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Based on observation, interview, and record review, the facility did not meet the Condition of Participation in Governing Body by failing to:

1. Ensure a secure and safe environment for the patients.
a. There were five (5) patients who eloped from the facility between March 2017 to February 2018 who were not located or returned to the facility. There was no follow-up and notification of the Department. (Refer to A 049)
b. The Medical Staff credentialing did not include basic life support (BLS) certificate and health screening: yearly PPD, Flu vaccination and documented Hepatitis B status or waiver. (Refer to A 049, A 286 and A 747).

2. Include Linen services in the contracted Services list and assure contracted services were delivered in a safe and effective manner. (Refer to A 085)

3. Assure that Hospital Medical Staff had BLS certificates as required by the Facility policy and Procedure for scope of emergency medical intervention. The Governing Body failed to assure in response to a Code Blue emergency the facility had the ability for initial treatment and to stabilize the patient and provide initial treatment including: items that are necessary for code Blue intervention including: suction, airway protection and emergency medications in a Crash cart for a Code Blue. (Refer to A 093)

4. Have an ongoing Quality Assessment Performance Improvement (QAPI) program that incorporated: assuring follow-up and safety of patients admitted to the facility, patients that had eloped and were not located or returned to the facility; assuring medical Staff credentialing included: BLS; yearly PPD, Flu vaccination and documented Hepatitis B status or waiver; assure all contracted services were included in the contracting list and evaluated. ( Refer to A 286)

5. Assure Medical staff practiced within the scope of their granted privileges including managing and following patient medical treatments. Granted privileges and patients were examined daily including follow-up exam by the internist of Family practice physician that was consulted to address the patients' medical care. (Refer to 355)

6. Assure Nursing Services conduct and accurate and complete patient assessments. Ensure nursing staff developed, implemented, and kept current nursing care plans. (Refer to A 385).

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility failed to provide a safe and secure environment for the patients by failing to:

1. Prevent the elopement of patients from the facility and assuring follow-up and safety of patients that eloped and were not located or returned to the facility including by notifying the Department Of Public Health of the Elopement.
2. Follow its delineation of privilege for medical staff and provide daily continuity of medical care and examination by a primary care physician either Internal medicine or family practice to manage and treat patients medical conditions. Assure medical Staff credentialing included BLS certificate.

Findings:

1. During an initial tour of the facility on 4/10/18 at 10:40 am with utilization review registered nurse (UR RN) when asked if there were elopements in the last year she indicated there were elopements and the last elopement was in February 2018.

During a review of a facility document titled, "Elopement March 2017 to February 2018" indicated five (5) patients eloped and had not returned to the facility. The five Eloped Patients (EP) were involuntary admits who eloped by climbing over the facility fence. Elopement dates were: EP #1 on 3/11/2017; EP #2 on 8/14/2017; EP #3 on 8/30/17; EP #4 on 12/27/17; and EP #5 on 2/1/2018. There was no documentation of follow up of patient outcome or reporting was done.

A review of the facility policy and procedure titled, " Elopement Precautions and Interventions" revised date of 1/18, indicated ... documented ".. 1. To prevent the unexpected departure of a patient who may be dangerous to others or to himself" and "2. To ensure the safety of the patient and the safety of other people when the patient is dangerous" and "Notification for Completed Elopement: Police Department, Patient's Emergency Contact; Nursing Supervisor; Director of Nursing and Director of Risk Management."

The facility failed to report elopements when the patients were not found to the Department of Public health. The facility failed to provide patient care in a safe setting and prevent the elopement of Patients.

2. During an initial tour on 4/10/18 at 11:20 am interview with RN2 indicated the Psychiatrist examines the patients daily. The Internal medicine doctor or the family practice doctor does an initial history and physical (H/P) and the nurse contacts the doctor with labs or medical questions. The Internal Medicine doctor or the Family Practice doctor do not examine the patients at the facility daily, the Psychiatrist examines the patients daily.

During an interview with the Medical Director on 4/12/18 at 1 p.m., he indicated the Psychiatrist examines patients every day, the Internal medicine or Family practice MD does an initial history and physical within 24 hrs of the Patient admission. The attending for the patient is the Psychiatrist, examines the patients daily, the Internal medicine or Family practice MD do not come in daily to examine the patients. The Psychiatrist will consult with the Internal Medicine or Family Practice physician for abnormal labs or other medical questions. Nursing staff fax abnormal labs to the medical physicians. The Nursing staff will call Internal medicine or Family practice MD for medical questions or if the patient needs to be transferred to the hospital. He indicated if patients need to see OBGYN they are referred out. Patients are sent out for specialty referrals including Orthopedics.

On 4/12/18 at 2:15 PM during a review of Medical Staff Credentialing records with MSC 1 a review of 10 randomly selected Medical staff charts all 10 of 10 medical staff credential charts did not have BCLS certification yearly PPD, Flu vaccination and documented Hepatitis B status or waiver for medical staff credentialing.

During an interview MSC1 none of the medical staff at the facility had BCLS certification; yearly PPD, Flu vaccination and documented Hepatitis B status or waiver on file. The facility did not have a policy or procedure requiring medical Staff to provide BCLS certification; yearly PPD, Flu vaccination and documented Hepatitis B status or waiver for medical staff credentialing.

A review of the Medical Staff credentials included; Delineation of Privileges for Internal medicine which included: Medical history and Physical examination; consultation for purpose of diagnosis and non-invasive treatment of medical problems; management of medical problems; orders of diagnostic testing regarding laboratory, radiology and nuclear imaging testing for purposes of diagnosis; and medication prescription and management in accordance with facility policy.

A review of the clinical privilege delineation for Psychiatry indicated Admitting and psychotherapy, History, Mental Status and Psychiatric Examination; Patient care orders Treatment planning; chemical dependency care.

During a review of 8 medical charts with UR RN on 4/13/18 at 8:40 am, the patients reviewed had medical conditions including: Hypertension; chest pain; abdominal pain; leg swelling; weight loss; asthma; chronic pain; diabetes; diabetic foot ulcer. When asked for daily notes and treatment by the internal medicine or family practice physician she indicated there were none. UR RN indicated there were no daily notes for review from the Internal Medicine or Family Practice MD for any patients. There were daily notes from the psychiatrist. She indicated there were no daily medical doctor examinations and follow up of medical conditions daily from internal medicine or family practice MD.

A review of the facility "Rules and Regulations" undated indicated "The attending physician is to assign a consulting physician to do the H&P and medical treatments" and .."Clinically privileged medical Staff that is functioning as consultants may write orders for medication and treatment.."

Based on interview and record review, the facility failed to ensure that there was an existing contract for the linen services that provides the service for the hospital.

This deficient practice had the potential for not meeting the needs of the patients.

Findings:

During an interview with the quality assurance and performance improvement (QAPI) director on 4/13/18 at 3:30 PM she indicated Linen was a contracted service.

During a review of the document titled, "Contracted Services" undated did not include Linen as one of the hospital's list of contracted services. When requested for a contract for linen there was none available for review.

A facility document titled, "The Board of Trustee Bylaws" undated indicated under contracted services "The Board shall require the Hospital to maintain a list of all contracted services to include the nature and scope of services" and "contracted services are performed safely and effectively through implementation of the performance improvement program".

The Governing body failed to assure all contracted services were listed including Linen services and Linen Contract service was available for review including documentation of quality assurance tracking for the linen contracted service. Contracted services were not provided in a safe manner.

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

1. Assure that Hospital Medical Staff had basic life support (BLS) certificates as required by the Facility policy and Procedure for scope of emergency medical intervention was provided for a Code Blue emergency.

2. Assure in response to a immediate life threatening emergencies, in Code Blue situations the facility was equipped and had the ability to provide initial treatment and stabilize the patient without:suction, airway protection and emergency medications available in a Crash cart for a Code Blue.

3. Assure the emergency medications are stored in the pharmacy as indicated in the facility policy titled "Emergency Medications".

Findings:

1. During a tour of the facility on 4/10/18 at 10:40 am no Crash carts were observed. During an interview with RN3 indicated there were no crash carts at the facility, but the facility had AED (automated external defibrillator) and oxygen and in case of emergency the Hospital calls 911. During an interview with the CNO on 4/12/18 at 1:05 PM, he indicated for medical emergencies the facility has oxygen, and staff is trained with BLS, 911 is called for Code Blue and patients are transferred by paramedics.

A review of a facility policy and procedure titled, "Emergency Medical Treatment for Patients/Code Blue" revised 11/17 documented included for Immediate life threatening emergencies: " a. page code blue," " b. dial 911," and "Initiate CPR and AED if needed".

During a review of the facility document undated titled, "Appendix I Rules and Regulations" documented "7.5.1" Capacity means the physical space, equipment supplies and services that the hospital provides and the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses" and the facility "is a Level IV psychiatric facility with the capability to provide basic life support in the medical emergencies until (911) response by paramedics. The Facility did not document how airway protection or suctioning can be performed or what plan was in place if ACLS was required as initial treatment or emergency medication was required as an initial treatment to stabilize the patient.

2. On 4/12/18 at 2:15 PM during a review of 10 Medical Staff credential files with Medical Staff Coordinator 1 (MSC1); 10/10 medical staff credential files reviewed did not have BLS certificate. During an interview with MSC1 when asked if any Medical staff had BLS required for credentialing, she indicated none had BLS on file for review and BLS was not required for credentialing. The facility did not have a policy and procedure for BLS requirement for credentialing of medical staff.

A review of the facility document titled, "Rules and Regulations" undated indicated "The medical Staff oversees the quality of care, treatment and services provided by those individuals with clinical privileges and shall participate in the monitoring of the quality and appropriateness of patient care."


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3. On 4/10/2018 at 2:45 PM, during an inspection of the pharmacy with a staff pharmacist and the director of pharmacy (DOP), the DOP indicated the pharmacy did not store, dispense, or outsource any medication for intravenous (inject through the vein) administration. The DOP also indicated the emergency medications were part of the floor stock medications at the nursing units.

Review of the hospital's policy and procedure titled, Emergency Medications, reviewed on 12/2017, reflected "Emergency medication stored as part of the floor stock medication. Administration of these medications shall be prepared in consultation with the medical staff. The policy also indicated the hospital's emergency medications included the intramuscular (inject through the muscle) injectable dosage forms of Haldol (a medication to treat psychosis), Ativan (a medication to treat anxiety), Cogentin (a medication to treat involuntary movements usually as a side effect from psychiatric medication), and Benadryl (a medication to treat allergies and used as sedative).

Based on record reviews and interviews, the hospital staff failed to document patients had acknowledged the receipt of the patient's rights information for two of 36 sampled patients. These information included "Condition of Admission" for Patient 7 and "Advance Directive Acknowledgement" for Patient 12.

Findings:

Review of Patient 7's electronic record, Part 1: Condition of Admission - Inpatient, dated 12/25/2017, did not indicate Patient 7 or patient's representative had initialed and signed where applicable on the form. The Part 1: Condition of Admission contained information including: Consent for Treatment, Consent for Admission to [the hospital], Consent for Release of Information, Guarantee of Payment, Assignment of Insurance Benefits, and Applicability to other Providers.

During a concurrent interview on 04/13/2018 at 9:30 am, the nursing supervisor indicated there should be an initial and a signature by the Patient or patient's representative; if patient could not sign, there should be a reason for not signing and a signature of a witnessing staff.

Review of Patient 12's electronic Advance Directive Acknowledgement, dated 12/30/2017, reflected that none of the check boxes that would have otherwise indicated if Patient 12 had executed directive, provided evidence of the directive, needed assistant in formulating a directive, or declined information.

During a concurrent interview on 4/13/2018 at 10:20 am, the business office manager acknowledged the staff did not check any of the check boxes. The business office manager indicated that the business office staff who signed the Patient 12's Advance Directive Acknowledgement electronic form should have checked the applicable box(es) or document the reason for not checking.

Based on interview and interview, the facility failed to provide patient care in a safe setting and ensure follow-up of patients who had eloped and were not located or returned to the facility. There was no facility policy for reporting elopements without the patient being found.

This deficient practice had the potential for patients not to receive appropriate care in a safe setting.

Finding:

1. During an initial tour of the facility on 4/10/18 at 10:40 am with The Utilization Review Registered Nurse (UR RN) when asked if there were elopements in the last year she indicated there were elopements and the last elopement was in February 2018.

During a review of a facility document titled, "Elopement March 2017 to February 2018." A review of the patients that eloped included 5 patients that had eloped and not been returned to the facility. The five Eloped Patients (EP) were involuntary admits that eloped by climbing over the facility fence. Elopement dates were: EP #1 on 3/11/2017; EP #2 on 8/14/2017; EP #3 on 8/30/17; EP #4 on 12/27/17; and EP #5 on 2/1/2018. There was no documentation of follow up of patient outcome or reporting was documented.

A review of the facility policy and procedure titled, Elopement Precautions and Interventions" dated revised 1/18, indicated ... documented ".. 1. To prevent the unexpected departure of a patient who may be dangerous to others or to himself " and " 2. To ensure the safety of the patient and the safety of other people when the patient is dangerous" and " Notification for Completed Elopement: Police Department, Patient's Emergency Contact; Nursing Supervisor; Director of Nursing and Director of Risk Management."

During an interview with QAPI Director, on 4/13/18 at 3:30 p.m., she indicated the elopements that did not return were reported to Department of Mental Health. No elopements where the patient was not found was reported to the Department of Public health. When asked for a policy on reporting on patients that eloped and are not found she indicated there was no facility policy for reporting elopements without the patient being found. When asked for the facility guideline used for determining reportable events to the department of public health a document was provided, undated titled, "Attachment A, Health and Safety Code 1279.1"

The facility failed to report elopements when the patients were not found to the Department of Public health. The facility failed to provide patient care in a safe setting and develop policy and comply with reporting requirements. The Governing Body failed to notify the Department of Public Health when Patients admitted to the facility had eloped and were not located or returned to the facility.



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2. During a tour on April 10, 2018, at 9:45 a.m., of Building A (3 units; East, North, and West)- accompanied by the registered nurses (RN 1 and RN 2), the following were observed:

a. In the Laundry/Utility Room; in the linen room a base cover was missing, in laundry room a small pencil was on the water drain pipe, missing floor tile, the sink was dirty.

When asked should the pencil be here, RN 2 stated maybe it was found in the patient's dirty clothing and/or used to mark on the patients' name. She further stated each morning the patients were given a "Good morning" paper and pencil to record how are they feeling today. RN 2 further stated, "Yes, all pencils that were given out were turned in daily. The staff only put out a certain amount each day."

b. All the patients' room had sockets and emergency sockets were exposed. When asked if the electrical sockets had current. RN 4 stated the electrical sockets did not have current "not working."

A review of the facility's Shift Unit Safety Checklist indicated "oncoming and off going staff must make Safety Rounds together" ....3. Patients Rooms/Bathrooms; included no visible contraband, soiled linens picked up, no damage to walls/furniture/bathroom/floors, etc ...each patient night light working. There was no documentation regarding the electrical sockets and emergency red sockets where intact, not manipulated/no attempts to arching.

A review of a facility's policy titled, "Pencil Counts,"#700.14 indicated to ensure safety of all patients on hospital units-distributed pencils would be accounted for by staff. The procedure included upon request of pencil by patient, the staff would note patient name, date and time that pencil was given to patient. Upon return of pencil by patient, staff would note date and time pencil was returned. The group leaders if pencils/markers were utilized during groups, the group leader would be responsible in ensuring that the correct number of pencil/markers were returned at the end of group.

3. Patient 13 was admitted to the facility on March 19, 2018 with diagnoses of Bipolar disorder with current manic recurrent features (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior).

Reviews of Seclusion and Restraint -Post Conference dated; March 21, 2018, at 11:06 a.m., March 22, 2018, at 11:50 a.m., March 24, 2018 at 9:55 p.m., and March 26, 2018, 12:31 p.m., indicated Type of Denial of Right was "Seclusion and Restraint." This was the means of restriction not the actual denial of rights.

A review of a facility's policy titled, Patient Rights and Notification," # 200.01 indicated 4. Patients rights shall include, but not limited to the following:
a. The right to wear own clothes, to keep and use his/her own personal possessions including toilet articles, and to keep and be allowed to spend a reasonable sum of his own money for vending machines purchases,
b. The right to have access to individual storage space for his private use,
c. The right to visit with family and significant others of their choice regardless of age in private each day,
d. The right to have reasonable access to telephones, both to make and receive confidential calls,
e. The right to have ready access to letter writing materials, including stamps, and to mail and receive unopened correspondence ...............receive information on how to acquire an advance directive.

Based on record review and interview, the facility failed to have an ongoing Quality Assessment Performance Improvement (QAPI) program that incorporated:

1. Assuring follow-up and safety of Patients admitted to the facility who had eloped and were not located or returned to the facility.
2. Assuring medical Staff credentialing that included BLS (basic life support) certificate and health screening to assure Medical Staff had yearly PPD (skin test for tuberculosis), Flu vaccination and documented Hepatitis B status or waiver in order to provide patient care in a safe and sanitary environment.

Findings:

1. During a review of a facility document titled, "Elopement March 2017 to February 2018" indicated five (5) patients who eloped and had not been returned to the facility. The five Eloped Patients (EP) were involuntary admits that eloped by climbing over the facility fence. Elopement dates were: EP #1 on 3/11/2017; EP #2 on 8/14/2017; EP #3 on 8/30/17; EP #4 on 12/27/17; and EP #5 on 2/1/2018. There was no documentation of follow up of patient outcome or reporting was documented.

During an interview with QAPI Director, on 4/13/18 at 3:30 PM she indicated the elopements that did not return were reported to Department of Mental Health. No elopements where the patient was not found was reported to the Department of Public health. A review of the Facility QAPI studies did not include follow up of eloped patients that did not return or were not located. When asked for a policy on reporting on patients that eloped and are not found she indicated there was no facility policy for reporting elopements without the patient being found

2. During a review of Medical Staff credentials with MSC1 on 4/12/18 at 2:15 PM she indicated none of the medical staff had requirements for: BLS, or had yearly PPD, Flu vaccination and documented Hepatitis B status or waiver. There were no: Governing Body or Medical Staff or QAPI or Infectious Disease policy or procedure for BLS certification; yearly PPD, Flu vaccination and documented Hepatitis B status or waive of the medical staff.

3. During an interview with QAPI director on 4/13/18 at 3:30 PM she indicated Linen was a contracted service.

During a review of the document titled" Contracted Services" undated did not include Linen contracted services list Contracted services for Linen was not included. There was no contract for linen was available for review.

A facility document titled, "The Board of Trustees Bylaws" undated indicated under contracted services "The Board shall require the Hospital maintain a list of all contracted services to include the nature and scope of services" and "contracted services are performed safely and effectively through implementation of the performance improvement program ".

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

1. Ensure the Medical staff practiced within the scope of their granted privileges including managing and following patient medical treatments and patients were examined daily including follow-up exam by the internist of Family practice physician that was consulted to address the patients' medical care.

2. Assure that Hospital Medical Staff had BLS (basic life support) certificates as required by the Facility policy and Procedure for scope of emergency medical intervention for Medical intervention was provided for a Code Blue emergency.

Findings.

1. During an initial tour on 4/10/18 at 11:20 a.m., interview with RN2 indicated the Psychiatrist examines the patients daily. The Internal medicine doctor or the family practice doctor does an initial history and physical (H/P) and the nurse contacts the doctor with labs or medical questions. The Internal medicine doctor or the family practice doctor do not examine the patients at the facility daily, the Psychiatrist examines the patients daily.

During an interview with the Medical Director on 4/12/18 at 1 p.m., he indicated the Psychiatrist examines patients every day, the Internal medicine or Family practice MD does an initial history and physical with in 24 hours of the Patient admission. The attending for the patient is the Psychiatrist. The Psychiatrist examines the patients daily, the Internal medicine or Family practice MD do not come in daily to examine the patients. The Psychiatrist will consult with the internal medicine or Family practice physician for abnormal labs or other medical questions. Nursing staff fax abnormal labs to the medical physicians. The Nursing staff with call Internal medicine or Family practice MD for medical questions or if the patient needs to be transferred to the hospital. He indicated if Patients need to see OBGYN (obstetrician/ gynecologist) they are referred out. Patients are sent out for specialty referrals including Orthopedics.

2. On 4/12/18 at 2:15 PM during a review of Medical Staff Credentialing records with MSC 1 included; Delineation of Privileges for Internal medicine which included: Medical history and Physical examination; consultation for purpose of diagnosis and non-invasive treatment of medical problems; management of medical problems; orders of diagnostic testing regarding laboratory, radiology and nuclear imaging testing for purposes of diagnosis; and medication prescription and management in accordance with. Facility policy

A review of the clinical privilege delineation for Psychiatry included: Admitting and psychotherapy; History, Mental Status and Psychiatric Examination; Patient care orders Treatment planning; chemical dependency care.

During a review of 8 medical charts with utilization review registered nurse (UR RN) on 4/13/18 at 8:40 am the patients reviewed had medical conditions including: Hypertension; chest pain; abdominal pain; leg swelling; weight loss; asthma; chronic pain; diabetes; diabetic foot ulcer. When Asked for daily notes and treatment by the internal medicine or family practice physician for medical treatment she indicated there were none. UR RN indicated there were no daily notes for review from the Internal Medicine or Family Practice MD for any patient's medical treatments. There were daily notes from the psychiatrist. She indicated there were no daily medical doctor examinations and follow up of medical conditions daily from internal medicine or family practice MD.

A review of the facility document titled, "Rules and Regulations of [Facility Name]" undated indicated" The attending physician is to assign a consulting physician to do the H&P and medical treatments" and .."Clinically privileged medical Staff that is functioning as consultants may write orders for medication and treatment.."

The facility failed to follow its delineation of privilege for medical staff and provide daily continuity of medical care and examination by a primary care physician either Internal medicine or family practice to manage and treat patients medical conditions. The facility failed to provide quality of care for the patients for non psychiatric medical conditions.

During a review of Medical Staff credentials with MSC1 on 4/12/18 at 2:15 PM she indicated none of the medical staff had requirements for: BLS, or had yearly PPD, Flu vaccination and documented Hepatitis B status or waiver. There were no: Governing Body or Medical Staff or QAPI or Infectious Disease policy or procedure for BLS certification; yearly PPD, Flu vaccination and documented Hepatitis B status or waive of the medical staff.

Based on observation, interview and record review, it was determined that the facility did not meet the Condition of Participation (COP) for Nursing Services by failing to:

1. Demonstrate how to perform the daily quality control monitoring of the glucometer machine prior to start of shift as stipulated in the Manufacturer's Manual. (Refer to A 0392)

2. Adequately assess patient's nutritional risk of chewing and swallowing difficulty upon admission and to provide ongoing nursing assessment to meet patient's needs. (Refer to A 0392)

3. Ensure complete and accurate assessment was conducted by the Registered Nurse, ensure the level of pain was initially assessed and re-assessed after pain medication was administered. Ensure a follow-up direct communication with the shelter was conducted for continuity of care for discharged patients. (Refer to A 0395)

4. Ensure nursing staff developed, implemented, and kept current nursing care plans. (Refer to A 0396)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality health care in a safe environment.

Based on record review and interview, the facility failed to;
1. Demonstrate how to perform the daily quality control monitoring of the glucometer machine prior to start of shift as stipulated in the Manufacturer's Manual. This deficient practice had the potential not to meet the needs of the patients.
2. Adequately assess patient's nutritional risk of chewing and swallowing difficulty upon admission and to provide ongoing nursing assessment to meet patient's needs. This deficient practice resulted in patient 1 chocking on food.

Findings:

1. On April 10, 2018, at between the hours of 10:45 a.m. through 2:45 p.m., the licensed staff in different units were requested to demonstrate the use of the glucometere machine:

a. LVN/LPT 2 from West Unit was requested to demonstrate how to perform quality control monitoring of glucometer machine using the control solutions. The glucometer machine with serial number of 106032314246. The test strip was opened and dated 4/1/18 with discard date of 10/1/18. The control solutions ( #1 lo and #3 high) had no documented opened date but had a discard date of April 2, 2019.

The LVN wearing a pair of gloves inserted the test strip into the port. On the face of the glucometer machine was a blood drop icon (signaling to drop the blood sample). The LVN placed a drop the control solution on top of the strip (instead on the end of the test strip to fill). There was no reading. The LVN pulled the strip and reinserted the strip and at this point the demonstration was stopped.

During an interview with the LVN/LPT, stated she was not trained on the use of the said glucometer to perform quality control solution monitoring.

b. LVN/LPT 3 from North Unit was requested to demonstrate how to perform quality control monitoring of glucometer using the control solutions. The control solution have discard date of June 7, 2018 but no opened date. The face of the machine showed the date as August 2017 and time as 1843 (6:43 p.m.) The actual date was April 10, 2018 and time was 11:30 a.m. The LVN with gloved hand demonstrated the quality control test by inserting the test strip and a blood icon appeared. The LVN placed a drop of the control solution on the end of the strip and a result appeared.

c. LVN 4 from South Unit, was requested to demonstrate how to perform quality control monitoring of glucometer using the control solutions. The control solutions have discard date May 11, 2018 but no opened date. The face of the machine showed blood icon and no date and time. There were two (2) bottles of test strip with discard date of September 22, 2018 and no date of opening. The LVN with gloved hand demonstrated the quality control test by inserting the test strip and placing a drop on the end of the test strip and reading came.

During an interview with LVN/LPT 3 at the end of observation, stated that the blood icon comes out when strip was inserted and a drop of control solution was applied to the test strip. She further stated the machine is cleaned with Sani-wipe cloth every after its use.

Review of the Manufacturer's User Manual indicated the following:

1). Personnel operating this meter must be proficient in the operating and maintenance procedures of the meter.
2). To perform a test, the operator inserts a test strip into the test strip port. Touch the end of the strip to a drop of blood, quality control (QC) solution, or linearity solution.
3). Prior to analysis, the operator may designate the test sample as a quality control sample (level C1, C2 or C3).
4). Set Date and Time format.
5). Testing a blood sample by inserting a test strip into the meter. All segments of the segments of the screen will display for 2 seconds. Then a flashing blood drop will display, touch the end of the test strip to the blood drop until the test strips fills and the meter beeps.

Review of the Insert for the Test Strip indicated the expiration date is printed on the vial of test strips. Once opened, the Test Strips are stable when stored as indicated up to 180 days or until the expiration date, which ever comes first.

Review of the Insert for the Glucose Control Solution indicated the expiration date is printed on the control vials. Once opened, solutions stored as indicated will be stable for up to 3 months or until the expiration date, which ever comes first.



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d. On April 10, 2018, at 10:40 a.m., LVN 5 was requested to demonstrate how to perform quality control monitoring of glucometer machine using the control solution. LVN 5, stated, "I don't do, Hi and Lo testing. It's done on the night shift by the night staff." LVN 5 stated she washes her hands, goes into patient's room with her supplies, identifies patient with wrist band, explains procedure, puts on gloves, and chooses a finger, pokes with lancet, gets a drop and waits till glucometer beeps, applies a drop enough to cover, beeps when read, removes strip, and wipes with bleach wipes.

A review of the Diabetic Patients list provided by the facility indicated 7 identified diabetic patients.


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2. During tray line observation on April 10, 2018 at 11:15 am, cook 1 was preparing the puree diet. During a concurrent interview with cook 1 and Director of Food Services, they stated that patient must be a new admission over the weekend and he is the only one with a puree diet order.

A review of the clinical record indicated Patient 1 was admitted to the facility on March 24, 2018, with diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms.

A review of the diet order dated March 24, 2018 indicated patient is on regular diet every meal.

A review of the electronic nursing notes dated April 7, 2018 indicated Patient 1 had a choking incident during dinner on April 6, 2018, at 5 PM. Patient 1's psychiatrist ordered monitor patient while eating meals on April 7, 2018 at 9:45 PM.

A review of the diet order dated April 8, 2018 indicated diet changed to puree diet every meal with comments "Patient keeps choking on food." Signed by patient 1's psychiatrist on April 8, 2018 at 4:33 am.

A review of Nutrition Assessment dated April 9, 2018 at 10:00 PM, indicated patient has problems swallowing and needs close supervision during meals to monitor chewing food thoroughly and slowly. Dietitian recommended pureed diet and speech evaluation.

During an interview with RN5 on April 11, 2018, at 3:20 PM she stated patient 1 chokes on food, and it is mostly during dinner time, patient 1 told RN that he chokes because of anxiety. She also stated that patient told her he doesn't want the puree diet. RN will call patient 1's psychiatrist to change diet order.

During an interview with Patient 1 on April 11, 2018, at 3:30 PM he stated "I always had choking problems ever since I was a kid. I would choke on hot dogs or big pieces of food." He stated he does not want the puree diet, he further stated "I like the food here, and I want the chow mein for tonight. I have signed a paper that I don't want the puree diet."

During an interview with registered dietitian on April 11, 2018, at 3:40 PM she stated that if a nutritional risk is triggered with initial nursing assessment, then she completes a nutritional assessments within 48 hours. She further stated there were no nutritional risk factors identified during initial nursing assessment. She recommended speech evaluation after choking episode.

A review of Patient 1's electronic medical record and physician orders on April 13, 2018, at 11:00 am indicated diet was changed to mechanical soft to prevent from choking.

During a concurrent interview with RN6 she stated that sometimes when patients are admitted with diagnosis of psychosis they often refuse to answer questions during intake and nursing assessment. She further stated that outpatient referrals such as speech therapy do not want to see patients while on hold in psychiatric hospital. Outpatient Referral wait until patient is discharged. RN6 also stated that we do not have services for inpatient speech therapist.

A review of the intake assessment dated March 24, 2018 at 7:58 PM, indicated Patient 1's level of consciousness was oriented x4.

A review of Initial nursing assessment dated March 24, 2018 at 8:42 PM, indicated Patient 1 was oriented to place, time and person.

According to initial nursing assessment patient had no nutritional problems including chewing/swallowing difficulty. Further details patient with no current medical conditions.

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

1. Ensure complete and accurate assessment was conducted by the Registered Nurse, .

2 Ensure the level of pain was initially assessed and re-assessed after pain medication was administered.

3. Ensure a follow-up direct communication with the shelter was conducted for continuity of care for discharged patients.
This deficient practice had the potential not to meet the patients need.

4. Document the wound type, size, and depth during the initial assessment and reassessment.
Provide treatment and care in a timely manner. This deficient practice had the potential to result in delay of the healing of the open wound.
This deficient practice had the potential to result in delay of the healing of the open wound.

Findings:

1. Review of the Facesheet indicated Patient 28 was admitted to the facility on January 25, 2018, with diagnosis of Bipolar disorder, current episode depressed, severe, without psychotic feature.

The Intake Assessment was conducted by a Licensed Psychiatric Technician (LPT) on 1/25/18. There was no indication the fifth vital sign which was pain was assessed, wound and nutritional concern.

The Nursing Assessment conducted by the RN failed to show documentation of the Skin/Skin Integrity Assessment was performed.

2. Review of the Facesheet indicated Patient 20 was admitted to the facility on September 22, 2017, with diagnosis of Major depressive disorder, recurrent severe without psychotic features, suicidal ideation and alcohol dependence.

The Intake Assessment was conducted by two (2) LVN (Licensed Vocational Nurse)/ LPT (Licensed Psychiatric Technician) on 9/22/17. The presence or absence of pain was not assessed.

3. Review of the Facesheet indicated Patient 29 was admitted to the facility on March 2, 2018, with diagnosis of alcohol dependence with withdrawal, uncomplicated and other stimulant dependence.

The Intake Assessment indicated that the presence of pain which was a pain scale of 5/10 in the arms.

a. The Nursing Assessment conducted by the mental health worker (MHW), LVN and RN on 3/3/18. The patient was assessed the presence of pain level 10/10 (severe) with body ache. The Skin/Skin Integrity was assessed as intact, however, the attached photos in the nursing assessment indicated multiple bruises, cuts all over the body. The history and physical examination (H and P) conducted by the physician on March 4, 2018 indicated the patient has right periorbital ecchymosis, has multiple small cuts and bruises throughout her body mostly on arms, shoulders, one at the base of her neck. The patient also has bruises on the back of right shoulder.

b. Review of the Flowsheets on the following dates indicated:

On March 3, 2018, at 3 p.m., the patient complained of general pain level 6/10 (moderate) for body aches. The patient was administered Tylenol 650 mg by mouth. There was no documented evidence to indicate the patient's pain level was re-assessed after medication was administered.

On March 4, 2018, at 3 a.m., the patient complained of pain on the head, back and neck. The pain level was 8/10 (severe). The patient was administered Ibufropen 400 mg orally. There was no documented evidence to indicate the patient's pain level was re-assessed after pain medication was administered.
At 7 a.m., the patient complained of headache. The pain level was 5/10 (moderate). The patient was administered Tylenol 650 mg. There was no documented evidence to indicate the patient's pain level was re-assessed after pain medication was administered.

On March 7, 2018, at 3 a.m., the patient complained of continuous right shoulder/collarbone pain. The pain level was assessed as 6/10 (moderate). There was no documentation the patient was administered pain medication or provided intervention to improve the level of pain.

Review of the physician order dated:
a. On March 2, 2018, indicated Acetaminophen Oral Tablet (Tylenol tablet) 650 mg oral take every four (4) hours as needed not to exceed 4000mg/24 hours for 30 days for mild pain.

b. On March 3, 2018 indicated Ibuprofen Oral Tablet (Motrin Tablet) 400 mg Oral tablet take three (3) a day (0800, 1400, 2000) for 30 days for pain.

Review of the facility policy number: 600.28 titled "Pain Management" indicated a thorough pain assessment using age specific criteria and consideration of mental status will include the use of pain scale correlating with the 0-10 scale (i.e. faces, non verbal patient scale), location, intensity, quality, duration, what alleviates it and what makes it worse. Present management including patient's goal will be performed on every patient having pain. Clarification for all areas and discipline - Mild - 1 to 3, Moderate - 4 to 6 and Severe - 7 to 10. Pain reassessment must be completed and documented within 60 - minutes. If unable to maintain pain level of < or = to 4, the chain of command may be enacted upon joint consideration between the patient and caregiver.

During an interview with Director of Quality and Risk Management (DQRM), while reviewing the clinical records, stated that pain should be assessed and re-assessed after pain medication was administered. The DQRM concurred the physician order for pain medication indicated only for mild pain and there was no documented evidence the pain medication order addressed the moderate and severe pain the patient experienced.

4. Review of the Facesheet indicated Patient 21 was admitted to the facility on February 21, 2018, with diagnosis of major depressive disorder, recurrent severe without psychotic features, post-traumatic stress disorder and migraine.

The Intake Assessment was conducted by the Licensed Vocational Nurse (LVN) on February 21, 2018. The patient was assessed as having pain on the legs and back, pain scale of 8/10.

The Nursing Assessment was conducted by the RN. The patient was assessed as having abdominal pain under gastrointestinal system but there was no level of pain documented. However, the question if currently experiencing pain, the answer was "No".

5. Review of the Facesheet indicated Patient 30 was admitted to the facility on February 21, 2018, with diagnosis of major depressive disorder, recurrent severe without psychotic features, suicidal ideation and alcohol abuse.

The Nursing Assessment was conducted by the RN on admission. There was no documentation the patient's skin integrity was assessed.

6. Review of the Facesheet indicated Patient 31 was admitted to the facility on March 23, 2018, with diagnosis of schizoaffective disorder, depressive type, suicidal ideation and essential hypertension.

The Intake Assessment conducted by RN indicated under the section of Pain Assessment the patient had intermittent left rib are cramping which 7/10 level. Under skin the patient was assessed having open wounds and skin irritations such as superficial abrasions, self-inflicted wound to right forearm from a broken CD case, mid frontal abrasion/contusion from "banging head 50 times last night".

The Nursing Assessment was conducted by the RN. The assessment indicated under cardiac there was a mild chest pain when the patient is stressed, under Gastro section there was abdominal pain but there was no level of pain based on the scale of 0-10 and under Pain Section currently experiencing no pain. Under the section for skin integrity the skin was compromised such as multiple self-inflicted scratches and bites to the right forearm, broken skin from self biting on right hand and bruise on the right lower leg below knee from kicking at her bed.

The History and Physical Examination conducted by the physician on March 25, 2018, indicated the patient's skin condition was intact.

7. Review of the Facesheet indicated Patient 12 was admitted to the facility on December 30, 2017, with diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, nicotine dependence and obesity.

The Intake Assessment was conducted by the LVN/LPT. There was no documentation to indicate RN conducted the assessment.

The Nursing Assessment indicated the patient skin integrity was intact. The History and
Physical Examination conducted by the physician indicated the skin had abrasion on the right upper extremity.

8. Review of the Facesheet indicated Patient 32 was admitted to the facility on April 5, 2018, with diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, other stimulant abuse and cannabis abuse. The patient was discharged on April 9, 2018 to a shelter. The facesheet did not include mother's name and contact number to verify discharge plans for the patient.

The patient was brought in by Police Department on a 5150 DTS/DTO (danger to self and to others). The patient stated he plans to cut self or burn himself, aggressive with mother. The patient had been hospitalized recently for attempted overdose on unknown pills. The patient uses crystal meth and smokes occasionally. The Psychiatric Progress Note dated April 9, 2018 indicated the patient was stabilizing and plan to discharge today for follow-up on outpatient basis.

Review of the Progress Note by Case Management dated April 9, 2018, indicated the patient was unable to provide contact number to verify the discharge plans, will accept a shelter referral and requested bus passes. The patient was discharge to a shelter.

The Discharge Consent Form indicated the name of the shelter, telephone number, no name of contact person and placement instruction that patient should line up by 3 p.m. The patient agrees to sign but there was documentation the patient sign the form.

During an interview with RN 2 while reviewing the clinical record, stated the patient was to go home and shelter referral was provided as backup plan and provided with bus passes. There was no documentation that the facility followed up if patient made it to the shelter.

Review of the facility policy number : 600.22 titled "Discharged/After Care Planning" indicated to identify the responsibility for ensuring that the prescribed follow-up is accomplished ... Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.

9. Review of the Facesheet indicated Patient 12 was admitted to the facility on December 30, 2017, with diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, schizoaffective disorder, nicotine dependence and obesity. The patient was discharge on January 24, 2018 to a shelter.

The patient was brought in by Police Department on a 5150 DTS/DTO (danger to self and to others). The patient had struck an employee at a fast food chain on the face because she heard the voice of God telling her to do it. The patient was agitated, loud, uncooperative, threatening staff and required emergency medications..

Review of the Progress Note by Case Management dated January 24, 2018, indicated the patient continues to refuse assistance with housing requesting to be sent to the shelter. She was discharged to the shelter by a church. The patient was transported to the shelter by the facility staff and given a referral to a mental health facility.

The Discharge Consent Form indicated the name of the shelter, telephone number, no name of contact person and placement instruction that patient should line up by 5 and doors open at 6 The patient signed and dated the Discharge Consent Form.

During an interview with RN 2 while reviewing the clinical record, stated the patient was to go to the shelter sponsored by a church .There was no documentation that the facility followed up if patient made it to the shelter.

Review of the facility policy number : 600.22 titled "Discharged/After Care Planning" indicated to identify the responsibility for ensuring that the prescribed follow-up is accomplished ... Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.



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10. A review of Patient 9 medical record indicated she was admitted on March 24, 2018 with diagnosis that included major depressive disorder and was diabetic.

A review of a facility's policy titled, "Skin Assessment and Wound Management," #900.55, indicated the following:
a. Wound care would be conducted as ordered by physician and staff would utilized Wound Management Protocol (WMP). The WMP purpose was to provide nursing personnel with simple guidance regarding appropriate wound care and promote a short healing duration. The characteristics of the wound included location of wound, size and depth of involvement, appearance of the wound surface, amount and characteristic of wound exudate, and describe the tissue around the wound (scarred, inflamed, etc.)

The Wound Documentation dated March 25, 2018 and March 28, 2018 were photographs of Patient 9's wounds on bilateral knees, lower extremities (mid right/anterior leg, the left and right toes were thick mycotic nails (Mycotic nails are nails that are infected with a fungus. The nail may be discolored, yellowish-brown or opaque, thick, brittle and separated from the nail bed. In some cases the nail actually may be crumbly). The record did not specify the type of wound, location of wound, size and depth of involvement, appearance of the wound surface, amount and characteristic of wound exudate, and describe the tissue around the wound (scarred, inflamed, etc.).

b. A review of the Acute Nursing Progress Notes dated March 30, 2018 indicated the physician was contacted regarding no assessment of the left great toe diabetic ulcer after contacting the medical doctor times (X) 3 days. Another physician assessed the patient ulcer and wound care orders received. Furthermore, Patient 9 was admitted March 24, 2018 and orders written 6 days later.

During an interview on April 11, 2018, at 8:15, 2018, RN 1 reviewed the photographs and stated location of wound, size and depth of involvement, appearance of the wound surface, amount and characteristic of wound exudate, and description of the tissue around the wound (scarred, inflamed, etc.) was not documented. RN1 further verified the order for treatment was 6 days later.

Based on record review and interview, the facility failed to ensure nursing staff developed, implemented, and kept current nursing care plans for 9 of 36 sampled patients (9, 12, 20, 21, 29, 30, 31, 33, and 34 ).

For Patient 33, who had AWOL (absent without leave) attempt from the patio unit, had no actual AWOL care plan developed.

For Patient 9, identified as high risk for fall, had a care plan developed, and the staff to implement the fall prevention protocol.

For Patient 34, who was identified as unpredictable and impulsive, and attacked staff on at least on two occasions, the assessment included "close observation status," did not have a care plan for danger to others.

For Patient 35, had return from the acute care facility, had wounds and there was no documentation of the wound description, location, size, and depth of involvement.

For Patient 20, there was no documentation the social worker (SW) and case management (CM) signed the master treatment plan. The Master Treatment Plan (MTP) failed to address the issue about patient's homelessness.

For Patient 29, review of the MTP established on 2/22/18 did not address the multiple bruises on the patient's body.

For Patient 21, review of the MTP failed to show documentation the patient's chronic constipation was addressed.

For Patient 30, there was no documentation the social worker (SW) and Activity Therapy Staff signed the MTP.

For Patient 31, There was no documentation the Case Management signed the MTP. There was no documentation the following concerns pain, skin condition and nutrition was addressed in the MTP.

For Patient 12, There was no documentation the Case Management signed the MTP. There was no documentation the following concerns such as homelessness and skin abrasions was addressed in the MTP.

This deficient practice had the potential for not meeting the needs of the patients.

Findings:

1. A review of the facility's 24 Hour Clinical Narrative Update/Justification for Continued Stay report indicated an incident occurred on February 20, 2018, at 12:45 p.m. from the North Adult patio unit, during a break, using a trash can to prop himself up and jump from the fence. Patient 33 was found in building C attempting to jump from fence, unsuccessful, and escorted back "assisted" by staff at 12:50 p.m. The patient became an imminent danger to the staff, as he became aggressive, postured at staff, and started yelling, "I don't want to be here." ...escorted to observation room (OR) after being administered medication and placed in restraints and seclusion. Patient 33 stated he would continue to cause trouble and leave when he gets out of OR, continued "you guys are dicks, and I will do what it takes to get out of here."

On April 13, 2018, at 8:45 a.m., RN 3 reviewed the medical record and stated, "Yes, the patient stated he no longer wanted to be here. Patient 33 was refusing medication prior to his AWOL incident. RN 3 further stated she was unable to find a care plan for actual AWOL. "Yes, there should be a care plan." The medical record had two care plans which included Psychosis and Seclusion and Restraint. These treatment plans were electronically standardized and not individualized to meet the patients' needs. She further agreed the interventions were all standardized and the staff had checked off the boxes. The interventions included to evaluate changes in behavior and /or triggers leading to explosive behavior. However, there were no documented triggers identified by the staff or refusals by the patient to elaborate on his triggers.

A review of the face sheet indicated Patient 33 was admitted to the facility on February 15, 2018, with diagnosis that included Paranoid schizophrenia (is the most common type of schizophrenia. Schizophrenia is defined as "a chronic mental disorder in which a person loses touch with reality." Schizophrenia is divided into subtypes based on the "predominant symptomatology at the time of evaluation.").

Reviews of Progress Notes dated February 21, 2018 at 7:28 a.m., and February 22, 2018, at 8:12 a.m., indicated continue on high elopement risk due to AWOL attempt. Patient 33 continues to be anxious, pacing, and unpredictable.

A review of a facility's policy titled, "Seclusion/Restraint of Patient," #200.16, revised on November 2017, indicated the post conference includes reviewing of the clinical information, reviewing the treatment plan and identifying opportunities for performance improvement. The treatment plan was "individualized to the needs of the patient ....."

2. A review of Patient 9's medical record indicated the patient was admitted on March 24, 2018 with diagnosis that included major depressive disorder.

a. The Nursing Assessment dated March 24, 2018, the Problem List indicated Fall Risk was an active problem. The fall prevention protocol/precaution included implementation and maintained YELLOW wristband in place, using assistive devices, and wearing nonskid socks.

There was a care plan titled, "Fall Risk," dated March 24, 2018, indicating Patient 9 would be free of falls during hospitalization and compliant with medications. The nursing interventions included encourage proper footwear, monitor vital signs for postural hypertension, and orient to environment and assess ability to call for assistance. There was no documentation of the YELLOW wristband placed or refusal to wear the wristband.

During a treatment observation, on April 11, 2018, at 8 a.m., in Patient 9's room, she was sitting in a chair and dressed. Patient 9 had on her right ankle, a small scab formation with blood. The patient was wearing shoes with non- skid socks on, and her blouse sleeves were rolled up. There was no YELLOW wristband.

During concurrent interviews, on April 11, 2018, at 8:30 a.m., RN 5 stated for a fall risk or actual fall there would be an assessment of the skin, neuro checks, pain, vital signs, and maybe move the patient closer to nurses station. RN5 further stated place a YELLOW wristband and update the plan of care. RN 1 provided copies of Progress Notes dated April 10, 2018, at 6 p.m. and 7:03 p.m., which indicated patient was given ID band to wear and refused to wear due to irritation. RN 1 stated, "Yes, the documentation did not specify the YELLOW wristband for falls was refused.

2. Patient 35 was admitted to the facility on January 26, 2018, with diagnosis that included Major Depression disorder. Patient 35 had an attempted suicide by hanging herself in the bathroom on January 29, 2018. Patient 35 fell and cut open her lip requiring 3 sutures at the acuity care facility. Placed on 1:1 means accompanied by staff and interactions are required at all times, 24 hours a day (this means arm's length unless a physician states otherwise).

A review of the photographs upon returning did not indicate specify the type of wound location of wound, size and depth of involvement, appearance of the wound surface, amount and characteristic of wound exudate, and describe the tissue around the wound (scarred, inflamed, etc.). Furthermore, there was two different dates on the photographs. There was no plan of care for the sutures to the lower lip and no mentioned of the left forehead abrasions which were noted on the photograph.

During an interview, on April 13, 2018, at 10:30 a.m., RN 7 reviewed the medical problem sheet and stated there was no care plan for the sutures. RN further stated there should be a care plan. When asked should there be documentation of the abrasion on the left forehead. RN stated, "Yes, there was no documentation of a care plan."

3. Patient 34 (P34) was admitted to the facility on February 22, 2018 with diagnosis of schizophrenia. A review of the Acute Nursing Progress Notes/24 Hour Clinical Narrative Update/Justification for Continued Stay dated;
-On February 23, 2018, at 10:32 a.m., Patient 34 attacked a staff member, after change of shift (at 14:40 p.m.,.), restrained to the floor, offered p.o. medication refused and IBM medication was given due to agitation and impulsive behavior. He was assessed as delusional and/or hallucinating and the actions taken were close observation.
-On February 23, 2018, at 10:30 p.m., history of aggressive behavior and impaired decision making ability, delusional and hallucinating and the actions included "close observation status."
-On February 24, 2018, 6:30 a.m., P34 paced the entire night, constantly at the nurses' station, making bizarre requests, cursing, and yelling at peers, difficult to redirect after smoke break, suddenly attacked staff causing injury to staff's upper lip and chin., placed in restraints. P34 was assessed as requiring "close observation status."
-On February 24, 2018, at 8 a.m., P34 was to be monitored for safety q [every] 15 minutes.
-On February 24, 2018, at 11:30 p.m., P34 was assessed as remains unpredictable, impulsive and "close observation status."

A review of the Master Treatment Plan (MTP) dated February 22, 2018, at 2:50 p.m., indicated P34 had two problems ; Psychosis and Restraints/Seclusion. The MTP Review Long Term -Updates to Problems/Goal as Identified in MTP included Psychosis an Restraints/Seclusion. There was no documented evidence of a care plan for danger to self (DTS) /or danger to others (DTO) and/or assaultive behavior with appropriate interventions in response to the identified documentation.

During interview on April 13, 2018, between 1:30 p.m. and 2:20 p.m. RN 6 reviewed the medical record and stated, "close observation, means monitor the patient more closely than q 15 mins [minutes] or high alert with him." RN 6 was unable to locate documentation of P34 being observed more closely.


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5. Review of the Facesheet indicated Patient 20 was admitted to the facility on September 22, 2017, with diagnosis of Major depressive disorder, recurrent severe without psychotic features, suicidal ideation and alcohol dependence.

Review of the Master Treatment Plan (MTP) indicated it was established on 9/22/18. The RN signed on 9/29/18, Psychiatry on 9/23/18, Activity Therapy Staff signed on 9/23/18, the patient refused to signed due agitation. There was no documentation the social worker (SW) and case management (CM) signed the master treatment plan.

The MTP failed to address the issue about patient's homelessness.

6. Review of the Facesheet indicated Patient 29 was admitted to the facility on March 2, 2018, with diagnosis of alcohol dependence with withdrawal, uncomplicated and other stimulant dependence.

Review of the MTP established on 2/22/18 did not address the multiple bruises on the patient's body.

7. Review of the Facesheet indicated Patient 21 was admitted to the facility on February 21, 2018, with diagnosis of major depressive disorder, recurrent severe without psychotic features, post-traumatic stress disorder and migraine.

Review of the Master Treatment Plan (MTP) failed to show documentation the patient's chronic constipation was addressed.

8. Review of the Facesheet indicated Patient 30 was admitted to the facility of December 27, 2017, with diagnosis of major depressive disorder, recurrent severe without psychotic features, suicidal ideation and alcohol abuse.

Review of the Master Treatment Plan (MTP) indicated it was established on 12/27/17. The patient signed on 12/27/17, the RN on 12/27/18, Psychiatrist on 1/17/18 and Case Management signed on 12/29/17. There was no documentation the social worker (SW) and Activity Therapy Staff signed the MTP.

9. Review of the Facesheet indicated Patient 31 was admitted to the facility on March 23, 2018, with diagnosis of schizoaffective disorder, depressive type, suicidal ideation and essential hypertension.

Review of the Master Treatment Plan (MTP) indicated it was established on 3/23/18. The patient signed on 3/23/18, the RN on 3/24/18, Psychiatrist on 3/23/18, Social Services on 3/27/19 and Activity Therapy Staff on 3/24/18. There was no documentation the Case Management signed the MTP.

There was no documentation the following concerns: pain, skin condition and nutrition were addressed in the MTP.

10. Review of the Facesheet indicated Patient 12 was admitted to the facility on December 30, 2017, with diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, nicotine dependence and obesity.

Review of the Master Treatment Plan (MTP) indicated it was established on 12/30/17. The patient signed on 1/24/18, the RN on 12/30/17, Psychiatrist on 12/31/17, Case Management signed 1/2/18 and Activity Therapy Staff 12/31/17. There was no documentation Social Services signed the MTP.
There was no documentation the Case Management signed the MTP.

There was no documentation the following concerns: homelessness and skin abrasions were addressed in the MTP.

During an interview with RN 3 while reviewing the clinical record, stated she concurred the patients' issues or concerns discussed were not addressed in the master treatment plan.

Review of the facility policy number: 600.19 titled, "Master Treatment Plan" indicated within eight (8) hours of admission, the RN, will initiate the Master Treatment Plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing intervention as determined by the initial assessments, the Physician's Treatment Plan and the physician's order. The team will consist of the physician, the RN, the social worker and representatives from other clinical disciplines, as appropriate.

Based on interviews and medical record reviews, the hospital failed to ensure the nursing staff followed the policy and procedure for patients who were on medications for pain management. There was lack of documented pain assessment prior to the administrations of as needed pain medications for two of 36 sampled patients (7, 10).

This failure had the potential of inadequate patient monitoring leading to unnecessary pain suffering, adverse/side effects, and/or medication errors.

Findings:

1. Review of Patient 7's clinical record indicated physician orders, dated 12/25/2017 and 12/31/2017, for hydromorphone (generic for Dilaudid, a schedule II controlled substance used to treat pain) 4 mg (milligram) every six hours as needed for severe pain. The medication administration record (MAR) for Patient 7's reflected the nursing staff had administered thirty-three doses of hydromorphone to Patient 7 during the patient's course of stay from 12/25/2017 to 01/04/2018.

Review of the electronic nursing flow sheets reflected the nursing staff administered without documenting pain assessment on twenty-four out of the aforementioned 33 doses.
During a concurrent interview on 04/12/2018 at 9 am, the nursing supervisor confirmed that there should be a pain assessment, which included documented pain score (numeric system to measure pain level) and reassessment of the effectiveness from medication, correlating with each dose administered as needed for severe pain.

The facility's policy and procedure, Pain Management, revised on 11/2017, indicated a pain assessment including a pain score of 7 to 10 for severe pain using the 0-10 pain scale and a pain reassessment be completed and documented.

2. Review of Patient 10's clinical record indicated a physician order, dated 04/06/2018, to administer hydrocodone-acetaminophen (generic for Norco, a schedule II controlled substance used to treat pain) 10-325 mg every eight hours as needed for severe pain.

On 4/11/2018 at 3 PM, during a review of Patient 10's MAR and a concurrent interview, the nursing supervisor and the director of pharmacy (DOP) confirmed the nursing staff had administered fourteen doses of hydrocodone-acetaminophen to Patient 10 from 04/06/2018 to 04/11/2018. The nursing supervisor and DOP also confirmed there was no documented pain assessment for the aforementioned fourteen as needed doses of pain medication.

Based on observation, interviews and record reviews, the hospital food and Nutrition Services failed to ensure staff was competent with respect to testing and reporting the concentration of the sanitizer used in low temperature dish machine to ensure it was at a safe concentration per manufacturer's instructions and hospital policy. This failure was evident when Dietetic Staff tested and documented elevated levels of chemical solution that exceeded manufacturing guidance for safe levels. This failure had the potential to result in toxic levels of chemical in the final rinse water used for pots and pans and possible chemical contamination of food.

Findings:

During an observation of the dish machine on April 10, 2018, at 8:41 am, the Director of Food services ran the dish machine and checked sanitizer level on the dish surface. She used Ecolab choline test paper, dipped the test paper on the surface of pots and pans and read the results. She read 100 ppm-parts per million. The recommended level for chlorine sanitizer on dish surface in final rinse is 50ppm-Parts per million per food and drug administration Food Code.

During a concurrent interview with the Director of Food Services, she stated that the sanitizer solution is chlorine based and normal range is 50-200ppm-parts per million.

A review of the hospital's "Low Temperature Dish machine Tracking Chart" (dated April 1-10, 2018) documentation showed Machine sanitizer at levels of 200 PPM for 16 times during this time period and levels of 150ppm for 8 times. This chart also included procedures and instructions for the Low Temperature Dish Machine. The instruction indicated, a minimum temperature is at 120 degrees Fahrenheit and minimum Chlorine required (PPM) is at 50PPM and greater. Special notes indicated, any temperatures or the final rinse sanitizer below the minimums requires action. It further continues to show what actions to take when temperature or sanitizer is below the shown minimums.

During an interview with a dietary aid on April 11, 2018, at 11:15 am, she stated that she should have reported > than 100 ppm to Director of Food Services but she did not because she did not know that levels greater than 100PPM per manufacturing guidelines could be toxic.

During an interview with the Director of Food Services on April 12, 2018, at 1:30 PM, she stated that she has contacted Ecolab (manufacturer for the chemical sanitizer test kits used for the low temperature dish machine). Director of Food Services acknowledged that levels documented on the "Low temperature Dish machine tracking Chart" are not acceptable.

A review of the hospital's policy titled "Infection Control, Reference #11001" (revised 10/1/17) stated, "Dishwasher: Shall maintain a final sanitation rinse of 120 degrees Fahrenheit and wash water of 120 degrees Fahrenheit or higher. Sanitizer is injected automatically into the final rinse at a dilution of 50PPM."

A review of Hospital provided ECOLAB's (Manufacturer of chlorine test paper) guidelines stated, Required Chlorine concentration is 100ppm-Parts per Million.

Based on interviews and record reviews, the hospital failed to ensure the therapeutic diet manual is in accordance with the current national standards, such as RDA or DRI. This failure occurred when the Therapeutic diet manual was more than 5 years old and was not reviewed, approved and signed by the clinic dietitian.

Findings:

A review of the hospitals dietary manual indicated that the manual was last revised on March 2012 and was signed by the Director of Food Services who is not a Registered Dietitian.

During an interview with the Registered Dietitian and Food Service Director on April 11, 2018, at 3:45 PM, both stated that they did not know the manual has to be signed by a Registered Dietitian. Director of Food Services further stated that our Diet Manual is old and it was last revised in 2012. She also stated we will order our new manual and will be reviewed and signed by the Registered Dietitian.

A review of the hospital's policy titled "Nutritional Evaluation/Diet Manual Policy, Reference #3014" (revised 10/1/17) indicated, "The Nutritional Services Diet Manual shall serve as an effective resource to provide education and direction for appropriate nutritional care to the patient population. It further stated, "Purpose: The purpose of this policy is to provide a basic outline of the contents of the Diet Manual ... The Diet Manual is approved annually by a clinical Dietitian ..."

Based on observation, interview and document review, facility staff failed to ensure the condition of the physical plant and the overall hospital environment was maintained in a manner to ensure the safety, well-being and the special needs of the patient population treated at the hospital.

Findings:

On 4/10/18 between 8 AM and 4 PM the following was observed:

Building A Common Area

1. The medication room counter had missing veneer at the edge of the sink counter exposing the particle board beneath.

Building A West

2. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

3. There was a large accumulation of cigarette butts at the outside patio lawn.

On 4/12/18 at 10:20 AM, the Housekeeping Supervisor stated that there was no procedure on how to remove cigarette butts from the lawn and no schedule to how clean and remove the cigarette butts from the area, but that it should be done at least one time daily.

On 4/12/18 at 10:35 am, the Housekeeper stated that the cigarette butts are cleaned up every morning.

Building A North

4. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

5. There was paste in the electrical receptacles of the bedrooms and bathrooms of patient rooms 234 and 239.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was paste in the electrical receptacles.

6. There was vinyl wall base missing at patient room 239.

Building B Common Area

7. There was a sign of water damage at a drop down ceiling tile outside the seclusion room.

During an interview at the same time as the observation the Plant Operations Manager stated that the damage was not from a roof water leak, that it was probable from air conditioning condensation and that he would have it checked out.

On 4/12/18 at 10:20 AM the Plant Operations Manager stated that he had not determined what the cause of the water damage was.

Building B North

8. The locked corridor bathroom had two grab bars in it that could be used as ligature anchors.

During an interview at the same time as the observation RN 8 stated that she had been at the unit 1 ½ years, that after patients are discharged from their rooms they are no longer allowed to use the bathrooms in the bedroom, and if the patients need to go to the bathroom the corridor bathroom is unlocked and the patients are allowed to go into the corridor bathroom alone.

9. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

Building B Southwest

10. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

Building B South

11. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.


On 4/11/18 between 8 AM and 4 PM the following was observed:

Building A East

12. The outside patio had a 2 ft. tall by ½ ft. wide tear creating an opening in the vinyl covering of the patios chain link perimeter fence. The opening was 3 ½ feet above the ground creating a foothold that could assist a person in scaling the remaining 6 ¼ ft. of the perimeter fence. 44 feet north east across an open lawn there was a 10 ft. chain link fence constructed of standard 2 inch mesh, a horizontal pipe at 5 feet above the ground and another horizontal pipe 10 ft. above the ground that could be used to scale the fence. There was a spruce tree that was taller than 10 ft. located 1 ft. from the fence. There was a 10 ft. concrete block perimeter fence locate 1 ½ ft. from the same spruce tree. The combination of these created a condition that could create an opportunity for elopement.

Review of non-sample Patient 36's face sheet indicated that the patient was admitted on 8/14/17 at 1548 (3:48 PM). Review of the Patient Observation Record indicated the patient was in the unit from 1530 (3:30 PM) to 2130 (9:30 PM), and was absent without leave (AWOL) at 2145 (9:45 PM).

13. At 11:55 am during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

14. There was paste in the electrical receptacles of the bedroom and bathroom of patient room 269.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was paste in the electrical receptacles.

15. There was vinyl wall base missing at patient room 269.

Building C Common Area

16. The locked seclusion room bathroom had a water supply pipe to the toilet that could be used as a ligature anchor.

During an interview at the same time as the observation the Plant Operations Manager stated that the unit staff goes into the bathroom with the patient while the patient uses the bathroom.

Review of policy 700.04 titled, 1 on 1 line of sight close monitoring, dated 11/17, indicated that direct supervision is provided during use of the bathroom

17. The medication room sink counter had missing veneer at the edge of the sink counter exposing the particle board beneath.

Building C South

18. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

Building C North

19. At 11:55 AM during an interview the Plant Operations Manager stated that the open faced electrical receptacles in the patient bedrooms did not have electrical power.

None of the electrical receptacles in the unit were plated. During a test of electrical receptacles in the unit it was determined that all electrical receptacles had electrical power.

During an interview at the same time as the observation the Plant Operations Manager acknowledged there was electrical power at the receptacles.

Based on observation, interview and document review facility staff failed to ensure that life safety from fire requirements were met.

Findings:

On 4/10/18 between 8 AM and 4 PM the following was observed:

Building A West

1. There was identification signage missing at the fire sprinkler's inspector test valve access door located at a patio wall.

During an interview at the same time as the observation the Plant Operations Manager confirmed the access door was to the inspector's test valve.

2. There was a large accumulation of cigarette butts in the patio lawn.

Building A North

3. There were two ¾ inch penetrations through one side of a smoke barrier wall located above the drop down ceiling of the cross corridor door by the laundry room.

4. The corridor door at patient room 236 failed to hold closed.

During an interview at the same time as the observation the Plant Operations Manager stated that the door failed to hold closed because the latch shifted because the patients sometimes slam the doors.
Building B Common Area

5. There was a 1 ½ inch by 1 inch penetration at the ceiling next to the fire sprinkler cover in the seclusion room bathroom

Building B Southwest

6. There was an electrical junction box missing a cover plate exposing electrical wiring. The box was located above the drop down ceiling at the cross corridor door by consult room 2.

During an interview at the same time as the observation the Plant Operations Manager stated that he didn't know what or if the electrical wiring was serving anything, and was having a vendor fix it.

7. The self-closing corridor door at the nurses office was held fully open by the use of a kick door holder engaged in front of the door.

During an interview at the same time as the observation the Plant Operations Manager stated he did not know how long the kick door holder has been there.

Building B South

8. The corridor door at patient room 168 failed to hold closed.

During an interview at the same time as the observation the Plant Operations Manager stated that the door failed to hold closed because the striker was not being engaged.


On 4/11/18 between 8 AM and 4 PM the following was observed:

Building A East

9. The day room self-closing corridor door was held fully open by a stack of five chairs that was placed in front of the door. At the time of the observation the Plant Operations Manager removed the stacked chairs to allow the door to close. At this time unit staff again placed the stacked chairs in front of the corridor door to hold the self-closing corridor door open.

During an interview at the same time as the observation RN 4 stated that the door needed to remain open if there was a patient in the day room. Stated that she had been told that the door needs to be kept open (by unidentified person), and that she did not know if there was a policy indicating that the door needed to be maintained open.

10. There was a missing cover at the pop down fire sprinkler located at the ceiling in the clothing storage room of the environmental services area.

Building C South

11. The day room self-closing corridor door was held fully open by a three foot by three food wood table that was placed in front of the door. Closer observation revealed there was a patient in the day room.

During an interview at the same time as the observation RN 9 stated that there was no reason for the door to be held open, that when there is a patient in the room there has to be a staff in the room with the patient, that and that the door was held open because the housekeeper was in the room.

12. The staff room corridor door was held fully open by a chair placed in front of the door. The room was unoccupied at the time of the observation.

13. The day room self-closing corridor door was held fully open by a chart rack placed in front of the door. The door opened to the open nursed station and exit corridor.

Building C North

14. The day room self-closing corridor door was held fully open by a wood chair.

Building F (Gym)

15. There was a loose electrical receptacle by the stage.

16. There was a missing electrical cover plate at an electrical box exposed orange and white electrical wires at the wall by the basketball hoop. During an interview at the time of the observation and after testing the wires, the Plant Operations Manager stated that the electrical wires had power.

17. There was a loose electrical receptacle and electrical box at the wall by the door with "No Exit" signage on it.

During an interview at the same time of the observations the Plant Operations Manager stated that the gym (building F) is used by both inpatients and outpatients.

Building G (Kitchen)

18. There was no exit sign at the kitchen exit door that exits directly to the outside.

During an interview at the same time as the observation the Plant Operations Manager identified the exit as an evacuation exit.

Review of the evacuation floor plan for the kitchen identified the door as an evacuation route.

Building I (Intake)

19. There was a one inch diameter penetration through the ceiling of the medical records room.

During an interview at the same time as the observation the Plant Operations Manager stated that penetration was from a data project that they forgot to seal.

20. The corridor door of consult door 2 failed to hold closed.

21. There was a broken electrical receptacle at the corridor by consult room 4.

22. There was a two foot by one foot section of wall missing in a closet housing a natural gas fueled fifty gallon capacity water heater.

During an interview at the same time as the observation the Plant Operations Manager stated that the wall needed to be replaced and that he did not know why the wall was opened.


On 4/12/18 during document review between 8 AM and PM the following was revealed:

23. There was no documented evidence that regulations were adopted for metal containers with self-closing devices into which ashtrays could be emptied were readily available to all areas where smoking was permitted.

24. There was no documented evidence of damper service and testing.

Based on observation, interview, and record review, the facility did not meet the condition of participation in infection control by failing to ensure a sanitary environment as follows:

1. Ensure the registered nurse followed the standard of practice in performing wound cleansing and treatment. (Refer to A 0749)

2. Ensure there were no corrugated cardboard boxes used for storage. (Refer to A 0749)

3. Ensure there were no expired patient supplies mixed with currently used supplies. (Refer to A 0749)

4. Follow accepted standards which maintain a sanitary physical environment. (Refer to A 0749)

5. Ensure faucet in the sinks in various areas in the hospital had no aerators (a device that is placed on the end of a faucet in order to add air to the water flow) and mineral deposit in the spigot of the faucet and base of the faucet. (Refer to A 749)

6. Ensure air vents are clean and not dusty. (Refer to A 0749)

7. Ensure the staff followed the Manufacturer's recommendation in cleaning and disinfecting the mattresses in the seclusion room. (Refer to A 0749)

8. Ensure the ice maker and ice bin were cleaned on a routine basis and follow proper sanitation practices to prevent the development of slime and mold that may contribute to accumulation of microorganisms. (Refer to A 0749)

9. Ensure infection control practices were followed in Food and Nutrition services when: the can opener blades had dried brownish residue and it was covered with a glue like and gummy substances. (Refer to A 0749)

10. Ensure that there was a system in place for disposition of Ready-to-eat, time/Temperature control for safety food by expiration date. This failure had the potential to result in food borne illness in patients, staff and visitors who consumed food in the hospital. (Refer to A 0749)

11. Ensure an air gap (space between the end of the pipe and the flood level of the drain) was maintained between a drain and the drainage pipe from a prep sink in the kitchen. (Refer to A 0749)

12. Assure Medical Staff had yearly PPD, Flu vaccination and documented Hepatitis B status or waiver in order to provide patient care in a safe and sanitary environment. (Refer to 749)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide an effective hospital wide infection control program in a safe and effective manner.

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

1. Ensure the registered nurse followed the standard of practice in performing wound cleansing and treatment.

2. Ensure there were no corrugated cardboard boxes used for storage.

3. Ensure there were no expired patient supplies mixed with currently used supplies.

4. Follow accepted standards which maintain a sanitary physical environment.

5. Ensure faucet in the sinks in various patient rooms had no aerators, no mineral deposit around the spigot and base of the faucet.

6. Ensure air vents are clean and not dusty.

7. Ensure the staff followed the Manufacturer's recommendation in cleaning and disinfecting the mattresses in the seclusion room.

These deficient practices had the potential for cross contamination and spread of infection.

8. Ensure the ice maker and ice bin were cleaned on a routine basis and follow proper sanitation practices to prevent the development of slime and mold that may contribute to accumulation of microorganisms. The failure to maintain the ice maker in a manner that is clean in the kitchen and cafeteria had the potential to result in food borne illness in patients, staff and visitors who consumed the ice.

9. Ensure infection control practices were followed in Food and Nutrition services when: the can opener blades had dried brownish residue and it was covered with a glue like and gummy substances. The can opener blade was worn and nicked with the potential to harbor harmful bacteria that were not easily cleanable. This failure had the potential to result in food borne illness in patients, staff and visitors who consumed food in the hospital.

10. Ensure that there was a system in place for disposition of Ready-to-eat, time/Temperature control for safety food by expiration date. This failure had the potential to result in food borne illness in patients, staff and visitors who consumed food in the hospital.

11. Ensure an air gap (space between the end of the pipe and the flood level of the drain) was maintained between a drain and the drainage pipe from a prep sink in the kitchen. The failure to maintain an air gap had the potential to result in contamination of food products that are washed, rinsed or thawed in the event of a negative water pressure event and waste water backed up into the drain pipe. This could have resulted in food borne illness in patients, staff and visitors who consumed food in the hospital.

12. Assure Medical Staff had yearly PPD, Flu vaccination and documented Hepatitis B status or waiver in order to provide patient care in a safe and sanitary environment.

Findings:

1. On April 11, 2018, at 8 a.m., during wound treatment observation, licensed vocational nurse (LVN 1) prepared the antibiotic Bacitracin, packets of gauze, tapes, sterile water and extra gauze in the medication room.

Patient 9 was in the group room and was requested to be taken to her bedroom for treatment to her right foot's great toe. The patient was prepared for the treatment and the LVN wore gloves. The wound was cleaned with gauze soaked with sterile water. The LVN started from the inner area then went outward, then back to the inner area of the wound that had been cleaned using the same gauze. The LVN placed the Bacitracin ointment in the same gloved hand and applied the ointment directly to the wound. The LVN removed the soiled gloved and put on a new one, covered the wound with gauze and applied tape.

During an interview with the LVN after the observation, the LVN stated she should have changed gloves after performing the cleaning of the wound which was a dirty task, should have not used the soiled gloves to apply the antibiotic to the wound, should have not re-use the same gauze to clean the wound from the cleaner area to a dirtier area because of cross contamination.

Review of the facility policy number : 900.55 titled, "Skin Assessment and Wound Management" indicated to clean the wound moisten gauze pads either by dipping the pads in wound cleaning solution and wringing out excess or by using a spray bottle solution to the gauze. Move from the least contaminated area to the most contaminated area and use a clean gauze for each wipe.

2. On April 13, 2018, at 3:45 p.m., with the facility staff members, the Laboratory Room was observed with seven (7) corrugated cardboard boxes that contained laboratory supplies such as vacutainers mixed with other laboratory supplies currently in use were on the floor or in the metal rack.
There was a heavy accumulation of ice in the specimen refrigerator.
There were debris of paper on the floor.

During an interview with the Infection Control Consultant, stated the corrugated boxes should not be found in the hospital area. She further stated that twice a year she conducts a check on the laboratory but unable to show documentation of such visit at the time.

3. In Building A -

East Area -
The Laundry Room, the faucet by the sink had mineral deposit, there were rust on the tubes connected to the washer/dryer and debris of paper, dust and wood block on the floor and back of the washer/dryer machines.

There was crack on the floor and metal curtain holder had heavy accumulation of rust in Room 270.

In the Consult Room was a Linen cart cover had stains and the linens on the bottom shelf was exposed to dust and dirt.

In the seclusion room, the air vent was dusty, with what appeared to be hair and dirty. There was a missing floor coving.

North Area -
In the hallway was a drinking fountain in which the removable plastic cover was dusty and with black material in the grooves of the cover. There was standing water on the well of the drinking fountain.

West Area -
In the Day Room, the faucet by the sink had aerator.

In the Contraband room, there was metal rack that contained patients personal belongings placed in an individual plastic container. Each container had residual tapes that were not fully removed and new label had been placed. There was a linen cart stored in which the linen cover was torn, with stains and some linens were exposed to the dirty and dusty floor. There were plastic bags and corrugated boxes that contained patients personal belongings on the floor.

In the laundry Room, the floor had stains and debris of paper and dust. The air vent was dusty and dirty. The washer/dryer had paper debris.

Nurse Station -
The sink had a faucet that had aerators, The caulking around the sink and on the sides were open and raised and moldy.

4. In Building B -
In the hallway was a drinking fountain in which the removable plastic cover was dusty and with black material in the grooves of the cover.

In the Contraband room, there was metal rack that contained patients personal belongings placed in an individual plastic container. Each container had residual tapes that were not fully removed and new label had been placed. There were dust and debris on the floor.

South West Area -
The handwashing sink had a faucet with mineral deposit around the spigot.

Nurse Station -
The handwashing sink had a faucet with aerator and mineral deposit around the spigot.

Clean Linen Room -
The base coving on the floor was missing.

In the Laundry Room, there was missing floor tile and base coving on the floor was loose. There was pencil and tape in the room. The sink had a faucet that had heavy accumulation of mineral deposit in the spigot. The sink was dirty with black material when wiped with paper towel it was removed.

5. In Building C -
North Area -
In the Group Meeting Room, the faucet had mineral deposit around the spigot.

In the Dining Room, there was a water jug in which the cover had residual tapes in it.

In the Supply Room, there were two (2) cardboard boxes the contained cold packs and paper medication cups stored with dirty patient supplies.

South Area -
In the exam room, there was a sink that had faucet with an aerator.
There were nineteen (19) individual packet of Sterile Cotton Tipped Applicator with an expiration date of October 2017.
There was a bottle of opened and undated PJP Prep Solution.
There were three (3) cardboard boxes that contained cold pack.



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6. The Adult North-
a. In the Patients' Personal belongings Room; a linen cart with the cover stained and torn, and linen exposed. Stored on the floor plastic bins some had personal belongings and empty bins with residual tape/label markings.
b. In the Laundry Room; the vent was dusty, dirty, and the floor had stains.

7. Unit B (High AWOL)-
a. Contraband Room; residual tape markings on the plastic bins which contained patients belongings,
b. In the Laundry/Utility Room; in the linen room a base cover was missing, in laundry room a small pencil was on the water drain pipe, missing floor tile, the sink was dirty.
c. The observation/seclusion/restraints room the dark blue mattress had stains.

During concurrent interviews on April 10, 2018, at 10 a.m., RN 2 stated, "Yes, the blue mattress was stained." The housekeeper stated she cleaned the blue mattress with prepared disinfectant; sprays the top mattress and wipes it, wipes down the legs of bed frame (moves the mattress half way off the bed frame which allows her wipe down half of the exposed bed frame), flips over mattress, wipes the mattress, and wipes down the other side of the exposed bed frame. She further stated 6 days ago she disposed of a torn and dirty mattress.

A review of a facilities policy, "Housekeeping Cleaning," undated, indicated the housekeeping department would provide the facility with safe and sanitary cleaning services. The procedure for cleaning included:
#5. Seclusion Room - wipe and sanitize using germicide or Sani Cloth bed daily or as needed due to patient use. This was not specific for cleaning mattress.
#12. Patient Laundry Rooms -included clean lint filters after every use, sanitize tables, and dust and wet mop floor.

During an interview on April 12, 2018, between 2 p.m. and 3:30 p.m., RN 7 stated she only comes to the facility once a week but available by telephone. In regards, to the mattress in the observation/seclusion/restraints room both light greenish-blue and dark blue are water proof and can be cleaned the same way. The EVS disinfectant spray should remain on the surface 10 minutes before wiping down. This was written in our policy differently. The EVS do not use disinfectants wipes and the disinfectants were all pre-mixed from the manufactures. RN 7 stated they have shown them how to clean -swipe and allow to dry. RN7 further stated the staff were not verbally able to communicate with her due to language barrier. She had not gone over with the EVS staff for the wet products/spray cleaners. She agreed the policy was vague and would include the contact time and along specifics in the policy.

Reviews of the facility's Shift Unit Safety Checklist indicated "oncoming and off going staff must make Safety Rounds together" ....2. Seclusion Rooms were cleaned. There was no mention of the mattress being checked for cleanliness. 6. Contraband Room was checked for cleanliness and organized at all times. 10. Laundry Room was cleaned including washer and dryer.

A review of a facility's policy titled, "Seclusion and Restraint of Patient, " #200.16 indicated the charge nurse or his/her designee staff would walk through each seclusion room room noting any damages, dirtiness, or unsafe conditions.



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8. During a tour of the kitchen on April 10, 2018, at 9 am, the ice machine stored in the kitchen was inspected. A clean paper towel swipe of the ice storage bin ceiling produced a significant amount of pink slimy substance. The substance was located along the horizontal chute where sheets of ice drops into the ice storage bin from the ice maker.

The Food Service Director indicated that the ice machine bin is cleaned and disinfected weekly by dietary staff and every six month the internal lines and filter is cleaned by manufacturer of the ice maker Air Supply. Food Service Director also indicated that the ice bin had recently been cleaned by dietary staff on April 8, 2018.

During a tour of the cafeteria on April 10, 2018, at 9:42 am, the ice machine stored in the café was inspected. When the ice dispensing area was wiped with a clean paper tower it also produced pink slimy substance.

During a concurrent interview with the Food Service Director, she stated that every six months maintenance by Air Supply is not enough, contractor should come in much sooner to disinfect the lines. She also stated that dietary staff who cleans once a week may have not cleaned the chute or ice dispensing area.

During an interview with RN7, on April 12, 2018, at 2 PM she stated that she is employed by the hospital as a consultant and works once a week for 8 hours. She stated she was available by phone or physically can come in any time they need her. RN7 stated she visits the kitchen twice a year as part of her rounds in the hospital. During the visit she checks temperature during tray line and logs, check cool down logs, how food is stored in refrigerator and freezers. She also checks dry storage area, checks for signs of vermin and checks for cleanliness. She was not aware of the infection control issues identified during the kitchen tour. She stated currently she is working on a quality improvement project in the kitchen with the Director of Food Services.

A review of the hospital's policy titled "Ice Machine-Handling and Sanitation, Reference No. 11008"(Revised 10/1/17) stated, " Ice storage chests shall be cleaned weekly ...Wipe down the interior, top, sides, spigot and bottom with the cleaning mixture and paper towels ...Sanitize the ice machine with sanitizing agent."

According to the 2017 USDA Food Code, Equipment contacting food that is not Time/Temperature control for safety food: such as enclosed components of ice makers shall be cleaned at a frequency specified by manufacturer or if manufacturer specifications are absent then at a frequency necessary to preclude accumulation of mold.

9. During a tour of the kitchen on April 10, 2018 at 9:23 am, one can opener blade in the cold preparation area was noted to be covered in brownish residue and clear substance that was sticky and gummy when touched. The blade was not smooth to the touch due the nicks in the side of the blades.

During a concurrent interview with the Director of Food Services, she stated that she was responsible for monitoring the integrity of the can opener blades and that she changes the blades when they are dull. She could not explain why the blades were covered with residue and nicked.

A policy for maintaining the can opener was requested. The Director of Food Services manager stated the hospital did not have a policy.

A review of the hospitals policy titled "Infection Control, Reference #11001"(revised 10/1/17) stated, "Equipment-Food grinder, chopper, mixer, slicer, blender and other appliances shall be disassembled, cleaned, sanitized, dried and reassembled after each use."

According to the 2017 USDA Food Code, cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. It also states food-contact surfaces of equipment shall be smooth, free of breaks, open seams, cracks chips, inclusions, pits, and similar imperfections. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms (a thin, slimy film of bacteria that adheres to a surface). Once established, these biofilms can release pathogens (disease causing organisms) to food. Biofilms are highly resistant to cleaning and sanitizing efforts.

10. During a tour of the kitchen on April 10, 2018, at 9:10 am, the reach in refrigerator closest to the stove and cooking area contained 4 small chefs' salads that were expired.

During a concurrent interview with the Director of Food Services, she stated that the cook is responsible for assuring that items had exceeded their use by date were discarded.

During a tour in the cafeteria on April 10, 2018, at 9:42 am, the unsweetened ice tea juice box in use was expired. The Director of Food Services stated the same dietary staff is responsible to check and discard expired items. Director of Food Services was not able to show if there was a system in place to visually inspect and monitor the discard dates.

According to the 2017 USDA Food Code, Ready-to-eat, Time/Temperature control for safety food should be marked by date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed, sold or discarded. It further states Time/Temperature control for safety refrigerated food must be consumed, sold or discarded by the expiration date.

11. During a tour of the kitchen on April 10, 2018, at 9:42 am, the drain pipe from the preparation sink was noted to be sitting at the level of the flood level of the drain fixture.

During a concurrent interview with the Director of Food Services, she stated "I will let plant manager aware and will be fixed right away."

According to the 2017 USDA Food Code, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (drain), equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. This is required because during periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system.



31993

12. During a review of Medical Staff credentials with MSC1 on 4/12/18 at 2:15 PM she indicated none of the medical staff had yearly PPD (purified protein derivative, TB test), Flu vaccination and documented Hepatitis B status or waiver. There was no policy and procedure for health assessment or screening required for Medical staff credentialing available for review.

During an interview with the Infection Control Coordinator (ICC) on 4/12/18 at 4 PM she indicated the facility followed Center for Communicable Disease Control (CDC) guidelines for infection control. ICC indicated there was no Policy requiring Medical Staff to have yearly PPD, Flu vaccination and documented Hepatitis B status or waiver .

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

I. Ensure the Psychiatric Evaluations identified patients' assets for eight (8) of 12 active sample patients (A3, A5, A6, A7, A8, A9, A11 and A12) in descriptive not interpretive terms. (Refer to B117)

II. Ensure that the Master Treatment Plans (MTPs) were comprehensive and individualized, including appropriate Short and Long-Term Goals and treatment Interventions, to address patients' identified problems for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). (Refer to B118, B121 and B122).

III. Ensure that all members of the treatment team document in their treatment/progress notes for 12 of 12 active sample patients (A1,A2,A3,A4,A5,A6,A7,A8,A9,A10,A11 and A12), that referenced assigned interventions to determine if the patient was making progress towards expected goal achievement or not, and modify Treatment Plans as needed. (Refer to B124)

IV. Ensure that appropriate and adequate active treatment/activities were offered to meet all patient needs, including alternative treatment interventions for those patients unable or unwilling to attend offered groups. (Refer to B125)

Based on document review and staff interview, the facility failed to ensure that the Psychosocial Assessments for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) included the anticipated Social Work roles in treatment and addressed identified high-risk behaviors. Also, 11 of the 12 Psychosocial Assessments were completed by non-MSW qualified staff and there was no documented evidence that these staff were supervised by a MSW qualified staff member. As a result, critical and professional patient psychosocial information necessary for informed treatment planning decisions was not available to the treatment teams.

Findings include:

I. Record Review:

1. Patient A1 was admitted for "Suicidal ideation with plan" on 4/5/18. The Psychosocial Assessment completed on 4/7/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including identified "SI (suicidal ideation) High Risk issues to be Addressed." The staff member's qualification for completing this Assessment was "MFTI" [Marriage and Family Therapist]. There was no documented evidence that a MSW qualified staff member supervised this Assessment.

2. Patient A2 was admitted for "having thoughts to hurt his parents as well as his friends" on 4/6/18. The Psychosocial Assessment completed on 4/8/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including interventions for identified high risk issues "HI/SI" (Homicidal ideations/Suicidal ideations). The staff member's qualification for completing this Assessment was "MFTI". There was no documented evidence that a MSW qualified staff member supervised this Assessment.

3. Patient A3 was admitted for "I have been contemplating about killing myself by overdosing." on 4//4/18. The Psychosocial Assessment completed on 4/5/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including addressing identified high risk issue "suicidal depression." The staff member's qualification for completing this Assessment was "MA". There was no documented evidence a MSW qualified staff member supervised this Assessment.

4. Patient A4 was admitted for "I want to kill myself" on 4/6/18. The Psychosocial Assessment completed on 4/8/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including "High Risk issues to be Addressed." "SI." (Suicidal ideation). The staff member's qualification for completing this Assessment was "MFTI". There was no documented evidence a MSW qualified staff member supervised this Assessment.

5. Patient A5 was admitted for "after the patient had suicidal ideation" on 1/16/18. The Psychosocial Assessment completed on 1/17/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including "High Risk issues to be Addressed." "Suicidal Ideation." The staff member's qualification for completing this Assessment was "MA". There was no documented evidence a MSW qualified staff member supervised this Assessment.

6. Patient A6 was admitted for "on 5150 as a danger to self and danger to others" on 3/7/18. The Psychosocial Assessment completed on 3/9/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including addressing the identified high-risk issue "Psychosis." Further, this Assessment was completed by a staff member with "BA" qualification. There was no documented evidence that a staff member with MSW qualification supervised this Assessment.

7. Patient A7 was admitted for "depressed mood and hallucinations" on 3/29/18. The Psychosocial Assessment completed on 3/30/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including the identified high-risk issues "bizarre, anxious behavior and reported [she/he] still hears voices." The staff member's qualification for completing this Assessment was "MFTI". There was no documented evidence a MSW qualified staff member supervised this Assessment.

8. Patient A8 was admitted for "Inability to care for self" on 3/14/18. The Psychosocial Assessment completed on 3/15/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including the identified high-risk issues "[patient name] is refusing to answer any questions." The staff member's qualification for completing this assessment was "BSW" and there was no documented evidence a MSW qualified staff member supervised this Assessment.

9. Patient A9 was admitted for "on 5150 based on danger to self" on 4/4/18. The Psychosocial Assessment completed on 4/6/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including identified high risk issues "Increase in bizarre and self-injurious behaviors." The staff member's qualification for completing this Assessment was "BA". There was no documented evidence a MSW qualified staff member supervised this Assessment.

10. Patient A10 was admitted for "on a 5150 hold danger to self" on 3/30/18. The Psychosocial Assessment completed on 4/2/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including identified risk issue "suicide risk."

11. Patient A11 was admitted for "on a hold for danger to self." on 4/2/18. The Psychosocial Assessment completed on 4/5/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including identified risk issue "suicidal ideation". The staff member's qualification for completing this Assessment was "BA". There was no documented evidence a MSW qualified staff member supervised this Assessment.

12. Patient A12 was admitted for "brought in on 5150, placed upon a hold for depression and suicidal threat" on 3/24/18. The Psychosocial Assessment completed on 3/26/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including identified risk issues "[pt. name] is minimizing [her/his] suicide ideation with a plan to overdose with pills." The staff member's qualification for completing this Assessment was "BSW". There was no documented evidence a MSW qualified staff member supervised this Assessment.

II. Policy Review:

Hospital policy #: 600.02, Title: Patient Comprehensive Screening, Referral and Clinical Assessments, under 5.0: Psycho-Social Evaluation, 5.9: Narrative Summary states, "Include recommendations for treatment and discharge plan."


III.. Staff interview:

A meeting that included a review of the above deficiencies in the Psychosocial Assessments with the Director of Clinical Services who supervises the Director of Social Services (who was unavailable for in person or telephone interview) was held on 4/11/18 at 3:00 p.m. The Director did not dispute the above deficiencies and stated, "no evidence of oversight, agree do not meet the standards."

Based on record review and staff interview, the facility failed to provide Psychiatric Evaluations that included an assessment of patient's assets in descriptive and not interpretive fashion for eight (8) of 12 active sample patients (A3, A5, A6, A7, A8, A9, A11 and A12). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in formulating treatment interventions.

Findings include:

I. Record Review:

1. Patient A3's Psychiatric Evaluation dated 4/6/18 had "Good ability for insight in the future." as the patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

2. Patient A5's Psychiatric Evaluation dated 1/17/18 had "Good ability for insight in the future" as the patient's strength. This same patient was also assessed by the psychiatrist as "change in behavior with severe dementia."

3. Patient A6's Psychiatric Evaluation dated 3/9/18 had no patient strengths assessment.

4. Patient A7's Psychiatric Evaluation dated 4/2/18 had no patient strengths assessment.

5. Patient A8's Psychiatric Evaluation dated 3/15/18 had "engaged in treatment." as patient's strength.

6. Patient A9's Psychiatric Evaluation dated 4/6/18 had "Appears healthy." which is not a personal attribute that can be utilized in current treatment planning.

7. Patient A11's Psychiatric Evaluation dated 4/4/18 had no patient strengths assessment.

8. Patient A12's Psychiatric Evaluation dated 3/27/18 had no patient strengths assessment.

II. Staff Interview:

Samples of these deficiencies were reviewed with the Medical Director on 4/12/18 at 10:00 a.m. He stated, "agree with absent and inappropriate patient strengths".

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

1. Develop and document comprehensive, multidisciplinary treatment plans (MTP) based on the individualized needs for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). The MTPs were initiated including problems and interventions on the day of the admission by a nursing staff member and were signed off by the members of the treatment team the next day or so, as the MTP. The treatment Goals were established 3 days later.

2. Ensure that the treatment goals and interventions were individualized, including modality and frequency documented on the MTP and addressed the identified needs of the patients. In addition, because goals and staff interventions are listed down columns, it is not possible to determine which "interventions" relate to which Long Term Goals (LTGs) or Short-Term Goals (STGs).

Failure to individualize Treatment Plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

Discipline --------------- Nursing:

A. Record Review

1. Patient A1 a 16 y/o (year old) was hospitalized on 4/5/18. The Psychiatric Assessment dated 4/6/18 documented principal diagnosis, "Major depressive disorder, severe with psychotic symptoms" with the history of "endorses hearing voices". The MTP of 4/5/18, for Problem 1. "Suicidal/Danger to self", listed for LTGs (a)."Patient will not harm self during hospitalization, (b.). (patient name) will deny suicidal ideation and thoughts of self-harm." For STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings. (b). Patient will identify alternatives to express suicidal feelings. (c). Patient will attend one process group daily and identify specific triggers leading to suicidal behaviors. (d). Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present. (e). Other: (name) will express depressive feelings and thoughts of self-harm without acting out." Further, there were no goals to address hallucinations/psychotic features.

Intervention: Nursing: "Identify increased or altered anxiety level and any negative changes every shift, implement additional safety observation by increased staff, monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent, encourage to alert staff for urges of self-harm." Modality- either group or individual and the frequency of these interventions were not identified. Also, these are routine nursing duties and not specific interventions by staff to address specific STGs or LTGs.

2. Patient A2: a 15-year-old patient was hospitalized on 4/6/18. The Psychiatric Assessment dated 4/7/18 documented primary diagnosis of "Major depressive disorder, first episode, severe" with complaint of "I am upset, I wanted to hurt people that are trying to harm me emotionally and physically." The MTP of 4/6/18, for Problem 1. "Danger to self", listed LTGs as "(a). Patient will not harm self during hospitalization. (b). (patient name) will deny suicidal ideation and thoughts of self-harm. For STGs: (a). "Patient will approach staff if having suicidal thoughts or feelings. Patient will identify alternative methods to express suicidal feelings. (b). Patient will attend one process group daily and identify specific triggers leading to suicidal behaviors. Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present and (c). (patient name) will express depressive feelings and thoughts of self-harm without acting out. No goals or interventions were listed for addressing anger and/or family issues, if any.

Intervention

Nursing: "Provide support and limit setting when patient exhibits dangerous behavior Q shift. Encourage patient to verbally express feelings and/or triggers which lead to dangerous/intentions. When patient identified with potential loss of control, ask patient what prn medication is most helpful and administer medication according to nursing assessment (no prn medications were ordered for this patient.) Initiate de-escalation activities as planned. Will redirect patient to attend all group with participation." These interventions are either staff expectations or routine nursing duties, as well as the frequency of contacts and/or modalities were not identified.

3. Patient A3: a16y/o patient hospitalized on 4/4/18. The Psychiatric Assessment dated 4/5/18 documented primary diagnosis as "Major depressive disorder, severe, single episode without psychosis" with chief complaints of "I have been feeling more depressed. I have been contemplating about killing myself by overdosing." The MTP of 4/4/18, for Problem 1. "Suicidal/Danger to self", listed for the LTGs (a). "Patient will not harm self during hospitalization and (b). (patient name) will deny suicidal ideation and thoughts of self-harm." For the STGs: (a). Patient will approach staff if having any suicidal thoughts or feelings (b)' Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors. Patient will attend one process group daily and identify specific triggers leading to suicidal behavior. (c)". Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (d) "(patient name) will express depressive feelings and thoughts of self-harm without acting out."

Intervention:

Nursing: "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observations by increased staff. Monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent. When patient identified with potential loss of control, ask patient what PRN medication is most helpful and administer medication according to nursing assessment. (No PRN medication was ordered). Encourage to alert staff of self-harm." The frequency and modality of these interventions were not identified and these interventions are either routine nursing duties and/or staff expectations rather than specific interventions to address specific LTGs or STGs.

4. Patient A4: A 14y/o was hospitalized on4/6/18. The Psychiatric Assessment dated 4/6/18 documented the primary diagnosis "Major depressive disorder, first episode, reporting she/he "is no longer loved by [her/his] family and is a forgotten child." The MTP of 4/6/18, for Problem 1. "Suicidal/Danger to self", listed for the LTGs (a). "Patient will not harm self during hospitalization and (b). (patient name) will deny suicidal ideations and thoughts of self-harm. For STGs: (a) "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "(patient name) will express feelings of depression or suicidal ideation without acting on them." There were no LTGs or STGs addressing problems with family or school.

Intervention

Nursing: "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observations by increased staff. Monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent. When patient identified with potential loss of control, ask patient what PRN medication is most helpful and administer medication according to nursing assessment. (No PRN medication was ordered). The frequency and/or modality of these interventions were not identified and these interventions were either routine nursing duties and/or, are not specific interventions by staff to address specific LTGs or STGs.

5. Patient A5: an 81 y/o patient was hospitalized on 1/16/18. The Psychiatric Assessment dated 1/16/18 documented a primary diagnosis of "Unspecified mood disorder and Dementia, unspecified with behavioral disturbance." The MTP dated 1/16/18 and multiple updates (no date) for Problem 1. "Danger to self", listed the LTG "Patient will not harm self during hospitalization and will deny SI upon discharge." For the STGs (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b) "Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e) "Will deny SI and thoughts of self-harm and state as safe plan for self-care." In speaking with three different staff members about Patient A5's clinical status, they indicated that Patient A5 had not had any suicidal ideation since admission. A physician's progress notes on 4/4/18 states "No suicidal ideation. No homicidal ideation, no paranoia. [she/he] has cognitive problems and [she/he] is demented." Physician note of 4/6/18 states "needs still a lot of redirections to continue following simple ADLs, such as eating and bathing." Goals identified were beyond the patient's ability due to her dementia with short and long-term memory difficulties. Treatment Plans continued to address suicidal ideation as a problem but did not formulate any LTGs or STGs addressing the symptoms of dementia., The Treatment Plan's problem list indicated dementia as not an "active" problem to be addressed.

Intervention

Nursing: "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observations by increased staff. Monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent. When patient identified with potential loss of control, ask patient what PRN medication is most helpful and administer medication according to nursing assessment. Will review and offer behavioral Advance directive if available." Due to patient's dementia she/he would not be able to perform the last three interventions listed. No interventions addressed dementia and did not list the frequency and/or modality of the interventions.

6. Patient A6: an adult was hospitalized on 3/7/18. Psychiatric assessment dated 3/8/18 documented primary diagnosis as "Schizophrenia, chronic, paranoid by history and has not been on any medication". The MTP dated 3/7/18, for Problem 1. "Psychosis", listed for the LTGs "(a) "Patient will demonstrate as decrease in psychotic symptoms" and (b) "(patient name) will make reality-based statements and goals by d/c." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b) "Patient will identify triggers that can lead to psychotic behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and /or behaviors." (d) "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." (e) "(patient name) will verbalize understanding of medication compliance."

Intervention

Nursing: "Identify in discussions with patient themes: coherent vs. incoherent (i.e. anxiety, fear). Focus on and direct patient's attention to concrete things in environment through demonstrating RN. Assure patient is compliant with prescribed medications." No frequency and/or modality of interventions were listed. Medication compliance is a routine nursing duty.

7. Patient A7: a 19y/o adult delivered a child "about 2 weeks ago", was hospitalized on 3/29/18. The Psychiatric Assessment on 3/29/18 documented a primary diagnosis of "unspecified psychosis, rule out postpartum depression with psychosis." The MTP of 3/30/18 for Problem 1. "Psychosis" listed for the LTGs (a). "Patient will demonstrate a decrease in psychotic symptoms." (b). "[patient name] will deny A/H (auditory hallucinations) and AV/H (auditory/visual hallucinations) upon d/c (discharge)." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b) "Patient will identify triggers that can lead to psychosis." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and/or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present."

Intervention

Nursing: "Identify in discussions with patient themes: coherent vs. incoherent (i.e. anxiety, fear). Focus on and direct patient's attention to concrete things in environment through demonstrating RN. Assure patient is compliant with prescribed medications." No frequency and/or modality of interventions listed. Medication compliance is a routine nursing duty. No goals or interventions specific to postpartum issues were identified.

8. Patient A8: an adult was hospitalized on 3/14/18. Psychiatric Assessment on 3/15/18 listed a secondary diagnosis of "other psychotic disorder not due to a substance or known physiological condition." No primary diagnosis was listed on the Psychiatric Evaluation. The MTP on 3/15/18 listed same secondary diagnosis as "Substantiated Diagnosis" and for the Problem 1. "Psychosis "the "LTGs were (a). "Patient will demonstrate a decrease in psychotic symptoms." (b) "(patient name) will be able to state a safe plan of self-care." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and. or delusions." (b). "Patient will identify triggers that can lead to psychotic behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and/or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." Treatment Plan update (no date) indicated "patient needs prompting for basic ADL's and hygiene" but was not addressed as a problem with goals and interventions by staff. Treatment Plan update (no date) also indicated that "patient does not attend process groups." yet, there were no goals or alternative interventions identified to address this issue.

Intervention

Nursing: Identify in discussions with patient themes: coherent vs. incoherent (I.e.) anxiety, fear). Focus on and direct patient's attention to concrete things in environment through demonstrating RN. Assure patient is compliant with prescribed medications. No frequency and/or modality of interventions listed. Medication compliance is a routine nursing duty.

9. Patient A9: an adult patient hospitalized on 4/4/18. Psychiatric Assessment on 4/6/18 listed a primary diagnosis of "unspecified psychosis, not due to substance abuse or psychological condition" and a secondary diagnosis "to rule out substance-induced psychosis." MTP on 4/4/18 for Problem 1. "DTS/DTO r/t [Danger to self/Danger to others related to] Psychosis", listed for the LTGs for the problem of "unspecified psychosis" as (a). "Patient will demonstrate a decrease in psychotic symptoms." (b). "(patient name) will report stabilization of acute symptoms of psychosis and return to normal functioning in affect and thinking to maintain a safe environment." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b). "Patient will identify triggers that can lead to psychotic behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and /or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." (e). "(patient name) will exhibit appropriate affect and responses to daily encounters." There was no goal to address patient's history of homelessness.

Intervention

Nursing: "Identify in discussions with patient themes: coherent vs. incoherent (I.e.) anxiety, fear). Focus on and direct patient's attention to concrete things in environment through demonstrating RN. Assure patient is compliant with prescribed medications." No frequency and/or modality of interventions were listed. Medication compliance is a routine nursing duty.

10. Patient A10: An adult was hospitalized on 3/30/18. Psychiatric Assessment on 4/1/18 listed a primary diagnosis of "Unspecified psychosis" with a history of poor medication compliance. MTP of 3/30/18 for Problem 1. "Danger to self r/t psychosis." listed LTGs as "(a). "Patient will not harm self during hospitalization." (b). "(patient name) will report significantly reduced hallucinations/delusions to re-establish (patient name) to maintain a safe environment with consistent medication compliance." For the STGs: (a) "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "(patient name) will report to staff any hallucinations/delusions."

Intervention

Nursing: "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observations by increased staff. Monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent. When patient identified with potential loss of control, ask patient what PRN medication is most helpful and administer medication according to nursing assessment." These interventions do not indicate frequency and/or modality, and these interventions are routine nursing duties.

11. Patient A11: An adult was hospitalized on 4/2/18. Psychiatric Assessment on4/4/18 listed a primary diagnosis of "Major depressive disorder, recurrent, severe without psychosis, Chronic alcohol dependence." MTP of 4/4/18 lists diagnosis as "Major depressive disorder, recurrent, severe with psychotic symptoms." The identified Problem 1 was "Danger to self r/t (related to) psychosis." The listed LTG was (a). "Patient will not harm self." The STGs were: (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b) "Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." Also, addressed on the MTP was Problem 2: Substance Abuse. For the LTG (a). "Patient will maintain sobriety during hospitalization." For the STGs: (a). "Patient will not experience complications from withdrawal symptoms." (b). "Patient will verbalize (2) self-regulation skill strategies to prevent relapse." (c). "Patient will attend one process group daily and identify specific triggers leading to specific cravings." (d). "Patient will identify leisure skill activities that can be utilized to assist in pursuit of sobriety."

Intervention

Nursing: for Problem of "Suicidal/Danger to self": "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observation by increased staff. Monitor patient as ordered by Physician. Encourage patient to seek staff when loss of control is imminent. When patient identified potential loss control, ask what PRN medication is most helpful and administer medication according to nursing assessment." No modality and/or frequency for these interventions were listed. These interventions are either staff expectations or routine staff duties rather than specific interventions provided by staff to address identified problems to attain identified goals. This patient was incapable of attending groups. As he/she was undergoing detoxification both physician and RN note (of 4/5/18) indicate "has been unsteady and needed full assistance to get out of bed to urinate"

Nursing: for problem of "Substance use": "Implement detox protocol (if required). Reduce patients' external stimuli and discuss with patient outside triggers to avoid before visitation." This patient was expected to attend all daily scheduled unit groups. Interventions do not list frequency and/ or modality and "implement detox protocol" is a routine nursing duty.

12. Patient A12: An adult was hospitalized on 3/24//18. Psychiatric Assessment on 3/25/18 listed a primary diagnosis of "Major depression, severe, recurrent." For Problem 1. "Suicidal/Danger to self": the MTP on 3/24/18 listed as LTGs (a). "Patient will not harm self during hospitalization." (b). "(patient name) will deny suicidal ideation and thoughts of self-harm." For the STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior" (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "Patient (patient name) will express depression and thoughts of self-harm without acting out."

Intervention

Nursing: "Identify increased or altered anxiety level and any negative changes every shift. Implement additional safety observations by increased staff. Monitor patient as ordered by physician Q-15. Encourage patient to seek staff when feeling loss of self-control imminent. When patient identified with potential loss of control, ask patient what PRN medication is most helpful and administer medication according to nursing assessment. Encourage to alert staff of urges of self-harm." Interventions do not list modality and/or frequency. Several interventions are routine nursing duties. These interventions are either staff expectations or routine staff duties rather than specific interventions provided by staff to address identified problems to attain identified goals.

Activity Therapy:

For all (A1-A12) active sample patients' activity therapy interventions were similar. "1. Assist patient in identifying unwanted leisure activities" and 2. "Monitor patient attendance and progress in activities as it relates to their suicidal thoughts and feelings or psychotic thoughts and development of new leisure skills." These interventions are generic and routine discipline functions and not individualized interventions to address patient specific problems or STGs and LTGs. The frequency of these interventions and/or the specific modality of interventions -individual or group were not identified.

B. Staff interview:

In a meeting with the Director of Nursing on 4/12/18 at 11:00 a.m. the Director of Nursing agreed that for Patients A1, A2, A3, and A4 there were no prn medications ordered as indicated on the nursing interventions. The DON also agreed that many nursing interventions were routine nursing duties.
In a meeting on 4/11/18 at 3 p.m., with the Director of Clinical services, who oversees the Activity Therapy services, the above activity therapy deficiencies were reviewed and he did not dispute the findings.

C. Policy Review:

Hospital Policy #: 600.19, Title: Master Treatment Plan (MTP) under procedure 2. States "The master treatment plan shall contain specific interventions that relate to goals, are written in behavioral and measurable terms...". Further under "Interventions: The intervention includes the following components: Specific intervention (group therapy... 1:1, etc.) Frequency: How often the intervention will be done... The specific focus of the intervention as related to the problem..."

Based on Record review and Staff interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered long term goals [LTGs] and short-term goals [STGs] stated in observable, measurable and behavioral terms for 12 of 12 active patients (A1, A2, A3, A4, A5, A6, A7, A8,A9, A10,A11 and A12). Several of the identified goals were generic staff expectations or did not address patient specific presenting problems and were not written in observable, behavioral and measurable terms. This lack of patient specific goals hampers the treatment team's ability to assess changes in patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient's needs.

Findings include:

I. Medical Record Review:

1. Patient A1 was hospitalized on 4/5/18. Patient's identified problems were "Suicidal/Danger to self" "As Evidenced By: Started thinking that [he/she] should just kill him/herself, got a blade and started to puncture [his/her] left wrist. Experiencing auditory hallucination saying "crap." The MTP dated 4/5/18, identified LTGs as (a). "Patient will not harm self during hospitalization", (b)." Other: [Name] will deny suicidal ideation and thoughts of self-harm." The STGs were: (a). "Patient will approach staff if having any suicidal thoughts or feelings", (b). "Patient will identify alternative methods to express suicidal feelings", (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behaviors", (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present", (e). "Other: [name] will express depressive feelings and thoughts of self-harm without acting out." No goals identified for the symptom psychosis.

2. Patient A2: a 15-year-old patient was hospitalized on 4/6/18. The Psychiatric Assessment dated 4/7/18 documented primary diagnosis of "Major depressive disorder, first episode, severe" with complaint of "I am upset, I wanted to hurt people that are trying to hurt me emotionally and physically." The MTP of 4/6/18, for Problem 1. "Danger to self", listed for the LTGs (a) ". Patient will not harm self during hospitalization." (b). "(patient name) will deny suicidal ideation and thoughts of self-harm." For the STGs: (a). "Patient will approach staff if having suicidal thoughts or feelings." (b) "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behaviors" (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present" and (e). "(patient name) will express depressive feelings and thoughts of self-harm without acting out." No goals or interventions were listed for addressing anger and/or family issues, if any.

3. Patient A3: a16y/o patient hospitalized on 4/4/18. The Psychiatric Assessment dated 4/5/18 documented primary diagnosis as "Major depressive disorder, severe, single episode without psychosis" with chief complaints of "I have been feeling more depressed. I have been contemplating about killing myself by overdosing." The MTP of 4/4/18, for Problem 1. "Suicidal/Danger to self", listed LTGs as "(a). "Patient will not harm self during hospitalization" and (b). "(patient name) will deny suicidal ideation and thoughts of self-harm." For the STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings" (b). "Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors." (c) "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "(patient name) will express depressive feelings and thoughts of self-harm without acting out."

4. Patient A4: A 14y/o was hospitalized on4/6/18. The Psychiatric Assessment dated 4/6/18 documented the primary diagnosis "Major depressive disorder, first episode" reporting she/he "is no longer loved by [her/his] family and is a forgotten child." The MTP of 4/6/18, for Problem 1. "Suicidal/Danger to self", listed LTGs as (a). "Patient will not harm self during hospitalization" and (b). "(patient name) will deny suicidal ideations and thoughts of self-harm." For the STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "(patient name) will express feelings of depression or suicidal ideation without acting on them." There were no LTGs or STGs addressing problems with family or school. Patient's history indicates "could not be in high school and having hard time with grades."

5. Patient A5: an 81 y/o patient was hospitalized on 1/16/18. The Psychiatric Assessment dated 1/16/18 documented a primary diagnosis of "Unspecified mood disorder and Dementia, unspecified with behavioral disturbance." The MTP dated 1/16/18 and multiple updates (no dates) for Problem 1. "Danger to self", listed LTGs as (a) "Patient will not harm self during hospitalization" and "will deny SI upon discharge." For the STGs (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "Will deny SI and thoughts of self-harm and state as safe plan for self-care." In speaking with three different staff members about the patient's clinical status, they indicated that Patient A5 has not had any suicidal ideation since admission. A physician's progress note on 4/4/18 states "No suicidal ideation. No homicidal ideation, no paranoia. [she/he] has cognitive problems and [she/he] is demented." Physician note of 4/6/18 states "needs still a lot of redirections to continue following simple ADLs, such as eating and bathing." Goals identified were beyond the patient's ability due to her dementia with short and long-term memory difficulties. Treatment Plans continued to address suicidal ideation as a problem, but do not formulate any LTGs or STGs addressing the symptoms of dementia. The problem list indicated dementia as, not an "active" problem to be addressed.

6. Patient A6: an adult was hospitalized on 3/7/18. Psychiatric Assessment dated 3/8/18 documented primary diagnosis as "Schizophrenia, chronic, paranoid by history and has not been on any medication". The MTP dated 3/7/18, for Problem 1. "Psychosis", listed LTGs as "(a). "Patient will demonstrate a decrease in psychotic symptoms" and (b). "(patient name) will make reality-based statements and goals by d/c." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b). "Patient will identify triggers that can lead to psychotic behaviors" (c) "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and /or behaviors. (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." (e). "(patient name) will verbalize understanding of medication compliance."

7. Patient A7: a 19y/o adult delivered a child "about 2 weeks ago", was hospitalized on 3/29/18. The Psychiatric Assessment on 3/29/18 documented a primary diagnosis of "unspecified psychosis, rule out postpartum depression with psychosis." The MTP of 3/30/18 for Problem 1. "Psychosis", listed LTGs as "(a). "Patient will demonstrate a decrease in psychotic symptoms." (b). "[patient name] will deny A/H (auditory hallucinations) and AV/H (auditory/visual hallucinations) upon d/c (discharge)." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b). "Patient will identify triggers that can lead to psychosis." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and/or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present."

8. Patient A8: an adult was hospitalized on 3/14/18. Psychiatric Assessment on 3/15/18 listed a secondary diagnosis of "other psychotic disorder not due to a substance or known physiological condition." No primary diagnosis listed on the Psychiatric Evaluation. The MTP on 3/15/18 listed same secondary diagnosis as "Substantiated Diagnosis" and for the Problem 1. "Psychosis", the "LTGs (a). "Patient will demonstrate a decrease in psychotic symptoms." (b) "(patient name) will be able to state a safe plan of self-care." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and. or delusions." (b). "Patient will identify triggers that can lead to psychotic behaviors." (c) "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and/or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." Treatment Plan update (no date) indicated that the patient requires prompting for basic ADL's and hygiene, but was not addressed as a problem with goals and interventions by staff. Treatment Plan update (no date) also indicated that "patient does not attend process groups" however, there were no goals or alternative interventions identified to address this issue.

9. Patient A9: an adult patient hospitalized on 4/4/18. Psychiatric Assessment on 4/6/18 listed a primary diagnosis of "unspecified psychosis, not due to substance abuse or psychological condition" and a secondary diagnosis to "rule out substance-induced psychosis." MTP on 4/4/18 for Problem 1." DTS/DTO r/t [Danger to self/Danger to others related to] Psychosis", listed LTGs for the problem of "unspecified psychosis" as "(a). "Patient will demonstrate a decrease in psychotic symptoms." (b). "(patient name) will report stabilization of acute symptoms of psychosis and return to normal functioning in affect and thinking to maintain a safe environment." For the STGs: (a). "Patient will self-report diminishing or absence of hallucinations and/or delusions." (b). "Patient will identify triggers that can lead to psychotic behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and /or behaviors." (d). "Patient will identify leisure skill activities that can be utilized as psychotic thoughts and/or behaviors present." (e) "(patient name) will exhibit appropriate affect and responses to daily encounters." There was no goal to address patient's history of homelessness, identified in the Psychosocial Assessment.

10. Patient A10: An adult was hospitalized on 3/30/18. The Psychiatric Assessment on 4/1/18 listed a primary diagnosis of "Unspecified psychosis" with a history of poor medication non-compliance. MTP of 3/30/18, for Problem 1. "Danger to self r/t psychosis", listed LTGs as "(a). "Patient will not harm self during hospitalization." (b). "(patient name) will report significantly reduced hallucinations/delusions to re-establish (patient name) to maintain a safe environment with consistent medication compliance." For the STGs (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "(patient name) will report to staff any hallucinations/delusions."

11. Patient A11: An adult was hospitalized on 4/2/18. The Psychiatric Assessment dated 4/4/18 listed a primary diagnosis of "major depressive disorder, recurrent, severe without psychosis, and Chronic alcohol dependence." The MTP dated 4/4/18 listed diagnosis as "Major depressive disorder, recurrent, severe with psychotic symptoms." And the identified Problem 1 was "Danger to self r/t (related to) psychosis." The LTGs was "Patient will not harm self." For the STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b) "Patient will identify alternative methods to express suicidal triggers leading to suicidal behaviors." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d). "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present."
Problem 2. "Substance abuse" the LTG was "Patient will maintain sobriety during hospitalization." For the STGs: (a). "Patient will not experience complications from withdrawal symptoms." (b). "Patient will verbalize (2) self-regulation skill strategies to prevent relapse." (c). "Patient will attend one process group daily and identify specific triggers leading to specific cravings." (d). "Patient will identify leisure skill activities that can be utilized to assist in pursuit of sobriety."

12. Patient A12: An adult was hospitalized on 3/24//18. The Psychiatric Assessment dated 3/25/18 listed a primary diagnosis of" Major depression, severe, recurrent." For Problem 1. "Suicidal/Danger to self": The MTP dated 3/24/18 listed as LTG (a) "Patient will not harm self during hospitalization." and (b) "(patient name) will deny suicidal ideation and thoughts of self-harm. "For the STGs: (a). "Patient will approach staff if having any suicidal thoughts or feelings." (b). "Patient will identify alternative methods to express suicidal feelings." (c). "Patient will attend one process group daily and identify specific triggers leading to suicidal behavior." (d) "Patient will identify leisure skill activities that can be utilized when suicidal thoughts or feelings present." (e). "Patient (patient name) will express depression and thoughts of self harm without acting out."

B. Policy Review:

Hospital Policy #: 600.19, Title: Master Treatment Plan (MTP) under "Treatment Plan components: Long Term Goal: The long term goal(s) for the problem is the specific behaviors that will hope to be seen at the time of discharge..., Short-term Goals: Short term, goals are stated as "stepping stones" to long term goals and are stated in specific behavioral, measurable and observable terms."

C. Staff interview:

In a meeting with the Director of Clinical Services on 4/11/18 at 3 p.m., the above policy and the deficiencies were reviewed and he did not dispute the findings.

Based on record review, staff interview and policy review the facility failed to provide Master Treatment Plan interventions/modalities for 12 out of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11and A12) that consistently addressed specific patient needs/problems. Many interventions were generic monitoring and discipline functioning that used identical or similar wording for patients regardless of the different presentations. In addition, some of the Treatment Plans failed to identify how these generic interventions would be delivered (individual or group) or how often the interventions would occur. These deficiencies resulted in Treatment Plans that were not individualized and did not reflect a comprehensive, individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific modalities/interventions needed. This failure potentially results in inconsistent and/or ineffective treatment.

The findings include:

I. Medical Record Review:

Treatment goals and interventions were a list of preprinted goals and interventions and there was no indication as to which goal the intervention related. Listed below are routine discipline interventions by the treatment team members that did not relate to specific problems and identified goals:

Patient A1 with a MTP dated 4/5/18 listed the problem as Suicide/Danger to self.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self- control and reduce suicidal thoughts.

Nursing: Implement additional safety observation by increased staff and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A2 with a MTP dated 4/6/18 listed the problem as Danger to Others/Physical Aggression.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Will redirect patient to attend all groups with participation.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A3 with a MTP dated 4/4/18 listed the problem as Suicidal/Danger to Self

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.
Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A4 with a MTP dated 4/6/18 listed problem as Suicidal/ danger to self.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: None identified.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A5 with a MTP dated 1/16/18 listed the problem as Suicidal/Danger to Self.

Psychiatry: Daily Assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A6 with a MTP dated 3/7/18 listed the problem as Psychosis.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize hallucinations and delusions.

Nursing: Assure patient is compliant with medication.

Social services: Evaluate housing structure to assist in maintaining a fail free environment.

Activity Therapy: None identified.

Patient A7 with a MTP dated 3/30/18 listed the problem as Psychosis.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize hallucinations and delusions.

Nursing: Assure patient is compliant with medication.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A8 with a MTP dated 3/15/18 listed the problem as Psychosis.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize hallucinations and delusions.

Nursing: Assure patient is in compliance with prescribed medication.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A9 with a MTP dated 4/4/18 listed the problem as Psychosis.

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize hallucinations and delusions.

Nursing: Assure patient is in compliance with prescribed medication.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A10 with a MTP dated 3/30/18 with a problem listed as Suicidal/Danger to Self

Psychiatry: Daily Assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A11 with a MTP dated 4/3/18 with the problem listed Suicidal/Danger to Self.

Psychiatry: No interventions listed.

Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Second problem identified as Substance Abuse.

Psychiatry: Daily Assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Implement detox protocol (if required)

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

Patient A12 with a MTP dated 3/24/18 with the problem listed Suicidal/ Danger to Self

Psychiatry: Daily assessment of mood and mental status and Medication consultation, evaluation, and management to stabilize mood, increase self-control and reduce suicidal thoughts.

Nursing: Implement additional safety observation by increased staff, and Monitor patient as ordered by physician q-15.

Social Service: Monitor progress in process group activity.

Activity Therapy: Assist patient in identifying unwanted leisure activities.

B. Staff Interview:

On 4/12/2018 at 11:00 a.m. in a meeting with the DON she agreed that the interventions were not specific. On 2/12/18 at 10:00 a.m. in a meeting with the medical director, regarding the lack of specificity and lack of individualized interventions, the director stated "this is what we do to all patients."

C. Policy Review

Policy 600.19 Interventions: Interventions for each appropriate discipline will be included for each problem. The intervention includes the following components:

Specific intervention (group therapy, administration of antidepressant, activities therapy, psych testing, 1:1 suicide precautions etc.).

Frequency: How often the intervention will be done (daily, 5 times per week, each shift, every 15 minutes as needed).

The specific focus of the intervention as related to the problem. (i.e. "to assist the patient in developing skills in dealing with conflict").

Based on record review and staff interview, the facility failed to ensure for 12 of 12 (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) active sample patients, the treatment members documented in their treatment/progress notes patients' response to treatment interventions and progress or lack of progress patients' were making towards their goal achievement. Specifically, there were no treatment/progress notes documented by Nursing, Social services and Activity Therapy staff. Failure to include this information by the members of the treatment team, hinders the treatment team's ability to know, if a staff member carried out identified intervention, what the patient's response was and if the patient is progressing towards attaining the established goal/or not, and if the plans need to be modified.

Findings include:

A. Record Review:

Staff was asked to provide copies of all Progress/Treatment notes for 1 week period between 4/3/18 and 4/9/18 for all disciplines including group notes and nursing shift notes. Review of these notes failed to show any treatment/progress notes written by nursing, social services or activity therapy staff pertaining to treatment interventions and treatment goals. There were only group notes for the groups a patient may have attended.

B. Staff interview:

In a meeting with the director of treatment services on 4/12/18 at 11:00 a.m., the director acknowledged this deficiency and that there was no hospital policy requiring a need for treatment/progress notes.

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

1. Provide active treatment, including alternative interventions, for two (2) of 12 active sample patients (A8 and A11). These patients were either not emotionally stable to participate in treatment at times or were not motivated to attend all groups as s/he was supposed to attend as listed on the unit activity schedule. Although the Treatment Plans for these patients included group therapies as one of the interventions, these patients regularly and repeatedly did not attend groups. According to unit staff, these patients spent many hours isolated in his/her room without any structured activities. These patients' non- participation in assigned treatment modalities negates the clinical effectiveness of the treatment goals and objectives, potentially delaying the patient's improvement.

2. Failure to offer groups/activities to meet the needs of majority of patients on the units.

Findings include:

A. Record review:

1. Patient A8 was admitted on 3/14/18. According to the Psychiatric Evaluation dated 3/15/18, the patient was admitted with "significant neg (negative) symptoms with severe paucity of thought." "Upon face to face (patient name) continues to be verbally unresponsive, mute..." Upon interview by the surveyor, the patient was found to be very vague and minimally responsive to the interview process.

The Master Treatment Plan (MTP), last review date not listed, but the target date for achievement of 4/10/18, for the problem, Psychosis, has the STG of "patient will attend one process group daily and identify specific triggers leading to psychotic thoughts and/or behaviors." Listed interventions were, Nursing: "will prompt for groups to learn coping skills.", Psychiatrist: "Daily assessment of mood and mental status." Social services: "Monitor progress in process group activity." Activity Therapy: "Monitor patient attendance and progress in activities as it relates to their psychotic thoughts and/or behaviors and development of new leisure skills." This same last MTP review update (Target date 4/2/18) states, "still isolative", "does not attend daily process group", "still struggles with identifying leisure activities."

A review of the group attendance notes for the week of 4/3/18 to 4/9/18 disclosed this patient attended 6 groups and did not attend 27 groups for the week.

2. Patient A11 was admitted on 4/2/18. According to the Psychiatric Evaluation dated 4/3/18, the patient was admitted with "I do not want to live anymore. I tried to drink myself to death." Upon interview by the surveyor it was reported Patient A11 "was hallucinating and seeing things, but not since last night". Regarding participation in group therapy, patient reported not attending most groups, and that when not attending "they give me a print out, no staff discusses or reviews the print out with me". Unit charge nurse RN3, when questioned as to what patients do when not attending groups, stated, "I don't know what they do if they are not attending groups. Groups are Case management, social work and activity therapy staff responsibility."

The MTP of 4/2/18 had for Problem 1. Suicidal/ Danger to self had STG: "Patient will attend one process group daily and identify specific triggers leading to suicidal behaviors." Interventions related to Problem 1. Nursing: Encourage patient to seek staff when feeling loss of self-control imminent. Psychiatrist: Medication consultation, evaluation and management to stabilize mood, increase self control and reduce suicidal thoughts. Social services: Monitor progress in process group activity. Assist patient in recognizing their specific triggers that have led to suicidal thoughts and feelings. Activity Therapy: "Monitor patient attendance and progress in activities as it relates to their suicidal thoughts and feelings and development of new leisure skills."

For Problem 2. Substance use, STGs: Patient will not experience complication from withdrawal symptoms. Patient will attend one process group daily and identify specific triggers leading to specific cravings."Interventions related to Substance abuse, Nursing: "Implement detox protocol. Reduce external stimuli.." Psychiatrist: Medication consultation, evaluation and management to reduce signs and symptoms of detox. Social Services: Provide chemical dependency education. Activity Therapy: "Monitor patient attendance and progress in activities as it relates to their substance abuse treatment and development of new leisure skills."

A review of the group attendance notes for the week of 4/3/18 to 4/9/18; this patient attended 5 groups and did not attend 27 groups for the week. This patient was unable to attend groups as he/she was undergoing detoxification.

B. Observation

On 4/10/18 there was a census of 16 patients on the ITU- east unit, at 11:00 a.m. during the unit walk through with the Director of Clinical services, only 7 of the 16 patients were attending a group "Learn and Process" and the other 9 patients were observed in bed rooms or pacing the hall. Sample patient A7 was in the bed. When the charge nurse RN2 was asked about the patient's non- attendance and alternative interventions, she stated, "They get a print out.", when asked if after the hand out was given, if anyone collects/reviews them, she said "No."

During a walk thorough on unit ITU north with the Director of Clinical services, at 1:20 p.m. on 4/10/18, 4 patients out of a census of 22 were in a group. When asked the unit physician # 1stated " Follow up on group non-attendance not consistently done."

During a walk through with the Director of Clinical Services on unit C-south on 4/11/18 at 11:26 a.m., 6 of the 21 census patients were not in group therapy. Sample patient A12 was in bed and not attending "Learn and Process" group. Patient stated "I fell and it hurts to sit in group." When unit RN4 was asked, she stated "hand outs given, hope patient reviews."

C. Interviews

In a meeting with the Director of Clinical Services on 4/11/18 at 9:30 a.m., patients' lack of attendance in group therapy and lack of alternative interventions was reviewed. He agreed with the findings and stated "Should be more interactive with patients who don't go to groups. I am sure we will come up with something."

Based on record review and staff interview the medical director failed to ensure that;

I. The Psychiatric Evaluations included: a) inventory of patients' assets for eight (8), (A3, A5, A6, A7, A8, A9, A11 and A12) of 12 active sample patients (Refer to B117).

II. Multidisciplinary, individualized, Comprehensive Treatment plans were developed for 12 of 12 (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) active sample patients (refer to B118), including appropriate STGs and LTGs (Refer to B121) and individualized treatment interventions of sufficient duration and intensity/frequency, that addressed the identified problems of the patients. (Refer to B122)

III. All members of the Treatment Team documented treatment/progress notes for 12 of 12 (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) active sample patients. (Refer to B124)

IV. Provide sufficient numbers of structured therapeutic activities including alternative treatments for patients unable/unwilling to attend group therapy. (Refer to B125)

The Director of Nursing must demonstrate competence to participate in interdisciplinary formulation of individual Treatment Plans: to give skilled nursing care and therapy and to direct, monitor, and evaluate the nursing care furnished. It was determined that the Director of Nursing failed to ensure/monitor that the Treatment Plan delineate the RN role in the care of the patient for 12 out of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12.) It is difficult to determine which nursing interventions related to specific treatment goals as nursing interventions are simply a list of preprinted interventions with several of the preprinted nursing interventions being routine nursing duties. This resulted in the absence of documented RN responsibility relating to the patient goals. (Refer to B122)

The Director of Social Work failed to assure the quality and appropriateness of services provided by the social work staff. Specifically, the Director failed to assure that the Psychosocial Assessments included the anticipated social work roles in treatment including appropriate interventions for identified high risk behaviors for 12 of 12 (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) active sample patients. The Director also failed to provide appropriate professional oversight for treatment/progress notes and Psychosocial Assessments performed by non MSW qualified staff, according to nationally accepted professional social work standards of practice. This failure results in a lack of professional social work information in treatment planning. (Refer to B108 and B124)