of "Gastroesophageal Reflux Disease (GERD)." Preprinted, short-term goals for the problem included "Patient will comply with medication administration, vital signs and lab monitoring as ordered" and "Patient will not experience any exacerbations related to GERD while hospitalized." On 06/16/21, staff initiated an Individual Treatment Plan for the medical problem of "Impaired Skin Integrity - Superficial Wound." Preprinted, short-term goals for the problem included "Patient will comply with medication administration, vital signs and lab monitoring as ordered" and "Patient will not experience any exacerbations related to the laceration while hospitalized." The preprinted goals for Insomnia, GERD, and Impaired Skin Integrity were all similar except for the indication and failed to establish goals that were individualized to the Patient. These preprinted goals were identical to those for Patient #1514, except for the indication.

d. On Patient #1516's MTP, signed on 08/23/21 and 08/25/21, staff documented for the Active Psychiatric Problem List Problem #1 "Depressed Mood with Psychosis" with the long-term goal of "Patient will demonstrate a minimum of 3 days of euthymic mood without suicidal ideation prior to discharge." Short-term goals for the problem included "Patient will report feeling more hopeful and articulate a plan for how he can keep safe in the community within 5 consecutive days prior to discharge." Investigator #15's review of the long-range and short-term goal failed to find a measurable method to quantify the Patient's progress. On 08/26/21, staff initiated an Individual Treatment Plan for the medical problem of "Insomnia." Preprinted, short-term goals for the problem included "Patient will comply with medication administration" and "Patient will sleep six hours each night by discharge." The preprinted goals were identical to those for Patient #1514 and Patient #1515.

e. On Patient #1520's MTP, signed on 08/23/21, 08/26/21, and 08/31/21, staff documented the Patient's Active Psychiatric Problem #1 "Disturbed Thought" without checking the box indicating the type of thought disorder. Staff documented that the problem "Disturbed Thought" was evidenced by patient not speaking and touching staff and peers inappropriately. The long-term goal was "Patient will not touch others inappropriately, and instead make her needs known." The Patient's short-term goals included "Patient will start to speak to staff and peers, making her needs known" and "Patient will not touch other inappropriately, and instead make her needs known." Investigator #15's review of Patient #1519's goal found them redundant and difficult to measure the Patient's progress.

On 08/23/21, staff initiated an Individual Treatment Plan for "Altered Comfort" and listed the following medical conditions to be addressed in the treatment plan: Chronic Pain, Seasonal Rhinitis, Osteoarthritis, Anemia, and Dry Eye. The preprinted long-term goal was "Patient will not experience exacerbation of anemia while hospitalized." The preprinted short-term goal noted that "Patient will comply with medication administration." Investigator #15 failed to find evidence of goals specifically related to the other medical conditions listed on the Treatment Plan, including Chronic Pain, Seasonal Rhinitis, Osteoarthritis, and Dry Eye. On 09/03/21, staff initiated an Individual Treatment Plan for the medical problem of "Potential of Injury Related to Fall" after Patient #1519 experienced a fall while at the facility. The staff failed to document a long-term goal, or discharge criteria. The short-term goal established by staff was that "Patient will comply with medication administration, vital signs, and lab monitoring as ordered."

f. On Patient #1523's MTP, signed on 08/02/21, 08/08/21, and 08/10/21, staff documented the Patient's Active Psychiatric Problem #1 to be "Delusional Beliefs." Investigator #15's review of the Individual Treatment Plan found that staff failed to check the box identifying the type of thought disorder. Staff documented that the Patient is unable to walk to the bathroom, change his clothes, or feed himself. The Patient's long-term goal was that "Patient's anxiety will decrease so that patient will walk and feed himself independently and not need physical aid" and the short-term goal was that "With reduced anxiety, Patient will be able to stand independently for five minutes without physical help from staff or peers." Investigator #15's review of the long-range and short-term goal failed to find a measurable method to quantify the Patient's progress towards "reduced anxiety." On 08/02/21, staff initiated an Individual Treatment Plan for the medical problem of "Hyperlipidemia." Preprinted, short-term goals for the problem included "Patient will comply with medication administration, vital signs, and lab monitoring as ordered." The preprinted goals were identical to those for Patient #1514 and Patient #1515.

3. On 09/15/21 at 1:00 PM, during an interview with Investigator #15, Registered Nurse (Staff #1507) stated that the hospital leadership is performing medical record audits of all charts to ensure accuracy and compliance to regulations and requirements. Staff #1507 provided Investigator #15 with the "Intake Audit Tool," dated 06/20, used by leadership to perform audits.

Staff #1507 verified that the audit tool consisted of the individual required components of the patient's medical records, and had a check box for either "yes" or "no," to signify if the document was present, however the audit tool did not reflect if the document was completed accurately.

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Based on interview, policy review and record review, the facility failed to ensure that the Master Treatment Plans (MTPs) contained individualized, active treatment interventions utilized to meet the patient's specific treatment needs for 9 of 10 active sample patients (Patient #1501, #1514, #1515, #1516, #1520, #1523, #1524, #1525, and #1526). The MTP's failed to include active treatment interventions that were based on presenting symptoms which resulted in the hospitalization. The interventions listed on preprinted Individual Treatment Plans were generic, often routine job duties, and failed to specify a method of delivery or the intended focus of treatment.

Failure to ensure that the MTP included individualized, active treatment interventions may result in a lack of guidance for staff to provide coordinated active treatment interventions, which may create a delay in the patient's progress and ultimately discharge from the hospital.

Findings included:

1. Document review of the hospital's document titled, "Treatment Planning," policy number PC.T.200, last reviewed 01/21, showed the following:

a. The treatment plan shall contain specific interventions that relate to goals, which are written in behavioral and measurable terms, and include achievement dates as well as person responsible for implementation. Development of the treatment plan will take into consideration patient care standards and program/unit or departmental policies as they relate to the individual patient. Routine interventions, for example 15-minute safety rounds, are not written in the interventions, because they are done on all patients.

b. Interventions for each appropriate discipline will be included for each problem. The intervention includes the specific intervention (action) and specific focus of the intervention as related to the problem (focus).

2. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that each patient's Master Treatment Plan (MTP) included individualized, active treatment interventions. The medical record review showed the following deficient interventions for problems and treatment goals assigned to physicians (MD), registered nurses (RN), social work staff (SW), and activity therapist (AT):

a. Patient #1501's MTP, signed 07/26/21 and 07/27/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Manic Mood with Psychosis":

i. Physician/Practitioner (MD) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a designated MD intervention for this problem.

ii. Nursing (RN) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a dedicated RN intervention for this problem.

iii. Social Worker (SW) Interventions: "Will provide psychoeducation and coping strategies (deep breathing, meditation, exercise, journaling, etc.), as well as about Dialectical Behavior Therapy (DBT) concepts (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) through process group programing." This intervention statement failed to include the specific, clear focus of treatment related to the Patient's unique presenting symptoms.

iv. Activity Therapist (AT) Interventions: "Will provide therapeutic groups to focus on increasing awareness to healthy leisure options for substance-free leisure, healthy coping skills and emotion regulation, as needed to assist patient in obtaining a healthy life balance, free of substance use." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include the specific, clear focus of treatment related to the Patient's unique presenting symptoms. The intervention referenced focusing on an increase awareness of substance-free leisure and creating a healthy life balance, free of substance use, however the problem statement does not indicate the Patient struggled with substance abuse.

b. Patient #1514's MTP, signed 05/28/21, 06/23/21, 06/25/21 and 06/28/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought - with Paranoia and Delusions":

i. Physician/Practitioner (MD) Interventions: "MD will modify or adjust medication regime. Monitor for side effects." These interventions included routine MD functions, such as assessing psychiatric symptoms, prescribing, and re-evaluating medication's efficacy. The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific antipsychotic medication(s) ordered or the specific targeted psychotic or behavioral symptoms to be addressed.

ii. Nursing (RN) Interventions: "RN will assess and medicate per order. Will assess for side effects and intervene appropriately. Will encourage to attend groups and participate in treatment." These interventions included routine RN functions, such as assessment and medication administration. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will educate Patient on triggers for self-harm and alternatives to acting out on harmful impulses. SW will encourage Patient's attendance at daily psychoeducation and process groups to help identify positive coping strategies needed to process feelings and emotions in appropriate ways, and to help understand how refusing to take medications leads to an increase of disorganization, paranoia, agitation, aggression, and threats of harm to others." This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a designated AT intervention for this problem.

c. Patient #1515's MTP, signed 06/18/21 and 06/21/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought - with Confusion":

i. Physician/Practitioner (MD) Interventions: "MD will provide psychiatric evaluation and prescribe medications, as indicated, for psychosis and mood lability, monitor for efficacy, compliance and side effects." These interventions included routine MD functions, such as assessing psychiatric symptoms, prescribing, and re-evaluating medication's efficacy. The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific antipsychotic medication(s) ordered or the specific targeted psychotic or behavioral symptoms to be addressed.

ii. Nursing (RN) Interventions: "RN will assess and medicate per order. Will assess for delusions and auditory or visual hallucinations and intervene as needed. Will assess for triggers and help patient use coping skills. Encourage to wear mask and wash hands." These interventions included routine RN functions, such as assessment, infection control, and medication administration. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Activity Therapist (AT) Interventions: "AT will provide therapeutic groups focusing on emotion regulation, increasing awareness to healthy leisure options and substance-free leisure, if appropriate, to assist Patient in obtaining a health life balance." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms. The intervention referenced focusing on an increase awareness of substance-free leisure and creating a healthy life balance, free of substance use, however the problem statement does not indicate the Patient struggled with substance abuse.

d. Patient #1516's MTP, signed 08/23/21 and 08/25/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Depressed Mood - With Psychosis":

i. Physician/Practitioner (MD) Interventions: "MD will provide psychiatric evaluation and prescribe medications, as indicated, monitor for efficacy, compliance and side effects." The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific antipsychotic medication(s) ordered or the specific targeted psychotic or behavioral symptoms to be addressed. These intervention statements are identical or similarly worded for Patient #1515.

ii. Nursing (RN) Interventions: "RN will monitor group compliance, educate Patient on diagnosis of Bipolar Depression and Anxiety. Report any adverse side effects to MD." These interventions included routine RN functions, such as assessment, psychoeducation, and medication administration. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will educate Patient on triggers for self-harm and alternatives to acting out on harmful impulses. SW will encourage Patient's attendance at daily psychoeducation and process groups to help identify positive coping strategies needed to process feelings and emotions in appropriate ways, and to help understand how refusing to take medications leads to an increase of disorganization, paranoia, agitation, aggression, and threats of harm to others." This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: "AT will provide therapeutic groups focusing on emotion regulation, increasing awareness to healthy leisure options and substance-free leisure if appropriate to assist patient in obtaining a healthy life balance." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms. These intervention statements are identical or similarly worded for Patient #1501 and Patient #1515.

e. Patient #1520's MTP, signed 08/23/21, 08/26/21 and 08/31, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought." Staff failed to document a "type" of indication related to the identified problem:

i. Physician/Practitioner (MD) Interventions: "MD to assess and medicate" The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific antipsychotic medication(s) ordered or the specific targeted psychotic or behavioral symptoms to be addressed.

ii. Nursing (RN) Interventions: "RN will monitor closely, provide verbal prompts to redirect Patient from touching others inappropriately. Encourage to take her medications." These interventions included routine RN functions, such as assessment and medication administration. The intervention statement noted the RN's intervention to encourage the Patient to take her medication, but it failed to name the specific medication, or the specific targeted psychotropic or behavioral symptom to be addressed. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will form a therapeutic bond with Patient using motivational interviewing and by learning her history, to further bond with the Patient. The SW will ask the Patient to speak at least three times a week." When Patient #1520 was admitted, she was not speaking. The intervention failed to include details of methods to use to form a therapeutic bond using motivational interviewing" with a Patient who was choosing not to speak. This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: "AT will facilitate groups focusing on coping/leisure skills, emotional regulation and social skills." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms.

f. Patient #1523's MTP, signed 08/02/21, 08/08/21 and 08/10/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought." The Patient's MTP Problem List identified the Active Psychiatric Problem #1 as "Delusional Beliefs." Staff failed to document a "type" of indication related to the identified problem:

i. Physician/Practitioner (MD) Interventions: "MD will evaluate, diagnose, start treatment, monitor for side effects, monitor labs, and psychoeducation." These interventions included routine MD functions, such as assessing psychiatric symptoms, prescribing, and re-evaluating medication's efficacy. The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific antipsychotic medication(s) ordered or the specific targeted psychotic or behavioral symptoms to be addressed.

ii. Nursing (RN) Interventions: "RN will encourage and assist patient with activities of daily living (ADLs) and encourage patient to attend group sessions for increased anxiety. Offer nutritious meals and fluids, monitor behaviors and blood sugar levels for Diabetes. Give medications as ordered." These interventions included routine RN functions, such as assessment and medication administration. The intervention statement noted the RN's intervention to monitor the Patient's blood sugar levels, however this intervention is not related to the problem of "Disturbed Thought." The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will meet with Patient individually (1:1) weekly to build rapport. SW will encourage Patient to get 7-8 hours of sleep per night and take medication. SW will encourage Patient to attend group and milieu activities." These interventions included routine SW functions, such as building rapport and encourage participation in treatment activities. This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: "AT will provide groups daily to increase emotional regulation, enhance self-expression, and promote health coping and leisure skills." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms. These intervention statements are identical or similarly worded for Patient #1525 and Patient #1526.

g. Patient #1524's MTP, signed by only one staff member, the Social Worker (SW) on 08/23/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought - With Paranoia and Delusions." The Patient's MTP Problem List identified the Active Psychiatric Problem #1 as "Suicidal Ideation.":

i. Physician/Practitioner (MD) Interventions: "MD started Prazosin for nightmares, was discontinued on 08/25/21." These interventions included routine MD functions, such as prescribing. The interventions are nonspecific, not individualized and failed to include active treatment interventions. Investigator #15 found no evidence that staff documented the date the interventions were initiated, frequency of the intervention, or name of responsible person in the Patient's medical record.

ii. Nursing (RN) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a designated RN intervention for this problem.

iii. Social Worker (SW) Interventions: "SW will encourage Patient to attend daily psychoeducation and process groups and encourage him to identify and share what contributes to symptoms of psychosis (paranoia and delusions) and what he can do to prevent symptoms from developing or being exacerbated. Discuss how he can utilize existing resources to support him in improving and maintaining improvements related to experienced symptoms of psychosis, paranoia, and delusions." These interventions included routine SW functions, such as encouraging participation in treatment activities. This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital. The intervention statement failed to include specifics related to the "existing resources to support him" and how they are related to the identified problem.

iv. Activity Therapist (AT) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a designated AT intervention for this problem.

h. Patient #1525's MTP, signed 08/19/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought - With Delusions":

i. Physician/Practitioner (MD) Interventions: "MD will evaluate, diagnose, start treatment, monitor for side effects, monitor labs, and psychoeducation. Will start Risperdal." These interventions included routine MD functions, such as assessing psychiatric symptoms, prescribing, and re-evaluating medication's efficacy. The interventions are nonspecific, not individualized and failed to include active treatment interventions. The intervention statement regarding medication(s) failed to identify the specific targeted psychotic or behavioral symptoms to be treated.

ii. Nursing (RN) Interventions: "RN will encourage the Patient to take her antipsychotic medication, redirect her from intrusive behaviors, and reorient her when she becomes paranoid." These interventions included routine RN functions, such as assessment and medication administration. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will meet with Patient individually (1:1) weekly to encourage her to take prescribed medication willingly. SW will encourage Patient to get 7-8 hours of sleep per night and take medication. SW will encourage Patient to attend group and milieu activity to reduce her paranoia and orient to reality." These interventions included routine SW functions, such as encouraging participation in treatment activities. This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: "AT will provide groups daily to increase emotional regulation, enhance self-expression, and promote healthy coping and leisure skills." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms. These intervention statements are identical or similarly worded for Patient #1523 and Patient #1526.

i. Patient #1526's MTP, signed 06/19/21, 06/20/21 and 06/22/21, included the following deficient intervention statements for the problem Active Psychiatric Problem #1 "Disturbed Thought - With Auditory Hallucinations and Confusion." The Patient's MTP Problem List identified the Active Psychiatric Problem #1 as "Medication Compliance":

i. Physician/Practitioner (MD) Interventions: Investigator #15's review of the Individual Treatment Plan failed to find a designated MD intervention for this problem.

ii. Nursing (RN) Interventions: "RN will provide medications as ordered by MD. Provide Patient with a calm, organized environment to provide a daily routine. Encourage Patient to talk slower and listen to Patient's questions. Provide a safe environment." It is unclear how the intervention statement noting the RN's intervention to encourage the patient to talk slower and listen to questions is related to the problem of "Disturbed Thought." These interventions included routine RN functions, such as assessment and medication administration. The interventions are nonspecific, not individualized and failed to include active treatment interventions.

iii. Social Worker (SW) Interventions: "SW will meet with Patient individually (1:1) weekly to encourage him to take prescribed medication willingly. SW will educate the Patient on the consequences of not taking his medication after discharge. SW will encourage the patient to attend group and milieu activities." These interventions included routine SW functions, such as encouraging participation in treatment activities. This intervention statement failed to include the specific, clear focus of treatment related to problems that brought the Patient to the hospital.

iv. Activity Therapist (AT) Interventions: "AT will provide groups daily to increase emotional regulation, enhance self-expression, and promote healthy coping and leisure skills." These interventions included routine AT functions, such as conducting group activities. This intervention statement failed to include specific, clear focus of treatment related to the Patient's unique presenting symptoms. These intervention statements are identical or similarly worded for Patient #1523 and Patient #1525.

3. On 08/13/21 at 1:30 pm, during an interview with Investigator #15, the Director of Social Services (Staff #1506) and the Director of Clinical Services (Staff #1512) verified that due to the current staffing situation, treatment documentation has been affected and is often incomplete. Staff #1506 stated that she was unsure how the staff was doing treatment team currently; she believed the providers and social workers were participating and the nurses were attending when they could.

4. On 08/27/21 at 11:15 AM, during an interview with Investigator #15, the Director of Quality (Staff #1502) stated that to address any missing or deficient information in the medical records, including treatment planning documents, all leadership are doing monthly whole chart reviews to determine the accuracy and completeness of the medical records. The data from these audits is reported to the Quality Council and the Governing Body. Staff #1502 stated that any missing documentation would be considered a "documentation issue, not a risk to patient safety."

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Based on interview, policy review and record review, the facility failed to ensure that detailed treatment notes were documented by Registered Nurses (RN) and Social Workers (SW) related to the active treatment interventions contained in the Master Treatment Plans (MTPs) or the patient's response to the interventions for 8 of 10 active sample patients (Patient #1501, #1514, #1515, #1516, #1520, #1523, #1525, and #1526).

Failure to ensure that staff document that interventions from the MTP are carried out, the patient's response to the interventions, and level of understanding of the information provided creates barriers for the treatment team in determining the patient's response to active treatment interventions and making it difficult to monitor changes in the patient's condition, determine the patient's progress, and revise the plan of care when necessary.

Findings included:

1. Document review of the hospital's document titled, "Treatment Planning," policy number PC.T.200, last reviewed 01/21, showed the following:

a. The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record. A patient's inability or refusal to participate in treatment planning, and the patient's reason for such shall be documented on the treatment plan.

b. Treatment plan reviews and updates shall include the following steps:

i. Review of progress towards goals and effectiveness of interventions for each open problem on the Problem List.

ii. Modifications or additions made to goals and interventions, as appropriate.

iii. Update discharge plan, estimated length of stay, and justification for continued stay.

2. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that detailed treatment notes were documented by registered nurses (RN) and social workers (SW) regarding active treatment interventions from the Master Treatment Plan (MTP). The medical record review showed the following deficient treatment notes for interventions on the MTP assigned to registered nurses (RN) and social work (SW) staff:

a. Patient #1501's MTP, signed 07/26/21 and 07/27/21, had the following deficient treatment notes related to interventions for Active Psychiatric Problem #1 Manic Mood with Psychosis:

i. Nursing Interventions - Investigator #15's review of the Individual Treatment Plan dated 07/26/21, failed to find a dedicated RN intervention for this problem. Without a specific detailed nursing intervention related to the problem, Investigator #15 was unable to audit the nursing documentation. A review of the Patient's medical records from 07/24/21 to 08/09/21 revealed that 11 of 15 Daily Nursing Progress Notes failed to document the Patient's progress related to the MTP.

ii. Social Worker Interventions: "Will provide psychoeducation and coping strategies (deep breathing, meditation, exercise, journaling, etc.), as well as about Dialectical Behavior Therapy (DBT) concepts (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) through process group programing. SW staff documented the frequency for these interventions "as needed" and "group daily." A review of the Patient's medical records from 07/24/21 to 08/09/21 revealed the SW staff documented one individual 1:1 session to discuss medication compliance. The Activity Therapist documented that Patient #1501 refused to attend and/or refused alternative activities for 19 of 29 groups. Investigator #15 found no documentation regarding the relevance of the materials offered to the Patient's identified problem or the Patient's progress related to the MTP.

b. Patient #1514's MTP, signed 05/28/21, 06/23/21, 06/25/21 and 06/28/21, had the following deficient treatment notes related to interventions for Active Psychiatric Problem #1 Disturbed Thought - with Paranoia and Delusions:

i. Nursing Interventions: "RN will assess and medicate per order. Will assess for side effects and intervene appropriately. Will encourage to attend groups and participate in treatment." Investigator #15's review of the medical record from 05/28/21 to 08/24/21 found that 12 of 13 Nursing Progress Notes failed to document the Patient's progress related to the intervention documented on the MTP to assess for side effect from the medication. On the Daily Nursing Progress Note, dated 08/25/21, nursing staff documented "encourage patient to join group and socialize." Staff failed to document the patient's response to the attempted intervention.

ii. Social Worker Interventions: "SW will educate Patient on triggers for self-harm and alternatives to acting out on harmful impulses. SW will encourage Patient's attendance at daily psychoeducation and process groups to help identify positive coping strategies needed to process feelings and emotions in appropriate ways, and to help understand how refusing to take medications leads to an increase of disorganization, paranoia, agitation, aggression, and threats of harm to others." The SW documented the frequency for these interventions "as needed" and "group daily." A review of the Patient's medical records from 05/28/21 to 08/24/21 revealed the Activity Therapist documented that Patient #1514 refused to attend and/or refused alternative activities for 50 of 54 groups. Investigator #15 found no documentation regarding the relevance of the materials offered to the Patient's identified problem or the Patient's progress related to the MTP. SW staff documented on the Group Progress Note dated 08/24/21, "Patient did not attend group at this time. Patient declined to join the group. Therapist will continue to invite and encourage group attendance to increase awareness of coping skills." Staff failed to document the patient's response to the attempted interventions.

c. Patient #1515's MTP, signed 06/18/21 and 06/21/21, had the following deficient treatment notes related to interventions for the Active Psychiatric Problem #1 Disturbed Thought - With Confusion:

i. Nursing Interventions: "RN will assess and medicate per order. Will assess for delusions and auditory or visual hallucinations and intervene as needed. Will assess for triggers and help patient use coping skills. Encourage to wear mask and wash hands." The frequency was daily. Investigator #15's review of the medical record from 06/16/21 to 08/24/21 found that 10 of 10 Nursing Progress Notes failed to document the Patient's progress related to the intervention documented on the MTP to assess for triggers and help Patient use coping skills.

ii. Social Work Intervention: "SW will provide Patient with individual 1:1 support weekly and work towards treatment and discharge planning goals. SW will encourage Patient to participate in groups and develop insight into the need to take medications and follow up with outpatient providers. Patient will learn new positive coping skills that will assist in recognizing warning signs of decompensation and how to safely address them." The frequency was weekly. Investigator #15's review of the medical record from 06/16/21 to 08/24/21 found that Patient #1515 failed to attend 31 of 51 Groups or Activities. Review of the Group Progress Notes showed that staff failed to document the Patient's progress related to the intervention and/or alternatives offered.

d. Patient #1516's MTP, signed 08/23/21 and 08/25/21, had the following deficient treatment notes related to interventions for the Active Psychiatric Problem #1 Depressed Mood - With Psychosis:

i. Nursing Interventions: "RN will monitor group compliance, educate Patient on diagnosis of Bipolar Depression and Anxiety. Report any adverse side effects to MD." The frequency was daily. Investigator #15's review of the medical record from 08/21/21 to 08/27/21 found that 5 of 5 Nursing Progress Notes failed to document the nursing intervention to educate the Patient on the diagnosis of Bipolar Depression and Anxiety or document the assessment of side effects to the medication.

ii. Social Worker Interventions: "SW will educate Patient on triggers for self-harm and alternatives to acting out on harmful impulses. SW will encourage Patient's attendance at daily psychoeducation and process groups to help identify positive coping strategies needed to process feelings and emotions in appropriate ways, and to help understand how refusing to take medications leads to an increase of disorganization, paranoia, agitation, aggression, and threats of harm to others." The frequency was weekly. Investigator #15's review of the medical record from 08/21/21 to 08/27/21 found that the Patient refused to attend 11 of 12 groups offered. Review of the Group Progress Notes showed that staff failed to document the Patient's progress related to the intervention and/or alternatives offered.

e. Patient #1520's MTP, signed 08/23/21,08/26/21 and 08/31, had the following deficient treatment notes related to the interventions for the Active Psychiatric Problem #1 Disturbed Thought:

i. Nursing Interventions: "RN will monitor closely, provide verbal prompts to redirect Patient from touching others inappropriately. Encourage to take her medications." The frequency was daily. Investigator #15's review of the medical record from 08/22/21 to 09/15/21 found that 30 of 30 Nursing Progress Notes failed to document the nursing intervention to encourage to redirect the Patient from touching others inappropriately, and the patient's response to the intervention.

ii. Social Worker Interventions: "SW will form a therapeutic bond with Patient using motivational interviewing and by learning her history, to further bond with the Patient. The SW will ask the Patient to speak at least three times a week." The frequency is weekly. Investigator #15's review of the medical record from 08/22/21 to 09/15/21 found that the Patient refused to attend 105 of 134 groups offered. Review of the Group Progress Notes showed that staff failed to document the Patient's progress related to the intervention and/or alternatives offered.

f. Patient #1523's MTP, signed 08/02/21,08/08/21 and 08/10/21, had the following deficient treatment notes related to the interventions for the Active Psychiatric Problem #1 Disturbed Thought:

i. Nursing Interventions: "RN will encourage and set up for assist with activities of daily living (ADLs) and encourage patient to attend group sessions for increased anxiety. Offer nutritious meals and fluids, monitor behaviors and blood sugar levels for Diabetes. Give medications as ordered." The frequency was daily. Investigator #15's review of the medical record from 08/02/21 to 09/15/21 found that 24 of 25 Nursing Progress Notes failed to document the nursing intervention to offer nutritious meals and fluids and monitor behaviors and blood sugar levels, and failed to document the patient's response to the intervention.

ii. Social Worker Interventions: "SW will meet with Patient individually (1:1) weekly to build rapport. SW will encourage Patient to get 7-8 hours of sleep per night and take medication. SW will encourage Patient to attend group and milieu activities." The frequency was weekly. Investigator #15's review of the medical record from 08/02/21 to 09/15/21 found that 103 of 103 Group Progress Notes failed to document the Patient's response to the intervention. Investigator #15's review of the medical record failed to find evidence of how the group material provided was relevant to the Patient's MTP.

g. Patient #1525's MTP, signed 08/19/21, had the following deficient treatment notes related to the interventions for the Active Psychiatric Problem #1 Disturbed Thought - With Delusions:

i. Nursing Interventions: "RN will encourage the Patient to take her antipsychotic medication, redirect her from intrusive behaviors, and reorient her when she becomes paranoid." The frequency was daily. Investigator #15's review of the medical record from 08/16/21 to 09/15/21 found that 20 of 20 Nursing Progress Notes failed to document the nursing intervention to redirect the Patient from intrusive behaviors and reorient when she becomes paranoid. Nursing staff failed to document the patient's response to any behavioral interventions.

ii. Social Worker Interventions: "SW will meet with Patient individually (1:1) weekly to encourage her to take prescribed medication willingly. SW will encourage Patient to get 7-8 hours of sleep per night and take medication. SW will encourage Patient to attend group and milieu activity to reduce her paranoia and orient to reality." The frequency was weekly. Investigator #15's review of the medical record from 08/16/21 to 09/15/21 found that 63 of 101 Group Progress Notes failed to document the Patient's response to the intervention or offer of alternative therapy. Investigator #15's review of the medical record failed to find evidence of how the group material provided was relevant to the Patient's MTP.

h. Patient #1526's MTP, signed 06/19/21, 06/20/21 and 06/22/21, had the following deficient treatment notes related to the interventions for the Active Psychiatric Problem #1 Disturbed Thought - With Auditory Hallucinations and Confusion:

i. Nursing Interventions: "RN will provide medications as ordered by MD. Provide Patient with a calm, organized environment to provide a daily routine. Encourage Patient to talk slower and listen to Patient's questions. Provide a safe environment." The frequency was daily. Investigator #15's review of the medical record from 06/19/21 to 09/15/21 found that 36 of 36 Nursing Progress Notes failed to document the nursing intervention to provide Patient with a calm environment. Nursing staff failed to document the correlation of any interventions provided to the MTP. Nursing staff consistently documented "continue to monitor plan of care." Nursing staff failed to document the patient's response to any behavioral interventions.

ii. Social Worker Interventions: "SW will meet with Patient individually (1:1) weekly to encourage him to take prescribed medication willingly. SW will educate the Patient on the consequences of not taking his medication after discharge. SW will encourage the patient to attend group and milieu activities." The frequency was weekly. Investigator #15's review of the medical record from 06/19/21 to 09/15/21 found that 98 of 151 Group Progress Notes failed to document the Patient's response to the intervention or offer of alternative therapy. Investigator #15's review of the medical record failed to find evidence of how the group topic or material provided was relevant to the Patient's MTP.

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Based on observation, medical record review, and review of policies and procedures, the facility failed to provide all necessary treatment measures to 4 of 10 active sample patients (Patient #1501, #1520, #1523, and #1526). The hospital failed to ensure that staff consistently document in the medical record attempts to engage patients in alternative active treatment measures when they chose not to attend groups. For patients who did not attend groups on a regular basis, the staff failed to revise the Master Treatment Plan (MTP) to reflect alternative treatment interventions to ensure that the patients achieve their treatment goals.

Failure to provide patients with active treatment interventions at sufficient, individualized levels, results in hospitalizations without all active treatment interventions for recovery and creates barriers to patient's progress, negatively impacting patient outcomes.

Findings included:

1. Document review of the hospital's document titled, "Scope of Services - Activities Therapy," policy number AT.SOS.101, last reviewed 01/21, showed the following:

a. Activities Therapy Services include:

i. Assessment of leisure, social, and activities abilities.

ii. Establishment of goals to improve leisure skills or awareness, impulsiveness, peer interaction, or self-confidence.

iii. Leisure education to help the patient acquire knowledge, skills and attitudes needed for independent leisure/social involvement, adjustment back into the community, decision making ability, and appropriate use of free time.

b. Treatment Plans: Goals are incorporated into treatment plan by recreation therapists, social services and/or chemical dependency counselors. Individual treatment plan will reflect interventions directly related to the patient's goals for therapeutic activities. The treatment plan and updates are to be reviewed and authenticated timely by the Certified Therapeutic Recreation Specialist (CTRS).

2. Document review of the hospital's document titled, "Social Services and Therapeutic Activities," policy number PC.ACT.01, approved 02/21, showed the following:

a. All therapy goals will be identified and documented in the Multidisciplinary Treatment Plan (MTP) form.

b. Any new goals identified during the course of treatment will be added to the MTP form.

c. All groups will be designated to address each patient's individual treatment goals and patient's response to interaction.

d. All therapists will document the patient's progress or lack of progress towards treatment in the Therapy Progress Notes.

3. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that staff consistently document in the medical record attempts to engage patients in alternative active treatment measures when they chose not to attend groups and revised the Master Treatment Plan (MTP) to reflect alternative treatment interventions. Medical record review showed the following deficient documentation of active treatment measures, alternative interventions, and the failure to initiate revisions to the MTP, when necessary.

Patient #1501

a. Patient #1501's MTP, signed 07/26/21 and 07/27/21, listed Psychiatric Problem #1 Manic Mood with Psychosis as evidenced by being detained in the community, naked, agitated and aggressive, attempting to light residence on fire. The Social Workers (SW) stated role was to provide psychoeducation and coping strategies (deep breathing, meditation, exercise, journaling, etc.), as well as about Dialectical Behavior Therapy (DBT) concepts (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) through process group programing. The Activities Therapists (AT) role was to provide therapeutic groups to focus on increasing awareness to healthy leisure options for substance-free leisure, healthy coping skills and emotion regulation as needed to obtain a healthy life balance, free of substance abuse.

b. Investigator #15's review of Patient #1501's Interdisciplinary Treatment Plan Updates (ITP), Social Work/Activity Therapy Group Progress Notes, and Daily Nursing Progress Notes for the period of 07/24/21 to 08/09/21 showed the following:

c. The ITP dated 08/03/21, was signed on 08/03/21 by the Social Worker (SW), signed on 08/10/21 by the Activities Therapist (AT), and was missing documentation and signatures from nursing services, the attending physician, and the patient. The SW documented that Patient #1501 was refusing group attendance and participation and making minimal progress on treatment goals. The AT documented that the Patient is sporadically attending groups, appears motivated, and is making progress towards goals. Progress is documented as "minimal" for Goal #1 - Patient to take antipsychotic medications willingly for the next 10 calendar days and is documented as "minimal" for Goal #2 - Patient will be free of delusional thought for 3 consecutive days prior to discharge. Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided by the multidisciplinary treatment team for Problem #1. Additionally, the documentation regarding the Patient's progress is contradictory between the SW and AT.

d. Investigator #15's review of the Group Progress Notes for the period of 07/24/21 to 08/09/21 found that Patient #1501 either actively refused to participate or was unable to participate (asleep) during group for 19 of 29 times. For the times that Patient #1501 did not attend group, he was given and accepted a handout/worksheet as alternative therapy 3 of 19 times. The Group Progress Note did not document the content of the handouts/worksheets or the type of alternative therapy provided. Investigator #15's review of the medical records failed to find evidence of documentation related to the Patient's response to the alternative therapy or progress towards treatment goals. Review of the Group Progress Notes showed that staff consistently documented for each refusal, "patient did not make progress. Patient declined to join group. Will encourage to participate in group activities." No individual therapy was provided.

e. Investigator #15's review of the Daily Nursing Progress Notes for the period of 07/24/21 to 08/09/21 revealed that 11 of 15 Daily Nursing Progress Notes failed to document the Patient's response to the interventions provided, or the Patient's progress related to the MTP identified problems and goals.

Patient #1520

a. Patient #1520's MTP, signed 08/23/21, 08/26/21, and 08/31/21, listed Psychiatric Problem #1 Disturbed Thought, as evidenced by touch staff inappropriately and failure to speak. The SW stated role was to form a therapeutic bond with Patient using motivational interviewing and by learning her history, to further bond with the Patient. The SW will ask the Patient to speak at least three times a week. The AT role was to facilitate groups for healthy coping/leisure skills, emotional regulation and social skills.

b. Review of Patient #1520's Interdisciplinary Treatment Plan Update (ITP), Social Work/Activity Therapy Group Progress Note, and Daily Nursing Progress Notes for the period of 08/22/21 to 09/15/21 showed the following:

c. The ITP dated 08/26/21, was signed on 08/27/21 by the Social Worker (SW), signed on 08/26/21 by the Activities Therapist (AT) and Registered Nurse (RN), signed by the attending physician, but not dated, and missing signature/participation from the patient. The SW documented that Patient #1520 was "mute and refusing to speak to staff and peers." The AT documented that the Patient is "sexually inappropriate, continues to be mute, and not redirectable." The RN documented "no new medical, vitals within normal limits (WNL)." Progress is documented as "None" for Goal #1 - "Patient will start to speak to staff and peers, making her needs known" and is documented as "None" for Goal #2 - "Patient will not touch others inappropriately. Instead she will use her voice to make her needs known." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1. Staff documented that "no changes" were made to the Patient's treatment plan.

d. The ITP dated 09/02/21, was signed on 09/02/21 by the Social Worker (SW), signed on 09/03/21 by the Activities Therapist (AT) and Registered Nurse (RN), signed by the attending physician on 09/02/21. The SW documented that Patient #1520 "pulled the fire alarm last night and tried to escape. Patient states she hears voices." The AT documented that the Patient is "demonstrating sporadic attendance at groups and has made some progress towards treatment goals." The RN documented "pulled fire alarm in attempt to escape." Progress is documented as "minimal" for Goal #1 - "Patient will start to speak to staff and peers, making her needs known" however staff documented speaking with the patient, who is no longer mute. Staff documented progress as "minimal" for Goal #2 - "Patient will not touch others inappropriately. Instead she will use her voice to make her needs known." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1. Staff documented that "no changes" were made to the Patient's treatment plan.

e. The ITP dated 09/10/21, was signed on 09/10/21 by the Social Worker (SW), signed on 09/14/21 by the Activities Therapist (AT) and Registered Nurse (RN), signed by the attending physician on 09/19/21. The SW documented that Patient #1520 "Patient is still delusional. Taking medications as prescribed. Found face down in her room, sent to the hospital." The AT documented that the Patient is "demonstrating sporadic attendance at groups, appears motivated when present and has made minimal progress towards treatment goals." The RN documented "Patient has a new order for Metamucil. Patient calm and present out on the unit. No distress. Patient is speaking on the phone several times." Progress is documented as "minimal" for Goal #1 - "Patient will start to speak to staff and peers, making her needs known" however staff documented speaking with the patient, who is no longer mute. This Goal remained unresolved on the MTP with no update. Staff documented progress as "minimal" for Goal #2 - "Patient will not touch others inappropriately. Instead she will use her voice to make her needs known." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1. Staff documented that "no changes" were made to the Patient's treatment plan and to continue the plan of care.

f. Investigator #15's review of the Group Progress Notes for the period of 08/22/21 to 09/15/21 found that Patient #1520 either actively refused to participate or was unable to participate (asleep) during group for 105 of 134 times. Staff documented that Patient #1520 was "asleep" 21 of 134 times. Investigator #15 found no evidence that staff documented providing the Patient with alternative therapies for these days. For the remaining times that Patient #1520 did not attend group, she was given and accepted a handout/worksheet as alternative therapy 24 of 105 times. The Group Progress Note did not document the content of the handouts/worksheets or the type of alternative therapy provided or the Patient's response to the intervention. Investigator #15's review of the medical records failed to find evidence of documentation related to the Patient's response or progress to the alternative therapy. Review of the Group Progress Notes showed that staff consistently documented for each refusal, "patient did not make progress. Patient declined to join group. Will encourage to participate in group activities." No individual therapy was provided.

g. Investigator #15's review of the Daily Nursing Progress Notes for the period of 08/22/21 to 09/15/21 revealed that nursing staff consistently documented that the Patient will "remain on the current plan of care," however, 30 of 30 Daily Nursing Progress Notes failed to document the Patient's progress related to the Patient's plan of care outlined in the MTP plan.

Patient #1523

a. Patient #1523's MTP, signed 08/02/21, 08/08/21, and 08/10/21, listed Psychiatric Problem #1 Disturbed Thought - Delusions, as evidenced by danger to self and grave disability. The SW stated role was to meet with Patient individually (1:1) weekly to build rapport. SW to encourage Patient to get 7-8 hours of sleep per night and take medication. SW to encourage Patient to attend group and milieu activities. The AT role was to provide groups daily to increase emotional regulation, enhance self-expression, and promote healthy coping and leisure skills.

b. Review of Patient #1523's Interdisciplinary Treatment Plan Update (ITP), Social Work/Activity Therapy Group Progress Note, and Daily Nursing Progress Notes for the period of 08/02/21 to 08/29/21 showed the following:

c. Investigator #15's review of the medical record failed to find an ITP for Patient #1523 for the week of 08/09/21.

d. The ITP dated 08/17/21, was signed on 08/17/21 by the Social Worker (SW), signed on 08/18/21 by the attending physician, and was missing documentation and signatures from activities therapy (AT), Registered Nurse (RN), and the patient. The SW documented that Patient #1523 was "making minimal progress towards his treatment goals. He is not attending group. He leaves his room for only a few minutes before his anxiety gets worse. He continues to seek attention by yelling for help, refusing to toilet on his own." Progress is documented as "minimal" for Goal #1 - "Patient will share 1 delusional belief with staff 3 out of 5 days" and is documented as "minimal" for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day for 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided , the Patient's response to the interventions provided, and the Patient's progress related to Problem #1.

e. The ITP dated 08/23/21, was signed on 08/23/21 by the Social Worker (SW), signed on 08/26/21 by the Activity Therapist (AT), signed on 08/23/21 by Registered Nurse (RN), signed on 08/26/21 by the attending physician, and was missing documentation and a signature from the patient. The SW documented that "although Patient has the physical ability, he still will not walk or take himself to the bathroom, when he has to go to the bathroom, he will start to yell 'help' in a panicked tone." The AT documented that Patient "has not made progress towards treatment goals as they do not attend groups." The Patient's "Progress" or continuation of "Plan of Care" is not documented for Problem #1, Goal #1 or Goal #2. Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions provided, and the Patient's progress related to Problem #1.

f. Investigator #15's review of the Group Progress Notes for the period of 08/02/21 to 08/29/21 found that Patient #1523 either actively refused to participate or was unable to participate (asleep) during group for 103 of 103 times. For the times that Patient #1523 did not attend group, he was given and accepted a handout/worksheet as alternative therapy 5 of 103 times. The Group Progress Note did not document the content of the handouts/worksheets or the type of alternative therapy provided. AT staff consistently documented the Patient's refusals to attend groups, stating "Patient refused to attend group. This AT will continue to encourage them to attend group for healthy coping and leisure skills." On 08/08/21, staff documented that the Patient refused to attend group, but noted that the Patient's response to the interventions as "some progress" and the Patient had not attended more than 5% of the groups offered. On 08/07/21, Patient #1523 refused to attend group. The AT documented that "handouts provided in the common area to read at leisure." Investigator #15's review of the medical records failed to find evidence of documentation related to the Patient's response or progress to the alternative therapy. Review of the medical records failed to show evidence of any changes to the MTP, patient goals and interventions, or treatment modalities. No individual therapy was provided.

g. Investigator #15's review of the Daily Nursing Progress Notes for the period of 08/02/21 to 08/29/21 revealed that 24 of 25 Daily Nursing Progress Notes failed to document the Patient's response to the interventions provided, or the Patient's progress related to the MTP identified problems and goals.

Patient #1526

a. Patient #1526's MTP, signed 06/19/21, 06/20/21 and 06/22/21, listed Active Psychiatric Problem #1 Disturbed Thought - With Auditory Hallucinations and Confusion, as evidenced by noncompliance with medication, disorganized thoughts, confused, and responding to internal stimuli. The SW stated role was to meet with Patient individually (1:1) weekly to encourage him to take prescribed medication willingly. SW will educate the Patient on the consequences of not taking his medication after discharge. SW will encourage the patient to attend group and milieu activities. The AT role was to provide groups daily to increase emotional regulation, enhance self-expression, and promote healthy coping and leisure skills.

b. Review of Patient #1526's Interdisciplinary Treatment Plan Update (ITP), Social Work/Activity Therapy Group Progress Note, and Daily Nursing Progress Notes for the period of 06/19/21 to 08/27/21 showed the following:

c. The ITP dated 06/28/21, was signed on 06/29/21 by the Social Worker (SW), signed on 07/05/21 by the Activities Therapist (AT), and signed on 06/28/21 by the nursing services (RN) and the attending physician. The SW documented that Patient #1526 was "making medium progress towards his treatment goals. He is eating, sleeping, and attending groups sporadically. He is responding to auditory hallucinations and is talking to himself when in room alone." The AT documented that "Patient demonstrates sporadic attendance and has made minimal progress towards treatment goals." Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is not documented for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

d. The ITP dated 07/06/21, was signed on 07/06/21 by the Social Worker (SW), nursing services (RN) and the attending physician, and is missing documentation and a signature from the Activitity Therapist (AT) and the patient. The SW documented that Patient #1526 was "making medium progress towards his treatment goals. He is eating, sleeping, and attending groups sporadically. He is responding to auditory hallucinations and is talking to himself when in room alone." Investigator #15 noted that this is documentation SW provided for Patient #1526 on the previous ITP on 06/28/21. The AT failed to document on the ITP dated 07/06/21. Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is not documented for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

e. The ITP dated 07/14/21, was signed on 07/14/21 by the Social Worker (SW) and attending physician and signed on 07/15/21 by the Activities Therapist (AT) and nursing services (RN), The SW documented that Patient #1526 was "making medium progress towards his treatment goals. He is eating 75% of meals, sleeping 7 hours on average, and does not attend group. He is responding to internal stimuli. He also has poor short-term memory." The AT documented that the Patient was "attending groups and has made minimal progress towards his treatment goals. We will continue to encourage Patient to participate in group activity." Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is not documented for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

f. The ITP dated 07/19/21, was signed on 07/20/21 by the Social Worker (SW), signed on 07/25/21 by the Activities Therapist (AT), and signed on 07/19/21 by nursing services (RN) and attending physician. The SW documented that Patient #1526 was "making medium progress towards his treatment goals. He is eating 75% of meals, sleeping 7 hours on average, and does not attend group. He is responding to internal stimuli. He also has poor short-term memory." Investigator #15 noted that this is documentation SW provided for Patient #1526 on the previous ITP on 07/14/21. The AT documented that the Patient "has not made progress, as Patient does not currently attend AT groups. AT will continue to encourage Patient to engage in group activities." Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is not documented for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

g. The ITP dated 07/26/21, was signed on 07/27/21 by the Social Worker (SW), signed on 07/28/21 by the Activities Therapist (AT), and signed on 07/26/21 by nursing services (RN) and attending physician. The SW documented that Patient #1526 was "making medium progress towards his treatment goals. He is eating 75% of meals, sleeping 7 hours on average, and does not attend group. He is responding to internal stimuli. He also has poor short-term memory." Investigator #15 noted that this is documentation SW provided for Patient #1526 on the previous ITP's dated 07/14/21 and 07/19/21. The AT documented that the Patient "has not made progress, as Patient does not currently attend AT groups. AT will continue to encourage Patient to engage in group activities." Investigator #15 noted that this is documentation SW provided for Patient #1526 on the previous ITP dated 07/19/21. Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is not documented for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

h. The ITP dated 08/06/21, was signed on 08/06/21 by the Social Worker (SW), Activities Therapist (AT), and attending physician and is missing documentation and signature from nursing services (RN). The SW documented that Patient #1526 was "making minimal progress towards treatment goals. He is often disruptive in the milieu, being loud and demanding to get his needs met. Patient informed of placement search continuing and records sent. Select group and fair hygiene." The AT documented that the Patient "sporadically attends groups and has made some progress towards treatment goals. Patient is irritable, however able to be calmed and redirected. AT will continue to encourage Patient to engage in activity group for emotional regulation and healthy leisure/coping skills." Progress is documented as "minimal" for Goal #1 - "Patient will willingly take medication as prescribed 70% of the time" and progress is documented as "minimal for Goal #2 - "Patient will engage in milieu activity and group treatment at least once per day, 3 out of 5 days." Investigator #15's review of the ITP failed to find evidence of documentation related to the interventions provided, the Patient's response to the interventions, and the Patient's progress related to Problem #1.

4. On 08/25/21 at 8:40 AM, Investigator #15 observed the Process Group titled, "Self-Esteem vs. Self-Compassion." The group was led by Activities Therapist (AT) (Staff #1511). The group took place on 3 West in the Day Room. The AT provided the patients who attended (7 of 27 patients) with pencils and three handouts that contained both Cognotive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) treatment modalities. Throughout the group, the AT encouraged the patients to fill out their responses on the handouts provided. The group ended at 9:15 AM.

5. On 08/25/21 at 9:30 AM, during an interview with Investigator #15, Staff #1511 stated that she facilitates the groups using a Process Group Curriculum, which is a 6-week rotation of curriculum, using various treatment modalities, including CBT and DBT. Staff #1511 stated that she was not aware of each of the client's individual treatment goals. Staff #1511 stated that if a patient does not attend the group she has conducted, she will leave a copy of the handout in the patient's room. Staff #1511 reported that typically staff do not document the Patient's response to the alternative interventions provided.
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Based on interview, policy review and record review, the facility failed to ensure that when the treatment plans were reviewed and the patient's progress evaluated, recommendations for revisions to the plan of care were implemented, as indicated for 4 of 10 active sample patients (Patient #1515, #1523, #1525, and #1526).

Failure to evaluate and provide recommendations to initiate changes to the plan of care in response to the patient's negative response or lack of progress to the provided interventions, results in hospitalizations without effective, patient-specific treatment and creates barriers to patient's progress, negatively impacting patient outcomes.

Findings included:

1. Document review of the hospital's document titled, "Treatment Planning," policy number PC.T.200, last reviewed 01/21, showed that treatment plan reviews and updates shall include the following:

a. Review of progress towards goals and effectiveness of interventions for each open problem on the Problems List.

b. Modifications or additions made to goals and interventions, as appropriate.

2. Document review of the hospital's document titled, "Social Services and Therapeutic Activities," policy number PC.ACT.01, approved 02/21, showed the following:

a. Any new goals identified during the course of treatment will be added to the Master Treatment Plan (MTP) form.

b. All groups will be designated to address each patient's individual treatment goals and patient's response to interaction.

c. All therapists will document the patient's progress or lack of progress towards treatment in the Therapy Progress Notes.

3. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1501, #1514, #1515, #1516, #1520, #1522, #1523, #1524, #1525, and #1526, to ensure that staff consistently made recommendations, and initiated modifications to the patient's treatment plan based on the patient's response and/or lack of progress to the interventions provided. Investigator #15's review of the active patient sample participation found that 10 of 10 of the active patient sample's MTP included treatment goals with interventions to provide daily groups and encourage patient attendance. The medical records review found that 4 of 10 of the sample patients had limited or minimal attendance at the daily groups (Activity and Process).

a. Patient #1515 failed to attend or participate in 31 of 51 group activities (Process or Activity) between 06/16/21 and 08/24/21. Investigator #15's review of the Group Progress Notes showed that staff failed to document the Patient's progress related to the intervention and/or alternatives offered. On the Group Progress Note, dated 08/16/21 (60 days after admission), staff documented that "Patient has made no progress towards his treatment goal. Staff will continue to encourage group participation and positive peer interaction." Investigator #15's review of the medical records failed to find evidence of recommendations for changes to the Patient's treatment plan based on the Patient's minimal progress towards group attendance and his treatment goals.

b. Patient #1523 failed to attend or participate in 103 of 103 group activities (Process or Activity) between 08/02/21 and 09/15/21. Review of the Group Progress Notes found that 103 of 103 Group Progress Notes failed to document the Patient's response to the intervention when alternative therapy (handout) was provided or the content of the alternative therapy provided. On the Group Progress Note, dated 08/25/21, Activities Therapy (AT) staff documented that the Patient was asleep and "refused to attend group. Staff will continue to encourage them to attend group for healthy coping and leisure skills." On the Daily Nursing Progress Note, dated 08/18/21, staff documented that the Patient continues to "require total assistance with activities of daily living (ADLs) and was unable to participate in groups." Investigator #15's review of the medical records failed to find evidence of recommendations for changes to the Patient's treatment plan based on the patient's lack of participation in group activities and limitations due to his physical limitations requiring assistance from staff for ADLs and increased anxiety.

c. Patient #1525 failed to attend or participate in 63 of 101 group activities (Process or Activity) between 08/16/21 and 09/16/21. Patient #1525 was a 50-year-old female Muslim from Bosnia, who presented as mute upon admission. Patient #1525 refused to join group activities from her admission on 08/16/21 to 08/19/21. Each day, the AT staff documented "Patient refused to attend group. Staff will continue to encourage them to attend group for healthy coping and leisure skills." On the Group Progress Note dated 09/01/21, AT staff documented that the Process Group included viewing a Ted Talk about Relationship Conflict and Resolution, and "unscramble the word activity." The theme of the word scramble was related to Christmas. The patient did not accept the activity because she "felt it interfered with her religious beliefs." Investigator #15's review of the Group Progress Notes found that staff failed to evaluate progress and make recommendations for changes to the Patient's treatment plan, based on the Patient's limited response to interventions and the Patient's individual needs, including language and cultural differences.

d. Patient #1526 failed to attend or participate in 98 of 151 group activities (Process or Activity) between 06/19/21 to 09/15/21. Investigator #15's review of the Patient's Weekly Treatment Plan Updates, dated 06/28/21, 07/06/21, 07/14/21, 07/19/21, and 07/26/21, found that staff documented that Patient #1526 was making "no progress" and "minimal progress," failing to attend group activities. There were no changes made to the MTP based on the Patient's limited progress. The AT staff documented weekly that "AT staff will continue to encourage the Patient to attend groups for healthy coping and leisure skills." Investigator #15's review of the medical records failed to find evidence of recommendations for changes to the Patient's treatment plan based on the patient's minimal participation in group activities and progress towards identified treatment goals.

4. On 08/24/21 at 10:50 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1510) stated that any needed changes to the Patient's treatment plan are addressed during Treatment Team. Staff #1510 reported that typically, the provider, the social worker, and the charge nurse attend treatment team. However, on 08/24/21, Staff #1510 stated that there was no treatment team that day and that the provider had already come in to talk to all patients. Investigator #15 asked Staff #1510 what was the process used by the treatment team to evaluate the patient's progress towards their treatment goals and revise the treatment plan. Staff #1510 was unsure of the process or how best to communicate that information.

5. On 08/24/21 at 3:40 PM, during an interview with Investigator #15, Social Worker (SW) (Staff #1509) reported that the social workers and providers communicate frequently, addressing any necessary changes to the Patient's treatment or discharge plan. Staff #1509 stated that treatment team usually consists of the provider and social workers, and the nursing staff attend when they can. Staff #1509 stated that "they used to attend daily, now they do what they can." Staff #1509 noted that the social work staff is responsible for making changes to the Patient's MTP.

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Item #1 Discharge Summary

Based on interview, record review, and review of policies and procedures, the facility failed to ensure that each patient who had been discharged, had a discharge summary, as demonstrated by record review for 3 of 10 discharge sample patients (Patient #1519, #1532, and #1534).

Failure to ensure that patients received a discharge summary may create barriers in securing appropriate services for aftercare and lead to adverse post-hospitalization outcomes.

Findings included:

1. Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective date 06/07/21, showed the following:

a. No patient should be discharged or signed out against medical advice (AMA) without first being evaluated by the Attending Physician or designee.

b. The medical record for a patient may reflect a combination Psychiatric Evaluation and Mental Status Examination and Discharge Summary for patients who are discharged within twenty-four (24) hours of admission. The discharge summary will contain the reason for admission, mental status, course in hospital, summary of treatment and prognosis.

c. Discharge documentation - Patients shall be discharged only on a written order of the Attending Physician. The record of each discharged patient must have a discharge summary, signed by the Attending Physician, of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate, as well as a brief summary of the patient's condition on discharge. The discharge summary must also include the reason for hospitalization, significant findings, procedures performed and treatments rendered, progress in meeting treatment goals, the name, dosage, frequency of any medications ordered for the patient at the time of discharge, and the discharge diagnosis.

d. All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge.

2. Document review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, last reviewed 02/21, showed the following:

a. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress towards goals, and community resources and referrals provided to the patient.

3. Document review of the hospital's policy and procedure titled, "AMA Discharge (Against Medical Advice)," policy number PC.D.420, last reviewed 02/21 showed the following:

a. In the event that a patient stated the intent to leave the hospital against medical advice (AMA), the patient is assessed for safety out of the hospital setting and nursing staff contact the patient's physician to discuss the patient's demand to leave AMA. If the patient continues to refuse to stay, and the physician deems the patient safe to leave, the following documentation should be completed:

i. Nursing staff completes the AMA Form with the patient. The patient signs the AMA Form, including the signature of one witness. If the patient refuses to sign the AMA Form, the refusal should be documented in the medical record.

ii. Nursing staff writes an AMA Discharge Note in the Nurses' Narrative which documents the circumstances and the warning given to the patient, objective signs and symptoms of the patient's physical and mental disorder, attempts made to persuade patient to stay, notification of appropriate authorities, if indicated.

4. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the discharge patient sample: Patient #1519, #1527, #1529, #1530, #1531, #1532, #1533, #1534, #1535, and #1536, to ensure that the patient's discharge documents, the Discharge Care Plan and the Discharge Summaries, were included in the medical record. The medical record review showed the following:

Patient #1519

a. Patient #1519, a 76-year-old female, was admitted on 07/28/21 after a suicide attempt in her assisted living home. Patient #1519 had a history of previous suicide attempts and self-harming behaviors. She was discharged on 08/16/21. During the medical record review on 09/15/21, Investigator #15 failed to find evidence of the Discharge Summary in Patient #1519's medical record.

b. In electronic (email) correspondence between Investigator #15 and the Director of Risk (Staff #1501) dated 09/16/21, Staff #1501 verified that the Discharge Summary was missing from Patient #1519's medical record. Staff #1501 indicated that the attending provider had an emergency and was unable to complete the Discharge Summary. Staff #1501 reported another provider should have been assigned the task of completing the Discharge Summary, however that did not occur.

Patient #1532

a. Patient #1532, a 33-year-old male, was admitted on 07/29/21 and discharged against medical advice (AMA) on 08/02/21. Review of Patient #1532's medical record showed the following:

i. On the Daily Nursing Progress Note dated 08/02/21, nursing staff documented at 7:00 PM that "patient stated, 'I don't want to be here, I am leaving' and left AMA". Nursing staff discharged patient AMA and documented that "provider was made aware."

ii. Investigator #15's review of the medical record failed to show evidence of an AMA Form, or documentation of refusal to sign the form, as directed by facility policy.

iii. On a document titled, "Discharge Summary," the provider wrote a single paragraph under the heading "Recommendations/Follow-up/After care. Th provider noted that "on August 2, 2021, I received a call from nursing staff stating that the patient would like to leave AMA. At the time of his leaving AMA, per nursing staff, he was alert and oriented, ambulates with a steady gait, vitals are stable per nursing."

b. Investigator #15's review of Patient #1532's discharge documents found no evidence of a Discharge Summary which contained a recapitulation of the patient's hospitalization, recommendations from appropriate services concerning follow-up or aftercare, and a brief summary of the patient's condition on discharge.

Patient #1534

a. Patient #1534, an 87-year-old female, was admitted on 07/31/21 and discharged on 08/06/21. Investigator #15's review of the Discharge Care Plan showed that the patient was discharged to an address in Auburn, WA. The "type of discharge" is noted as "transfer." Review of the Discharge Care Plan showed that staff failed to document the following information: reason for the transfer to a medical care facility, scheduled aftercare appointments, important contact information, discharge plan review, recovery and support, and discharge medication.

b. Investigator #15's review of the medical record for Patient #1534 failed to find evidence of a Discharge Summary.

5. On 09/15/21 at 11:30 AM, during an interview with Investigator #15, Staff #1501 verified that the Discharge Summary was missing for Patient #1534.

Item #2 Recapitulation of the Patient's Hospitalization

Based on interview, record review, and review of policies and procudures, the facility failed to ensure that each patient had a discharge summary which contained a recapitulation of the patient's hospitalization that included the summary and rationale for admission and synopsis of accomplishments achieved towards treatment plans, as demonstrated by record review for 7 of 10 discharge sample patients (Patient #1519, #1529, #1530, #1531, #1532, #1533, and #1534).

Failure to ensure that patients received a discharge summary that contained a recapitulation of their hospitalization, including rationale for admission, the extent to which treatment goals were met may create barriers or delays in securing appropriate services for aftercare and lead to adverse post-hospitalization outcomes.

Findings included:

1. Document review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective date 06/07/21, showed the following:

a. The medical record for a patient may reflect a combination Psychiatric Evaluation and Mental Status Examination and Discharge Summary for patients who are discharged within twenty-four (24) hours of admission. The discharge summary will contain the reason for admission, mental status, course in hospital, summary of treatment and prognosis.

b. Discharge Documentation - Patients shall be discharged only on a written order of the Attending Physician. The record of each discharged patient must have a discharge summary, signed by the Attending Physician, of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate, as well as a brief summary of the patient's condition on discharge. The discharge summary must also include the reason for hospitalization, significant findings, procedures performed and treatments rendered, progress in meeting treatment goals, the name, dosage, frequency of any medications ordered for the patient at the time of discharge, and the discharge diagnosis.

c. All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge.

2. Document review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, reviewed 02/21, showed the following:

a. The patient's demonstrated readiness for discharge should be linked to the achievement of treatment goals.

b. Discharge goals represent the achievements expected for the identified problem by the time of discharge when the patient is ready to move into a less intensive level of care.

c. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress towards goals, and community resources and referrals provided to the patient.

3. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the discharge patient sample: Patient #1519, #1527, #1529, #1530, #1531, #1532, #1533, #1534, #1535, and #1536, to ensure that the patient's discharge summary contained a recapitulation of the patient's hospitalization, that included rationale for admission and synopsis of treatment achieved during the hospitalization. The medical record review showed the following:

a. Investigator #15's review of the medical records showed that medical staff failed to document a Discharge Summary, or document a review or recapitulation of the patient's hospitalization, rationale for admission, or synopsis of treatment during hospitalization for the following patients: Patient #1519, #1532, and #1534.

b. On Patient #1529's Discharge Summary, discharged 06/07/21 and dated 06/26/21, the provider documented that the patient "fully met his treatment goals while in the hospital." Investigator #15 found no evidence that staff documented the Patient's individual psychiatric and medical treatment goals, interventions provided, or the patient's response to the interventions.

c. On Patient #1530's Discharge Summary, discharged 08/02/21 and dated 08/07/21, the provider documented that the patient "fully met her treatment goals while in the hospital." Investigator #15 found no evidence that staff documented the Patient's individual psychiatric and medical treatment goals, interventions provided, or the patient's response to the interventions

d. On Patient #1531's Discharge Summary, discharged 07/16/21 and dated 08/06/21, the provider documented that the patient "fully met his treatment goals while in the hospital." Investigator #15 found no evidence that staff documented the Patient's individual psychiatric and medical treatment goals, interventions provided, or the patient's response to the interventions.

e. On Patient #1533's Discharge Summary, discharged on 08/10/21 and dated 08/17/21, the provider documented that the patient "partially met his treatment goals while in the hospital. Due to the patient being discharged AMA due to a voluntary drop by the prosecutor." Investigator #15 found no evidence that staff documented the Patient's individual psychiatric and medical treatment goals, interventions provided, or the patient's response to the interventions.

4. On 09/15/21 at 11:30 AM, during an interview with Investigator #15, Staff #1501 verified that some of the patient's Discharge Summaries were missing documentation of the recapitulation of the hospitalization. Staff #1501 stated that the hospital recently hired a new Medical Director and the discrepencies with missinig and incomplete documentation will be taken up with the new Director.

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Based on interview, record review, and review of policies and procedures, the facility failed to ensure that each patient who had been discharged, had a discharge summary in the medical record that included recommendations for appropriate services concerning follow-up and/or aftercare, as demonstrated by record review for 8 of 10 discharge sample patients (Patient #1519, #1527, #1530, #1531, #1532, #1533, #1534, and #1536).

Failure to ensure that each patient had a discharge summary in their medical record that included recommendations for appropriate services concerning follow-up and/or aftercare, may create delays in securing appropriate services for aftercare and lead to adverse post-hospitalization outcomes.

Findings included:

1. Document review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective date 06/07/21, showed the following:

a. Discharge documentation - Patients shall be discharged only on a written order of the Attending Physician. The record of each discharged patient must have a discharge summary, signed by the Attending Physician, of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate

2. Document review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, reviewed 02/21, showed the following:

a. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress towards goals, and community resources and referrals provided to the patient.

3. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the discharge patient sample: Patient #1519, #1527, #1529, #1530, #1531, #1532, #1533, #1534, #1535, and #1536, to ensure that the patient's discharge documents, including the Discharge Care Plan and the Discharge Summaries contained recommendations for appropriate services concerning follow-up and aftercare. The medical record review showed the following:

a. Investigator #15's review of the discharge patient sample showed that 3 of 10 patient's medical records did not include a Discharge Summary: Patient #1519 discharged on 08/16/21, Patient #1532 discharged on 08/02/21, and Patient #1534 discharged on 08/06/21. Investigator #15 found no evidence that staff documented recommendations for aftercare arrangements for services and supports or provided the discharge related documents including treatment recommendations and discharge medications to the patient, family, and/or post-hospital treatment entities.

b. Patient #1527 was admitted on 06/15/21 and discharged on 06/19/21. On the Discharge Care Plan, dated 06/19/21, staff documented that the discharge on 06/19/21 was a "planned discharge." Investigator #15's review of the Discharge Care Plan found no evidence that staff documented scheduled aftercare appointments, support and crisis contact information, or completed a discharge plan review with patient. On the Discharge Summary, dated 06/28/21, the medical provider documented that the "patient was advised to follow-up with her primary care physician within 2-4 weeks, as instructed." Investigator #15 found no evidence that staff documented recommendations for aftercare arrangements for services and support, such as mental health or therapy services, psychiatric medication management, case management, or provided the Patient's primary care provider post hospitalization treatment recommendations and discharge medications.

c. Patient #1530 was admitted on 07/22/21 and discharged on 08/02/21. On the Discharge Summary, dated 08/07/21, the medical provider documented that "the severity of her mental illness means that she will likely remain disabled." Investigator #15's review of the Patient's Discharge Care Plan found that staff failed to schedule aftercare appointments for the Patient. For the aftercare appointments, including mental health/therapy, medication management, addiction treatment, case management, and primary care services, staff documented that "it is recommended that you contact your service provider after discharge." Investigator #15 found no evidence that staff provided Patient #1530 with an aftercare plan that included supports and services post-hospitalization.

d. Patient #1531 was admitted on 07/13/21 and discharged on 07/16/21. Investigator #15's review of the Patient's Discharge Care Plan, dated 07/16/21, found that staff failed to schedule aftercare appointments for the Patient. For the aftercare appointments, including mental health/therapy, medication management, addiction treatment, case management, and primary care services, staff documented that "it is recommended that you contact the hospital in order to be provided a primary care provider." Investigator #15 found no evidence that staff provided Patient #1531 with an aftercare plan that included supports and services post-hospitalization.

e. Patient #1533 was admitted on 07/28/21 and discharged on 08/10/21. On the Discharge Summary, dated 08/17/21, the provider noted that the patient was being discharged against medical advice (AMA) due to a voluntary drop by the courts. The provider documented that "due to the severity of the patient's mental illness he likely could not live independently and would have difficulty completing his activities of daily living (ADL) independently. Investigator #15's review of the Patient's Discharge Care Plan, dated 08/10/21, found that staff failed to document the location where the patient was discharged to, or the method of discharge transportation. Investigator #15 found no evidence that staff developed an aftercare plan, that included supports and services post-hospitalization for Patient #1533.

f. Patient #1536 was admitted on 07/19/21 and discharged on 07/26/21. Investigator #15's review of the Patient's Discharge Care Plan, dated 07/26/21, found that staff failed to schedule aftercare appointments for the Patient. For the aftercare appointments, including mental health/therapy, medication management, addiction treatment, case management, and primary care services, staff documented that the patient "refused - See attached resource list." Investigator #15 found no evidence of a "resource list" in the Patient's medical records. Investigator #15's review of the discharge documents in the medical records, found no evidence that staff provided Patient #1536 with an aftercare plan that included supports and services post-hospitalization.

4. On 08/24/21 at 3:45 PM, during an interview with Investigator #15, Social Worker (SW) (Staff #1509) stated that they often assist with discharge planning for patients. Staff #1509 verified that staff should be documenting all discharge planning activities in the SW Progress Notes. The SW is responsible for setting up the aftercare appointments for the patients. Staff #1509 stated that sometimes it is difficult to find the patient appropriate housing or community support, but those attempts would be documented in the Patient's medical records.

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Based on interview, record review, and review of policies and procedures, the facility failed to ensure that each patient had a discharge summary, which contained a baseline of the patient's psychiatric, physical, and social functioning status at time of discharge as a summary of the patient's condition on discharge, as demonstrated by record review for 8 of 10 discharge sample patients (Patient #1519, #1529, #1530, #1531, #1532, #1533, #1534, and #1536).

Failure to ensure that patients received a discharge summary that contained the patient's baseline functioning at the time of discharge, may create barriers in securing appropriate services for aftercare and lead to adverse post-hospitalization outcomes.

Findings included:

1. Document review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective date 06/07/21, showed the following:

a. The medical record for a patient may reflect a combination Psychiatric Evaluation and Mental Status Examination and Discharge Summary for patients who are discharged within twenty-four (24) hours of admission. The discharge summary will contain the reason for admission, mental status, course in hospital, summary of treatment and prognosis.

b. Discharge documentation - Patients shall be discharged only on a written order of the Attending Physician. The record of each discharged patient must have a discharge summary, signed by the Attending Physician, of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate, as well as a brief summary of the patient's condition on discharge. The discharge summary must also include the reason for hospitalization, significant findings, procedures performed and treatments rendered, progress in meeting treatment goals, the name, dosage, frequency of any medications ordered for the patient at the time of discharge, and the discharge diagnosis.

2. Document review of the hospital's policy and procedure titled, "Discharge Planning and Aftercare," policy number PC.D.401, last reviewed 02/21, showed the following:

a. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress towards goals, and community resources and referrals provided to the patient.

3. On 09/15/21, Investigator #15 reviewed the medical records for the following patients selected as the discharge patient sample: Patient #1519, #1527, #1529, #1530, #1531, #1532, #1533, #1534, #1535, and #1536, to ensure that the patient's discharge summary contained documentation of the patients baseline psychiatric, physical and social functioning status at the time of discharge. The medical record review showed the following:

a. Investigator #15's review of the medical records showed that medical staff failed to document a Discharge Summary, or document a baseline psychiatric, physical and social functioning status, including a summary of the patient's condition at the time of discharge for the following patients: Patient #1519, #1532, and #1534.

b. Review of Patient #1529's Discharge Summary, discharged on 06/07/21 and dated 06/27/21, showed the following:

i. The provider's documentation for the Patient's "Physical/Medical Condition on Discharge" was a list of the Patient's medical history and co-morbidities, which included Hypothyroidism, unspecified Epilepsy, Polyneuropathy, and Restless Legs Syndrome. The provider noted the lab results, obtained on 06/01/21. Investigator #15 found no evidence of staff documenting the Patient's physical and behavioral status at the time of discharge.

ii. Investigator #15 found the review of the Patient's Discharge Summary to contain conflicting or incongruent documentation. The provider's documentation for the Patient's "Functional Condition on Discharge" noted that Patient #1529 demonstrated "fair functional condition at the time of discharge" due to the Patient's neuropathy, which makes it difficult to work and causes "somewhat slower mobility." The provider also documented that the Patient has "no limitations on functional skills at the dime of discharge."

iii. Patient #1529's Mental Status Examination on Discharge identically matched two other Patient's in the Discharge Patient Sample (Patient #1530 and #1531). Based on the data from the Patient's Mental Status Examination (MSE) and review of the Discharge Summary, Investigator #15 found no evidence the provider documenting the Patient's psychiatric and social functioning, or summary of the patient's condition at the time of discharge.

c. Review of Patient #1530's Discharge Summary, discharged on 08/02/21 and dated 08/07/21, showed the following:

i. The provider's documentation for the Patient's "Physical/Medical Condition on Discharge" listed a medical history of the patient's co-morbidities, which included history of Acute Pancreatitis, Anemia, Endometriosis, Hyperlipidemia, Thrombocytopenia, and Chronic Pain. The provider noted the lab results, obtained prior to admission. Investigator #15 found no evidence of staff documenting the Patient's physical status or condition at the time of discharge.

ii. Based on the data from Patient #1530's Mental Status Examination (MSE) and review of the Discharge Summary, Investigator #15 found no evidence of the Patient's psychiatric and social functioning or summary of the patient's condition at the time of discharge.

d. Review of Patient #1531's Discharge Summary, discharged on 07/16/21 and dated 08/06/21, showed the following:

i. The provider's documentation for the Patient's "Physical/Medical Condition on Discharge" noted that Patient #1531 had no chronic medical comorbidities and no known allergies. The provider noted the lab results, obtained in the emergency department prior to admission. Investigator #15 found no evidence of staff documenting the Patient's physical status or summary of condition at the time of discharge.

ii. Based on the data from Patient #1531's Mental Status Examination (MSE) and review of the Discharge Summary, Investigator found no evidence of the Patient's psychiatric and social functioning or summary of condition at the time of discharge.

e. Review of Patient #1533's Discharge Summary, discharged on 08/10/21 and dated 08/17/21, showed the following:

i. The provider's documentation for the Patient's "Physical/Medical Condition on Discharge" listed a medical history of the patient's co-morbidities, which included Exotropia of the left eye, history of Developmental Delay, and Traumatic Brain Disorder (TBI). The provider noted the lab results, obtained on 08/04/21. Investigator #15 found no evidence of staff documenting the Patient's physical status or condition at the time of discharge.

ii. Based on the data from Patient #1533's Mental Status Examination (MSE) and review of the Discharge Summary, Investigator found no evidence of the Patient's psychiatric and social functioning or condition at the time of discharge.

f. Review of Patient #1536's Discharge Summary, discharged on 07/26/21 and dated 08/07/21, showed the following:

i. The provider's documentation for the Patient's "Physical/Medical Condition on Discharge" noted that the Patient had no chronic medical comorbidities and no known drug allergies. The provider noted the lab results, obtained prior to admission. Investigator #15 found no evidence of staff documenting the Patient's physical status or summary of condition at the time of discharge.

ii. Based on the data from Patient #1536's Mental Status Examination (MSE) and review of the Discharge Summary, Investigator found no evidence of the Patient's psychiatric and social functioning or condition at the time of discharge.

4. On 09/15/21 at 11:45 AM, during an interview with Investigator #15, the Chief Medical Officer (Staff #1514), Staff #1514 confirmed that the medical records discharge summaries were incomplete. Staff #1514 stated that he will be meeting with the hospital's providers in the near future to address these discrepencies.
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Based on observation, interview, policy review and record review, the hospital failed to ensure that the hospital had adequate numbers of qualified professional and supportive staff to carry out an intensive and comprehensive active treatment program and to protect and promote the physical and mental health of the patients.

Failure to ensure that hospital had adequate numbers of qualified professional and supportive staff puts the patient at risk for inappropriate or ineffective treatment and creates increased negative patient outcomes.

Findings included:

1. Failure to ensure adequate numbers of qualified, trained, registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.

Cross Reference: A1704

2. Failure to ensure that the Therapeutic Activities Program provided appropriate services to meet the needs and interest of the patients, directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.

Cross Reference: A1725

Due to the scope and severity of deficiencies cited under 42 CFR 482.62, the Condition of Participation for Special Staff Requirements for Psychiatric Hospitals was NOT MET.

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Item #1 - Staff Training

Based on interview, policy review, and record review, the facility failed to ensure that the hospital had adequate numbers of nursing personnel who have education, experience and/or training in psychiatric care to provide the nursing care necessary under each patient's active treatment program.

Failure to ensure that the hospital has adequate nursing personnel who have education and/or training in the care of psychiatrics may create barriers in providing care according to the patient's individualized treatment plan and/or may create an ineffective response by staff in response to an acute escalation in behavior resulting in the potential risk of patient and staff safety.

Findings included:

1. Document review of the hospital's document titled, "Orientation Checklist for Agency/Contractor/Students," no document number, no effective date, showed the following:

a. Physical Management Training is only included for extended contracts over 13 weeks.

b. If the agency staff person will be used on a longer-term contract basis, have them complete a more in-depth orientation including physical management training.

c. When possible, do not schedule the agency staff person to be the only person within their discipline on the unit (for example: nurse).

2. Document review of the hospital's document packet titled, "Registered Nurse (RN)/Licensed Practical Nurse (LPN) Competency Packet which is utilized to train and determine competencies for all nursing staff, including contract agency staff, found no evidence of training and/or competency checklist related to physical management training or training and/or competency checklists related to documentation of the patient's treatment goals and objectives, interventions, response to treatment, and assessment of patient progress.

3. On 08/12/21, investigator #15 reviewed the Personnel Training Records for 34 Cascade Behavioral Health Staff. The review showed the following:

a. Review of the list of staff's "Workplace Violence" training status provided by the facility showed that the list did not contain completion dates for 14 of 34 staff reviewed.

b. Review of staff "Skills Fair" packets (an annual competency training), conducted in July 2021, provided by the facility showed the following:

i. Checklists for Seclusion and Restraint training were not completed for 17 of 34 staff reviewed.

ii. Checklists for Seclusion and Restraint training did not contain a supervisor/evaluator signature or date verifying the "hands on" portion of the competency for 23 of 34 staff reviewed.

iii. Checklists for Seclusion and Restraint training did not contain the date of the supervisor/evaluator signature for 7 of 34 reviewed.

iv. Checklists for Seclusion and Restraint training did not contain the date that the checklist was filled out for 5 of 34 staff reviewed.

v. Checklists for the Observation Rounds training were not completed for 17 of 34 staff reviewed.

vi. Checklists for the Observation Rounds training did not contain a supervisor/evaluator signature or date for 22 of 34 staff reviewed.

vii. Checklists for the Observation Rounds training did not contain the date of the supervisor/evaluator signature for 7 of 34 reviewed.

viii. Checklists for the Observation Rounds training did not contain the date that the checklist was filled out for 5 of 34 staff reviewed.

4. On 08/12/21 at 11:45 AM, during an interview with Investigator #15, the Corporate Director of Quality (Staff #1505) stated that she was unable to speak to the missing and incomplete training competency documentation and suggested that investigators speak with the Chief Nursing Officer (CNO).

5. On 08/12/21 at 3:30 PM, during an interview with Investigator #15, the Chief Nursing Officer (CNO) (Staff #1507), stated that "most are done properly." However, Staff #1507 then stated that the hospital discovered the last week of July that the Skills Fair packets were all incomplete and "will have to be re-done."

6. On 08/13/21 at 12:00 PM, during an interview with Investigator #15, the Director of Risk (Staff #1501), verified that the hospital did not have a policy outlining staff training requirements.

7. On 08/18/21 at 10:45 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1519) stated that the Skills Fair in July "was filling out the checklists only. They were told to make sure that everybody answered every question and then they checked us off." Staff #1519 stated that there was no hands-on training for any of the competencies at the Skills Fair in July. Staff #1519 stated that now, during COVID, staff is trained in Seclusion and Restraint by watching a video, no hand-on training.

8. On 08/19/21 at 11:45 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1521) stated that the training received previously from the hospital educator included teaching staff how to recognize when a patient is escalating and the best way to approach the patient safely. Staff #1521 did participate in the Skills Fair in July, stating "it was a joke! They put answers on the wall. There was not any training and no hands-on skills." "They gave you a packet, told you to fill it out and give to the Infection Control Nurse. Then it will go to the Chief Nursing Officer (CNO)." Staff #1521 stated that not every nurse at the Skills Fair had the same training and skill level. New employees were instructed to fill out the paperwork in the same manner as staff that had been at the hospital for a long time.

8. On 08/24/21 at 11:20 AM, Investigator #15 visited the 3West unit, which is considered an adult psychiatric unit, which typically admits the most behaviorally acute patients who are being involuntarily detained. The patient census was 27. Staffing on the unit during day shift consisted of 5 nurses (RN) and 3 behavioral health assistants (BHA). Three of the RNs were orienting to the hospital, two of the nurses orienting were travelers (agency contract staff) with limited orientation training, and the other RN had only been at the hospital for two days. One of the BHAs was performing one to one (1:1) observations only. Typical core staffing for the unit is: 4 RN's 3 BHA's, 1 social worker, and 1 activities therapist. The nursing staff did not participate in the Treatment Team for the day, as the provider had already come to the unit to speak to the patients. Nursing staff was unable to speak to the patient's individual treatment plans, and suggested the investigator look at the Patient's Observation Logs to see if there were any "special precautions."

9. Investigator #15 failed to find evidence documenting that the hospital and nursing leadership monitor and evaluated all nursing staff, including new hires and contract agency staff, consistently for competency and education and/or experience in psychiatric care.

Item #2 - Staffing to Ensure Safe Environment

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure a safe and secure environment for patients and/or staff, by providing adequate numbers of qualified professional and supportive staffing, including mental health workers, to carry out active treatment programs and to protect and promote the physical and behavioral health of the patients, for 3 of 3 patient's medical records reviewed (Patient #1501, #1503, and #1508).

Failure to maintain a safe and secure environment with adequate numbers of qualified professional and supportive staff, including mental health workers, puts patients and/or staff at risk for serious injury and/or death.

Findings included:

1. Document review of the hospital's policy titled, "Patient Levels and Safety Precautions," policy number PC.PLSP.100, last reviewed 01/21, showed the following:

a. All patients are screened for precautions and orders will be obtained by admitting provider upon admission. Safety precautions are as follow:

i. Suicide Precautions - observations are one to one (1:1) preferred; at the very least "Line of Sight."

ii. Elopement Precautions - verbalizing threatening to escape.

iii. Assault Precautions - recent history of assault or verbalizing threats to assault. Patient cannot discharge while this precaution is active.

iv. Fall Precautions - interventions vary depending of Morse Fall Scale score. High score increased level of observation, as appropriate.

v. Sexually Acting Out Precautions - patients who are verbalizing intent to act out sexually or seen engaging in sexual activity.

vi Medical Alert - patient who have unstable medical conditions.

vii. Sexual Victimization - patient who have a history of sexual victimization.

2. Document review of the hospital's policy titled, "Patient Observations," policy number PC.P.300, last reviewed 02/21, showed the following:

a. All patient will be on a minimum of 15-minute observations (Q15).

b. The practitioner may order changes as the patient's condition warrants.

c. The Registered Nurse (RN) may increase the level of observation if the patient's condition changes.

d. The RN may not decrease the level of observation without an order by the practitioner.

e. Levels of Observations are as follows:

i. Every 15-minute (Q15) checks. All patients are monitored at minimum once in every 15-minute block of time.

ii. Every 5-minute (Q5) checks. This level of observation is required when the patient could, at any time, try to harm themselves or others.

iii. One to One (1:1) observation. The highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming themself or others. The practitioner may specify waking hours or continuous 1:1. Staff who are assigned to monitor the 1:1 patient observation will have no other assignments.

iv. The RN will assess 1:1 patient a minimum of two times per shift and document patient condition in the progress note. Assessment will include the need for continued 1:1 observation.

f. Staff documents all patient observations on the Q15 (and Q5) observation forms, including: Level of observation, precautions, patient location, patient behavior, activity, time and staff initials and signature.

g. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance or to back fill time frames that were not completed in a timely manner.

3. Review of the hospital's document titled, "Behavioral Health Associate I - Job Description," dated 01/20, showed the following:

a. The Behavioral Health Associate (BHA) is responsible for providing personal care services under the direction of clinical or nursing leadership.

b. The BHA is responsible for conducting safety checks and ensuring that supervision is conducted at 15-minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed.

c. The BHA is responsible for documenting timely, accurate, and appropriate clinical information in the patient's medical record.

d. The BHA may oversee or assist patients with activities of daily living (ADLs), including toileting, bathing, dressing, grooming oral hygiene, meals, snacks, hydration and changing bed linens.

e. The BHA will engage patients in activities and interactions, designed to encourage achievement of treatment goals.

4. Review of the hospital's document titled, "Scope of Care Provided - Dual Diagnosis Unit," not dated, showed the following:

a. The holistic care of the patient is the responsibility of the interdisciplinary team which includes ancillary staff (BHAs).

b. Core Staffing as follows:

i. Day and Evening Shift: 4 Registered Nurses (RN), 2 Behavioral Health Associates (BHA), 1 Social Worker (SW), 1 Recreational Therapist.

ii. Chief Nursing Officer, Nurse Manager, Director of Addictions, Director of Social Services, and House Supervisor on site and available, as needed.

iii. Night Shift: 2 RNs, 1 BHA.

5. Document review of the hospital's policy titled, "Staffing Assignments," policy number PC.L.900, last reviewed 01/21, showed the following:

a. To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following:

i. A registered nurse (RN) supervises and evaluates the nursing care of each patient.

ii. A RN receives report before assigning appropriate aspects of nursing care to RNs and BHAs.

iii. Patient care assignment is commensurate with qualifications of each staff member and the identified nursing need of the patient according to acuity.

iv. Patient care assignment is based on acuity and equally distributed among staff and will be documented on the Staffing Assignment Sheet.

v. Staffing Assignment Sheets will be reviewed and maintained by the Director of Nursing.

6. On 9/15/21, Investigator #15 reviewed the medical records for 3 patients to verify that the patient's observation status was assigned by staff according to provider orders, and appropriate monitoring was implemented, based on patient acuity, as defined by hospital policies and procedures. The medical record review showed the following:

Patient #1501

a. On 08/12/21 at 3:00 PM, Investigator #15 and the Director of Risk (Staff #1501) reviewed the medical records for Patient #1501, a 27-year-old male admitted on 07/24/21, on an involuntary detainment with a psychiatric diagnosis of Psychosis. Documents obtained during admission showed that the Designated Crisis Responder (DCR) noted that "it took 7 police officers to restrain" the Patient. Review of the Patient's medical record showed the following:

i. On the admission order, dated 07/24/21, staff documented that Patient #1501 was placed on Q15 observations and no safety precautions were initiated.

ii. On 07/28/21, Patient #1501 had an incident that required chemical restraint.

iii. On 07/30/21, the provider ordered the Patient's level of observation changed to Q5, based on danger to others. No changes were made to the Patient's safety precautions at the time of the order.

iv. Review of the medical record from 07/30/21 to 08/01/21 showed that the Patient was on Q15 observations, with no safety precautions noted. Staff failed to implement the provider's order for Q5 observations.

v. On 08/01/21 at 9:00 PM, the Patient was placed in seclusion and restraint, after an incident of escalating aggressive and violent behavior, which resulted in multiple staff injuries.

vi. On 08/02/21 at 12:00 AM, Patient #1501 was released from seclusion and restraint. The observation log for 08/02/21 from 12:00 AM to 7:25 AM documented Q5 observations, with safety precautions noted as elopement and suicide precautions. The observation log for 08/02/21 from 7:30 AM to 3:45 PM documented Q5 observations and noted as elopement and assault precautions. Investigator #15 found no orders to change the Patient's safety precautions in the medical record.

vii. On 08/02/21, Patient #1501 was placed in seclusion and restraint from 3:50 PM to 08/3/21 at 5:45 AM.

viii. Review of the medical record failed to show evidence documenting Patient #1501's Q5 observations between 7:30 AM to 11:00 AM on 08/03/21.

ix. The Patient's observation status was changed from Q5 to Q15 at 10:00 AM on an unknown date.

x. Review of the medical record failed to show evidence of a provider order changing the Patient's observation level from Q5 to Q15.

7. On 09/30/21 at 9:50 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff # 1522) stated that they were working on 08/01/21. All of the beds were full on the unit, with a census of 30 patients. Staff #1522 stated that the staffing was "bad, they were short nurses." Staff #1522 called to request additional staff, due to being short one nurse, an increased level of acuity, and a patient who required 1:1 observation. Staff #1522 stated that one member of the leadership team responded "let them be short" when she requested additional staff for the unit. Staff #1522 reported that Patient #1501 had been escalating all week and had been refusing all medications since the previous day. At 7:20 PM, Patient #1501 became increasingly aggressive and threatening to other patients and staff. A code grey (combative or violent patient) was called when the Patient acquired a set of keys from a staff member and was able to elope, moving between other units within the facility.

Staff #1522 reported that she attempted to contact the Chief Nursing Officer (CNO) regarding the escalating incident but did not receive a call back. Staff #1522 stated that the attempt to deescalate the Patient and place him in seclusion and restraint took over 2 hours. Staff #1522 stated that Patient #1501 kicked her twice and several other staff members were injured during the incident on 08/01/21.

Staff #1522 stated that usually night shift has bad staffing and if they are short, or a patient needs 1:1 observation, the CNO will tell the nurses "to call the provider to have them lower the 1:1 to Q5 or remove the 1:1 altogether. Staff #1522 stated that the staff do not feel safe.

8. Thus, the hospital failed to ensure that nursing staff assessed Patient #1501's nursing and clinical needs, including accurately identifying the acuity level, appropriate safety precautions and observation levels to create staff assignments for ancillary staff (BHAs), which created an unsafe environment for patients and staff.

Patient #1508

a. On 08/12/21 at 11:00 AM, Investigator #15 and the Director of Risk (Staff #1501), reviewed the medical record for Patient #1508, who was admitted to 2 West Unit on 05/20/21, with a psychiatric diagnosis of Schizoaffective Disorder. The patient was noncompliant with his medications and presented as delusional and paranoid. He had multiple recent suicide attempts and was recently arrested for assaulting a fellow resident at his living facility. While the patient was in the Emergency Department, he was in 2-point restraints and attempted to hit the medical provider. Review of the medical record showed the following:

i. On the Initial Psychiatric Evaluation, dated 05/21/21, the provider documented that Patient #1508 was placed on Suicide Precautions, Assault Precautions and Q15 observations.

ii. Investigator #15's review of the Interdisciplinary Master Treatment Plan Weekly Updates (ITP) for the following dates, 05/27/21, 06/24/21, 07/01/21, 07/08/21 and 07/22/21, showed the following:

Staff documented that Patient #1508 was making minimal progress and remained "unpredictable and physically aggressive and continues to assault/hit peers."

Staff documented that Patient #1508 remained on Q15 observations.

b. On the Daily Nursing Progress Note, dated 07/19/21, staff documented that at 11:45 AM, Patient #1508 physically assaulted another patient who was sitting in their wheelchair. Patient #1508 kicked the other patient in the face multiple times.

c. Investigator #15's review of the Patient Observation records for 07/19/21 showed that the Patient was on Q15 observations, with no precautions noted, at the time of the assault on 07/19/21 at 11:45 AM.

d. On the Incident Report for 07/19/21, staff documented that at 2:45 PM, Patient #1508 assaulted the same patient a second time a few hours later. The second assault took place in front of the nurse's station, with the victim sitting in his wheelchair. Patient #1508 repeatedly kicked the victim in the neck and leg. At the time of the second assault, Patient #1508 was on Q15 observations, with no precautions noted.

e. On 07/19/21 at 3:00 PM, the provider wrote an order to place Patient #1508 on 1:1 monitoring.

f. Investigator #15's review of the medical record found that the hospital failed to ensure that nursing staff assessed Patient #1508's nursing and clinical needs, including accurately identifying the acuity level, appropriate safety precautions and observation levels to create staff assignments for ancillary staff (BHAs), which lead to a preventable patient assault.

9. On 08/11/21 at 11:30 AM, during an interview with Investigator #15, Director of Risk (Staff #1501), stated that Patient #1508 should have been placed on 1:1 observation after the first assault, and verified that they were on Q15 instead. Staff #1501 was unable to speak to short staffing for the day of the incident of 07/19/21.

Patient #1503

a. On 08/13/21 at 2:00 PM, Investigator #15 and the Director of Risk (Staff #1501), reviewed the medical record for Patient #1503, a 31-year-old female, admitted on 07/15/21, on an involuntary detainment with a psychiatric diagnosis of Schizophrenia and Developmental Delay. The Patient had a history of aggressive behavior and stated that she was hearing voices telling her to kill herself. Review of the Patient's medical record showed the following:

i. On the Initial Psychiatric Evaluation, dated 07/16/21, the provider documented that Patient #1503 was placed on Suicide Precautions, Assault Precautions and Q15 observations.

ii. On 07/16/21 at 12:00 PM, the provider wrote an order to place Patient #1503 on 1:1 observation for assaultive behavior. Investigator #15's review of the medical record showed that the patient was on continuous 1:1 monitoring during her admission from 07/15/21 to 08/02/21.

iii. On the Discharge Summary, dated 08/09/21, the provider documented that Patient #1503 was "unwilling to be off the 1:1 monitoring the entire time she was at the hospital." The provider noted that there was some "concern that the patient was attention seeking." On 08/01/21 the provider documented that Patient #1503 "picked up a trash can and attacked an RN." The provider told the patient that "if she continued to harm staff she would be discharged." Based on the provider's assessment of Patient #1503, the provider agreed with the Patient's request to leave and discharged her.

iv. Investigator #15's review of the Discharge Summary, dated 08/09/21, found that the provider noted that the "Patient would even want a 1:1 to help her bathe. We did feel that there was attention seeking borderline behavior with her request for 1:1 support." The provider noted that the hospital could not meet her needs with the constant 1:1, so she was discharged to a shelter.

10. Investigator #15's review of the medical record found that the hospital was unable to provide the staffing and supportive care required to ensure the safety of Patient #1503 and create a safe environment for treatment.

11. On 08/19/21 at 11:45 AM, during an interview with Investigator #15, a Registered Nurse (RN) (Staff #1521) stated often the managers will ask us to call the provider to say "our patient is cooperating now, so you can release them." Staff #1521 stated that the hospital has been short staffed. Because of the short staffing, managers will ask you "if you can just put the patient on close monitoring, like Q5 or Line of Sight, not 1:1?" When that happens, then no staff is assigned to observe the patient? We try our best, but if we can't do 1:1, the manager tells us we must do observations as "Line of Sight instead, which does not require a designated staff member for the observation."

12. On 09/28/21 at 12:05 PM, during an Interview with Investigator #15, a Behavioral Health Associate (BHA) (Staff #1527), Staff #1527 clarified that observations every 5 minutes (Q5) is for when patients are a danger to themselves or others. Patients have to be monitored every 5 minutes. Staff #1527 stated that often for their unit, there will be a patient census of 30 patients, with 3 BHA's, and there may be 5-7 patients who are on Q5. The 3 BHAs will divide up, sometime monitoring 10 patients with 2-3 of the patients requiring Q5 monitoring. The BHAs are also responsible for "lots of other activities, such as food and drinks, ADL's, and laundry." Staff #1527 stated that it creates a "risky situation, because it's difficult to do Q15 and Q5 observation rounds when serving food and drinks and helping a patient to toilet or shower." Staff #1527 stated that there are days that "we don't take breaks, and when we do take a break, that leaves the other BHA's to watch 15-30 patients." "When the unit has a high acuity, none of us get to go, we are stuck," Staff #1527 stated that there are days when a patient needs a higher level of observation (1:1), and there is no extra staff to help, we basically have to treat them as a Q5 and take extra time to visit that patient."

Staff #1527 reported that if they have a patient that requires 1:1 observation, often the nurses are instructed to call the provider to "force them to lift that patient from 1:1 observation. It's not because the patient is ready to be released from the higher level of observation. The nurse managers and supervisors call the provider and tell them that the patient is calm." I have witnessed that when a patient was a danger, and the 1:1 is lifted, then the patient goes on to hurt other patients."

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Based on interview, policy review, and record review, the hospital failed to ensure that staff provided individualized therapeutic interventions that are appropriate to the needs and interests of the patient to restore and maintain optimal levels of physical and psychological functioning, as indicated for 1 of 10 active sample patients (Patient #1523).

Failure to ensure that the hospital provided individualized therapeutic interventions and activities based on the patient's specific needs may create a barrier to receiving treatment and a decline in the patient's physical or psychological functioning.

Findings included:

1. Document review of the hospital's policy titled, "Treatment Planning," policy number PCT.T.200, last reviewed 01/21, showed that the initial treatment plan, and any subsequent revisions of the plan, shall:

a. Reflect the patient's clinical needs, condition and functional strengths and limitations.

b. Specific goals for achieving emotional and/or physical health.

c. Specify services and interventions to be provided to achieve patient goals, and to indicate the staff person(s) and/or discipline responsible for provision of services.

2. Document review of the hospital's policy titled, "Scope of Services," no policy number, not dated, showed that "the holistic care of the patient is the responsibility of the interdisciplinary team, which included ancillary and consultative staff.

3.Record review of the hospital's service agreement titled, "Non-Physician Practitioner Service Agreement, dated 08/09/21, between the hospital and Highline Physical Therapy Group, showed the contract outlines the agreement with Highline Physical Therapy Group to provide physical therapy (PT) and occupational therapy (OT) services to the hospital. Prior to this date, the hospital was not providing physical or occupational therapy services to their patients.

4. On 08/27/21, Investigator #15 reviewed the medical record for Patient #1523. Patient #1523 was a 67-year-old male who was admitted on 08/02/21, due to grave disability. His admitting psychiatric diagnosis was Schizoaffective Disorder, Post Traumatic Stress Disorder (PTSD), and Anxiety and his medical diagnoses included Chronic Encephalopathy, Diabetes, Hypertension (high blood pressure), and Bladder Cancer (surgery 4 months prior). The Patient had multiple prior hospitalizations and has been supported in the community by Catholic Community Services (CCS) and the Veteran Administration (VA). Review of the medical record showed the following:

a. On the Patient's Individual Treatment Plan for Psychiatric Problem #1, dated 08/26/21, staff documented that the "Patient was unable to take himself to the bathroom. Patient needs physical help to feed self, bathe, and change clothes." Staff initiated a short-term goal for the Patient to "stand independently for 5 minutes without assistance." The target date for the short-term goal was 09/03/21. Interventions for nursing and social work included "encourage the Patient to use physical abilities." Investigator #15's review of the Individual Treatment Plan failed to find evidence of a referral for physical or occupational therapy to assist the patient with increased mobility and ability to perform ADL's independently.

b. On the Psychosocial Assessment, dated 08/24/21, staff documented that the Patient was "currently unable to walk or go to the bathroom independently, even though he has the ability to do so." Staff documented that after 3 decades of alcohol abuse, the Patient's "cognitive functioning is compromised to the point he can't take care of himself. Needs complete care to eat and use the bathroom."

c. On the Weekly Treatment Update, dated 08/23/21, Social Work (SW) staff documented that the Patient "does not walk or take himself to the bathroom. No group attendance." The Activities Therapist (AT) documented that the Patient does not attend groups.

d. Investigator #15's review of the medical record found that Patient #1523 failed to attend or participate in 103 of 103 group activities (Process or Activity) between 08/02/21 and 09/15/21. Review of the Group Progress Notes found that 103 of 103 Group Progress Notes failed to document the Patient's response to the intervention when alternative therapy (handout) was provided or the content of the alternative therapy provided. On the Daily Nursing Progress Note, dated 08/18/21, staff documented that the Patient continues to "require total assistance with activities of daily living (ADLs)" and was unable to participate in groups.

e. Investigator #15's review of the medical record failed to find evidence of recommendations for changes to the Patient's treatment plan, such as physical or occupational therapy, based on the patient's lack of participation in group activities and limitations due to his physical limitations requiring assistance from staff for ADLs.

f. On a Social Services Progress Note, dated 08/26/21, the Discharge Planner/Social Worker documented that when the Patient discharges, the plan would be to temporarily discharge him to an assisted living facility so that he can receive assistance from PT and OT for his ADLs.

5. On 08/24/21 at 4:00 PM, during an interview with Investigator #15, Discharge Planner/Social Worker (Staff #1509) stated that she was not aware that the hospital had contracted for PT and OT services for the Patients.

6. On 08/27/21 at 9:25 AM, during an interview with Investigator #15, the Director of Social Services (Staff #1506) and the Chief Clinical Officer (Staff #1512), the Investigator asked the staff to review Patient #1523's medical records and address why the hospital did not provide the Patient with additional therapeutic services to meet his physical and psychiatric needs. Both stated that they believed that the hospital had contracted out for PT and OT services, but they were unsure. Staff #1512 stated that should be followed by the Medical Team and referred the Investigator to the Chief Nursing Officer (CNO) and Chief Medical Officer (CMO).

7. On 08/27/21 at 10:45 AM, during an interview with Investigator #15, Staff #1501 stated that the hospital had secured a contract with an agency nearby that would provide PT and OT services to the hospital's patients. Staff #1501 provided Investigator #15 a copy of the contract for review. Staff #1501 stated that the hospital did not have a policy related to physical and occupational therapy services.

8. Investigator #15's review of the medical record found that staff failed to provide Patient #1523 with adequate and individual interventions and therapies to maintain and restore his physical and psychosocial functioning related to his inability to ambulate and perform his ADL's. Investigator #15's interviews with staff found that staff, including leaders had an incongruent understanding of the services available for the patients, and the hospital staff's responsibility as to who would implement and oversee these interventions.

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