HospitalInspections.org

Based on observation, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure a safe setting for patients.
Findings include:
1) Review of the facility's network policy "Storage and Maintenance of Patient Supplies," dated August 11, 2011, revealed " ... II. Policy It is the policy of Albert Einstein Medical Center to ensure that patient supplies are maintained in a clean manner and that a routine check of supply item expiration dates and package integrity are conducted ..."
Observation on March 18, 2014, of the 2 East Eating Disorder Unit and the 2 North Affective Disorder Psychiatric units shared storage room, revealed 72 Peptamen 1.5 complete High Calorie Elemental Nutrition 250 ml cans marked expired December 2009.
Interview on March 18, 2014, at 10:30 AM, with EMP2 confirmed the above Elemental Nutrition cans were expired.
2) Review of the facility's network policy "Vacuuming Carpet," dated May 31, 2002, revealed " ... B. Inspection Standard ... 1. Carpet will be free of gross contamination. 2. Carpet will present a clean appearance. 3. No debris will be evident ..."
Observation on March 18, 2014, of the 2 South Adolescent Psychiatric Unit's patient rooms 246 and 247, revealed an excessive amount of debris on the carpets to include food particles and other unknown debris.
Interview on March 18, 2014, at 1:30 PM, with EMP2 confirmed the above carpets had debris to include food particles and other unknown debris.
3) Review of facility policy "EOC [Environment of Care] Common Area Risk Assessment, " no date revealed " ... Furniture, General Safety, Other ... Is furniture in good repair and properly secured (floor/walls)? ... "
Observation on March 18, 2014, of the 2 Center Adolescent Psychiatric Unit's Day Room, revealed 14 chairs that were in disrepair to include the fabric being worn / torn off from the chairs.
Interview on March 18, 2014, at 11:30 AM, with EMP2 confirmed the above mentioned chairs were in disrepair.
Observation on March 18, 2014, of the 2 South Adolescent Psychiatric Unit's Day Room revealed six chairs that were in disrepair to include the fabric being worn / torn off from the chairs.
Interview on March 18, 2014, at 1:45 PM, with EMP2 confirmed the above mentioned chairs were in disrepair.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide a safe setting that was free from confinement, punishment, and mental anguish for four of four applicable records reviewed (MR8, MR31, MR32, and MR33).

Findings include:

1) Review of facility document " Adolescent Program Intensive Individual Therapeutic Program (IITP) Guidelines, " revised October 2012, revealed " ... Steps to Implement an IITP: 1. The treatment team will decide if the adolescent is to be started on a 60 minute in / 0 minutes out plan that ends after 24 hours, or an extended IITP plan (for serious violence, injury or potential for injury or repeated IITP's). ... 4. Adolescents who are on 60/0 for 24 hours must complete their packets, and process their behaviors with staff before returning to the community. ... 5. Adolescents who are on extended plans for dangerous behavior must stay in their room for 24 hours and will not earn points during this time. ... "

Review of facility document " Adolescent Program Room Contract, " dated April 2011, revealed " ... When I am in my room I will: ... 2. stay away from the doorway of my room ... 5. stay in my room until staff tell me it is time to come out ... "

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that the facility's guidelines for IITP's entails room confinement which can include keeping the patients in their rooms for 24 hours. EMP3 confirmed that the Adolescent Room Contract states that patients are to stay in their room until staff tell me them it is time to come out.

2) Review of MR8 progress note, dated February 24, 2014, at 11:31 AM, revealed " ... Pt is angry and visibly upset after getting in an argument [with] a peer and then [with] ... teacher. [Patient] was then sent to ... room from group and told to stay there the rest of the day ..."

Review of MR8 nursing note, dated February 26, 2014, at 10:35 AM, revealed " ... " Am I still on 1 hour in 1 hour out? " ... Pt's room contract continued throughout shift ... "

Review of MR8 nursing note, dated March 2, 2014, at 10:27 PM, revealed " ... " Why I have to go in my [expletive] room?! " ... Pt was encouraged to control self during community meeting and to be quiet. [Patient] continued to talk and provoke female peer from across the room. [Patient] was sent to ... room by staff. Pt responded by refusing to go to ... room. [Patient] eventually went while cursing the staff out. [Patient] eventually came out of ... room and sat in the hallway. Pt was ignored by staff and returned to room without incident ... "

Review of MR8 nursing note, dated March 9, 2014, at 11:00 PM, revealed " ... " What time will I be able to come out?" ... Pt was visible in the community. Pt spent the whole shift in ... bedroom as a result of 60/0 protocol. Pt required minor redirection to get out of ... doorway ... "

Review of MR8 nursing note, dated March 10, 2014, at 4:10 PM, revealed " ... [Patient] was placed in 4-pt restraints for safety of self & others @ 10:50 ... [Patient] to remain in room except for phone call/visit until tomorrow for safety of self & others, reevaluate safety needs tomorrow AM. "

Further review of the patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that the patient identified in MR8 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient ' s plan of care did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

3) Review of MR31 nursing note, dated November 15, 2013, at 8:37 PM, revealed " ... Pt was on 60/0 room contract due to a physical altercation with a male peer on day shift. Pt was compliant with room contract. ... "

Review of MR31 nursing note, dated November 16, 2013, at 2:30 PM, revealed " ... I had a good day even though I was on 60-0 ... "

Review of MR31 nursing note, dated November 28, 2013, at 9:55 PM, revealed " ... "Do I have to be in my room the whole shift?" ... Pt started the shift while out in the community. [Patient] was later redirected back in ... room due to being in restraints earlier. Pt appeared very agitated because ... couldn't come out. [Patient] remained in the room throughout shift. .... "

Review of MR31 physician note, dated November 29, 2013, at 2:36 PM, revealed patient stating " I'm not on 60/0. " Further review of the physician note revealed " Pt tearful crying w/ staff. [Patient] was frustrated refused time out ... required PRN Abilify / Ativan ... "

Review of MR31 nursing note, dated December 4, 2013, at 10:00 PM, revealed that the patient stated " I'm not staying in my room! " Further review of the note revealed " ... Disruptive, rude during group discussion and required time out. Uncooperative while timing out; standing outside ... door screaming at staff ... To begin room contract of 45 min in room 15 min out tomorrow to promote better control ... "

Review of MR31 nursing note, dated December 5, 2013, at 10:00 AM, revealed " PRN - Benadryl 50 mg PO PRN given for agitation when staff redirected [patient] back to room to finish ... room contract time. Took it willingly - calmer in 1 hr ... "

Review of MR31 nursing note dated December 7, 2013, revealed " Pt was being defiant and oppositional over doing ... laundry this morning ... Required a few staff to keep in room when told ... would be on 1 [hour] in 1 out again for this behavior. Became combative & aggressive Pt had to be placed in restraints ... "

Review of MR31 nursing note, dated December 9, 2013, at 9:45 PM, revealed ... "Pt was placed on 60/0 earlier due to attempting to fight a peer over the Wii game. Pt remained in ... room throughout the shift. Pt was compliant with the 60/0 room contract ... "

Further review of the patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:00 PM, with EMP3 confirmed that the patient identified in MR31 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient identified in MR31 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.


4) Review of MR32 nursing note, dated November 16, 2013, at 2:00 PM, revealed that the patient stated " I've learned my lesson. " Further review of the note revealed " patient is currently on restrictive 60-0, has been quiet seclusive to self no sign of any distress ... "

Review of MR32 Social Worker note, dated November 18, 2013, at 5:35 PM, revealed that the social worker indicated to the patient " Pretty unfair? " The patient responded " No, it's straight unfair." " SW spoke with [patient] on 11/18. " Patient reported having the "worst weekend ever" because was on 60-0 following the altercation on Friday with a male peer on the unit. The patient was placed in restraints. Patient expressed to Social Worker that " it was unfair that [patient] had to be penalized when [patient] was the one who got punched. ...SW acknowledged that it might seem unfair but that staff felt the 60-0 was necessary to ensure [patient] and other's safety on the unit. "

Review of MR32 nursing note, dated November 23, 2013, revealed " ... Pt was on Room Contract today 60/0 getting in a fight last night ... "

Review of MR32 nursing note, dated December 3, 2013, which revealed " ... Pt was agitated this morning because staff told ... to stay in ... room when [patient] told staff ... needed to go to the Quiet Room ... "

Review of the patient ' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:10 PM, with EMP3 confirmed that the patient identified in MR32 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient identified in MR32 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

5) Review of MR33 nursing note, dated March 14, 2013, at 10:55 PM, which revealed " ... Pt notified of 60/0 ITTP to end at 1930 tomorrow ... verbal threats. Physical aggression ... "

Interview on March 21, 2014, at 11:30 AM, with EMP3 confirmed that the patient identified in MR33 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient identified in MR33 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility used room confinement as an intervention in which the patient did not consent to being in their room for an agreed upon timeframe for three of three applicable records reviewed (MR8, MR31, and MR32).

Finding include:

Review of facility document "Adolescent Program Intensive Individual Therapeutic Program (IITP) Guidelines," revised October 2012, revealed " ... Steps to Implement an ITTP: ... 2. Nursing staff (a BHA or a RN) will review the Room Contract with the adolescent, explaining the expectations for them while in and out of the community. The patient and staff member will sign the contract. One copy goes in the medical record and the other is kept in the patient's room ... "

1) Review of MR8 revealed a progress note dated February 24, 2014, at 11:31 AM which revealed " ... Pt is angry and visibly upset after getting in an argument [with] a peer and then [with] [patient] teacher. [Patient] was then sent to [Patient's] room from group and told to stay there the rest of the day ... "

Review of MR8 nursing note, dated March 2, 2014, at 10:27 PM, revealed " ... " Why I have to go in my [expletive] room?! " ... Pt was encouraged to control self during community meeting and to be quiet. [Patient] continued to talk and provoke female peer from across the room. [Patient] was sent to ... room by staff. Pt responded by refusing to go to ... room. [Patient] eventually went while cursing the staff out. [Patient] eventually came out of ... room and sat in the hallway. Pt was ignored by staff and returned to room without incident ... "

Further review of MR8 revealed no "Room Contract" signed by the patient or documentation which showed that the patient was in agreement with the room confinements. The patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that there was no documented evidence that the patient signed the "Room Contract" or was in agreement with the room confinement. EMP3 confirmed that the patient ' s plan of care did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

2) Review of MR31 revealed a nursing note dated November 28, 2013, at 2:00 PM which revealed " ... Pt escorted to quiet room and offered Beady several times, each time [Patient] refused to take it. Still trying to push past staff to get out of quiet room. Pt finally took Benadryl 50 mg PO but still tried to push past staff ... "

Review of MR31 revealed a nursing noted dated November 28, 2013, at 9:55 PM which revealed " ... ""Do I have to be in my room the whole shift?" ... Pt started the shift while out in the community. [Patient] was later redirected back in [patient's] room due to being in restraints earlier. Pt appeared very agitated because [patient] couldn't come out. [Patient] remained in the room throughout shift. .... "

Review of MR31 revealed a nursing note dated December 7, 2013, which revealed " Pt was being defiant and oppositional over doing [patient's] laundry this morning ... Required a few staff to keep in room when told [Patient] would be on 1 [hour] in 1 [hour] out again for this behavior. Became combative & aggressive Pt had to be placed in restraints ... "

Further review of MR31 revealed no "Room Contract" signed by the patient or documentation which showed that the patient was in agreement with the room confinement. The patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:00 PM, with EMP3 confirmed that there was no documented evidence that the patient signed the "Room Contract" or was in agreement with the room confinement. EMP3 confirmed that the patient identified in MR31 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

3) Review of MR32 revealed a Social Worker note dated November 18, 2013, at 5:35 PM which revealed ... ""Pretty unfair? No, It's straight unfair" SW spoke with [patient] on 11/18. [Patient] reported that [patient] had the "worst weekend ever" because [patient] was on 60-0 following the altercation [patient] had on Friday with another male peer on the unit and had to be put in restraints ... [Patient] expressed to SW that [patient] felt it was unfair that [Patient] had to be penalized when [patient] was the one who got punched. SW acknowledged that it might seem unfair but that staff felt the 60-0 was necessary to ensure [patient] and other's safety on the unit.

Further review of MR32 revealed no "Room Contract" signed by the patient or documentation which showed the patient was in agreement with the room confinement. The patient ' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:10 PM, EMP3 confirmed that there was no documented evidence that the patient signed the "Room Contract" or was in agreement with the room confinement. EMP3 confirmed that the patient identified in MR32 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to discontinue the use of physical restraints at the earliest possible time and failed to provide adequate documentation regarding justification for the continued use of physical restraints for one of thirty medical records reviewed (MR).

Findings include:

Review on March 20, 2014, of policy "Use of Restraint/Seclusion," dated December 16, 2013, revealed " ...A. Restraints/seclusion shall be used only: to ensure the immediate physical safety of the patient, or others when less restrictive interventions have been ineffective ... B. Restraint/seclusion will be discontinued as soon as the patient's behavior no longer meets the criteria for restraint/seclusion. ... V. Responsibilities: ... C. Education ... All staff having direct patient contact must have training in the following prior to participation in the application of restraints or seclusion: VI. Clinical identification of behavioral changes that indicate that the restraint/seclusion is no longer necessary..."

Review of MR12 revealed that the patient was 20 years old and admitted to the facility on February 10, 2014. Further review of MR12 revealed that the patient was admitted after a physical altercation. Patient revealed, "I stopped taking my meds."

Review of MR12 revealed that on February 20, 2014, patient was in doorway of own bedroom when staff arrived with lunch meals. Further review revealed that " as trays were being passed the patient became irate and pushed four trays to the ground ..."

Review of a physician's order, dated February 20, 2014, timed 12:00, revealed "Four Point Restraints-up to four hours for safety and risk to harm self/others."

Review of MR12 documentation, dated February 20, 2014, timed at 14:30, revealed "Pt. in 4 pts, pt has fallen asleep." Further review of documentation, timed at 14:45 revealed "Patient is sleeping at this time."

Interview on March 20, 2014, at 1:15 PM, with EMP4, confirmed that there was not adequate documentation regarding justification for the continued use of physical restraints on this patient. Interview at 2:45 PM, with EMP5 and EMP6 confirmed that there was no documentation regarding justification of the continued use of restraints.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to include in the patient's interdisciplinary care plan the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention for four of four applicable records reviewed (MR8, MR31, MR32, and MR33).

Findings include:

Review of facility policy "Inpatient Interdisciplinary Treatment Plan," dated January 5, 2012, revealed " ... The treatment plan consists of the initial Comprehensive Master Treatment Plan and the Treatment Plan Review. The plan is reviewed at least every 7 days and updated as needed based on new changes in the patient's need or condition ... B. Treatment Plan Review ... 1. The Treatment Plan Review must be completed every 7 days after the initial plan has been made or at more frequent intervals when the reassessment process identifies that change in treatment is required due to a change in the patient's condition ... 5. Newly identified problems, goals and interventions are added as needed ... "

Review of facility document " Adolescent Program Intensive Individual Therapeutic Program (IITP) Guidelines, " revised October 2012, revealed " ... Steps to Implement an ITTP: 1. The treatment team will decide if the adolescent is to be started on a 60 minute in / 0 minutes out plan that ends after 24 hours, or an extended IITP plan (for serious violence, injury or potential for injury or repeated IITP's). ... 4. Adolescents who are on 60/0 for 24 hours must complete their packets, and process their behaviors with staff before returning to the community. ... 5. Adolescents who are on extended plans for dangerous behavior must stay in their room for 24 hours and will not earn points during this time. ... "

1) Review of MR8 nursing documentation dated February 24, 2014, February 26, 2014, March 2, 2014, March 9, 2014 and March 10, 2014 revealed that the patient was under room confinement. Further review of the patient ' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that the patient ' s plan of care did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

2)Review of MR31 revealed that the patient was under room confinement on November 15, 2013, November 16, 2013, November 28, 2013, November 29, 2013, December 4, 2013, December 5, 2013, December 7, 2013 and December 9, 2013. Further review of the patient ' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:00 PM, with EMP3 confirmed that the patient identified in MR31 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

3) Review of MR32 revealed that the patient was under room confinement on November 16, 2013. Review of MR32 Social Worker note, dated November 18, 2013, at 5:35 PM, revealed that the social worker indicated to the patient " Pretty unfair? " The patient responded " No, it's straight unfair." " SW spoke with [MR32] on 11/18. " Patient reported having the "worst weekend ever" because was on 60-0 following the altercation on Friday with a male peer on the unit. The patient was placed in restraints. Patient expressed to Social Worker that " it was unfair that [MR32] had to be penalized when [MR32] was the one who got punched. ...SW acknowledged that it might seem unfair but that staff felt the 60-0 was necessary to ensure [MR32] and other's safety on the unit. "

Further review of MR32 revealed that the patient was under room confinement on November 23, 2013 and on December 3, 2013. Review of the patient ' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:10 PM, with EMP3 confirmed that the patient identified in MR32 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

4) Review of MR33 revealed a nursing note dated March 14, 2013, at 10:55 PM which revealed " ... Pt notified of 60/0 ITTP to end at 1930 tomorrow ... verbal threats. Physical aggression ... "

Interview on March 21, 2014, at 11:30 AM, with EMP3, confirmed that the patient identified in MR33 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

This condition level deficiency was cited during a Division of Life Safety survey completed on March 10, 2014. Further details are provided in the Division of Life Safety report.

Based on observations, staff and patient interviews, medical record review and facility document review there is a systematic failure of the facility to:

I. Adequately develop and document individualized treatment interventions based on the needs of seven (7) of eight (8) sample patients (A2, B10, Db8, E11, F15, H5 and I9). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B122)

II. Provide active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B125, Section I)

II. Provide a sufficient number of structured therapeutic groups/activities on the weekends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B125, Section II)

Based on observations, staff interview and medical record review, it was determined that the facility failed to adequately develop and document individualized treatment interventions based on the needs of seven (7) of eight (8) sample patients (A2, B10, Db8, E11, F15, H5 and I9). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient needs and findings.

Findings include:

A. Patient A2 -Comprehensive Treatment Plan dated 3/12/14:

1. For problem, "inability to care (self)" and "explosive/aggressive", there were no nursing interventions to care for this patient in the clinical area.

The Rehabilitation therapy intervention stated as "Rehab. (Rehabilitation) groups to include music groups, expressive therapy groups, OT (Occupation Therapy) groups, psychotherapy groups." Failed to include focus of treatment.

2. Even though the problem statement section documented that Patient A2 presented increased paranoia, hallucinations and confusion. There were no staff interventions other than medications to address care of the patient.

3. Even though this patient was non-English speaking and had an interpreter for treatment, this issue was not addressed in the treatment plan.

B. Patient B10-Comprehensive Treatment Plan dated 3/6/14:

1. For problem, "Impulsive behavior," there were no nursing or physician interventions to care for this patient.

2. For problem, "Aggressive/Assaultive behavior," the physician, nurse and case manager intervention stated, "Group sessions up to 10 times a week targeting expression of feelings, identification and practice of coping skills." This intervention failed to include the specific groups the patient was to attend.

C. Patient Db8-Comprehensive Treatment Plan dated 3/10/14:

1. For problem, "Suicidal/Self injurious behaviors", nursing and physician interventions consisted of "Order and administer medication" and "Monitor medication for safety, efficacy and adverse effect." These are not patient specific interventions and are role functions only.

2. For problem, "Suicidal/Self injurious behaviors," the case manager intervention stated, "Group sessions up to 10 times per week targeting depression and anxiety." This intervention failed to include the specific groups the patient was to attend.

D. Patient E11-Comprehensive Treatment Plan dated 1/14/14:

1. For problem, "Agitation," nursing and physician interventions consisted of "Order and administer medication" and "Monitor medication for safety, efficacy and adverse effect." These are not patient-specific interventions and are role functions only.

2. For problem, "Aggressive/Assaultive behavior", the physician and nurse intervention stated "Group sessions up to 3 times per week targeting development of positive anger management coping and communication skills." This intervention failed to include the specific groups the patient was to attend.

E. Patient F15-Comprehensive Treatment Plan dated 3/13/14:

1. For problem, "Suicidal/Self-injurious behaviors as evidenced by S/I (Suicide ideation) thoughts of joining decreased parents." Plan to overdose on pills, "there were no nursing interventions other than observation level SPI-1 to prevent harm to self or others to address safety of the patient in the clinical area."

2. Observations during rounds on Ward 3 Center on 3/18/14 at 2:05 p.m. revealed Patient F15 asleep in bed. During interview at this time, this patient stated that s/he had been sleeping most of the time while in the hospital due to being "so tired." Later in the interview, s/he talked about staying in bed in the hospital as s/he had while at home and stated the need to become involved in treatment. During this interview, Patient F15 presented severe symptoms of depression and talked about his/her long history of dealing with depression, suicide ideations and hearing voices.

3. The plan included an intervention stated as "Group session up to 10 times per week targeting addiction/mental health education." This intervention was not correlated to a problem and goal.

4. For problem, "Substance use or abuse," an intervention was stated as "Group sessions up to 10 times per week to build awareness, relapse prevention skills." This intervention failed to include the specific groups the patient was to attend.

F. Patient H5-Comprehensive Treatment Plan dated 3/12/14:

1. For problem stated as "Aggressive/Assaultive behavior, there were no nursing interventions to address the care of the care of this patient in the clinical area."

The intervention stated as "Group session up to 5 times per week targeting impulse control, exploration of feeling," failed to include the specific groups that the patient was to attend.

2. The plan for Patient H5 included several interventions that were not correlated to a problem and goal.

During interview with the Director of Nursing and RN7 on 3/19/14 at 1:20 p.m., RN7 verified that the documented interventions in Patient H5's plan failed to correlate with the identified problem, "Aggressive/Assaultive Behavior."

G. Patient I9-Comprehensive Treatment Plan dated 1/30/14 with last revision date of 3/13/14:

For problem stated as "explosive/aggressive, paranoid thinking, changes in medication leading to increased paranoia...not sleeping...intrusive, sexually inappropriate...", there were no nursing interventions to address the care of the care of this patient in the clinical area other than "will assist (patient) in talking about angry feeling (sic) before (patient) explode (sic)."

An intervention was stated as, "Rehab (Rehabilitation) + (and) occupational services will help (patient)'s mental focus with groups." This intervention failed to include specific group(s) and focus for treatment.

H. Interview:

During interview on 3/19/14 at 3:40 p.m., the Director of Nursing stated, "I see what you mean. There are no specific nursing interventions. The plans should be individualized."

Based on observations, staff and patient interviews, medical record review and facility document review the facility failed to :

1. Provide active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion.

II. Provide a sufficient number of structured therapeutic groups/activities on the week-ends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement.

Specific findings include:

I. Failure to provide treatment for Patient E13:

A. Patient E13 was a 14-year old patient admitted on 2/19/14 with a diagnosis of Oppositional Defiant Disorder. This patient was placed on room restriction for up to 24 hours and then one (1) hour in his/her room and allowed one (1) hour out several times during hospitalization. The use of this protocol was not directed by policy, nor was it directed by the treatment team to include the physician. The treatment plan failed to address the use of this protocol with Patient E13. Even though the patient was given self-learning packets, the staff did not work with him/her other than to "process" the completed packet. Treatment/progress notes failed to document specific use of or patient discussion regarding these assigned packets.

B. Review of progress notes revealed the following documentation:

1. A medical resident note on 2/24/14 at 11:31 a.m. stated, "Pt (Patient) is angry and (illegible word) upset after getting in an argument c/ (with) a peer and then c/ (with) (his/her) teacher. (S/he) was sent to (his/her) room from group and told to stay there the rest of the day."

2. A Behavior Health Assistant (nursing) note on 2/25/14 at 10:37 p.m. stated, "(S/he) was very loud, talkative and silly. Pt (Patient) was timed out about 2x (2 times) during shift." This note failed to document specific times that the patient was in "time out."

A review of the "Rounds Sheet" for Unit 2 South for this 2/25/14 shift documented that Patient E13 was in his/her room from 3:45 p.m. to 6:00 p.m., 7:00 p.m. to 7:45 p.m. and from 8:45 p.m. to 9:45 p.m.

3. A medical resident note for Patient E13 on 2/26/14 at 10:00 a.m. that was countersigned by a physician stated, "Pt (Patient) c/o (complained) frustration (sic) about being sent to (his/her) room bc (because) of using verbal profanity c/ (with) a male staff + (and) was placed on 1 hr (hour) in + (and) 1 hr (hour) out of room as a consequence...Pt (Patient) is currently on 1 hr (hour) in & (and) 1 hr (hour) out restrictions."

4. A Behavior Health Assistant (nursing) note on 2/26/14 at 3:00 p.m. stated, "Patient had been plac (sic) on an every other hour in (his/her) room plan. This is based on consistent inappropriate and disrespectful behavior to peers and staff."

A review of the "Rounds Sheet" for Unit 2 South for this 2/26/14 shift documented that Patient E13 was in his/her room from 3:30 p.m. to 5:15 p.m., 6:15 p.m. to 7:15 p.m. and from 8:15 p.m. to 9:45 p.m.

5. A nursing note on 3/2/14 at 9:20 p.m. stated, "Redirected during group (community mtg (meeting) an immediately became verbally assaultive toward a female staff. (She) disregarded all directives and non compliant with basic unit rules...To begin room contract of 1 hour out-1 hour in the community."

A review of the "Rounds Sheet" for Unit 2 South on 3/3/14 documented that Patient E13 was in his/her room from 3:30 p.m. to 5:45 p.m. and from 7:00 p.m. to 8:00 p.m.

6. A Behavior Health Aide (nursing) on 3/9/14 at 11:00 p.m. stated, "Pt (Patient) spent the whole shift in (his/her) bedroom as a result of 60/0 protocol...Pt (Patient) ate meals and appeared mediation compliant. Pt (Patient) was calm and compliant."

7. According to progress notes on 3/10/14, Patient was restrained for aggression towards staff. Following release of restraints and nursing note on 3/10/14 at 4:10 p.m. stated, "(Patient) to remain I room except for phone call/visit until tomorrow (3/11/14) for safety of self + (and) others, reevaluate safety needs tomorrow AM."

8. A nursing note on 3/10/14 at 9:00 p.m. stated, "Maintained on 60/0 room contract."

9. A Behavior Health Aide (nursing) note on 3/11/14 at 2:50 p.m. stated, "Pt (Patient) spent the first part of the shift in (his/her) bedroom as a result of 60/0 consequence."

C. Review of the Intensive Individual Program:

1. The "Intensive Individual Therapeutic Program (IITP) Summary" stated:

a. A RN makes the decision to implement an IITP and what type will be used. (60/0 to be used only for serious violence).

b. A RN selects the appropriate packet for the patient to complete.

c. Patients on 60/0 stay in their room for 24 hours-no point earned during that time.

d. Patient on any other IITP will earn points for participating in groups and activities.

e. The team makes the decision to move a patient forward, backward or off room contract. This is decided at morning meeting or during change of shift report (nights to days or days to evenings).

f. A BHA (Behavior Health Assistant) or RN will review completed packets with the patient and sign the front when it is acceptable.


2. The "Adolescent Program Intensive Individual Therapeutic Program (IITP) Guidelines" stated:

a. The purpose of the IITP is to maintain the safety of the patient and the rest of the unit. They help the adolescent focus therapeutically on their dangerous behavior and how to express their emotions safely.

b. The treatment team will decide if the adolescent is to be started on a 60 minute in/0 minutes out plan that ends after 24 hours. Or an extended IITP plan. An individualized plan such as starting with 45 minutes in/15 minutes out or a 1 hour in/1 hour out plan are also options.

c. Extended IITP's are to be reviewed at least once per day and evening shift, with the goal of reducing room time as quickly and as therapeutically as possible. Patients will spend at least one entire day or evening shift on 45/15, 30/30 and15/45 before moving off the IITP.

D. Review of Patient E13's Comprehensive Treatment Plan (dated 2/20/14 with latest review of 3/20/14) revealed failure to address the use of the "Intensive Individual Treatment Plan."

E. Review of a program packet completed by Patient E13 on 2/28/14 while restricted to his/her room revealed worksheets with questions regarding "difficult situations to handle, self goals, what s/he has learned while hospitalized, etc."

F. Review of physician orders revealed no orders related to the use of the IITP with Patient E13.

G. Interviews:

1. During interview on 3/19/14 at 11:00 a.m., RN2 reported that a patient may be placed on a room contract (Intensive Individual Treatment Program) for physical violence when other interventions have been tried (and failed). The patient stays in their room, given "packets" chosen by the RN which they process with staff when completed. She reported that the packet is completed by the patient while alone in his/her room. She referred to this procedure as "extended time out" and 60/0 (up to 24 hours in assigned room. Patient eats meals in the room and can make phone calls. She reported that all activities and group treatments are not attended by the patient who is on an Intensive Individual Treatment Program contract. She reported that the terms of the contract (time limits and activities) depend on "what was told to the patient by the team." When asked whether a patient would be able to come out of their room if they completed their work assignment/packet and staff felt that the patient's behavior had improved, she replied, "Not if the RN had told the patient that s/he had to stay in their room for 8 hours. The patient would remain in their room until the time limit had been met. Decisions to use this program are made by an RN."

2. During interview with the Director of Nursing and RN 2 about the restriction program (60/0) on 3/20/14 at 1:00 a.m., RN 2 stated, "It sounds like discipline." The Director of Nursing added, "Yes, I agree." There is no active treatment when patient is confined to the room. "The whole adolescent program needs to be reevaluated." "The nursing groups are not documented in the chart or on the ward sheets."

3. During interview on 3/20/14 at 1:35 p.m. the Medical Director agreed that the RNs placed patients on Intensive Individual Treatment programs for up to 24 hours without physician direction and that there was no treatment plan for patients while remaining in their rooms.

4. During interview on 3/20/14 at 4:10 p.m. non-sample Patient E13 stated, "I was bored in my room. Staff checked in once awhile. I did not go to school or groups while on 60/0."

II. Failure to provide sufficient weekend treatment groups/activities:

A. Belmont Center has a high level of acuity with a short length of staff for patients on all 10 wards. The majority of the patients require a highly-structured ward environment. During the survey, many patients were observed lying in bed, milling about the units or sitting idle when structured groups/activities were not available to the patients.

B. Review of the Unit Program Unit Schedules revealed that each of the 10 wards had
0-2 structured groups conducted by Rehabilitation Therapy staff on Saturdays and Sundays. The remainder of groups/activities on the weekends were leisure-oriented and were scheduled to be conducted by nursing personnel. The majority of these activities were titled "Independent Activities", which stated, "You are invited to choose an activity that interest you from several options which may include artwork, journaling, games, reading, or watching TV. Our purpose is to provide a safe and comfortable setting for personal expression and exploration through activity."

With the exception of three (3) wards which had minor documentation that failed to include type of group and patient response, there was no documented proof that these nursing groups were carried out.

C. Interviews:

1. During interview on 3/19/14 at 9:15 a.m. active sample Patient Da10 from Unit 2 East stated, "There are no groups on the weekends. It is very boring."

2. During interview on 3/19/14 at 10:10 a.m. active sample Patient Db8 from Unit 2 North stated, "Weekends are very loose around here. Not much going on."

3. During interview on 3/19/14 at 2:05 p.m. RN10 stated, "Weekends are absolutely sparse. We have fewer rehab staff....like one person for 3 units. Nursing tries to have bingo."

4. During interview on 3/19/14 at 2:20 p.m. RN2 stated, "It is harder to get the creative staff in on weekends. It falls to nursing and we try to do some leisure activities like a movie or something."

5. During interview on 3/20/14 at 10:15 a.m. the Direction of Rehabilitation Therapy stated, "Our goal is to have 1 one-hour group per weekend per unit."

6. During interview with the DON and RN7 on 3/19/14 at 1:20 p.m., RN7 stated that the nursing groups are "informal, lately the snows have interfered with consistency." We try to help patients meet their goals, talk about something patients want to talk about such as medication. She stated we are "trying to ramp up" groups. At the "hand off meeting we talk about what might be done on that shift."

Review of record documentation for Unit 1 Southwest during this meeting revealed that the DON and RN7 could find documented proof of one nursing group (education-topic listed as Patients Rights and Responsibilities) on 3/11/14 that was attended by active sample Patient H5.

Review of the program book of groups conducted by nursing on Unit 1 South from 3/7-19/14 with the DON and RN7 during this meeting revealed only four (4) groups: "Tony's Group (topic not listed)" on 3/7/14 and 3/11/14, "Activities" on 3/16/14 and "Coping Skills" on 3/19/14.

The DON stated (referring to groups led by nursing), "We know we have a problem."

7. During interview on 3/20/14 at 11:20 a.m., the DON stated, "There is much not documented (referring to scheduled nursing groups)."

Based on staff interviews, medical record review, facility document review and facility staffing patterns there is a systematic failure of the facility to:

I. Ensure adequate nursing staff to provide safety and treatment for acutely ill patients on three admission units for the 11 p.m. to 7 a.m. shift. The staffing pattern of 1 Registered Nurse and 1 Mental Health Technician during the night shift on each of these units result in a lack of professional on-going assessments of very vulnerable patients and the inability to properly manage an emergency situation such as assaults, medical codes and difficult admissions. (Refer to B150)

II. Assure that the Medical Director and the Director of Nursing monitored treatment and took corrective actions. Specifically:

A. The Medical Director failed to provide adequate medical oversight to ensure quality medical services. The Medical Director failed to:

1. Adequately develop and document individualized treatment interventions based on the needs of seven (7) of eight (8) sample patients (A2, B10, Db8, E11, F15, H5 and I9). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided and to plan revisions based on individual patient needs and findings. (Refer to B144)

2. Provide for active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B144)

3. Provide a sufficient number of structured therapeutic groups/activities on the weekends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B144)

B. The Director of Nursing failed to:

1. Provide adequate numbers of Registered Nurses and Mental Health Technicians (referred by the facility as Behavioral Health Associates) to supervise and monitor patients on the night tours of duty on the Child admission unit (1 South) and on 2 Adult admission units (3 South and 3 Southwest) resulting in the inability to ensure the safety of patients and staff and provide treatment to acutely ill patients. (Refer to B148)

2. Adequately develop and document individualized treatment interventions based on the needs of seven (7) of eight (8) sample patients (A2, B10, Db8, E11, F15, H5 and I9) resulting in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B148)

3. Provide active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B148)

4. Provide a sufficient number of structured therapeutic groups/activities on the weekends based on patient needs for 10 of 10 units (1 Center, 1South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South, and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified needs, thereby delaying treatment. (Refer to B148).

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

I. Adequately develop and document individualized treatment interventions based on the needs of seven (7) of eight (8) sample patients (A2, B10, Db8, E11, F15, H5 and I9. This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B122)

II. Provide active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B125, Section I)

II. Provide a sufficient number of structured therapeutic groups/activities on the weekends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B125, Section II)

Based on staff interview and medical record review , the Director of Nursing failed to provide adequate nursing oversight to ensure quality nursing services. Specifically, the Director of Nursing failed to:

I. Provide adequate numbers of Registered Nurses and Mental Health Technicians to supervise and monitor patients on the night tours of duty on the Child Admission unit and on two (2) Adult Admission units resulting in the inability to ensure the safety of staff and patients and provide treatment to acutely ill patients. (Refer to B150)

II. Adequately develop and document individualized nursing interventions based on the needs of seven (7 )of eight (8) sample patients (A2, B10, Db8, E11, F15, H5, and I9. This deficiency resulted in a failure to provide a basis for accurate implementation, evaluation of treatment provided, and to plan revisions based on individual patient needs and findings.

Findings include:

Record Review

A. Patient A2-Comprehensive Treatment Plan dated 3/12/14:

1. For problem, "inability to care (self)" and "explosive/aggressive," there were no nursing interventions to care for this patient in the clinical area.

2. Even though the problem statement section documented that Patient A2 presented increased paranoia, hallucinations and confusion, there were no nursing interventions.

3. Even though this patient was non-English speaking and had an interpreter for treatment, this issue was not addressed in the treatment plan.

B. Patient B10-Comprehensive Treatment Plan dated 3/6/14:

For problem, "Impulsive behavior," there were no nursing interventions to care for this patient.

C. Patient Db8-Comprehensive Treatment Plan dated 3/10/14:

For problem, "Suicidal/Self injurious behaviors," there were no nursing interventions other than "administer medication" and "monitor medication for safety, efficacy and adverse effect." These are not patient specific interventions and are role functions only.

D. Patient E 11-Comprehensive Treatment Plan dated 1/14/14 with last review dated 3/18/14:

For problem, "Agitation", nursing interventions consisted of "administer medication" and "monitor medication for safety, efficacy and adverse effect." These are not patient-specific interventions and are role functions only.

E. Patient F15-Comprehensive Treatment Plan dated 3/13/14:

For problem, "Suicidal/Self-injurious behaviors as evidenced by S/I (Suicide Ideation) thoughts of joining deceased parents. Plan to overdose on pills", there were no nursing interventions other than observation level SPI-1 to prevent harm to self or others to address safety of the patient in the clinical area.

F. Patient H5-Comprehensive Treatment Plan dated 3/12/14:

For problem stated as "Aggressive/Assaultive behavior", there were no nursing interventions to address the care of this patient in the clinical area.

G. Patient I9-Comprehensive Treatment Plan dated 1/30/14 with last revision date of 3/13/14:

For problem stated as "explosive/aggressive, paranoid thinking, changes in medication leading to increased paranoia..not sleeping...intrusive, sexually inappropriate..." there were no nursing interventions to address the care of this patient in the clinical area other than "will assist (patient) in talking about angry feeling (sic) before (patient) explode (sic)."

H. Interviews:

1. During interview with the Director of Nursing and RN7 on 3/19/14 at 1:20 p.m., RN7 stated that the plan did document interventions in the patient's plan under another problem section on the treatment plan.

2. During interview on 3/19/14 at 3:40 p.m., the Director of Nursing stated, "I see what you mean. There are no specific nursing interventions. The plans should be individualized."

III. Provide active treatment for one (1) non-sample active patient (E13) whose care was reviewed for active treatment. Patient E13 was an adolescent patient who was required to remain in his/her assigned room for periods of time up to 24 hours without sufficient alternative treatment. The failure to ensure active treatment for this patient resulted in his/her being hospitalized without all interventions for recovery being provided in a timely fashion. (Refer to B125, Section I)

IV. Provide a sufficient number of structured therapeutic groups/activities on the weekends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B125, Section II)

Based on review of facility staffing data, staff interview and review of facility documents, the facility failed to provide adequate numbers of Registered Nurses and Mental Health Technicians (referred to as Behavioral Health Associates) to supervise and monitor patients on the night tours of duty on the Child Admission Unit (1 South) and on 2 Adult Admission units (3 South and 3 Southwest) resulting in the inability to ensure the safety of staff and patients and provide treatment to these acutely ill patients. Additionally, the facility does not have a policy to determine staffing levels.

Findings include:

A. Staffing Data

1. The Child Unit, with a capacity of 12 beds, had 11 patients on the first day of the survey (3/18/14). The staffing consisted of one (1) Registered Nurse and one (1) Mental Health Technician on the 11 p.m. to 7 a.m. shift for the nights of 3/14/14, 3/15/14, 3/16/14, 3/17/14 and 3/18/14.

The Nursing Needs Assessment form completed by the charge unit on the Child Unit for 3/18/14 noted that four (4) patients were "potentially assaultive," three (3) patients were "actively assaultive," one (1) patient was an "acute risk for suicide" and 1 patient was "experiencing active hallucinations/delusions and are in potential jeopardy (health/safety) and require close monitoring by nursing staff." This unit admits patients on the 11:00 p.m. to 7:00 a.m. shift.

2. The Adult Unit, 3 South, with a capacity of 19 beds, had 17 patients on the first day of the survey. The staffing consisted of one (1) Registered Nurse and one (1) Mental Health Technician on the 11:00 p.m. to 7:00 a.m. shift for the night of 3/14/14. The Nursing Needs Assessment form completed by the charge nurse on the Adult 3 South Unit on 3/18/14 noted that seven (7) patients were "potentially assaultive," five (5) patients were "actively assaultive," eight (8) patients were "low risk suicidal," three (3) patients were "intermediate risk suicidal," one (1) patient was "acute risk suicidal" and four (4) patients were "experiencing active hallucinations/delusions and are in potential jeopardy (health/safety) and require close monitoring by nursing staff." The Nursing Needs Assessment form noted that there was an "average of 4 admissions weekly" on the 11:00 p.m. to 7:00 a.m. shift.

3. The Adult Unit, 3 South West, with a capacity of 10 beds, had 9 patients on the first day of the survey. The staffing consisted of 1 Registered Nurse and 1 Mental Health Technician on the 11 PM to 7 AM shift for the nights of 3/14/14, 3/15/14, 3/16/14, 3/17/14 and 3/18/14. The Nursing Needs Assessment form completed by the charge nurse on 3/18/14 noted that "5 patients have been threatening" and 2 patients "are experiencing active hallucinations/delusions and are in potential jeopardy (health/safety) and require close monitoring by nursing staff." This unit admits patients on the 11 p.m. to 7 a.m. shift.

B. Interview:

On 3/20/14 at 11:00 a.m. the Director of Nursing stated, "Staffing is horrible, it is a huge problem. We need more staff at night. Each staff is allowed a 45 minute break each night and that leaves only one staff on these units." When the surveyor inquired about a staffing policy, the Director of Nursing stated, "We do not have a policy for staffing. I need to work on that."

C. Facility Documents:

Review of documents revealed that nursing staff failed to provide a sufficient number of activities/groups on the weekends based on patient needs for 10 of 10 units (1 Center, 1 South, 2 Center, 2 East, 2 North, 2 South, 3 Center, 3 East, 3 South, and 3 Southwest). This failure to provide active treatment for all patients resulted in patients being hospitalized without being given the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B125, Section II)

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide a safe setting that was free from confinement, punishment, and mental anguish for four of four applicable records reviewed (MR8, MR31, MR32, and MR33).

Findings include:

1) Review of facility document " Adolescent Program Intensive Individual Therapeutic Program (IITP) Guidelines, " revised October 2012, revealed " ... Steps to Implement an IITP: 1. The treatment team will decide if the adolescent is to be started on a 60 minute in / 0 minutes out plan that ends after 24 hours, or an extended IITP plan (for serious violence, injury or potential for injury or repeated IITP's). ... 4. Adolescents who are on 60/0 for 24 hours must complete their packets, and process their behaviors with staff before returning to the community. ... 5. Adolescents who are on extended plans for dangerous behavior must stay in their room for 24 hours and will not earn points during this time. ... "

Review of facility document " Adolescent Program Room Contract, " dated April 2011, revealed " ... When I am in my room I will: ... 2. stay away from the doorway of my room ... 5. stay in my room until staff tell me it is time to come out ... "

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that the facility's guidelines for IITP's entails room confinement which can include keeping the patients in their rooms for 24 hours. EMP3 confirmed that the Adolescent Room Contract states that patients are to stay in their room until staff tell me them it is time to come out.

2) Review of MR8 progress note, dated February 24, 2014, at 11:31 AM, revealed " ... Pt is angry and visibly upset after getting in an argument [with] a peer and then [with] ... teacher. [Patient] was then sent to ... room from group and told to stay there the rest of the day ..."

Review of MR8 nursing note, dated February 26, 2014, at 10:35 AM, revealed " ... " Am I still on 1 hour in 1 hour out? " ... Pt's room contract continued throughout shift ... "

Review of MR8 nursing note, dated March 2, 2014, at 10:27 PM, revealed " ... " Why I have to go in my [expletive] room?! " ... Pt was encouraged to control self during community meeting and to be quiet. [Patient] continued to talk and provoke female peer from across the room. [Patient] was sent to ... room by staff. Pt responded by refusing to go to ... room. [Patient] eventually went while cursing the staff out. [Patient] eventually came out of ... room and sat in the hallway. Pt was ignored by staff and returned to room without incident ... "

Review of MR8 nursing note, dated March 9, 2014, at 11:00 PM, revealed " ... " What time will I be able to come out?" ... Pt was visible in the community. Pt spent the whole shift in ... bedroom as a result of 60/0 protocol. Pt required minor redirection to get out of ... doorway ... "

Review of MR8 nursing note, dated March 10, 2014, at 4:10 PM, revealed " ... [Patient] was placed in 4-pt restraints for safety of self & others @ 10:50 ... [Patient] to remain in room except for phone call/visit until tomorrow for safety of self & others, reevaluate safety needs tomorrow AM. "

Further review of the patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 19, 2014, at 11:30 AM, with EMP3 confirmed that the patient identified in MR8 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient ' s plan of care did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.

3) Review of MR31 nursing note, dated November 15, 2013, at 8:37 PM, revealed " ... Pt was on 60/0 room contract due to a physical altercation with a male peer on day shift. Pt was compliant with room contract. ... "

Review of MR31 nursing note, dated November 16, 2013, at 2:30 PM, revealed " ... I had a good day even though I was on 60-0 ... "

Review of MR31 nursing note, dated November 28, 2013, at 9:55 PM, revealed " ... "Do I have to be in my room the whole shift?" ... Pt started the shift while out in the community. [Patient] was later redirected back in ... room due to being in restraints earlier. Pt appeared very agitated because ... couldn't come out. [Patient] remained in the room throughout shift. .... "

Review of MR31 physician note, dated November 29, 2013, at 2:36 PM, revealed patient stating " I'm not on 60/0. " Further review of the physician note revealed " Pt tearful crying w/ staff. [Patient] was frustrated refused time out ... required PRN Abilify / Ativan ... "

Review of MR31 nursing note, dated December 4, 2013, at 10:00 PM, revealed that the patient stated " I'm not staying in my room! " Further review of the note revealed " ... Disruptive, rude during group discussion and required time out. Uncooperative while timing out; standing outside ... door screaming at staff ... To begin room contract of 45 min in room 15 min out tomorrow to promote better control ... "

Review of MR31 nursing note, dated December 5, 2013, at 10:00 AM, revealed " PRN - Benadryl 50 mg PO PRN given for agitation when staff redirected [patient] back to room to finish ... room contract time. Took it willingly - calmer in 1 hr ... "

Review of MR31 nursing note dated December 7, 2013, revealed " Pt was being defiant and oppositional over doing ... laundry this morning ... Required a few staff to keep in room when told ... would be on 1 [hour] in 1 out again for this behavior. Became combative & aggressive Pt had to be placed in restraints ... "

Review of MR31 nursing note, dated December 9, 2013, at 9:45 PM, revealed ... "Pt was placed on 60/0 earlier due to attempting to fight a peer over the Wii game. Pt remained in ... room throughout the shift. Pt was compliant with the 60/0 room contract ... "

Further review of the patient' s plan of care revealed no documented evidence that the treatment team assessed the patient for the use of the IITP nor was the patient ' s plan of care revised to include this intervention.

Interview on March 20, 2014, at 2:00 PM, with EMP3 confirmed that the patient identified in MR31 was sent to own bedroom on the above dates and times and instructed to stay in the room. EMP3 confirmed that the patient identified in MR31 interdisciplinary care plan did not include the use of an Intensive Individual Therapeutic Program (IITP), which included room confinement as an intervention in the patient's interdisciplinary care plan.


4) Review of MR32 nursing note, dated November 16, 2013, at 2:00 PM, revealed that the patient stated " I've learned my lesson. " Further review of the note revealed " patient is currently on restrictive 60-0, has been quiet seclusive to self no sign of any distress ... "

Review of MR32 Social Worker note, dated November 18, 2013, at 5:35 PM, revealed that the social worker indicated to the patient " Pretty unfair? " The patient responded " No, it's straight unfair." " SW spoke with [patient] on 11/18. " Patient reported having the "worst weekend ever" because was on 60-0 following the altercation on Friday with a male peer on the unit. The patient was placed in restraints. Patient expressed to Social Worker that " it was unfair that [patient] had to be penalized when [patient] was the one who got punched. ...SW acknowledged that it might seem unfair but that staff felt the 60-0 was necessary to ensure [patient] and other's safety on the unit. "

Review of MR32 nursing note, dated November 23, 2013, revealed " ... Pt was on Room Contract today 60/0 getting in a fight last night ... "

Review of MR32 nursing note, dated December 3, 2013, which revealed " ... Pt was agitated this morning because staff told ... to stay in ... room when [patient] told staff ... needed to go to the Quiet Room ... "

Review of the patient ' s plan of car