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Based on record review and interview, the facility failed to ensure that Social Work Assessments for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2) addressed the anticipated role of the Social Worker in treatment and discharge planning. This failure results in a lack of information to formulate Social Service interventions for patients.

Findings include:

A. Record Review

The "Psychosocial Assessment" was a four page preprinted form filled in by hand by the assigned social worker. It collected basic social information that can be used in treatment and discharge planning with the last section labeled "Preliminary Discharge Plans" which has four blank lines to fill in. The assessment form lacked the option to discuss any treatment groups led by social workers or counseling sessions that the social worker might undertake. Thus, specific roles for social work in treatment were not identified and the information put in the discharge plan was very limited as to the role of the social worker.

1. Patient A1, admitted 4/11/11, had a psychosocial completed 4/13/11 with the Preliminary Discharge Plan filled in with "once stable pt will d/c back to his board and care w/county f/u." No further role for the Social Worker (SW) was identified.

2. Patient A2, admitted 3/20/11, had a psychosocial completed 3/23/11 with the Preliminary Discharge Plan filled in with "needs evaluation of living arrangements w/ SCC (sic Santa Clara County) f/u." No further role for the SW was identified.

3. Patient B1, admitted 4/3/11, had a psychosocial completed 4/5/11 with the Preliminary Discharge Plan filled in with "Pt will D/C when she is safe with D/C, stable to follow up the D/C orders." This lacked any discharge plan and no further role for the SW was identified.

4. Patient B2, admitted 4/13/11, had a psychosocial completed 4/16/11 with the Preliminary Discharge Plan filled in with "The D/C plan still being evaluated by assigned ccw1 (Sic). F/U to be provided by Aetna provider." This lacked any discharge plan and no further role for the SW was identified.

5. Patient C1, admitted 4/11/11, had a psychosocial completed 4/12/11 with the Preliminary Discharge Plan filled in with "Pt may D/C home or to Casa Fremont when stable and f/u with IOP." No further role for the SW was identified.

6. Patient C2, admitted 4/6/11, had a psychosocial completed 4/8/11 with the Preliminary Discharge Plan filled in with "Pt will D/C home when stable and f/u with Kaiser." No further role for the SW was identified.

7. Patient D1, admitted 4/18/11, had a psychosocial completed 4/20/11 with the Preliminary Discharge Plan filled in with "D/C home with roommate when stable with followup through Kaiser outpatient services." No further role for the SW was identified.

8. Patient D2, admitted 4/12/11, had a psychosocial completed 4/14/11 with the Preliminary Discharge Plan filled in with "D/C home with father when stable with f/u with outpatient services with Lassen County mental health." No further role for the SW was identified.

9. Patient E1, admitted 3/31/11, had a psychosocial completed 4/2/11 with the Preliminary Discharge Plan filled in with "The pt to d/c to his home when stable with f/u provided by MHN provider and/or FH PHP!" No further role for the SW was identified.

10. Patient E2, admitted 4/11/11, had a psychosocial completed 4/14/11 with the Preliminary Discharge Plan filled in with "need shelter with f/u services." No further role for the SW was identified.

B. Staff Interview

In an interview on 4/21/11 at 2:35PM, the Interim Director of Social Services agreed that the psychosocial assessment should be more than a checklist and that the role of the SW in the assessment should be more specific and complete.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 4 of 10 active sample patients (patients A1, B2, C1 and C2) included an assessment of recent and remote memory function in measurable, behavioral terms that clearly reflected patients' abilities in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions might be measured.

Findings include:

A. Record Review:

The psychiatric evaluation is a mixture of dictated and fill in the blank forms with the Mental Status Exam (MSE) a section of the evaluation.

1. Patient A1, admitted 4/11/11, had a psychiatric evaluation done 4/12/11 with an MSE which reported "COGNITION/MEMORY: Unable to cooperate." There was no further attempt to evaluate memory in this 69 years old elderly man as his psychotic symptoms improved, limiting the opportunity to assess the patient's cognitive status.

2. Patient B2, admitted 4/13/11, had a psychiatric evaluation done 4/13/11 with an MSE which had no mention of memory function.

3. Patient C1, admitted 4/11/11 had a psychiatric evaluation done 4/11/11 with an MSE which had no mention of memory function.

4. Patient C2, admitted 4/6/11, had a psychiatric evaluation done 4/7/11 with an MSE which had no report of memory function.

B. Staff Interview

The Medical Director was interviewed on 4/21/11 at 1:30pm. He was asked about the MSE and the lack of documentation of memory testing. He nodded and said he would discuss this with the medical staff.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an inventory of patients' assets for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation.

Findings include:

A. Record Review

The psychiatric evaluation is a mixture of dictated and fill in the blank forms with the ASSETS & STRENGTHS a section of the evaluation.

1. Patient A1, admitted 4/11/11, had a psychiatric evaluation done 4/12/11 with "Other" checked for ASSETS & STRENGTHS and nothing listed on the accompanying line. This is not useful in treatment planning.

2. Patient A2, admitted 3/20/11, had a psychiatric evaluation done 3/21/11 with "ASSETS: The patient is in good physical health." This will have limited use in treatment planning.

3. Patient B1, admitted 4/3/11, had a psychiatric evaluation done 4/4/11 which had no mention of Strengths & Assets.

4. Patient B2, admitted 4/13/11, had a psychiatric evaluation done 4/13/11 which had no mention of STRENGTHS & ASSETS.

5. Patient C1, admitted 4/11/11, had a psychiatric evaluation done 4/11/11 with no mention of ASSETS AND STRENGTHS.

6. Patient C2, admitted 4/6/11, had a psychiatric evaluation done 4/7/11 with no mention of ASSETS AND STRENGTHS.

7. Patient D1, admitted 4/18/11, had a psychiatric evaluation done 4/18/11 with no mention of ASSETS AND STRENGTHS.

8. Patient D2, admitted 4/12/11, had a psychiatric evaluation done 4/12/11 with no mention of ASSETS AND STRENGTHS.

9. Patient E1, admitted 3/31/11, had a psychiatric evaluation done 4/1/11 with "Motivated for treatment" checked for Assets and Strengths which is of limited use in treatment planning.

10. Patient E2, admitted 4/11/11, had a psychiatric evaluation done 4/11/11 which included "Inventory of assets: The patient is on SSI" which is of limited use in treatment planning.

B. Staff Interview

In an interview on 4/21/11 at 1:30pm with the Medical Director, the issue of identifying assets in the psychiatric evaluation was discussed and he said he would discuss this with the medical staff.

Based on policy/document review, record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that included all required elements for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). The written MTPs failed to identify and/or utilize patient strengths (Refer to B119); and they lacked measurable long term and short term goals (Refer to B121), individualized treatment interventions and modalities (Refer to B122); and/or the specific names of staff responsible for the interventions (Refer to B123).

In addition, the initial MTPs for patients A2, B1, C1, C2, D1, E1 and E2 were developed and signed by the interdisciplinary team before all assessments were completed. The date of the initial MTPs for patients A1 and B2 were not specified on the plan. Staff and patient/family signatures were missing from some of the MTPs and/or review/update sheets for patients A1, B1, C1 and C2. The MTP review/update sheets for patients A1 and A2 also failed to record patient progress toward the treatment goals

Failure to develop treatment plans, based on completed assessments and including all required components, hampers staff's ability to provide individualized and coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

Findings include:

A. Policy/Document Review

1. The facility's policy PC #224, titled "Interdisciplinary Treatment Plan (ITP), last revised 10/06, specifies on page 2: Item A3: "Within 72 hours (3 days) of admission, the interdisciplinary treatment team shall further develop the patient's treatment plan based on a comprehensive assessment of the patient's presenting problems, physical health, emotional, social and behavioral status." Item A4: "At least every 7 days, the Treatment Plan shall be reviewed and updated. Treatment plan reviews /updates shall include the following steps as appropriate: a. Review of progress towards goals and effectiveness of interventions for each active problem on the Master Problem List." Policy PC #224 also states on page 3: Item 4: "The Interdisciplinary Treatment Plan (MTP) Update Form will be completed at least every 7 days" and Item 4a: "It is the responsibility of the Social Services staff to go over the treatment plan with the patient and obtain his/her signature, or document that the patient could not, or refused to, sign."

2. The facility's Master Treatment Plan (MTP) form includes a face page with the following notation at the bottom of the page: "The following assessment data was reviewed and incorporated into this patient's individualized plan of care: Initial medical screening, nursing assessment (including risk assessment), history and physical, psychosocial, initial psychiatric eval. (evaluation)." This notation is followed by lines for the signatures of the interdisciplinary team (social services, MD, AT and nursing) and the "Initial Treatment Team Date."

B. Record Review

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11). The date of the initial treatment team meeting was not specified on the plan; thus it was not possible to determine whether all assessments had been completed when the MTP was developed. The treatment plan review/update sheet of 4/21/11 failed to document the patient's progress toward the treatment goals, and did not include any staff or patient/family signatures.

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). The initial MTP was signed by the interdisciplinary team on 3/21/11 before completion of the psychosocial assessment (3/23/11). None of the weekly MTP review/update sheets (3/28/11; 4/11/11; 4/18/11) documented patient progress toward the treatment goals.

3. Patient B1 (admitted 2/3/11; last MTP review 4/18/11). The initial MTP was signed by the interdisciplinary team on 4/4/11, before completion of the psychosocial assessment (4/5/11).

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). There were no MD or social services staff signatures on the MTP, and the date of the initial treatment team meeting was not documented on the MTP. Thus, it was not possible to determine whether all assessments had been completed before development of the MTP.

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). The initial MTP was signed by the interdisciplinary team on 4/11/11 (date of admission) before completion of the psychosocial assessment (4/12/11). The MTP review/update sheet for 4/19/11 included no physician signature.

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). The initial MTP was signed by the interdisciplinary team on 4/7/11, before completion of the psychosocial assessment (4/8/11). The MTP review/update sheet for 4/15/11 included no physician or patient/family signatures.

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). The initial MTP was signed by the interdisciplinary team on 4/19/11, before completion of the psychosocial assessment (4/20/11).

8. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). The initial MTP was signed by the interdisciplinary team on 4/1/11, before completion of the psychosocial assessment (4/2/11).

9. Patient E2 (admitted 4/11/11; last MTP review 4/19/11). The initial MTP was signed by the interdisciplinary team on 4/12/11, before completion of the psychosocial assessment (4/14/11).

C. Staff Interviews

In an interview on 4/21/11 at 2p.m., the Director of Nursing acknowledged the above deficiencies in the master treatment plans.

Based on policy and document review, record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that were based on patient strengths (as well as disabilities) for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). The MTPs incorrectly listed external resources, e.g., "supportive family," as patient strengths/assets and/or failed to specify how identified patient strengths/assets would be used to support the inpatient treatment. Failure to identify and incorporate patient strengths in the Master Treatment Plan diminishes the effectiveness of treatment interventions, and can hamper the patient's achievement of treatment goals.

Findings include:

A. Policy/Document Review

1. Facility policy PC #224, titled "Interdisciplinary Treatment Plan" (ITP), revision 10/06, includes the following statement on page 1 under the section Policy: "The treatment plan shall be individualized to meet the patient's unique needs and circumstances as identified through assessment data and patient/family in-put to the extent possible, and shall be appropriate to the patient's needs, strengths, limitations and goals...." "The ultimate responsibility for the development, implementation and the overall treatment planning process shall rest with the physician."

2. The facility's Master Treatment Plan form, also called the Interdisciplinary Treatment Plan, included a check-list of items on page 1 to identify patient strengths/assets. The list also included an item labeled "other" where additional assets/strengths could be written on the form.

B. Record Review

1. There were no patient assets/strengths identified on the MTP or incorporated in the treatment plan or treatment plan revision/update sheets for 5 of the active sample patients: A1 (admitted 4/11/11; last MTP review 4/21/11); A2 (admitted 3/20/11; last MTP review 4/18/11); B2 (admitted 4/13/11; last MTP review 4/21/11); D1 (admitted 4/18/11; MTP 4/19/11) and D2 (admitted 4/12/11; last MTP review 4/21/11).

2. Patient B1 (admitted 4/3/11; last MTP review 4/18/11): The only identified patient strength/asset on the MTP for this patient was "Good ADL's." There was no evidence on the MTP or MTP review/update sheets of how the identified strength was to be used to support the patient's treatment goals.

3. Patient C1 (admitted 4/11/11; last MTP review 4/19/11): One of the identified patient strengths/assets on the MTP was "support of family/friends." This is an external resource, not a patient strength that could be used for inpatient treatment. The MTP also did not include any information about how the support from family/friends would be incorporated into the treatment plan. The only other listed patient strength/asset was "Average or Above Average Intelligence." The treatment plan included no details of how this asset would be used to assist the patient achieve the treatment goals.

4. Patient C2 (admitted 4/6/11; last MTP review 4/15/11): The two strengths/assets checked on this patient's MTP were "support of family/friends" and "stable housing." These were external resources, not patient strengths/assets. There also was no evidence of how the support of family or friends would be utilized to help the patient achieve the inpatient treatment goals.

5. Patient E1 (admission 3/31/11; last MTP review 4/14/11): The only asset/strength checked on the patient's MTP was "Cooperative During Assessment." There were no additional patient strengths/assets written in on the plan or incorporated into the goals or interventions.

6. Patient E2 (admission 4/11/11; last MTP update 4/19/11): Assets/strengths checked on the patient's MTP were "Support of family/friends"; "Past History of Treatment Success"; and "Cooperative During Assessment." There was no information on the plan of how the family and/or friends (external resources) would be included in the patient's treatment or discharge planning. There was no further reference to past treatment success on the plan.

C. Staff Interviews

1. In an interview on 4/21/11 at 9:30a.m., after reviewing the treatment plans for patients C1 and C2, the attending physician, MD1, agreed that the MTPs did not adequately identify and use patient strengths/assets. She also acknowledged the physician's responsibility (as leader of the treatment team) for ensuring complete MTPs.

2. In an interview on 4/21/11 at 2p.m., after reviewing the sample patient's treatment plans, the Director of Nursing (DON) acknowledged that the plans did not include patient assets that had been identified in the assessments.

Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans that identified short term (ST) and long term (LT) goals stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). In addition, the treatment goal identified by patient A1, and documented on the "Patient Statement to Aid in Treatment Planning" form, was not incorporated into the MTP. The Activity Therapy (AT) goals were identical for patients A1, B2, C1, D1, D2 and E2, and were stated as staff goals for the patient's participation in treatment, not specific patient outcome behaviors. Some of the goals for patients D1 and E2 also were unrealistic expectations. Lack of measurable, patient-specific goals hampers the treatment team's ability to measure change in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs. Failure to incorporate the patient's verbalized goals into the treatment plan can result in lack of attention to these goals.

Findings include:

A. Policy Review

The facility's policy PC#224, titled "Interdisciplinary Treatment Plan (ITP)" and last revised on 10/06, states on page 2 under Section B.3. " The Master Treatment Plan shall: "...b. contain long-term goal(s) which identify specific behavior(s) anticipated to be accomplished by the time of discharge" and "c. contain short term goals that are written in behavioral terms and are individualized, specific, measurable, attainable, reasonable and include target dates. The short term goals are stated as 'stepping stones' to the long-term goals(s).

"Policy PC #224, also states on page 2 under Section B.1.:" The 'Statement to Aid in Treatment Planning': the patient will be asked to complete this from [sic] at the time of admission as able and as appropriate to the patient's condition." The form included the following three questions regarding treatment goals: "What goals do you hope to accomplish while you are here? In what ways might our staff be able to assist you in meeting these goals? What has prevented you from achieving your goals in the past?"

B. Record Review

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11) was admitted with an "acute exacerbation of symptoms related to Schizophrenia/Paranoid Type" as noted in the MTP. Symptoms included "decreased sleep," "suicidal ideation," and "depressed mood." The patient also had a seizure disorder. For the problem, "Alteration in Mood: Depressed with Suicidal Ideation," the listed LT goal was "Anxiety is maintained at level at which (pt) feels no need to harm self." This goal was not measurable as stated. The ST goal, "[Pt] will express daily needs to staff" also was not measurable. For the problem, "Seizure Disorder," the LT goal was "[Pt] seizure D/O (disorder) will be sufficiently stabilized." This goal was not measurable as stated. The ST goals were "[Pt] will verbalize understanding of medical recommendations...follow medical recommendations...verbalize understanding of the disease process and ongoing treatment." These goals did not identify the specific knowledge required; thus there was no way to determine whether the goals had been met. The ST goal, "[Pt] will be able to attend/tolerate/participate entire [sic] AT group x 3 consecutive days..." was a staff goal for patient participation in treatment, not a specific patient outcome behavior.

On the "Patient Statement to Aid in Treatment Planning" sheet, for the question "What goals do you hope to accomplish while you are here?" the patient had replied "another place to live." The MTP included an Axis IV diagnosis of "Problems related to social environment." However, the plan did not address this issue, nor did it mention the patient's verbalized goal of obtaining another place to live.

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). The patient was hospitalized for "major depressive D/O and alcohol dependence " as noted on the MTP. For the listed problem "Alteration in Mood-Depressed with Suicidal Ideation," a non-measurable LT goal was "Anxiety is maintained at level at which [Pt] feels no need to harm self." A non-measurable ST term goal was "[Pt] will express daily needs to staff." For the problem "ETOH (alcohol) abuse," a ST goal was "Pt will continue to be monitor [sic] on Q-15 minutes for safety." This is a staff intervention, not a patient outcome behavior. For the problem, "Risk for Self-harm," a ST goal was "Pt will seek out staff as needed when self-harm feelings occur." There is no way to determine whether a patient is sharing his/her feelings; thus the goal was not measurable as stated.

3. Patient B1 (admitted 4/3/11; last MTP review 4/18/11). The patient was diagnosed with "Bipolar" disorder, and according to the MTP, was hospitalized for a "manic episode" with "disorganized thoughts", "suicidal ideation" and "paranoia." For the listed problem, "Altered thought process with SI (suicidal ideation); the LT goal was "[Pt] no longer demonstrates loose associations or tangential thinking." This goal is not measurable as stated. Non-measurable ST goals were: "[Pt] demonstrates ability to communicate needs and wants to staff and peers" and "[Pt] will be able to identify new healthy coping skills with [sic] attending at groups." For the medical problem, "Hypertension," the LT goal was "ongoing"; the ST goal was "demonstrate knowledge and compliance with reduced sodium diet." Neither of these goals was measurable.

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). According to the MTP, the patient was diagnosed with "Schizophrenia" and was hospitalized for "altered thought process" and "assaultive behavior." For the listed problem, "Altered Thought Process," the LT goal was "[Pt] will stabilize on medication that decrease sign [sic] and symptom without harmful side effects..." (non-measurable). The ST goals were "[Pt] will demonstrate ability to communicate needs and wants to staff and peers" and "Pt will be able to identify 2-3 + (positive) coping skills (not specified) to reduce ATP [sic]..." These goals also were not measurable. The LT goals listed for the identified medical problems, "hypertension" and "high blood sugar" also were non-measurable. These included: "Patient's hypertension will be sufficiently stabilized without further complications" and "Patient's blood sugar will remain stable." The ST goals for these problems were non-specific behaviors, e.g. "Pt can identify 1 symptom (not specified) that would warrant further treatment"; "[Pt] will verbalize understanding of medical recommendations (not specified) while hospitalized"; "[Pt] will verbalize knowledge of 3 (illegible) medications." An additional goal, "[Pt] will be able to attend/tolerate entire AT group x 3 conseq. days..." was a staff goal for patient participation in treatment, not a specific patient outcome behavior related to the patient's identified problem(s).

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). The patient was an adolescent admitted for "mood disorder"; "suicidal ideation"; and "anxiety" as noted on the MTP. For the problem, "Altered mood depressed c SI (with suicidal ideation), non-measurable ST goals were "[Pt] will seek out staff when feelings of self harm occur" and "[Pt] will learn 2-3 positive coping skills (not specified) in order to reduce symptoms of depression and SI." For the problem, "Anxiety," the ST goals were "[Pt] will demonstrate a greater sense of control + assurance in own ability to manage anxiety" (non-measurable), and "[Pt] will verbalize recognition that anxiety + worry is excessive + unreasonable." It is not possible to determine whether the patient's feelings are "excessive or unreasonable." This also is a value judgment that is not a useful goal for the patient.

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). According to the MTP, the patient was an adolescent admitted for acute symptoms of "psychotic disorder" (hallucinations) and "depressive disorder." For the listed problem, "Altered thought process," the LT goal was "Stabilize on medication to decrease S/S (signs and symptoms) without harmful S/E (side effects...)" The symptoms and side effects were not specified; thus the goal was not measurable. Two of the ST goals, " Demonstrate ability to communicate needs and wants to staff..." and "...learn 2-3 positive coping skills in order to reduce thoughts of paranoia and delusions" were also non-measureable. ST goals for the listed active medical problems, "constipation"; "nasal congestion"; and "poor po (oral) intake" were "[Pt] will verbalize understanding of medical recommendations" and "[Pt] will follow recommendations of medical staff." The specific recommendations were not documented, so the goals were not measurable. An additional patient goal, "Pt will be able to attend, participate + tolerate the entire AT grp (group) x 3 consec. (consecutive) days" was a staff goal for patient participation in treatment, not a specific outcome related to the patient's identified psychiatric problem. This goal also was identical to the AT goal for patients A1 and B2 above.

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). This patient had a history of "Bipolar Disorder" and "Polysubstance Abuse" as noted on the MTP. At the time of admission, he was in an acute manic state with "no sleep for 2 nights"; "hyper-religiosity" and " pressured and tangential speech." For the problem, "Altered Mood-Manic," the LT goal was "[Pt] will receive adequate sleep that facilitates an optimal level of functioning." The hours of required sleep were not specified; thus the goal was not measurable. The ST goals, "[Pt] will demonstrate ability to express ideas in a logical manner..." and [Pt] will be able to identify 3 consequences to manic behaviors (pressured speech; lack of sleep)..." were unrealistic for a patient in a manic state. Another ST goal " [Pt] will stabilize on meds to reduce S/S of mania without S/E..." was not measurable, as the symptoms and side effects were not specified. For the listed medical problems, "Spinal stenosis", "Diverticulosis"; and "hypertension," the LT goal was listed as "[Condition] will be...stabilized..." The symptoms to be observed were not specified, so these goals were not measurable. The ST goals, "[Pt] will verbalize understanding of disease process and ongoing treatment"; "identify symptoms that would warrant further treatment," and "verbalize understanding of medical recommendations" were also not measurable. An additional patient goal, "[Pt] will be able to attend/tolerate/participate entire AT Group x 3 consecutive days..." was stated as a staff goal for the patient's participation in treatment, not a patient outcome to be achieved. This goal was identical to the AT goal for patients A1, B2 and C2 above, despite the patients' different presentations.

8. Patient D2 (admitted 4/12/11; last MTP review 4/21/11). This patient was diagnosed with "Schizophrenia, Paranoid Type," and according to the MTP, was admitted with acute symptoms of paranoia and "out of control" behavior. For the listed problem, "Altered Thought Process," one of the ST goals was "[Pt] demonstrates ability to communicate needs and wants to staff and peers." This goal is not measurable as stated. The goal, "[Pt] will be able to attend/tolerate/participate entire [sic] AT Group x 3 consecutive days..." was a staff goal for patient participation in treatment, not a specific goal for the patient to achieve in the treatment modality. It also was identical to the AT goal for patients A1, B2, C2 and D1 above, despite these patients' different presentations.

9. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). According to the MTP, this patient was hospitalized for acute symptoms of "Major Depressive D/O (Disorder)" and "Recurrent Severe PTSD (Post Traumatic Stress Disorder)." For the listed problem, "Alteration in Mood-Depressed with SI (Suicidal Ideation), the LT goal was "[Pt's] anxiety is maintained at level at which he feels no need to harm self." This goal is not measurable as stated. Non-measurable ST goals were "will express daily needs to staff..." and "[pt] will be able to identify 2-3 + coping skills to reduce depression..." For the problem, "Self-Harm Risk," a non-measurable ST goal was "[Pt] will seek out staff as needed when self-harm feelings occur..." For the listed medical problem, "Pleurisy," the ST goals were "verbalize understanding of medical recommendations", "follow medical recommendations", and "identify symptoms that would warrant further Tx (treatment)..." The medical recommendations and symptoms were not specified, thus the goals were not measurable.

10. Patient E2 (admitted 4/11/11; last MTP review 4/19/11). This patient was admitted to the hospital with acute symptoms of acute psychosis ("delusions and hallucinations"), as noted on the MTP. For the problem, "Altered Thought Process," the LT goal was "Pt. is able to recognize that disorganized thinking and impaired verbal communication occurs at times of increased stress and is able to intervene to interrupt the process." This goal is not measurable as stated; it also is unrealistic for a patient with acute psychotic symptoms. One of the stated ST goals was "Pt. will state understanding of medications, dosages, route and side-effects within 3 days." This was an unattainable goal for a psychotic patient; the required information about the medications also was not specified. Additional ST goals were "Pt will attend & participate appropriately in daily groups" and "[Pt] will be able to participate/tolerate entire AT group x 3 consecutive days" were non-measurable staff goals for the patient's participation in treatment, not specific patient outcomes to be achieved. The AT goal for this patient also was identical to the AT goal for patients A1, B2, C1, D1 and D1 above. The ST goals for the listed medical problems, "epigastric pain" and "constipation," focused on the patient's "understanding" of symptoms and medical recommendations. However, the specific symptoms and medical recommendations were not specified on the treatment plan.

C. Interviews

1. In an interview on 4/21/11 at 9:30a.m., after discussing the treatment plans of sample patient C1 and C2, MD1 (attending psychiatrist) agreed that the goals on the patient's treatment plans were not measurable behaviors that could be used to determine the patients' progress in treatment.

2. In an interview on 4/21/11 at 2p.m., after reviewing the sample patients' treatment plans, the DON agreed that the goals on the treatment plans were not consistently written as measurable and patient-specific goals. The DON stated: "I agree with all you ' re finding."

Based on policy and document review, record review and staff interviews, the facility failed to develop Master Treatment Plans that specified individualized treatment interventions for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). Most of the interventions for the listed psychiatric problems on the plans were generic discipline tasks that included no specified frequency or focus for the listed activities/modalities. The interventions also were identical or very similar for all patients. The master treatment plans lacked physician interventions for the listed psychiatric problems. In addition, the treatment plan for patient D1, hospitalized for an acute manic episode, failed to include any of the preventive (de-escalation) activities that were identified at admission and documented on the "Medical and Behavioral Advance Directives" form. Failure to document specific treatment approaches on patients' treatment plans hampers staff's ability to assure consistency of treatment, and can result in failure to deliver effective interventions.

Findings include:

A. Policy/Document Review

1. The facility's policy PC #224, titled "Interdisciplinary Treatment Plan (ITP)," states on page 2 under Item B.3: "The Master Treatment Plan shall: ...d. have interventions that directly relate to the goals. The interventions must be include [sic] the following components: Action (specific interventions, i.e., group attendance), Frequency...Focus..."

2. The facility's "Medical and Behavioral Advance Directives" form, completed during the admission process, includes a list of activities that can be checked off to indicate things that the patient believes "...can help me regain control of my emotions and behavior" and/or "help me to calm down and feel better" and another list of "situations that can trigger my emotions or behaviors." The directions written on the form explain that the intent of the "Behavioral Advance Directive" is to identify activities/situations that can "assist the treatment team in the development of strategies and approaches to...avoid the use of seclusion and restraint."

A. Record Review

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11). According to the MTP, the patient was hospitalized for an "acute exacerbation of symptoms related to Schizophrenia/Paranoid Type." The MTP listed 3 active psychiatric problems - "mood disorder with suicide ideation"; "seizure disorder"; and "risk for self harm." There were no physician interventions on the MTP for any of these problems. Examples of generic staff interventions were: Nursing -- "staff will give medications as ordered by physician"; "nursing to assess for self-harm thoughts q shift and as needed to establish needed precaution level"; "everyday, encourage [pt] to participate in groups + activities"; "Staff will be alert for signs of increasing agitation so intervention can be employed as early as possible to prevent harm to the pt." Social Work - "SS (social services) staff will meet with pt and encourage pt to attend process group in order to develop positive coping skills in managing stressors." AT - "AT staff will encourage participation in group to help build positive coping skills."

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). According to the MTP, the patient was hospitalized for "major depressive D/O and alcohol dependence." The MTP listed 3 active psychiatric problems - "Alteration in Mood - Depressed with Suicidal Ideation"; "ETOH (alcohol) abuse" and "Risk for Self-harm." There were no physician interventions on the MTP for any of these problems. Examples of generic staff interventions were: Nursing - "Staff will give medication as ordered by physician"; "Nursing to assess [Pt] for self-harm thoughts q shift + as needed to establish needed precaution level"; "Everyday, encourage [Pt] to participate in groups + unit activities"; "RN will monitor VS (vital signs) + physical symptoms to assess detox status q shift"; "Staff will provide education about s/s (signs and symptoms) of withdrawal daily." Social Work - "SS staff will encourage pt to attend group and meet 1:1 with staff in order to develop positive coping skills and manage stressors." AT - "AT staff to engage client daily to help pt. build mood, control and coping skills."

3. Patient B1 (admitted 4/3/11; last MTP review 4/18/11). According to the MTP, the patient was diagnosed with "Bipolar" "disorder" and was hospitalized for a "manic episode" with "disorganized thoughts", "suicidal ideation", and "paranoia." The MTP listed 2 psychiatric problems - "altered thought process with suicidal ideation" and "altered mood - manic." There were no physician interventions on the MTP for either problem. Examples of generic staff interventions were: Nursing - "Staff will monitor pt q 15 mins (minutes) for safety q shift"; "RN will assess pt q shift to determine mental status mood and behavioral status"; "Nursing to assess pt. for self-harm thoughts q shift and as needed to establish precaution level"; "Staff will give medication as ordered." Social Work - "SS staff will encourage pt. to attend at processing group in order to learn new healthy coping skills to reduce her anxiety"; "C/M (Case Manager) meetings to develop new coping skills to use to meet short term goals." AT - "AT staff to engage client daily to help pt. build mood, organization + positive coping skills to deal with mood/pain issues."

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). According to the MTP, the patient was diagnosed with "Schizophrenia" and was hospitalized for "altered thought process" and "assaultive behavior." The MTP listed 2 active psychiatric problems - "altered thought process" and "assaultive behavior." There were no physician interventions on the MTP for either problem. Examples of generic staff interventions were: Nursing -- "Staff will provide frequent, consistent reorientation to topic and situation"; "Staff will talk about concrete reality when pt beg (begins) to verbalize dissociated thoughts." Social Work - "SS staff will provide 1:1 and group intervention to give the opportunity to discuss and gain insight into psychosis"; "SS staff will provide 1:1 and group interaction in order to give the pt. the opportunity to share and gain insight into assaultive Bx (behavior)." AT - "AT staff to engage client daily to help pt. build mood, organization and coping skills."

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). According to the MTP, the patient was an adolescent admitted for "mood disorder"; "suicidal ideation"; and "anxiety." The MTP listed 2 active psychiatric problems - "Altered mood - depressed with Suicidal Ideation" and "Anxiety." The only listed physician intervention to address these problems was "MD to assess mood, mental status and effectiveness of medication." Examples of generic staff interventions on the MTP were: Nursing -- "Encourage [Pt] to seek out staff when feelings of self harm occur"; "RN to assess mood, mental status and [pt's] perception of the effectiveness of medications q shift and prn (as needed) to determine needed precaution level"; "Nursing to administer medications as ordered by the MD"; "Staff will provide diversional activities to assist [Pt] in distraction from worry thoughts." Social Work - "[Provide] process groups daily in order [for Pt] to learn positive coping skills." AT - "AT staff will engage + encourage pt daily to build mood, control and coping skills."

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). According to the MTP, the patient was an adolescent admitted for acute symptoms of "psychotic disorder" (hallucinations) and "depressive disorder." The MTP listed 1 active psychiatric problem - "Altered thought process." There were no physician interventions on the MTP for this problem. Examples of generic staff interventions were: Nursing - "Staff [to] provide frequent, consistent reorientation to time and situation"; "Patient education about illness to promote self-care and prevention of relapse 3 x/week." Social Work - "Staff will work with [Pt] daily in order to use reality testing and coping skills to help pt's functioning in the community." AT - "AT staff will engage + encourage pt daily to help build organization, focus to task + compliance to Tx (treatment).

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). According to the MTP, this patient had a history of "Bipolar Disorder" and "Polysubstance Abuse." At the time of admission, he was in an acute manic state with "no sleep for 2 nights"; "hyper-religiosity" and "pressured and tangential speech." The MTP listed 3 active psychiatric problems - "Altered Mood - Manic", "Aggressive behavior toward others" and "Substance Abuse." There were no listed physician interventions on the MTP for any of these problems. Examples of generic staff interventions were: Nursing - " RN to assess mood, behavioral status and pt. perception of effectiveness of medication q shift every day " ; " Staff will set clear limits on pt's behaviors..."; "Staff will encourage pt to utilize + coping skills and communicate with staff prior to aggression"; "Staff will offer redirection in with least restrictive measures to help pt. cope with feelings"; "Monitor vital signs and physical symptoms to assess withdrawal status and need for as needed (prn) medication on an ongoing basis." Social Work - "SS staff to provide daily groups and 1:1 interactions to encourage development of coping skills." AT - "At staff will encourage participation in group to help build positive mood/coping skills." This patient had completed a "Behavioral Advance Directive" at admission which listed 12 separate activities that would help him calm down when upset. None of these activities were incorporated into the treatment plan, even after the patient became aggressive on the unit on the second day of his hospitalization (4/19/11) and was placed in restraints.

8. Patient D2 (admitted 4/12/11; last MTP review 4/21/11). According to the MTP, this patient was diagnosed with "Schizophrenia, Paranoid Type," and was hospitalized for acute symptoms of paranoia ("out of control behavior"). The MTP listed "Altered Thought Process" as the active psychiatric problem. There was no listed physician intervention on the MTP to address this problem. Examples of generic staff interventions were: Nursing - "Staff will talk about concrete realities when pt. begins to verbalize dissociated thoughts"; "Daily goals and wrap-up group to assist patient in setting productive goals." Social Work - "SS staff to provide daily process groups and 1:1 interactions to encourage development of coping skills." AT - "AT staff will encourage participation in group to help build positive thought/coping skills."

9. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). According to the MTP, this patient was hospitalized for acute symptoms of "Major Depressive D/O (Disorder)" and "Recurrent Severe PTSD (Post Traumatic Stress Disorder)." The MTP listed 2 psychiatric problems - "Altered mood - Depressed with Suicidal Ideation" and "Self Harm Risk." There were no physician interventions on the MTP for either problem. Examples of generic staff interventions were: Nursing - "Staff will give medications as ordered by physician"; "Encourage pt. to participate in groups and unit activities every day." Social Work - "SS staff will provide 1:1 and group intervention daily to give pt. opportunity to share and gain insight into depression"; "SS staff will provide 1:1 and group interventions daily in order to give the pt. opportunity to share and gain insight into self-harm Bx (behavior)." AT - "AT staff to lend support, engage and encourage social expression daily to help build mood, coping skills and Tx (treatment) compliance."

10. Patient E2 (admitted 4/11/11; last MTP review 4/19/11). According to the MTP, the patient was admitted to the hospital with acute symptoms of acute psychosis ("delusions and hallucinations"). The MTP listed "Altered Thought Process" as the active psychiatric problem. There were no listed physician interventions on the MTP for this problem. Examples of generic staff interventions were: Nursing - "Staff will talk about concrete realities when pt. begins to verbalize dissociated thoughts"; "On a daily basis, RN assessment to determine suicidality, mood, mental status and pt perception of effectiveness of medications." Social Work - "SS will provide daily process groups & 1:1 to allow pt to verbalize feelings and reality test." AT - "AT staff to encourage expression/participation daily to help pt. build mood, control and coping skills."

B. Staff Interviews

1. In an interview on 4/21/11 at 9:30a.m., Physician MD1 acknowledged the lack of physician interventions on the sample patient's written treatment plans. She also noted that the treatment plans did not adequately reflect the physician ' s actual participation in the treatment planning process.

2. The Medical Director was interviewed on 4/21/11 at 1:30pm. The issue of identifying individualized and specific interventions by the medical staff on treatment plans was discussed and he said he would discuss this with the medical staff.

3. In an interview on 4/21/11 at 2p.m., the patient treatment plans were reviewed with the Director of Nursing. The DON acknowledged that many of the interventions on the plans were generic tasks rather than individualized interventions for the patients.

4. In an interview on 4/21/11 at 4p.m., the Director of Activity Therapy acknowledged that the AT interventions on the patients' treatment plans were identical or very similar for all patients.

Based on policy review, record review and interview, the facility failed to identify the name of the physician responsible for the MD interventions listed on the Master Treatment Plans of 8 of 10 active sample patients (A1, A2, B1, B2, C1, D1, E1 and E2); the MTPs for the other 2 sample patients (C2 and D2) listed no physician names for any of the interventions on the plans. All of the sample patient's MTPs named multiple RNs, LPTs, and MHTs (Mental Health Technicians) for the listed nursing interventions, without differentiation of their roles or work shifts, so it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered. These failures can result in diffusion of responsibility, lack of staff accountability, and potentially, failure to deliver all required interventions to meet patients' identified needs.

Findings include:

A. Policy Review

The facility's policy #224, titled "Interdisciplinary Treatment Plan (ITP), dated 10/06, includes the following statement on pages 2-3: Item B.3.d. "...The interventions must include the following components:...the names (s) and discipline of the specific staff member responsible for the provision of the intervention."

B. Record Review

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11). This patient had a history of falls during seizures. The MTP did not include the name of the physician responsible for the listed MD intervention for "fall prevention" management. One RN and 4 MHTs were named as the responsible persons for the other 9 checked fall prevention interventions, with no differentiation of their responsibilities.

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). The MTP included the medical problems, "Pain" due to a "dislocation of the right shoulder" (injury prior to hospitalization), and "Asthma." The MTP did not include the name of the physician responsible for the listed MD interventions for these problems. Six RNs and 6 MHTs were named as the responsible persons for the nursing staff interventions for pain management; 5 RN and 5 MHT names were listed for the nursing interventions for Asthma control.

3. Patient B1 (admitted 4/3/11; last MTP review 4/18/11). The MTP included no staff names or disciplines for the listed interventions problem #2: "Hypertension." There was no physician name identified for the listed MD intervention for the problem "Chronic Pain." Five RNs and 3 MHTs names were listed for the 6 checked nursing interventions for this problem, with no differentiation of their individual responsibilities.

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). The MTP included no physician name for the listed MD intervention for problem #3: "Hypertension." Six RNs and 3 MHTs names were listed for the 9 checked nursing interventions. Five RN and 3 MHT names were listed for the hand-written interventions for problem #4: "History of Elevated Blood Sugar" with no differentiation of their specific roles.

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). The MTP included no physician name for the listed MD intervention for the medical problem "Hypothyroidism." For this problem, there were 6 RN and 2 LPN names listed for the 4 nursing interventions. The MTP listed 6 RN, 1 LPT, and 4 MHT names for the 3 problem #1: "Mood Disorder" interventions, and 5 RN, 2 LPT, and 2 social worker names for the 2 listed interventions for "Anxiety." The staff names were not associated with any specific intervention, so it was not possible to determine who was responsible for each intervention on the various work shifts.

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). The MTP listed multiple RN, LPT, and MTP names as responsible persons for the nursing interventions for the medical problems "Constipation"; "Insomnia"; Nasal Congestion" and "Poor po (oral) intake." Thus, it was not possible to ascertain who was responsible for what specific intervention. There were no physician names listed for any of the interventions on the MTP.

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). For the problem "Altered Mood-Manic," the MTP listed the names of 4 RNs, 1 LPT, 3 MHTs and 1 MD as responsible for the 2 listed "staff" interventions, with no differentiation of their specific responsibilities. For the problem "Aggressive Toward Others," 5 RNs, 3 LPTs, and 7 MHT were listed for 3 "staff" interventions. There were also multiple RN and MHT names for the listed interventions for "Substance Abuse"; "Spinal Stenosis"; "Diverticulosis" and "HTN (hypertension)." There was no physician name for the listed MD intervention for the patient's hypertension.

8. Patient D2 (admitted 4/12/11; last MTP review 4/21/11). There were multiple RN, LPT, and MTP names as responsible persons for the 7 interventions to address problem #2: "Obesity." It was not possible to determine which staff was responsible for each of the interventions. There were no physician names for any of the interventions on the plan.

9. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). The MTP listed multiple RN and MHT names as responsible persons for the interventions to address the psychiatric problems, "Alteration in Mood-Depressed with Suicidal Ideation" and "Self-harm Risk" with no differentiation of their roles or work shifts. There were no physician names for the MD interventions listed for the problems, "Fall Risk" and "Nausea."

10. Patient E2 (admitted 4/11/11; last MTP 4/19/11). The MTP included no physician names for the listed MD interventions to address the medical problems "Headache"; "Epigastric pain" or "Asthma." There were multiple RN and MHT names listed for the interventions related to these problems; however, it was not possible to determine which staff was responsible for each intervention.

B. Interview

In an interview on 4/21/11 at 9:30a.m., after reviewing and discussing the treatment plans for sample patients C1 and C2, physician MD1 acknowledged that the interventions on the patients' MTPs were not assigned to specific staff. She stated that that needed to be corrected.

Based on record review and interview, it was determined that the Director of Nursing (DON) failed to ensure the quality of nursing input in the development of Master Treatment Plans (MTPs) for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). Specifically, the DON failed to ensure that:

I. The MTPs for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2) clearly specified nursing interventions to address the patient's individual treatment needs. The nursing interventions for most of the listed problems on the plans were generic nursing tasks that included no specified frequency or focus. The interventions also were identical or very similar for all patients. Failure to document specific treatment approaches on patients' treatment plans hampers staff's ability to assure consistency of treatment, and can result in failure to deliver effective interventions.

II. The MTPs for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2) clearly identified the names of nursing staff responsible for nursing interventions on the treatment plans. The sample patient's MTPs named multiple RNs, LPTs, and MHTs (Mental Health Technicians) for the listed nursing interventions, without differentiation of their roles or work shifts, so it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered. This deficient practice can result in diffusion of responsibility, lack of staff accountability, and potentially, failure to deliver all required interventions to meet patients' identified needs.

Findings include:

A. Lack of Individualized Nursing Interventions on MTPs

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11). According to the MTP, the patient was hospitalized for an "acute exacerbation of symptoms related to Schizophrenia/Paranoid Type." Examples of generic nursing interventions were: "staff will give medications as ordered by physician"; "nursing to assess for self-harm thoughts q shift and as needed to establish needed precaution level"; "everyday, encourage [pt] to participate in groups + activities"; "Staff will be alert for signs of increasing agitation so intervention can be employed as early as possible to prevent harm to the pt."

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). According to the MTP, the patient was hospitalized for "major depressive D/O and alcohol dependence." Examples of generic nursing interventions were: "Staff will give medication as ordered by physician"; "Nursing to assess [Pt] for self-harm thoughts q shift + as needed to establish needed precaution level"; "Everyday, encourage [Pt] to participate in groups + unit activities"; "RN will monitor VS (vital signs) + physical symptoms to assess detox status q shift"; "Staff will provide education about s/s (signs and symptoms) of withdrawal daily."

3. Patient B1 (admitted 4/3/11; last MTP review 4/18/11). According to the MTP, the patient was diagnosed with "Bipolar" disorder" and was hospitalized for a "manic episode" with "disorganized thoughts", "suicidal ideation", and "paranoia." Examples of generic nursing interventions were: "Staff will monitor pt q 15 mins (minutes) for safety q shift"; "RN will assess pt q shift to determine mental status mood and behavioral status"; "Nursing to assess pt. for self-harm thoughts q shift and as needed to establish precaution level"; "Staff will give medication as ordered."

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). According to the MTP, the patient was diagnosed with "Schizophrenia" and was hospitalized for "altered thought process" and "assaultive behavior." Examples of generic nursing interventions were: "Staff will provide frequent, consistent reorientation to topic and situation"; "Staff will talk about concrete reality when pt beg (begins) to verbalize dissociated thoughts."

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). According to the MTP, the patient was an adolescent admitted for "mood disorder"; "suicidal ideation"; and "anxiety." Examples of generic nursing interventions were: "Encourage [Pt] to seek out staff when feelings of self harm occur"; "RN to assess mood, mental status and [pt's] perception of the effectiveness of medications q shift and prn (as needed) to determine needed precaution level"; "Nursing to administer medications as ordered by the MD"; "Staff will provide diversional activities to assist [Pt] in distraction from worry thoughts."

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). According to the MTP, the patient was an adolescent admitted for acute symptoms of "psychotic disorder" (hallucinations) and "depressive disorder." Examples of generic nursing interventions were: "Staff [to] provide frequent, consistent reorientation to time and situation"; "Patient education about illness to promote self-care and prevention of relapse 3 x/week."

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). According to the MTP, this patient had a history of "Bipolar Disorder" and "Polysubstance Abuse." At the time of admission, he was in an acute manic state with "no sleep for 2 nights"; "hyper-religiosity" and "pressured and tangential speech." Examples of generic nursing interventions were: "RN to assess mood, behavioral status and pt. perception of effectiveness of medication q shift every day"; "Staff will set clear limits on pt's behaviors..."; "Staff will encourage pt to utilize + coping skills and communicate with staff prior to aggression"; "Staff will offer redirection in with least restrictive measures to help pt. cope with feelings"; "Monitor vital signs and physical symptoms to assess withdrawal status and need for as needed (prn) medication on an ongoing basis."

8. Patient D2 (admitted 4/12/11; last MTP review 4/21/11). According to the MTP, this patient was diagnosed with "Schizophrenia, Paranoid Type," and was hospitalized for acute symptoms of paranoia ("out of control behavior"). Examples of generic nursing interventions were: "Staff will talk about concrete realities when pt. begins to verbalize dissociated thoughts"; "Daily goals and wrap-up group to assist patient in setting productive goals."

9. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). According to the MTP, this patient was hospitalized for acute symptoms of "Major Depressive D/O (Disorder)" and "Recurrent Severe PTSD (Post Traumatic Stress Disorder)." Examples of generic nursing interventions were: "Staff will give medications as ordered by physician"; "Encourage pt. to participate in groups and unit activities every day."

10. Patient E2 (admitted 4/11/11; last MTP review 4/19/11). According to the MTP, the patient was admitted to the hospital with acute symptoms of acute psychosis ("delusions and hallucinations"). Examples of generic nursing interventions were: "Staff will talk about concrete realities when pt. begins to verbalize dissociated thoughts"; "On a daily basis, RN assessment to determine suicidality, mood, mental status and pt perception of effectiveness of medications."

11. In an interview on 4/21/11 at approximately 2p.m., the patient treatment plans were reviewed with the Director of Nursing. The DON acknowledged that many of the interventions on the plans were generic tasks rather than individualized interventions for the patients.

B. Failure to Clearly Identify Nursing Staff Responsible for Interventions on the MTPs

1. Patient A1 (admitted 4/11/11; last MTP review 4/21/11). This patient had a history of falls during seizures. One RN and 4 MHTs were named as the responsible persons for 9 checked fall prevention interventions on the MTP, with no differentiation of their responsibilities.

2. Patient A2 (admitted 3/20/11; last MTP review 4/18/11). The MTP included the medical problems, "Pain" due to a "dislocation of the right shoulder" (injury prior to hospitalization), and "Asthma." Six RNs and 6 MHTs were named as the responsible persons for the nursing staff interventions for pain management; 5 RN and 5 MHT names were listed for the nursing interventions for Asthma control.

3. Patient B1 (admitted 4/3/11; last MTP review 4/18/11). Five RN and 3 MHT names were listed for the 6 checked nursing interventions for the problem, "Hypertension," with no differentiation of their individual responsibilities.

4. Patient B2 (admitted 4/13/11; last MTP review 4/21/11). The MTP included the names of 6 RNs and 3 MHTs for the 9 checked nursing interventions for "Hypertension." Five RN and 3 MHT names were listed for the interventions for "History of Elevated Blood Sugar," with no differentiation of their specific roles.

5. Patient C1 (admitted 4/11/11; last MTP review 4/19/11). For the problem, "Hypothyroidism" 6 RN and 2 LPN names were listed for the 4 nursing interventions. The MTP also listed 6 RN, 1 LPT, and 4 MHT names for the "Mood Disorder" interventions, and 5 RN and 2 LPT names for the 2 listed "Anxiety" interventions." The staff names were not associated with any specific intervention, so it was not possible to determine who was responsible for each intervention on the various work shifts.

6. Patient C2 (admitted 4/6/11; last MTP review 4/15/11). The MTP listed multiple RN, LPT, and MTP names as responsible persons for the nursing interventions for the medical problems "Constipation"; "Insomnia"; "Nasal Congestion" and "Poor po (oral) intake." Thus, it was not possible to ascertain who was responsible for what specific intervention.

7. Patient D1 (admitted 4/18/11; MTP 4/19/11). For the problem "Altered Mood-Manic," the MTP listed the names of 4 RNs, 1 LPT, 3 MHTs as nursing staff responsible for the 2 listed interventions, with no differentiation of their specific responsibilities. For the problem "Aggressive Toward Others," 5 RN, 3 LPT, and 7 MHT names were listed for the 3 "staff " interventions. There were also multiple RN and MHT names for the listed interventions for "Substance Abuse"; "Spinal Stenosis"; "Diverticulosis" and "HTN (hypertension)."

8. Patient D2 (admitted 4/12/11; last MTP review 4/21/11). There were multiple RN, LPT, and MTP names listed as responsible persons for 7 interventions to address the problem, "Obesity." It was not possible to determine which staff was responsible for each of the interventions.

9. Patient E1 (admitted 3/31/11; last MTP review 4/14/11). The MTP listed multiple RN and MHT names as responsible persons for the interventions to address the psychiatric problems, "Alteration in Mood-Depressed with Suicidal Ideation" and "Self-harm Risk" with no differentiation of their roles or work shifts.

10. Patient E2 (admitted 4/11/11; last MTP 4/19/11). There were multiple RN and MHT names listed for the interventions related to the patient's medical problems, "Headache"; "Epigastric Pain" and "Asthma." Thus, it was not possible to determine which staff was responsible for each intervention.

11. In an interview on 4/21/11 at approximately 2p.m., after reviewing and discussing the treatment plans for the sample patients, the DON acknowledged that the nursing interventions on the patients' MTPs were assigned to multiple staff rather than to the person(s) with the primary responsibility for ensuring that the interventions were carried out.

Based on record review and interview, the Director of Social Services failed to ensure that Social Work Assessments for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2) addressed the anticipated role of the Social Worker in treatment and discharge planning. (Refer to B 108).

The Interim Director of Social Services was interviewed on 4/21/11 at 2:35PM. She agreed that the psychosocial assessment should be more than a checklist and that the role of the SW in the assessment should be more specific and complete.