HospitalInspections.org

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

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated multidisciplinary care; potentially resulting in patient's treatment needs not being met. Specifically, the facility failed to:

A. Ensure that the written Treatment Plans included treatment goals described in observable and measurable terms and based on the problems identified for treatment. This deficiency results in Treatment Plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients and creates the potential that the Treatment Plan will fail to address patient needs during hospitalization and at discharge. (Refer to B121)

B. Develop individualized Treatment Plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplish treatment goals. This deficiency potentially results in staff being unable to provide consistent and focused active treatment. (Refer to B122)

C. Ensure the name and discipline of the staff persons responsible were identified for each intervention listed on the Master Treatment Plans (MTPs). This failure has the potential to result in the patient and other staff being unaware of which staff person is assuming responsibility for the intervention being implemented and documented. (Refer to B123)

II. Ensure that registered nurses, psychologists, and social workers adequately documented active treatment interventions assigned on the Master Treatment Plan and listed on unit schedules. The facility failed to show detailed and comprehensive information about attendance and non-attendance in active treatment sessions for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the Treatment Plan when the patient did not respond to treatment interventions. (Refer to B124)

III. Ensure that adequate active treatment measures and care were provided for three (3) of eight (8) active sample patients (A6, B3, and B23) to move these patients to a higher level of functioning. Specifically, these patients were unwilling or not motivated to attend or participate in active treatment groups. In addition, the Master Treatment Plans (MTPs) were not revised to reflect alternative treatment measures to assist patients to achieve treatment goals. Failure to provide active treatment in addition to psychopharmacology and at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement. (Refer to B125-I)

IV. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) non-sample active patients (C3 and C5) and one (1) discharged patient (C4) whose records were reviewed for seclusion and restraint episodes. Specifically, the facility failed to ensure adequate documentation of comprehensive face-to-face assessments with all of the required components. Also, the facility failed to revise the Master Treatment Plan to include goals and modalities to address aggressive behaviors after episodes of restraint. Failure to conduct a comprehensive face-to-face assessment of the patient's psychological and physiological status potentially results in inadequate information to determine whether other factors such as medication side effects or medical problems may have led to the patient's aggressive behavior. (Refer to B125-II)

V. Ensure that (RNs) assigned to conduct the 1-hour face-to-face assessments were provided comprehensive training to ensure competency to complete physical and behavioral evaluations after episodes of restraint or seclusion. Specifically, all trained registered nurses (RNs) at the facility were considered to be qualified to complete the one-hour face-to-face assessment in place of a Licensed Independent Practitioner (LIP) or physician. The lack of an adequate and comprehensive RN training program results in a failure to ensure that patients who experience episodes of restraint are appropriately evaluated to determine their physical as well as psychological status after the use of a restraint procedure. (Refer to B125-III)

Based on record review and staff interview the facility failed to provide individualized patient related goals (Long-Term Goals, Short-Term Goals and Objectives as called by facility) that were patient-specific and were stated in measurable, observable and behavioral terms for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Computer generated goals and objectives were similar or the same for these eight (8) of eight (8) sample patients, and although stated as patient goals they were staff expectations or treatment compliance issues. Four of eight active sample patients (A6, A9, B3, and B18) had the concurrent problem of substance use and all of them had identical short-term goals and objectives listed on their Master Treatment Plans. This failure hinders the ability of the treatment team to measure the change in the progress of the patients as a result of treatment interventions and may contribute to a failure of the team to modify plans in response to patient needs resulting in prolonged hospitalizations.

Findings include:

A. Record Review

1. Patient A6 admitted on 3/12/18 with a diagnosis of Major Depressive Disorder, Recurrent and Unspecified Cannabis Related Disorder in the Master Treatment Plan (MTP) was signed by the MD on 3/14/18. This MTP included a Long-Term Goal of: "Upon discharge, I will have zero intent to harm myself"; Short-Term Goal: "I will reduce intent to harm myself to zero within 5 to 7 days as evidence by not exhibiting any self-harming behaviors, verbalizing a minimum of one new coping skill and not having thoughts of harming self"; Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will develop and display 3 coping mechanisms to redirect impulse to harm myself."

For the problem of substance abuse, the MTP included a Long-term goal of: "Upon Discharge, I will no longer depend on marijuana and alcohol." Short-term goal included: "I will learn the negative effects of Substance abuse on my mental and physical health within 5 to 7 days." Objective included: "I will attend all offered Substance Abuse groups weekly. I will develop and display 2 coping mechanisms to curtail substance use." These treatment goals were not individualized and identical to goal statements for active sample patients B1 and B3 regarding self-harm goals. The treatment goals statements were identical to those goals for active sample patient A9, B3, and B18 for the problem of substance abuse.

2. Patient A9 admitted on 3/14/18 with diagnoses of Major Depressive Disorder, Recurrent and Alcohol Use Disorder in the Master Treatment Plan (MTP) signed by the MD on 3/19/18. This MTP included a Long-Term Goal: "Upon discharge, I will have zero intent to harm others": Short-Term Goal: "I will reduce intent to harm others to zero within 5 to 7 days as evidence by not exhibiting any aggressive behaviors, verbalizing a minimum of one new coping skill and not having thoughts to harm others"; Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will develop and display 3 coping mechanisms to redirect impulse to harm others."

For the problem of substance abuse, the MTP included a Long-term goal: "Upon Discharge, I will no longer depend on marijuana and alcohol." Short-term goal included: "I will learn the negative effects of Substance abuse on my mental and physical health within 5 to 7 days." Objective included: "I will attend all offered Substance Abuse groups weekly. I will develop and display 2 coping mechanisms to curtail substance use."

These treatment goals were not individualized and identical goal statements were included for active sample patients B3 and B18 regarding harm to others. The treatment goals statements were identical to goal statements regarding substance abuse problems for active sample patients A9, B3, and B18.

3. Patient B1 admitted on 3/12/18 with a diagnosis of Unspecified Schizophrenia in the Master Treatment Plan (MTP) was signed by the DO on 3/17/18. This MTP included a Long-Term Goal of: "Upon discharge, I will have zero intent to harm myself; Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goals: "I will reduce intent to harm myself to zero within 5 to 7 days as evidenced by not exhibiting any self-harming behaviors, minimum of one new coping skill and not having thoughts of harming self. I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will display zero responses to intrusive thoughts that lead to danger to myself. I will display zero responses to intrusive thoughts that interrupt daily activities."

These treatment goals were not individualized and identical to goal statements for active sample patients A6 and B3 regarding self-harm. The treatment goals statements were also identical to goal statements for active patients B3, B8, B11 and B23 regarding psychotic symptoms problem.

4. Patient B3 admitted on 11/01/17 with a diagnosis of Schizophrenia in the Master Treatment Plan (MTP) was signed by the DO on 3/21/18. This MTP included a Long-Term Goal of: "Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goal: "I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will display zero responses to intrusive thoughts that interrupt daily activities." Long-term Goals of zero intent to harm self and zero intent to harm others were documented as met.

For the problem of substance abuse, the MTP included a Long-term goal of: "Upon Discharge, I will no longer depend on marijuana." Short-term goal included: "I will learn the negative effects of Substance abuse on my mental and physical health within 5 to 7 days." Objective included: "I will attend all offered Substance Abuse groups weekly. I will develop and display 2 coping mechanisms to curtail substance use." The treatment goals statements were identical to goal statements of active sample patients B1, B8, B11, and B23 for psychotic symptoms problem. The treatment goals statements regarding substance abuse were identical to those goals for active sample patients A6, B3, and B18.

5. Patient B8 admitted on 1/11/18 with a diagnosis of Schizoaffective Disorder, Bipolar type in the Master Treatment Plan (MTP) [was not signed by MD as of 3/19/18] signed by the Treatment Planning Coordinator on 2/08/18. This MTP included a Long-Term Goal of: "Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goal: "I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will display zero responses to intrusive thoughts that lead to danger to myself. I will display zero responses to intrusive thoughts that interrupt daily activities." The treatment goals statements were identical to those goals for active sample patients B1, B3, B11, and B23.

6. Patient B11 admitted on 1/25/18 with a diagnosis of Schizoaffective Disorder, Bipolar type in the Master Treatment Plan (MTP) [was not signed by MD as of 3/19/18] signed by the Treatment Planning Coordinator on 1/26/18. This MTP included a Long-Term Goal of: "Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goal: "I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will display zero responses to intrusive thoughts that lead to danger to myself. I will display zero responses to intrusive thoughts that interrupt daily activities." These treatment goals statements were identical to those goals for active sample patients B1, B3, B8, and B23.

7. Patient B18 admitted on 3/16/18 with a diagnosis of Bipolar I Disorder in the Master Treatment Plan (MTP) [was not signed by MD as of 3/19/18] signed by the Treatment Planning Coordinator on 3/19/18. This MTP included a Long-Term Goal of: "Upon discharge, I will have zero intent to harm others; Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goals: "I will reduce intent to harm others to zero within 5 to 7 days as evidenced by not exhibiting any aggressive behaviors towards bothers, verbalizing minimum of one new coping skill and not having thoughts of harming others. I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will develop and display 3 coping mechanisms to redirect impulses to harm others." These treatment goals were identical to those goals for active sample patients A9 and B3 regarding harm to others. In addition, the treatment goals statements regarding psychotic problems were identical to those goals for active sample patients B1, B3, B11, and B23.

For the problem of substance abuse, the MTP included Long-term goal: "Upon Discharge, I will no longer depend on Methamphetamines, Marijuana, Heroin, LSD and Shrooms [Psilocybin mushrooms]." Short-term goal included: "I will learn the negative effects of Substance abuse on my mental and physical health within 5 to 7 days." Objective included: "I will attend all offered Substance Abuse groups weekly. I will develop and display 2 coping mechanisms to curtail substance use." These treatment goals statements were identical to goal statements of active patient A9, A6, and B3 for substance abuse problem.

8. Patient B23 admitted on 1/02/18 with a diagnosis of Schizophrenia in the Master Treatment Plan (MTP) [was not signed by MD as of 3/19/18] signed by the Director of Quality Improvement on 2/24/18. This MTP included a Long-Term Goal of: "Upon discharge, my psychotic symptoms will cause no disruption in my ability to function with activities of daily living, eating adequate meals daily and having a viable plan for shelter." Short-Term Goal: "I will be alert and oriented to a minimum of one: Person, Place, Date or Situation and attend to activities of daily living within 5 to 7 days." Objectives: "I will adhere to my medication regimen as prescribed with minimal staff prompting daily. I will attend to activities of daily living with minimal staff prompting daily. I will display zero responses to intrusive thoughts that interrupt daily activities." These treatment goals statements were identical to those goals for active sample patients B1, B3, B8, and B11.

None of the treatment goals above were individualized or written in specific behavioral descriptions regarding what the patient would be doing or saying to show goal attainment. For example, goals related to self-harming behaviors, psychotic symptoms, and attending to activities of daily living were not stated in behavioral terms. Treatment goals regarding the patient adherence to medications were staff expectations or treatment compliance issues.

B. Interview

In an interview with the Director of Nursing DON on 03/21/18 at 12:15 p.m., she agreed that the goals and objectives were generic.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that delineated individualized active treatment interventions to address the specific and unique psychiatric treatment needs for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Instead, MTPs included identical non-specific interventions that were clinical tasks associated with routine discipline functions. Active treatment interventions identified for the registered nurse did not include meeting with the patient in individual or group sessions to assist them in improving their psychiatric symptoms. This deficiency results in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates signed by the MD/DO*in parentheses): A6 (3/14/18); A9 (3/19/18); B1 (3/17/18); B3 (3/21/18); B8 (No MD signature. Signed by the Treatment Planning Coordinator on 2/08/18); B11 (No MD signature. Signed by the Treatment Planning Coordinator on 1/26/18); B18 (No MD signature. Signed by the Treatment Planning Coordinator on 3/19/18); and B23 (No MD signature. Signed by the Director of Quality Improvement on 2/24/18). This review revealed identical deficient intervention statements assigned to the psychiatrist (MD/DO), registered nurse (RN), social worker (SW), psychologist (PsyD.), and occupational therapist (OT). *[The facility reported that the completion date for the MTP was the date the plan was signed by the MD/DO.]

1. Clinical Presentations.

a. Patient A6 was admitted 3/12/18 with a diagnosis of "MDD (Major Depressive Disorder). Recurrent Episode, Severe with Anxious Distress." The MTP included a problem of "Danger to [himself /herself]; secondary to depressed mood ..." " ... Patient reports feeling depressed, hopeless, helpless with ruminating thoughts of killing [himself/herself] 'cutting deep into my veins with a razor ...' Patient has self-medicated in the past with cannabis, alcohol,"

b. Patient A9 was admitted 3/14/18 with a diagnosis of Major Depressive Disorder, Recurrent Episode, Severe. The MTP included a problem of "Danger to others; secondary to depressed mood ..." " ... patient's mother called 911 for assistance due to concerns about patient verbalizing HI [Homicidal Ideation]. Patient reports having insomnia with appetite fluctuating ... feeling paranoid and hypervigilant ... avoid the bullies ... Patient ... gets easily bored, frustrated and agitated causing explosive outbursts when stressed."

c. Patient B1 was admitted 3/12/18 with a diagnosis of "Unspecified Schizophrenia Spectrum and other psychotic disorder." The MTP included a problem of "Danger to [himself /herself]; secondary to altered thought processes." " ... not sleeping or eating catatonic features and delusions ... [H/she] endorses hearing the devil ... says that the devil is mad at [him/her] ... didn't take medications ... missing for 16 hours ... also non-compliant with htn [hypertension] medications ..."

d. Patient B3 was admitted 11/1/17 with a diagnosis of "Schizophrenia." The MTP included the problem: "Gravely Disabled; secondary to altered thought processes." "Patient was taken by [his/her] sister & mother to ...medication clinic for evaluation due to increased 'agitation, threatening, pacing with clenched fists' ...has been non-compliant with [his/her] medications ... has not been sleeping, screaming in the middle of the night and exhibiting self-harm behavior ...

e. Patient B8 was admitted 1/11/18 with a diagnosis of Schizoaffective Disorder, Bipolar type." The MTP included a problem of "MIST [Mentally Incompetent to Stand Trial] - Gravely disabled; secondary to altered thought processes, with mood lability ..." " ... initially arrested for ... Trespass to Injure Property/ Interfere with Business ... Patient had been using the bathroom at Best Buy to bathe ... [S/he] insists that [s/he] should not have been charged with these charges because [s/he] actually owns the Best Buy ... Patient ... believes [s/he] has cancer ... believes [his/her] cancer smells and has taken to wear hats fashioned from toilet paper to prevent [his/her] cancer from recurring."

f. Patient B11 was admitted 1/25/18 with a diagnosis of Schizoaffective Disorder, Bipolar type." The MTP included a problem of "MIST [Mentally Incompetent to Stand Trial] - Gravely disabled; secondary to altered thought processes, with mood lability ..." " ... initially arrested for violating a restraining order initiated by [his/her] father ... [H/she] is delusional ... and insist that [his/her] father 'knows people on the inside ...' therefore was set up to enter prison by [his/her] father..."

g. Patient B18 was admitted 3/15/18 with a diagnosis of "Bipolar 1 Disorder, Current or most recent episode manic, severe." The MTP included a problem of "Danger to others; secondary to mood lability." "Patient presents as aggressive and agitated ... was last on medications three years ago that [h/she] was court ordered to take ... multiple calls made to 911 as the patient attempted to attack a stranger ... Pt. has been arrested multiple times for assault and has been threatening [his/her] family ... is uncooperative, irritable, and agitated."

h. Patient B23 was admitted 1/2/18 with a diagnosis of "Schizophrenia." The MTP included a problem of "Gravely disabled; secondary to altered thought processes, with mood lability ..." "Patient was found mentally incompetent to stand trial ... [S/he] was exhibiting disorganized thinking, e.g. 'I support myself with a W2 from all the screw-ups from back in the day ... the county federal reserve because of Babe Ruth.' [S/he] was perseverating on [Company name] Insurance and her/his] belief that [s/he] owns this company ... believes that [s/he] has $25 million ..."

2. The MTP included the following identical and generic interventions listed for all eight (8) active sample patients despite their different clinical presentations.

a. MD/DO Interventions:

"Assess therapeutic response to treatment 4 times per week for duration of hospitalization for (left blank)." "Prescribe, titrate and monitor medication effectiveness and side effects 4 times per week for duration of hospitalization for (list of medications ordered)." These interventions were all routine MD duties and failed to show individual sessions with each patient to provide information about medications and psychiatric illness.

b. Registered Nurse Interventions:

"Administer medication as prescribed per shift for duration of hospitalization for (list of medications ordered)." "Assess for behaviors that may lead to harm to self and others as needed up to 8 hours per shift for duration of hospitalization." These interventions were all routine RN duties and failed to show individualized sessions with each patient to provide information about medications and psychiatric illness. "Daily education to reinforce coping skills at least once per shift for duration of hospitalization." "Emphasize importance of attending to activities of daily living per shift for duration of hospitalization." These two interventions failed to include a specific focus of coping skills based on each patient's unique psychiatric symptoms or needs. Also, the interventions did not identify whether they would be delivered in group or individual sessions.

c. Occupational Interventions:

"Determine the Functional Level within 3 days [sic] and once per week for duration of hospitalization." 'Encourage participation in structured tasks to combat symptoms of depression daily for duration of hospitalization." The interventions regarding "Functional Level" and "encouraging participation" were routine OT tasks not specific interventions with descriptions of structured tasks based on each patient's unique need. "Educate about the importance of independent performance of activities of daily living via active participation in nutrition, social skills and grooming groups 3 times per week for duration of hospitalization." The latter intervention was non-specific and failed to include a focus of treatment based on each patient's unique psychiatric symptoms or needs.

3. Identical generic social work interventions included the following:

a. Seven active sample patients (A6, B1, B3, B11, B18, and B23) all had the following identical generic social work intervention:

"Collect collateral information during 1:1 sessions 3 times per week for duration of hospitalization."

b. Seven active sample patients (A9, B1, B3, B8, B11, B18, and B23) all had the following identical generic intervention: "Provide 1:1 supportive therapy 3 times per week for duration of hospitalization."

c. Four active sample patients (B3, B8, B11, and B23) all had the following identical generic intervention: "Educate about aftercare services during 1:1 sessions 3 times per week for duration of hospitalization."

These interventions were not individualized, were non-specific, and did not identify a focus of treatment based on each patient's unique psychiatric problems and specific discharge planning and aftercare needs.

4. Identical generic psychologist interventions included the following:

a. Seven active sample patients (A6, B1, B3, B8, B11, B18, and B23) all had the following identical generic interventions: "Provide 1:1 and group cognitive reframing to focus on recognizing and de-emphasizing negative beliefs during 3 sessions for 45 min [minutes] per week for duration of hospitalization for (left blank)." "Provide 1:1 and group Motivational Interviewing to facilitate medication adherence 3 times per week for duration of hospitalization for (left blank)." These interventions were non-specific and did not identify a specific focus of treatment based on the patient's unique psychiatric symptoms or needs.

5. For the problem of "Substance Abuse as evidenced by self-report use of [listed alcohol and other illicit drug used by each patient]," Patient A6, A9, B3, and B18 all had the following identical and generic interventions:

a. MD/DO Interventions:

"Educate about the importance of not mixing prescribed medications with alcohol or illicit substances 4 times per week for duration of hospitalization.

b. Registered Nurse Interventions:

"Encourage patient to attend substance abuse individual and group therapy as appropriate per shift for duration of hospitalization."

b. Psychologist Interventions:

"Conduct 1:1 and group therapy to assist in developing ability to curtail substance abuse 3 times per week for duration of hospitalization." "Conduct 1:1 and group therapy to assist in developing and displaying insight into the negative effects of substance abuse on mental health 3 times per week for duration of hospitalization." These interventions were not individualized, were non-specific, and did not identify a focus of treatment based on each patient's unique substance abuse history and current needs.

e. Social Worker Interventions:

"Educate about substance abuse treatment program for discharge referrals during 1:1 sessions 3 times per week for duration of hospitalization for (left blank)." "Facilitate Substance Abuse Group once per week minimum for duration of hospitalization." "Identify useful community resources to assist with linkage to substance abuse aftercare services during individual sessions 3 times per week for duration of hospitalization." These interventions were not individualized, were non-specific, and did not identify a focus of discharge and aftercare based on each patient's unique substance abuse history and current needs.

B. Interviews

1. During an interview on 3/20/18 at 2:15 p.m., the Director of Occupational Therapy acknowledged that interventions were not individualized or stated in terms that met the individual and unique needs of each patient.

2. During an interview on 3/20/18 at 3:10 p.m., the Director of Nursing concurred that the MTPs did not contain individualized interventions and were routine nursing duties rather than active treatment interventions reflecting meeting with patients in individual or group sessions to meet the individualized needs of the patients.

3. During an interview on 3/21/18 at 9:30 a.m., the Medical Director did not dispute the findings that interventions were routine MD functions. It was noted that there was evidence in progress notes that MDs provided medication education. However, the intervention regarding medication education was not included as a planned intervention on the MTPs.

4. During an interview on 3/21/18 at 9:35 a.m. with the Assistant Director of Psychology, treatment interventions were discussed. He did not dispute the findings that psychology interventions were identical and not based on the unique presenting psychiatric symptoms and needs.


C. Policy Review

The facility's policy titled "Treatment Planning Multidisciplinary" and reviewed "01/2015" stipulated that "The physician provides short-term goals, long term goals, discharge criteria/tentative discharge plan, LOS [length of stay] ... The physician dates and signs the treatment plan." The facility failed to ensure that all MTPs were signed by the physician.

Based on record review and the staff Interview, the facility failed to ensure the name and discipline of the staff persons responsible for the interventions listed on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). This failure results in the treatment team's inability to monitor staff accountability for specific interventions...

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates signed by the MD/DO* in parentheses): A6 (3/14/18); A9 (3/19/18), B1 (3/17/18); B3 (3/21/18); B8 (No MD signature. Signed by the Treatment Planning Coordinator on 2/08/18); B11 (No MD signature. Signed by the Treatment Planning Coordinator on 1/26/18); B18 (No MD signature. Signed by the Treatment Planning Coordinator on 3/19/18); and B23 (No MD signature. Signed by the Director of Quality Improvement on 2/24/18). This review revealed that the facility failed to ensure that the name and discipline of the staff persons responsible for specific interventions were listed on the Master Treatment Plans. All of the interventions had the treatment planning coordinator as the assigned staff for interventions. *[The facility reported that the completion date for the MTP was the date the plan was signed by the MD/DO.]

B. Interview

1. In an interview with DON and PI manager on 3/21/18 at 12:15 p.m., when this deficiency was brought to their attention, DON acknowledged and stated, "It is the computer problem. It does not allow us to put staff responsible."

2. In an interview on 3/21/18, at 9:30 a.m., the Medical Director concurred with the surveyor that MD signature was missing in the Treatment Plans of active patients B8, B11, B18, and B23. She also acknowledged that the staff name and discipline responsible for the interventions was missing in the Treatment Plans of all active sample patients.

C. Policy Review

The facility's policy titled "Treatment Planning Policy number 801" with a review date of 1/2015 under "PROCEDURE FOR COMPLETING TREATMENT PLAN FORMS" stated, "All treatment Team members are responsible for signing and dating the Interdisciplinary Treatment Plan." It also stated that "The physician's signature in the Multidisciplinary Treatment Plan verifies his/her agreement with it." Missing MD signatures in the treatment plans of active patients B8, B11, B18, and B23 violated this policy. This policy did not include a requirement that the treatment providers' discipline must be identified on the treatment plan.

Based on record review and interview, the facility failed to ensure that registered nurses, psychologist, and social workers adequately documented active treatment interventions on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Specifically, documentation did not consistently include the patients' attendance or non-attendance in planned and scheduled active treatment sessions, specific topics discussed, the patients' behavior during the selected interventions, and their response to the interventions, including the level of participation, understanding of the information provided, and specific patient comments, if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patient's condition, and revising the Treatment Plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates signed by the MD/DO* in parentheses): A6 (3/14/18); A9 (3/19/18), B1 (3/17/18); B3 (3/21/18); B8 (No MD signature. Signed by the Treatment Planning Coordinator on 2/08/18); B11 (No MD signature. Signed by the Treatment Planning Coordinator on 1/26/18); B18 (No MD signature. Signed by the Treatment Planning Coordinator on 3/19/18); and B23 (No MD signature. Signed by the Director of Quality Improvement on 2/24/18). This review revealed identical deficient intervention statements assigned to the psychiatrist (MD/DO), registered nurse (RN), social worker (SW), psychologist (PsyD.), and occupational therapist (OT). *[The facility reported that the completion date for the MTP was the date the plan was signed by the MD/DO.]
This review revealed the following findings regarding assigned treatment interventions to psychiatrists (MD), registered nurses (RN), social workers (SW), and activity therapists (AT).

1. Registered Nurse Intervention:

a. All eight active sample patients had identically worded interventions: "Daily education to reinforce coping skills at least once per shift for duration of hospitalization."

b. A review of notes from the electronic medical record 3/13/18 through 3/19/18 were reviewed and revealed that there were limited treatment notes reflecting that the RN provided education regarding coping for these patients. There were only four (4) notes documented: 1. An RN note for Patient A6, dated 3/15/18 at 12:17 p.m., reported: "The patient educated to learn healthy coping and recognize situation that put [him/her] at high risk for safety and impulse control." 2. An LVN note for Patient B8, dated 3/14/18 at 8:07 p.m. reporting "Patient is reoriented to reality and educated on positive coping skills ..." 3. Another note for Patient B8 that documented, " ...educated about the need for positive coping skills ..." 4. An LVN note for Patient B18, dated 3/16/18 at 8:58 p.m. documented, "The patient educated about medications and alternative ways to cope with anxiety and agitation." There was no documentation regarding specific information about what was taught such as, the particular coping skills discussed/taught, the name of medications discussed, and the patient's response to these interventions, including the level of participation, behaviors exhibited, and specific comments, if any, made by the patients during interventions.

c. During an interview on 3/20/18 at 3:10 p.m., the Director of Nursing concurred with the findings that nursing documentation of treatment notes relating to the MTP lacked specific information about participation or non-participation in assigned active treatment interventions. She agreed that there was no information regarding what coping skills were discussed and the patient's response to the intervention. She stated, "We need to write notes similar to those written by psychology."

d. During an interview on 3/21/18 at 1:10 p.m., with RN3, documentation of treatment notes related to the nursing interventions on the Treatment Plan was discussed. RN3 admitted that there were no treatment notes that documented patient education as assigned on the MTP related to coping skills for active sample patient B3.

2. Social Worker Interventions

a. Seven active sample patients (A9, B1, B3, B8, B11, B18, and B23) all had the following identical generic intervention: "Provide 1:1 supportive therapy 3 times per week for duration of hospitalization."

b. Four active sample patients (B3, B8, B11, and B23) all had the following identical generic interventions: "Educate about aftercare services during 1:1 sessions 3 times per week for duration of hospitalization."

c. Five active sample patients (A6, A9, B3, and B18) all had the identically worded interventions: "Educate about substance abuse treatment program for discharge referrals during 1:1 sessions 3 times per week for duration of hospitalization for (left blank)." "Facilitate Substance Abuse Group once per week minimum for duration of hospitalization."

d. A review of progress notes from 3/13/18 through 3/19/18 revealed that there were limited treatment notes reflecting that the SW provided the following interventions assigned on MTPs. There were three treatment notes regarding the substance group. 1. One note for Patient A6 dated 3/13/16 for the group held from 12:00 p.m. to 12:45. 2. One note for Patient B8, dated 3/7/18 for a group held from 11:00 a.m. to 11:45 a.m. 3. One note for Patient B11, dated 3/17/18 for a group held from 11:00 a.m. to 11:45 a.m. There were no notes at all for patients A9, B3, and B18 who had substance abuse identified on their MTPs. There was no documented information about patient non-attendance, the number of group contacts, or attempts to provide alternative active treatment interventions when patients refused or missed group treatment sessions.

3. Psychology Interventions:

a. Seven active sample patients (A6, B1, B3, B8, B11, B18, and B23) all had the following identical generic intervention: "Provide 1:1 and group Motivational Interviewing to facilitate medication adherence 3 times per week for duration of hospitalization for (left blank)."

b. A review of treatment notes from 3/13/18 through 3/19/18 revealed no treatment notes reflecting that the above intervention had been implemented. The documentation showed psychologists documented when patients attended groups but failed to document non-attendance in groups. There were no treatment notes for the seven patients above regarding their receiving individual or group sessions reflecting the use of "Motivational Interviewing to facilitate medication adherence." There was no documented information about the number of group contacts or attempts to provide alternative active treatment interventions when patients refused or missed group treatment sessions.

c. During an interview on 3/21/18 at 9:35 a.m. with the Assistant Director of Psychology, treatment notes were discussed. He acknowledged that there were no treatment notes documented regarding medication adherence using m\Motivational Interviewing. He also stated that psychology only documented group treatment notes for patients who attended the group sessions.

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

I. Ensure that adequate active treatment measures and care were provided for three (3) of eight (8) active sample patients (A6, B3, and B23) to move these patients to a higher level of functioning. Specifically, these patients were unwilling or not motivated to attend or participate in active treatment groups. There was an inadequate frequency and intensity of active treatment to assist each patient to achieve goal attainment. Also, there was no consistent documentation in the medical record to show attempts to engage these patients in alternative active treatment measures. Despite, inconsistent or a lack of regular attendance in groups, the Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients to achieve treatment goals. Failure to provide active treatment in addition to psychopharmacology and at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement.

Findings include:

A. Patient A6

1. Patient A6 was admitted on 3/12/18. The patient's Psychiatric Evaluation, dated 3/13/18, documented a diagnosis of "MDD (Major Depressive Disorder). Recurrent Episode, Severe with Anxious Distress." The Psychiatric Evaluation noted that, " ... Patient reports feeling depressed, hopeless, helpless with ruminating thoughts of killing [himself/herself] 'cutting deep into my veins with a razor ...' and was unable to control such impulses ... Patient has self-medicated in the past with cannabis, alcohol ..."

2. During an observation on the Adolescent Unit on 3/19/18 at 12:15 p.m. Patient A6 was in (his/her) bedroom during the time a group titled, "Substance Abuse/Social Skills" conducted by occupational staff, scheduled from 10:00 a.m. to 10:45 a.m. was being held. During another observation on 3/20/18 from 11:30 a.m. to 12:30 p.m., a group titled Substance Abuse (Social Work) scheduled at 12:00 p.m., Patient A6 was reportedly taking a shower. During an interview at 12:10 p.m., the patient stated, "I don't go to groups. I sit in the back and read." When asked if staff come to spend time with (him/her), (h/she) stated, "No one comes to talk to me, just check to see if I am still alive."

3. Patient A1's MTP, signed by MD 3/14/18, included the following interventions to address presenting psychiatric problem of: "Danger to [himself/herself]; secondary to depressed mood ..."

a. MD Intervention: The MTP listed, "Assess therapeutic response to treatment 4 times per week for duration of hospitalization for (list of medications)." "Prescribe, titrate and monitor medication effectiveness and side effects 4 times per week duration of hospitalization for (left blank)."

b. Nursing Intervention: The MTP listed, "Administer medication as prescribed per shift daily for the duration of hospitalization for (list of medications)." "Daily education to reinforce coping skills at least once per shift for duration of hospitalization for (left blank)." "Emphasize importance of attending to activities of daily living per shift daily for duration of hospitalization for (left blank) but listed "14-day Hold (active)."

c. Occupational Therapy Intervention: The MTP listed, "Determine the Functional Level within 3 days [sic] of admission and once per week for duration of hospitalization for Functional level being assessed." "Educate about the importance of independent performance of activities of daily living via active participation in nutrition, social skills and grooming groups 3 times per week for duration of hospitalization for (left blank)."

d. Psychologist Interventions: The MTP listed, "Facilitate identification of precipitants/triggers that lead to hospitalization during 3 1:1 sessions per week for duration of hospitalization." "Provide 1:1 and group cognitive reframing to focus on recognizing and de-emphasizing negative beliefs during 3 sessions for 45 minutes per week for duration of hospitalization for (left blank)." "Provide 1:1 and group Motivational Interviewing to facilitation medication adherence 3 times per week for duration of hospitalization."

e. Social Work Interventions: The MTP listed, "Collect collateral information during 1:1 sessions 3 times per week for duration of hospitalization."

For the problem of, "Substance abuse as evidenced by self-reported use of marijuana and alcohol," the social work interventions included, "Educate about substance abuse treatment program options for discharge referrals during 1:1 sessions 3 times per week for duration of hospitalization for (left blank)." "Facilitate Substance Abuse Group once a week minimum for duration of hospitalization."

4. A review of progress and group/individual treatment notes from 3/13/18 through 3/19/18. [The time and title of the group identified on the unit schedule indicated in bracket]. This review revealed the following findings:

a. MD notes: A progress note dated 3/16/18 reported, "[H/she] is attending and participating in some groups and activities but tends to isolate [himself/herself] from peers & staff ..."

b. Registered Nurse Notes: The review of progress notes by registered nurses consistently documented that the patient was "Isolative" and "remained in room most of the morning." There were no RN treatment notes for interventions assigned on the MTP regarding daily education regarding coping skills.

c. Psychologist Notes: There were three psychology group notes during this period: On 3/13/18 and 3/16.18 [Symptom Management] from 2:15 p.m. to 3:00 p.m. and on 3/15/18 - [Self-Harm] from 12:00 p.m. to 12:45 p.m. There was also one individual note, dated 3/14/18, from 9:00 a.m. to 10:00 a.m. There was no other documented information during this period to reflect contact with the patient to engage [him/her] to provide alternative active treatment measures.

d. Activity Therapy Notes: The occupational therapist progress note, dated 3/20/18, documented that, " ...Pt [Patient] has attended and selectively participated in 0-2 groups per day for a total of 8 OT [8 out of 21 possible sessions per week] ... since 3/17/18 [his/her] overall functional performance has decompensated as [h/she] has been refusing to attend any scheduled groups ..." There were no active treatment measures documented that showed alternative active treatment measures had been offered during this period. Also, there was no documentation as of 3/21/18 that showed that the group leader(s) met or attempted to meet with the patient to discuss the group material provided and the patient's response to these interventions.

e. Social Worker Notes: The review of progress notes by social worker disclosed three notes - One group note 3/13/18 [Substance abuse] from 12:00 p.m. to 12:45 p.m.; two individual sessions on 3/13/18 from 6:17 p.m. - 6:32 p.m. and 3/14/18 from 12:31 - 1:16 p.m. There were no treatment notes regarding educating the patient in individual sessions about substance abuse.

5. The form used to document the location of patients titled, "Care and Observation Record" showed that on 3/21/18, the patient was in [his/her] room during morning and afternoon groups.

6. Despite this documentation of the patient's lack of involvement in active treatment, the MTP was not revised for Patient A6 to include alternatives to the facility's group treatment program or active treatment measures designed to engage the patient in active treatment. There was limited evidence to show attempts to engage this patient in active treatment.

7. In an interview on 3/20/18 at 2:10 p.m. with OT1, the lack of involvement in active treatment by active sample patient A6 was discussed. OT1 did not dispute the findings. [H/she] acknowledged that this patient was not participating in active treatment on the unit. [H/she] stated, "We go to the unit to talk to patients [in individual sessions] when time permits."

B. Patient B3

1. Patient B3 was admitted on 11/ 01/17. The patient's psychiatric evaluation dated on 11/02/17 documented a diagnosis of "Schizophrenia r/o [rule out] SAD [Seasonal Affective Disorder], BSD, r/o Unknown Substance Psychiatric Disorder." The Psychiatric Evaluation noted that the patient was brought to the hospital due to increased "agitation, threatening, pacing" and "responding to internal stimuli."

2. During an observation on the Adult Unit 3/19/18 at 10:30 a.m., Patient B3 was in [his/her] bedroom during the time a group titled "Substance Abuse" was being conducted by a social work staff member from 10:00 a.m. to 10:45 a.m. A total of 10 of 25 patients attended this group. The patients participating in this group included six (6) non-sample patients and three (3) active sample patients [B8, B11, and B18]. No other active treatment measures were scheduled for patients not attending the group session during this period.

3. During another observation on 3/19/18 at 12:50 p.m., a group titled "Symptom Management" scheduled from 12:45 p.m. to 1:30 p.m. was held; Patient B3 was documented as being in [his/her] room. A total of 7 of 25 patients attended this group. The patients attending this group included four (4) non-sample patients (3) active sample patients [B1, B8, and B11]. No other active treatment measures for those patients not attending the group session were scheduled during this period.

4. A review of progress and group/ individual treatment notes from 3/13/18 to 3/20/18 revealed the following findings:

a. MD notes: Progress note dated 3/19/18 at 9:00 documented, "[H/she] tends to attend select group activities with some interaction with [his/her] peers and staff."

b. Nurses Notes: Progress note dated 3/17/18 at 10:30 a.m. revealed "[H/she] is wearing the clothes that [h/she] slept in, when prompted to shower after breakfast to shower this AM [h/she] refused, [h/she] went back to bed after medications and remains asleep." No evidence of documentation of alternative treatment was noted in the medical record.

c. OT Notes: Progress note dated on 3/14/18 revealed "patient has attended 13 out of 25 scheduled OT treatment groups since [his/her] last progress note was written on 3/07/18 .... [his/her] participation has declined this past week." There was no documentation that alternative treatment was provided to the patient when [h/she] refused to go to the groups.

5. During an interview on 3/19/18 at 11:00 a.m., the patient reported to the surveyor that [h/she] did not like to attend groups in the morning. "It was too hot." [H/she] revealed that [h/she] would go to afternoon groups outside. Patient revealed that [h/she] had Level 3 privileges. The DON informed surveyor that Level 3 is the highest privilege level.

7. In an interview on 3/20/18 at 1:45 p.m. with the Director of Activity, she acknowledged that patients refusing to attend groups were at times asked to participate in the group but that no alternative treatment was provided to these patients. She agreed with the surveyor that there was no documentation of the alternative active treatment provided to the sample patient B3.

8. In the treatment planning meeting on 3/20/18 at 10 a.m., while discussing the treatment planning of sample patient B3 who has level 3 privileges, when the surveyor asked how patients were motivated to attend groups, physician 1 responded, "Use the level systems of privileges."

C. Patient B23

1. Patient B23 was admitted on 1/22/18. The patient's Psychiatric Evaluation, dated 1/3/18, documented a diagnosis of "Schizophrenia." The Psychiatric Evaluation noted that, " ... Per 5150, [h/she] was exhibiting disorganized thinking, e.g. 'I support myself with a W2 from all of the screw-ups from back in the day ... the county federal reserve because of Babe Ruth."

2. During an observation on the Adult Unit on 3/19/18 at 10:30 a.m., Patient B23 was in [his/her] bedroom during the time a group titled, "Substance Abuse" was conducted by a social work staff member from 10:00 a.m. to 10:45 a.m. A total of 10 of 25 patients attended this group. The patients attending this group included six (6) non-sample active patients and three (3) active sample patients [B8, B11, and B18]. No other active treatment measures were scheduled for those patients not attending the group session during this period.

3. During an interview at 11:00 a.m., RN2 admitted that several patients did not consistently attend groups and named several patients including active sample patients B3, B12, and B23.

4. During another observation on 3/19/18 at 12:50 p.m., a group titled "Symptom Management" scheduled from 12:45 p.m. to 1:30 pm was held. Patient B23 was documented as being in [his/her] room at that time. During an interview on 3/19/18 at 2:45 p.m., the patient stated, "I'm not interested in groups. Sometimes I go to the afternoon groups." A total of 7 of 25 patients attended this group. The patients attending this group included four (4) non-sample active patients and three (3) active sample patients [B1, B8, and B11]. No other active treatment measures for patients not attending the group session were scheduled during this period

5. During an observation on 3/21/18 at 1:00 p.m., a group titled "Symptom Management" and scheduled from 12:45 p.m. to 1:30 p.m. was held in the group room. Patient B23 was documented as being in [his/her] room. A total of 5 of 22 patients attended this group. The patients attending this group included two non-sample patients and two (2) active sample patient [B8, and B11]. No other active treatment measures for patients not attending the group session were scheduled during this period

6. Patient B23's MTP, not signed by the MD as of 3/19/18 included the following interventions to address presenting psychiatric problem of, "Danger to [himself/herself]; secondary to depressed mood."

a. MD Intervention: The MTP listed, "Assess therapeutic response to treatment 4 times per week for duration of hospitalization for (list of medications)." "Prescribe, titrate and monitor medication effectiveness and side effects 4 times per week duration of hospitalization for (left blank)."

b. Nursing Intervention: The MTP listed, "Administer medication as prescribed per shift daily for the duration of hospitalization for (list of medications)." "Assist in identification, review, and evaluation of negative self-perceptions at least once per shift daily for duration of hospitalization for (left blank). "Daily education to reinforce coping skills at least once per shift for duration of hospitalization for (left blank)." "Emphasize importance of attending to activities of daily living per shift daily for duration of hospitalization for (left blank) but listed "NCS [No Concentrated Sweets] and Low Fat - Diet (active) and 14-day Hold (active)."

c. Occupational Therapy Intervention: The MTP listed, "Determine the Functional Level within 3 days [sic] of admission and once per week for duration of hospitalization for Functional level being assessed." "Educate about the importance of independent performance of activities of daily living via active participation in nutrition, social skills and grooming groups 3 times per week form duration of hospitalization for (left blank)." "Provide purposeful, goal-oriented tasks and activities to build skills in self-awareness, stress management, social skills, and problem-solving during daily group activities per week for duration of hospitalization."

d. Psychologist Interventions: The MTP listed, "Facilitate identification of precipitants/triggers that lead to hospitalization during 3 1:1 sessions per week for duration of hospitalization." "Provide 1:1 and group cognitive reframing to focus on recognizing and de-emphasizing negative beliefs during 3 sessions for 45 minutes per week for duration of hospitalization for (left blank)." "Provide 1:1 and group Motivational Interviewing to facilitation medication adherence 3 times per week for duration of hospitalization." "Provide 1:1 and group supportive treatment to assist reality orientation during 3 sessions per week for 45 minutes for duration of hospitalization for (left blank)." "Provide 1:1 and group therapy to assist in developing and displaying a viable plan for self-care by responding to staff directives and recognizing the necessity to follow through with activities of daily living 3 times per week for duration of hosp [hospitalization] for (left blank).

e. Social Work Interventions: The MTP listed, "Collect collateral information during 1:1 sessions 3 times per week for duration of hospitalization." "Develop and maintain therapeutic relationship by providing resource and opportunity information during individual and group sessions at least 3 times per week for duration of hospitalization." "Educate about aftercare services during 1:1 sessions 3 times per week for duration of hospitalization."

7. A review of progress and group/individual treatment notes from 3/13/18 through 3/19/18 was conducted. [The time and title of the group identified on the unit schedule indicated in bracket]. This review revealed the following findings:

a. MD notes: A progress note dated 3/7/18 at 3:38 reported, "Pt [Patient] encountered today in [his/her] room where [h/she] was sleeping ... Encouraged to attend more groups instead of isolating to [his/her] room ... Remains fixated with delusions that [h/she] is a wealthy millionaire ..."

b. Registered Nurse Notes: The review of progress notes by registered nurses consistently documented that the patient was "Selectively mute & makes no disclosures, isolative and withdrawn to self," "Attended outside groups ... but no interactions and came back inside shortly after," and "Refused to shower and attend group when prompted by staff."

c. Psychologist Notes: There was limited documentation submitted for the period 3/13/18 through 3/19/18 for this patient. One individual note, dated 1/30/18, reported that, " ... The patient did not respond to either attempt to meet with [him/her] ... [h/she] has started attending the occasional group but is not interactive once there ..." There was one [Symptom Management] group note submitted dated 1/16/18, that reported, " ...Patient declined to share [his/her] answers to the group and remained a passive participant."

d. Activity Therapy Notes: The occupational therapist progress note, dated 3/20/18, documented that, " ...Pt [Patient] has attended and selectively participated in 0-2 groups per day for a total of
8 OT [8 out of 21 possible sessions per week] ... since 3/17/18 [his/her] overall functional performance has decompensated as [h/she] has been refusing to attend any scheduled groups ..." There were no active treatment measures documented that showed alternative active treatment measures were offered during this period. Also, there was no documentation as of 3/21/18 that showed that the group leader(s) met or attempted to contact the patient to discuss the group material provided and document the patient's response to these interventions.

e. Social Worker Notes: The review of progress notes by social workers disclosed that there were three notes - One group note 3/13/18 [Substance abuse] from 12:00 p.m. to 12:45 p.m.; two individual sessions on 3/13/18 from 6:17 p.m. - 6:32 p.m. and 3/14/18 from 12:31 - 1:16 p.m. There were no treatment notes regarding educating the patient in individual sessions about substance abuse.

5. The form used to document the location of patients titled, "Care and Observation Record" was reviewed for the period from 3/13/18 through 3/21/18. Patient B23 was documented as being in his/her room or walking in the hallway during scheduled group treatment sessions. These data showed the following findings:

a. From 3/13/18 to 3/19/18, the patient was primarily documented as, "2, 27" (in bed asleep).

b. The patient was only observed for short periods in scheduled active treatment on 3/16/17 and 3/17/18 from 2:30 p.m. to 2:45 p.m. and 3/18/18from 2:15 p.m. to 3:45 p.m. The patient was documented as "11" (OT [Occupational therapy] room) and "12" (RT [Recreational therapy] area).

6. Despite this documentation of the patient's consistent lack of involvement in active treatment, the MTP was not revised to include alternatives to the facility's group treatment program or active treatment measures designed to engage the patient in the psychiatric treatment program. There was limited evidence to show clinical staff's attempts to engage this patient in active treatment.

7. In an interview on 3/20/18 at 3:10 p.m. with the Director of Nursing (DON), the lack of involvement in active treatment by active sample patient B23 and the limited number of patients attending the group sessions on the Adult Unit were discussed. She admitted that this was a concern and that staff always attempt to get patients to go to groups. She did not dispute the findings that there were no planned alternatives provided for patients not attending groups.

II. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) non-sample active patients (C3 and C5) and one (1) discharged patients (C4) whose records were reviewed for seclusion and restraint episodes. Specifically, the facility failed to ensure documentation of a comprehensive face-to-face assessment of the patient's status that included a review of the patient's immediate situation; a statement regarding the patient's response to the seclusion or restraint intervention; an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results if any; and the a statement showing justification to continue or discontinue the restrictive procedure. Also, the facility failed to revise the Master Treatment Plan to include goals and modalities to address aggressive behaviors after episodes of restraint. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects or medical problems may have led to the patient's aggressive behavior. In addition, failure to revise Master Treatment Plans results in patients being hospitalized without adequate interventions for their recovery being provided, potentially delaying their improvement.

Findings include:

A. Document Review

1. Patient C3 was restrained three (3) times during February 2018 - on 2/25/18 at 7:00 a.m. and released at 8:00 a.m. and at 8:50 pm and released at 10:22 pm. The patient was restrained again on 2/26/18 at 9:15 am. and released at 10:45 am. The review of these episodes revealed the following findings:

a. The "Physician Seclusion & Restraint Order Sheet" for the restraint on 2/25/18 at 7:00 am. noted that the patient was restrained for the following behaviors, "Attempt to punch staff attempt to bang hands ... on wall. Screaming ... refusing redirection ..."

The form used to record the one-hour face-to-face evaluation titled, "Licensed Independent Practitioner (M.D.; Ph.D.; RN Supervisor)" documented, "Patient in 4 pt. [point] restraints being monitored ... Patient stated [s/he] had no pain or difficulty breathing ... Patient is calm and quiet with occasionally yelling." This documentation contained limited information about the patient's immediate situation after the use of restraint and did not include an evaluation of the patient's response to the restraint intervention. In addition, there was a limited, but not comprehensive assessment of the patient's medical conditions, including a review of systems especially circulatory and respiratory status, skin integrity, any evidence of injury, and a medication review.

- The section of this form under "Recommendations" noted, "Staff will attempt to move the patient to [his/her] assigned room after assessing for agitation. Patient will be released from restraints and seclusion accordingly." This documentation failed to specify criteria used to continue the restraint procedure given that the documented note stated that the patient was "calm and quiet." The documentation also failed to specify behavioral descriptions to be used to assess agitation.

b. The "Physician Seclusion & Restraint Order Sheet" for the restraint on 2/25/18 at 8:50 pm. noted that the patient was placed in 4-point leather restraints for the following behaviors, "Head banging, punching self, posturing at staff, spitting at staff, threatened to kill staff."

- The form used to record the one-hour face-to-face evaluation titled, "Licensed Independent Practitioner (M.D.; Ph.D.; RN Supervisor)" documented, "Pt. [Patient] is agitated and hyperverbal, demanding to be released from restraints. Pt. refuses to contract for safety @ this time, states, 'as soon as I get out of this I'm going bang my head on the wall.' Pt. began spit [sic] and refused to calm down @ this time." This documentation failed to include a comprehensive assessment of the patient's medical conditions, including a review of systems especially circulatory and respiratory status, skin integrity, vital signs, a review of recent lab results if any, and any evidence of injury, and/or medication review including whether medications were given when patient was restrained.

c. The "Physician Seclusion & Restraint Order Sheet" for the restraint on 2/26/18 at 9:15 a.m. noted that the patient was placed in 4-point leather restraints for the following behaviors, "Ripped off bottom of T-shirt. Tried to strangle [himself/herself]. Refused to change into gowns to maintain safety. Banged head spit [sic]"

- The form used to record the one-hour face-to-face evaluation titled, "Licensed Independent Practitioner (M.D.; Ph.D.; RN Supervisor)" documented, "Client continues to bang head against bed. Fighting restraints. Spitting at staff. Cursing and unable to calm [himself/herself] ... Refused to comply with denial of Rights order for clothes. Attempting to twist [his/her] arm in restraints. Client given emergency injection which staff are [sic] waiting for response." This documentation failed to include a comprehensive assessment of the patient's medical conditions, including a review of systems especially circulatory and respiratory status, skin integrity, vital signs a review of recent lab results if any, any evidence of injury, and medication review including the type and amount of medication(s) given when the patient was restrained.

- The section of this form under "Recommendations" failed to identify the specific behaviors noted that justified continuing the restraint procedure. The documentation also failed to specify behavioral descriptions to be used to "re-assess the continued need for seclusion and restraint."

d. The patient's current MTP, signed by the MD on 3/17/18, and was not revised to reflect episodes of restraint. There was no problem statement that included the patient's aggressive behaviors which resulted in the use of four-point restraints to control these behaviors. There were no goals and interventions written to address non-aggressive behaviors that the patient could use instead of aggression to prevent further use of restrictive procedures.

2. Patient C4 was restrained in 4-point restraints on 2/11/18at 2:35 pm. and released at 3:15 pm. The review of this episode revealed the following findings:

a. The "Physician Seclusion & Restraint Order Sheet" for the restraint on 2/11/18 at 2:35 pm. failed to document descriptions of the behaviors that justified the restraint. This form only noted "a Danger to Others." However, the "Assessment and Behavioral Management Documentation Sheet" completed by the RN reported, "Pt [Patient] threw a chair at staff member and attacked him after."

b. The form used to record the one-hour face-to-face evaluation titled, "Licensed Independent Practitioner (M.D.; Ph.D.; RN Supervisor)" documented "Patient was sitting in the hallway. Suddenly threw a chair simultaneously attacking a male staff ... On face-to-face patient is confused, agitated, fighting restraints. Haldol 5 mg, Ativan 1 mg, Benadryl 50 mg given IM ..." This documentation failed to include a comprehensive assessment of the patient's medical conditions, including a review of systems especially circulatory and respiratory findings/status, skin integrity, vital signs, a review of recent lab results if any, any evidence of injury, and a medication review.

c. The section of this form under "Recommendations" noted, "Continue [sic] S&R. Release when calm. 1:1 observation, offer fluids, ROM, check v/s." This documentation failed to specify behavioral criteria used to recommend the continuation the restraint. The face-to-face documentation also failed to specify criteria and behavioral descriptions for release from the restraint procedure.

d. The patient's current MTP, signed by the MD on 2/14/18, was not revised to reflect the episode of restraint. There was no problem statement that included the patient's aggressive behavior and the use of four-point leather restraints to control this aggressive behavior. There were no goals and/or interventions written to address the aggressive behavior. There were no goals and/or interventions written to address non-aggressive behaviors that the patient could use instead of aggression to prevent further restrictive procedures.

3. Patient C3 was placed in four-point restraints on 3/20/18 at 8:45 am and released at 9:30 am The review of this episode revealed the following findings:

a. The "Physician Seclusion & Restraint Order Sheet" for the restraint on 3/20/18 at 8:45 am noted that the patient was restrained for the following behaviors, " ... banging doors, threatening staff yelling, posturing, psychotic, agitation."

The form used to record the one-hour face-to-face evaluation titled, "Licensed Independent Practitioner (M.D.; Ph.D.; RN Supervisor)" documented, "Unpredictable [sic] Threatening. Yelling [sic] in restraints." This documentation had limited information about the patient's immediate situation after the use of restraint and did not include an evaluation of the patient's response to the restraint intervention. In addition, there was no comprehensive assessment of the patient's medical conditions, including a review of systems especially circulatory and respiratory status, skin integrity, any evidence of injury, and medication review.

- The section of this form under "Recommendations" noted, "Continue Restraints. Will [increase] Zyprexa scheduled for [sic] aggression." This documentation failed to specify criteria used to justify the continuation of the restraint procedure. The documentation also failed to specify behavioral descriptions to be used to assess agitation.

d. The patient's current MTP, signed by the DO on 3/21/18, was not revised to reflect the episode of restraint. The MTP included documentation of behaviors leading to the use of four-point restraints, but did not note any needed change to the MTP. Therefore, there was no updated problem statement reflecting the patient's aggressive behaviors and the use of four-point restraints to control aggressive behaviors. There were no goals and interventions written to address non-aggressive behaviors that the patient could use instead of aggression to prevent further restrictive procedures.

B. Policy Review

The facility's policy titled "Violent Restrain/Seclusion" revised "01/2018" stipulated that, "... A physician or authorized licensed staff member shall see the patient and evaluate the need for restraint or seclusion within one hour after initiation of restraint or seclusion regardless of whether the patient is still in restraint or seclusion. A. The evaluation must include the following: 1. An evaluation of the patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. B. Make appropriate revisions to the patient's treatment plan ..." The facility failed to follow all of these policy requirements.

C. Interviews

1. During an interview on 3/20/18 at pm. with the Nurse Manager, episodes of restraint were reviewed. He acknowledged that the face-to-face assessment did not include a comprehensive face-to-face evaluation with all of the requirement components. He thought that the document for the restraint of Patient C3 on 2/25/18 at 7:00 am met the requirements. However, he did not dispute that this evaluation did not include all of the components of a comprehensive face-to-face evaluation.

2. During an

Based on record review, staff interviews and observations the Medical Director failed to ensure quality and appropriateness of the care provided to the patients. Specifically, the Medical Director failed to:

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's treatment needs not being met. Specifically, the facility failed to:

A. Ensure that the written Treatment Plans included treatment goals that were described in observable and measurable terms and based on the problems identified for treatment. This deficiency results in Treatment Plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients and creates the potential that the Treatment Plan will fail to address patient needs during hospitalization and at discharge. (Refer to B121).

B. Develop individualized Treatment Plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals. This deficiency potentially results in staff being unable to provide consistent and focused active treatment. (Refer to B122).

C. Ensure the name and discipline of the staff person responsible for selected interventions were identified on the Master Treatment Plans (MTPs). This failure has the potential to result in the patient and other staff being unaware of which staff person is assuming responsibility for the intervention being implemented and documented. (Refer to B123)

II. Ensure that adequate active treatment measures and care were provided for three (3) of eight (8) active sample patients (A6, B3, and B23) to move these patients to a higher level of functioning. Specifically, these patients were unwilling or not motivated to attend or participate in active treatment groups. In addition, the Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures for these patients to assist them to achieve treatment goals. Failure to provide active treatment in addition to psychopharmacology and at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement. (Refer to B125-I)

III. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) non-sample active patients (C3 and C5) and one (1) discharged patient (C4) whose records were reviewed for seclusion and restraint episodes. There was a failure to ensure adequate documentation of comprehensive face-to-face assessments with all of the required components. Also, there was a failure to ensure that revision of Master Treatment Plans include goals and modalities to address aggressive behaviors after episodes of restraint/seclusion. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects or medical problems may have led to the patient's aggressive behavior. (Refer to B125-II)

Based on observation, record review, and interview, the facility failed to have a Director of Nursing (DON) to provide adequate oversight to ensure quality nursing services. Specifically, the facility failed to:

I. Ensure that Master Treatment Plans (MTPs) clearly delineated active treatment interventions to address specific patient psychiatric problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). Specifically, Master Treatment Plans (MTPs) included routine and generic nursing functions written as active treatment interventions. These statements included nursing functions such as administering medication and assessing patients. In addition, patient education interventions failed to include whether interventions would be delivered in individual or groups sessions. This deficiency potentially results in nursing staff being unable to provide direction, consistent approaches, and focused active treatment for each patients identified psychiatric problems. (Refer to B122)

II. Ensure that registered nurses, psychologists, and social workers adequately documented active treatment interventions assigned on the Master Treatment Plan and listed on unit schedules. The facility failed to show detailed and comprehensive information about attendance and non-attendance in active treatment sessions for eight (8) of eight (8) active sample patients (A6, A9, B1, B3, B8, B11, B18, and B23). This failure hinders the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the Treatment Plan when the patient did not respond to treatment interventions. (Refer to B124)

III. Ensure that adequate active treatment measures and care were provided by registered nurses for three (3) of eight (8) active sample patients (A6, B3, and B23) to move these patients to a higher level of functioning. Specifically, these patients were unwilling or not motivated to attend or participate in active treatment groups. In addition, the Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients to achieve treatment goals. Failure to provide active treatment in addition to psychopharmacology and at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement. (Refer to B125-I)

IV. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) non-sample active patients (C3 and C5) and one (1) discharged patient (C4) whose records were reviewed for seclusion and restraint episodes. Specifically, the facility failed to ensure adequate documentation of comprehensive face-to-face assessments with all of the required components. Also, the facility failed to ensure revision of the Master Treatment Plan to include goals and modalities to address aggressive behaviors after episodes of restraint. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects or medical problems may have led to the patient's aggressive behavior. (Refer to B125-II)

V. Ensure that (RNs) assigned to conduct the 1-hour face-to-face assessments were provided comprehensive training to ensure competency to complete physical and behavioral evaluations after episodes of restraint or seclusion. Specifically, all trained registered nurses (RN) at the facility were considered to be qualified to complete the one-hour face-to-face assessment in place of a Licensed Independent Practitioner (LIP) or physician. The lack of an adequate and comprehensive RN training program results in a failure to ensure that patients who experience episodes of restraint are appropriately evaluated to determine their physical as well as psychological status after the use of a restraint procedure. (Refer to B125-III)