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 unreasonable 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. "

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.

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 ... "

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.

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 ... "

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.

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.

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.

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.

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.

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.

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.

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.

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.

Based on record reviews, patient and staff interviews, and other document reviews, the facility failed to provide and/or document a sufficient number of structured therapeutic groups/activities on the weekends for 7 (1 South, 2 Center, 2 North, 2 South, 3 Center, 3 East, and 3 Southwest) of 10 units. This failure resulted in: (1) the patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement, and/or (2) the patient record not reflecting treatment that was received, thereby causing documentation to be unavailable to assist with the patient's treatment and treatment planning.


Findings include:


A review of the Program Weekly Schedule for each of the ten units indicated that each unit had either one or two structured groups led by Rehabilitative Therapy staff on Saturdays and Sundays. The remainder of the structured activities and groups on each unit on weekends are led by nursing staff. Nursing staff has been instructed to document groups that nurses and Behavioral Health Aides (BHA) offer on weekends on a "Patient Education" form that is individualized for each patient. Each of ten randomly selected patients' "Patient Education" sheets (A, B, C, D, E, F, G, H, I, and J) was reviewed specifically for therapeutic interventions offered during the weekend prior to the survey. These sheets were cross-referenced with the units' Program Weekly Schedules.


A. Record Reviews


1. Patient B, admitted on 6/18/14 to Unit 1 South. The Master Schedule indicates that the unit offers 8 nursing groups or activities on Saturdays. Patient B's individual Patient Education sheet reflects attendance at two groups on Saturday 6/21/14. The Master Schedule indicates that the unit offers 8 nursing groups or activities on Sundays. Patient B's individual Patient Education sheet reflects attendance at three groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.


2. Patient C, admitted on 6/6/14 to Unit 2 Center. The Master Schedule indicates that the unit offers nine (9) nursing groups or activities on Sundays. Patient C's individual Patient Education sheet reflects attendance at three (3) groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled. Furthermore, Patient C stated in an interview on 6/23/14 at 11:30 p.m. that s/he was not allowed to go off the unit for any off-unit groups or activities over the 6/21/14 -6/22/14 weekend. "Wrap-up group was cancelled Saturday night because gym time got extended for those who were able to leave the unit. No one offered me a wrap up even though I was left on the unit."


3. Patient D, admitted on 6/19/14 to Unit 2 North as a patient with anorexia nervosa. The Master Schedule indicates that the unit offers an "After Meal Support (AMS) group" after both lunch and dinner each day of the week, including Saturdays and Sundays. Patient D's individual Patient Education sheet reflects that Patient D attended only one AMS support group on Saturday 6/21/14 and one on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between AMS groups attended and AMS groups scheduled. Furthermore, in an interview on 6/23/14 at 11:00 a.m., RN1 stated that the evening AMS group is only conducted Monday - Friday and not on weekend. When asked why AMS groups are not offered after weekend evening meals, RN1 replied, "That's a good question."


4. Patient F, admitted on 6/10/14 to Unit 2 South. The Master Schedule indicates that the unit offers seven (7) nursing groups or activities on Saturdays. Patient F's individual Patient Education sheet reflects attendance at two (2) groups on Saturday 6/21/14. The Master Schedule indicates that the unit offers six (6) nursing groups or activities on Sundays. Patient F's individual Patient Education sheet reflects attendance at one group on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.


5. Patient G, admitted on 6/12/14 to Unit 3 Center. The Master Schedule indicates that the unit offers 6 nursing groups or activities on Saturdays. Patient G's individual Patient Education sheet reflects attendance at one group on Saturday 6/21/14. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Sundays. Patient G's individual Patient Education sheet reflects attendance at three groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.


6. Patient H, admitted on 6/8/14 to Unit 3 East. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Sundays. Patient H's individual Patient Education sheet reflects attendance at one group on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.


7. Patient J, admitted on 6/3/14 to Unit 3 Southwest. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Saturdays. Patient J's individual Patient Education sheet reflects attendance at zero groups on Saturday 6/21/14. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Sundays. Patient J's individual Patient Education sheet reflects attendance at zero groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled. Furthermore, RN 2 stated in an interview on 6/23/14 at 4:00 p.m., "Pt. J is difficult to get into groups. But last weekend I can only find documentation of one activity--- a movie with Michael Jackson."


B. Patient Interviews


1. In an interview on 6/23/14 at 11:30 a.m., Patient B stated, "There weren't any groups on the weekend except Level Groups that are off the unit. I was Red [level] so I couldn't go to groups. I watched movies on the weekend."

2. In an interview on 6/23/14 at 11:50 a.m., Patient C stated, "I was confined to the unit this weekend. There weren't any wrap-up groups on Saturday or Sunday because the others stayed late at the gym."

3. In an interview on 6/23/14 at 10:00 a.m., Patient D stated, "On the weekend there isn't that much going on. There weren't many groups and the ones we did have were short. I haven't talked to the team yet - I'll talk to them today since it is Monday."

4. In an interview on 6/23/14 at 10:30 a.m., Patient E stated, "The weekend was slow. We had a couple of groups and then watched movies and played cards."

5. In an interview on 6/23/14 at 11:00 a.m., Patient F stated, "On weekends, we watch movies, relax, and socialize. It is a little boring."

6. In an interview on 6/23/14 at 2:00 p.m., Patient G stated, "There's nothing to do here on weekends. The groups don't work anyway."

7. In an interview on 6/23/14 at 4:15 p.m., Patient H stated, "Weekends around here are boring. I mostly just stay in my room."

8. In an interview on 6/23/14 at 1:00 p.m., Patient J stated, "There were no activities here on the weekend."

C. Staff Interviews

1. In an interview on 6/23/14 at 11:00 a.m., RN1 stated that the evening AMS (After Meals Support) dinner group is only conducted Monday through Friday. When asked why AMS groups are not offered after weekend evening meals, RN1 replied, "That's a good question."

2. RN2 stated in an interview on 6/23/14 at 4:00 p.m., "Pt. J is difficult to get into groups. But last weekend I can only find documentation of one activity--- a movie with Michael Jackson."

3. BHA1 stated in an interview on 6/23/14 at 10:25 a.m., "Since the wrap up group isn't on the Patient Education form, it could mean one of two things: the group was done and not documented or the group wasn't done. There is no way to know which is the case without asking someone who worked Saturday night."

4. RN4 stated in an interview on 6/23/14 at 3:30 pm., "On weekends, nursing does more groups because the activities department is not fully staffed."

5. The Director of Rehabilitative and Volunteer Services stated in an interview on 6/24/14 at 9:00 a.m., "The therapeutic activity staff offers either one or two groups per day on the weekend shifts. The nursing staff offers the majority of the groups on the weekend." She also stated that she requested an additional 20-hour per week position for a therapeutic activity person in the last fiscal year, but was denied that request.

6. The Medical Director acknowledged in an interview on 6/24/14 at 10:15 a.m. that group activities are still weaker on weekends and referred to increased budgeting for the next fiscal year. He was not aware, but did not express surprise, that much of the group therapy activities on weekends are the responsibility of nursing rather than activity therapists or social workers.

7. The Acting Director of Nursing stated in an interview on 6/24/14 at 10:30 a.m., "The Director of Nursing tried to say 'no' to nursing being the discipline that is responsible for weekend therapy. But it comes down to the number of FTE's that the organization has available. There are no additional FTE's in the therapeutic activities department. So nursing said that they would try to pick up the weekend activity programming."

D. Additional Document Reviews and Corresponding Interviews

1. On 6/23/14, the surveyors were provided, by the Director of Quality Management and Regulatory Affairs, a one page paper entitled: New Procedure for Documenting Groups. She reported that the Director of Nursing Education gave her the paper and stated that each individual nurse manager had been given the paper to use to educate his/her own nursing staff. The document reads, in part, "Remember that RN and BHA led activities such as BINGO, arts and crafts, decorating for the holidays, exercise/dancing, movies, etc ...where patients are gathered for a specific period of time and purpose count as a social group that promotes socialization, peer support, and are examples of positive ways to cope with stress and decrease anxiety. Therefore, please make sure these activities are documented as groups. So that you are giving yourselves credit for the wonderful work you do with patients each day!" However, in an interview on 6/23/14 at noon, the nurse manager of 1S/2C/2S stated: "If staff on 2C are documenting gym, recreation groups, and board game groups on the Patient Education sheet, then they are over-documenting. They should only document community and wrap-up groups." In a separate interview on 6/23/14 at 1:30 p.m., the Acting Director of Nursing acknowledged that the nurse manager's statement contradicts the written instructions.

2. An additional 2-page document also provided to the surveyors by the Director of Quality Management and Regulatory Affairs entitled: 1S/2C/2S Nursing Group Descriptions (revised 6/2014) reads, in part, "Nursing Staff are to complete a Belmont Patient Education sheet for individual patients twice on day shift and twice on evening shift, including weekend nursing run groups." In an interview on 6/23/14 at 1:15 p.m., RN3 stated that her interpretation of the document is, "We should record a minimum of two groups per shift. But if we do any nursing group, we document it." In a separate interview on 6/23/14 at 1:30 p.m., the Acting Director of Nursing acknowledged that the 2-page document is unclear and is left open to different interpretations by the nursing staff.

3. A one-page audit document for nursing groups recorded on the Patient Education form was also provided to the surveyors by the Director of Quality Management and Regulatory Affairs. The audit tool identified only two variables with a yes/no response: "1. Nursing groups are documented on individual- specific education forms, and 2. Nursing groups (sic) stored in unit-specific binder." There was no means to document the number of groups attended on weekends by the patient, which was the deficient practice identified in the March 2014 survey. Nor was there any means to cross-reference the number of groups offered on weekends with the number of groups attended by the patient. There was no means to document when a scheduled group was not offered and the reason why it was not offered. There was no means to document alternative activities that were offered when a patient could not attend off-unit activities on the weekend. In an interview on 6/23/14 at 4:00 p.m., the Director of Quality Management and Regulatory Affairs stated that the audit tool was developed by the Director of Nursing and that "it will need to be revised to add additional significant information."







07813

Based on record review, patient and staff interviews, and other document reviews, the Director of Nursing (DON) failed to provide adequate nursing oversight to ensure quality nursing services. Specifically, the DON failed to ensure that nursing staff provided and/or documented a sufficient number of structured activities/groups on the weekends for seven (7) (B, C, D, F, G, H, J) of 11 patients in the active sample. This deficiency resulted in: (1) the patients being hospitalized without the opportunity to receive nursing interventions to meet identified treatment needs, thereby delaying their improvement, and/or (2) the patient record not reflecting nursing treatment that was received, thereby causing documentation to be unavailable to assist with the patient's treatment and treatment planning.

Findings include:

A review of the Program Weekly Schedule for each of the ten units indicated that each unit had either one or two structured groups led by Rehabilitative Therapy staff on Saturdays and Sundays. The remainder of the structured activities and groups on each unit on weekends are led by nursing staff. Nursing staff has been instructed to document groups that nurses and Behavioral Health Aides (BHA) offer on weekends on a "Patient Education" form that is individualized for each patient. Each of ten randomly selected patients' "Patient Education" sheets (A, B, C, D, E, F, G, H, I, J) was reviewed specifically for therapeutic interventions offered during the weekend prior to the survey. These sheets were cross-referenced with the units' Program Weekly Schedules.

A. Record Reviews

1. Patient B, admitted on 6/18/14 to Unit 1 South. The Master Schedule indicates that the unit offers eight (8) nursing groups or activities on Saturdays. Patient B's individual Patient Education sheet reflects attendance at two groups only on Saturday 6/21/14. The Master Schedule indicates that the unit offers eight (8) nursing groups or activities on Sundays. Patient B's individual Patient Education sheet reflects attendance at three groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.

2. Patient C, admitted on 6/6/14 to Unit 2 Center. The Master Schedule indicates that the unit offers nine (9) nursing groups or activities on Sundays. Patient C's individual Patient Education sheet reflects attendance at three (3) groups only on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled. Furthermore, Patient C stated in an interview on 6/23/14 at 11:30 p.m. that s/he was not allowed to go off the unit for any off-unit groups or activities over the 6/21/14 -6/22/14 weekend. "Wrap-up group was cancelled Saturday night because gym time got extended for those who were able to leave the unit. No one offered me a wrap up even though I was left on the unit."

3. Patient D, admitted on 6/19/14 to Unit 2 North as a patient with anorexia nervosa. The Master Schedule indicates that the unit offers an "After Meal Support" (AMS) group after both lunch and dinner each day of the week, including Saturdays and Sundays. Patient D's individual Patient Education sheet reflects that Patient D attended only one AMS support group on Saturday 6/21/14 and only one on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between AMS groups attended and AMS groups scheduled. Furthermore, in an interview on 6/23/14 at 11:00 a.m., RN1 stated that the evening AMS group is only conducted Monday - Friday and not on weekend. When asked why AMS groups are not offered after weekend evening meals, RN1 replied, "That's a good question."

4. Patient F, admitted on 6/10/14 to Unit 2 South. The Master Schedule indicates that the unit offers seven (7) nursing groups or activities on Saturdays. Patient F's individual Patient Education sheet reflects attendance at two groups only on Saturday 6/21/14. The Master Schedule indicates that the unit offers six (6) nursing groups or activities on Sundays. Patient F's individual Patient Education sheet reflects attendance at one group on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.

5. Patient G, admitted on 6/12/14 to Unit 3 Center. The Master Schedule indicates that the unit offers six (6) nursing groups or activities on Saturdays. Patient G's individual Patient Education sheet reflects attendance at one group only on Saturday 6/21/14. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Sundays. Patient G's individual Patient Education sheet reflects attendance at three groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.

6. Patient H, admitted on 6/8/14 to Unit 3 East. The Master Schedule indicates that the unit offers 5 nursing groups or activities on Sundays. Patient H's individual Patient Education sheet reflects attendance at one group on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled.

7. Patient J, admitted on 6/3/14 to Unit 3 Southwest. The Master Schedule indicates that the unit offers 5 nursing groups or activities on Saturdays. Patient J's individual Patient Education sheet reflects attendance at zero groups on Saturday 6/21/14. The Master Schedule indicates that the unit offers five (5) nursing groups or activities on Sundays. Patient J's individual Patient Education sheet reflects attendance at zero groups on Sunday, 6/22/14. The medical record does not document any reason for the discrepancy between groups attended and groups scheduled. Furthermore, RN 2 stated in an interview on 6/23/14 at 4:00 p.m., "Pt. J is difficult to get into groups. But last weekend I can only find documentation of one activity--- a movie with Michael Jackson."

B. Patient Interviews

1. In an interview on 6/23/14 at 11:30 a.m., Patient B stated, "There weren't any groups on the weekend except Level Groups that are off the unit. I was Red [level] so I couldn't go to groups. I watched movies on the weekend."

2. In an interview on 6/23/14 at 11:50 a.m., Patient C stated, "I was confined to the unit this weekend. There weren't any wrap-up groups on Saturday or Sunday because the others stayed late at the gym."

3. In an interview on 6/23/14 at 10:00 a.m., Patient D stated, "On the weekend there isn't that much going on. There weren't many groups and the ones we did have were short. I haven't talked to the team yet - I'll talk to them today since it is Monday."

4. In an interview on 6/23/14 at 10:30 a.m., Patient E stated, "The weekend was slow. We had a couple of groups and then watched movies and played cards."

5. In an interview on 6/23/14 at 11:00 a.m., Patient F stated, "On weekends, we watch movies, relax, and socialize. It is a little boring."

6. In an interview on 6/23/14 at 2:00 p.m., Patient G stated, "There's nothing to do here on weekends. The groups don't work anyway."

7. In an interview on 6/23/14 at 4:15 p.m., Patient H stated, "Weekends around here are boring. I mostly just stay in my room."

8. In an interview on 6/23/14 at 1:00 p.m., Patient J stated, "There were no activities here on the weekend."

C. Staff Interviews

1. In an interview on 6/23/14 at 11:00 a.m., RN1 stated that the evening AMS (After Meals Support) dinner group is only conducted Monday through Friday. When asked why AMS groups are not offered after weekend evening meals, RN1 replied, "That's a good question."

2. RN2 stated in an interview on 6/23/14 at 4:00 p.m., "Pt. J is difficult to get into groups. But last weekend I can only find documentation of one activity--- a movie with Michael Jackson."

3. BHA1 stated in an interview on 6/23/14 at 10:25 a.m., "Since the wrap up group isn't on the Patient Education form, it could mean one of two things: the group was done and not documented or the group wasn't done. There is no way to know which is the case without asking someone who worked Saturday night."

4. RN4 stated in an interview on 6/23/14 at 3:30 pm., "On weekends, nursing does more groups because the activities department is not fully staffed."

5. The Director of Rehabilitative and Volunteer Services stated in an interview on 6/24/14 at 9:00 a.m., "The therapeutic activity staff offers either one or two groups per day on the weekend shifts. The nursing staff offers the majority of the groups on the weekend." She also stated that she requested an additional 20-hour per week position for a therapeutic activity person in the last fiscal year, but was denied that request.

6. The Medical Director acknowledged in an interview on 6/24/14 at 10:15 a.m. that group activities are still weaker on weekends and referred to increased budgeting for the next fiscal year. He was not aware, but did not express surprise, that much of the group therapy activities on weekends are the responsibility of nursing rather than activity therapists or social workers.

7. The Acting Director of Nursing stated in an interview on 6/24/14 at 10:30 a.m., "The Director of Nursing tried to say 'no' to nursing being the discipline that is responsible for weekend therapy. But it comes down to the number of FTE's that the organization has available. There are no additional FTE's in the therapeutic activities department. So nursing said that they would try to pick up the weekend activity programming."

D. Additional Document Reviews and Corresponding Interviews

1. On 6/23/14, the surveyors were provided, by the Director of Quality Management and Regulatory Affairs, a one page paper entitled: New Procedure for Documenting Groups. She reported that the Director of Nursing Education gave her the paper and stated that each individual nurse manager had been given the paper to use to educate his/her own nursing staff. The document reads, in part, "Remember that RN and BHA led activities such as BINGO, arts and crafts, decorating for the holidays, exercise/dancing, movies, etc ...where patients are gathered for a specific period of time and purpose count as a social group that promotes socialization, peer support, and are examples of positive ways to cope with stress and decrease anxiety. Therefore, please make sure these activities are documented as groups. So that you are giving yourselves credit for the wonderful work you do with patients each day!" However, in an interview on 6/23/14 at noon, the nurse manager of 1S/2C/2S stated: "If staff on 2C are documenting gym, recreation groups, and board game groups on the Patient Education sheet, then they are over-documenting. They should only document community and wrap-up groups." In a separate interview on 6/23/14 at 1:30 p.m., the Acting Director of Nursing acknowledged that the nurse manager's statement contradicts the written instructions.

2. An additional 2-page document also provided to the surveyors by the Director of Quality Management and Regulatory Affairs entitled: 1S/2C/2S Nursing Group Descriptions (revised 6/2014) reads, in part, "Nursing Staff are to complete a Belmont Patient Education sheet for individual patients twice on day shift and twice on evening shift, including weekend nursing run groups. In an interview on 6/23/14 at 1:15 p.m., RN3 stated that her interpretation of the document is, "We should record a minimum of two groups per shift. But if we do any nursing group, we document it." In a separate interview on 6/23/14 at 1:30 p.m., the Acting Director of Nursing acknowledged that the 2-page document is unclear and is left open to different interpretations by the nursing staff.

3. A one-page audit document for nursing groups recorded on the Patient Education form was also provided to the surveyors by the Director of Quality Management and Regulatory Affairs. The audit tool identified only two variables with a yes/no response: "1. Nursing groups are documented on individual-specific education forms, and 2. Nursing groups (sic) stored in unit-specific binder." There was no means to document the number of groups attended on weekends by the patient, which was the deficient practice identified in the March 2014 survey. Nor was there any means to cross-reference the number of groups offered on weekends with the number of groups attended by the patient. There was no means to document when a scheduled group was not offered and the reason why it was not offered. There was no means to document alternative activities that were offered when a patient could not attend off-unit activities on the weekend. In an interview on 6/23/14 at 4:00 p.m., the Director of Quality Management and Regulatory Affairs stated that the audit tool was developed by the Director of Nursing and that "it will need to be revised to add additional significant information."





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