HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

The governing body failed to ensure that the facility was in compliance with the conditions of participation for Patient Rights, Nursing Service, Physical Environment and Infection Control.

Please see A115, A385, A700, A747

Based on review of credential files, review of medical staff bylaws, rules and regulations, and interview for 12 of 12 credential files, the facility failed to ensure that the staff was appointed by the hospital's governing body and/or failed to ensure that credential files were complete. The findings include:
1. Review of 11 physician and 1 dentist ' s credential files on 12/17/15 identified that the Executive Committee of the Medical Staff Organization, the Governing Body appointed staff between 2/7/14 to 6/23/15, which was prior to the date the facility applied to become a hospital. Interview with the Superintendent on 12/17/15 identified that there were no recent appointment letters to reflect that the staff were appointed to the hospital medical staff. The medical staff bylaws and rules and regulations identified in part the Medical Executive Committee shall review the application for clinical privileges and shall recommend approval or rejection of the application to the governing body for the granting of medical staff membership or rejection thereof.

2. Further review of the 12 credential files identified that all staff was tested for tuberculosis. Although 5 of the 12 credential files had documentation to reflect the applicant did not have any health restrictions, the documentation was from 1996-2007 and the remaining 7 files were lacking documentation to reflect a current physician ' s statement attesting to the applicant ' s physical health. The medical staff bylaws and rules and regulations directed a physician ' s statement attesting to the applicant ' s physical health in regards to their ability to perform their assigned job duties.

The Condition of Participation for Patients Rights has not been met.

Based on observation, review of clinical records, review of facility incident reports, facility policies and procedures and staff interviews related to incidents of self harm, assault, unauthorized leave, and/or destruction of property, the facility failed to maintain patients in a safe environment and failed to address specific patient safety issues based upon individual incidents and/or corresponding safety assessments.

Please see A142 and A144

Based on a tour of the hospital and staff interview, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner as to promote the safety and well-being of patients. The finding includes:


On 12/08/15 during documentation review with the Plant Facilities Engineer 1 and Environment of Care Coordinator it was identified that the facility lacked a collaborative environmental risk based assessment with medical, psychiatric, engineering and infection control assisting. Review of the facility assessment available dated 01/26/15 lacked governing body signoff and/or input to address the breakable windows, non institutional sprinkler heads, patient belongings that could be utilized to harm themselves or others i.e. belts, suspenders, shoe laces, headphones with cords, radios with cords.

Based on observation, review of clinical records, facility incident reports, facility policies and procedures and staff interviews for 3 of 10 sampled patients (Patients # 4, 5 and 25) reviewed for incidents of self harm, assault, unauthorized leave, and/or destruction of property, the facility failed to maintain patient safety and/or develop, implement, and/or review and revise the Interdisciplinary Treatment Plan (ITP) to address specific patient safety issues based upon individual assessments and/or that the assessments were identified on the patients ' Safety Plans. The findings include:

1. Patient #25 was admitted on 1/16/15 with diagnoses of oppositional defiant disorder, mood disorder, post-traumatic stress disorder (PTSD), with behaviors of self-injury. Review of the severity of risk profile noted on the Utilization Review Form dated 10/26/15 identified that the patient was assessed for danger to self: 1.5 = which is not a component of the risk scale and assessed for danger to others: 1.5 = which is not a component of the risk scale. Review of the clinical record identified that on 10/31/15 at 1:45 PM MD #8 observed Patient #25 with a cord around his/her neck and the patient was pulling the cord tightly causing the patient ' s face becoming erythematous over a five (5) minute period, when Patient #25 eventually stopped. MD #8 identified 2 demarcated reddened linear marks around the patient ' s entire neck. Review of the interdisciplinary treatment plan failed to identify Patient #25 ' s self-strangulation/self-harm attempt and did not identify a review or revision for Patient #5 ' s safety interventions. Subsequently, a review of facility documentation and Patient #25 ' s clinical record identified on 11/9/15 at 6:40 PM Patient #25 came out of the bedroom and into the milieu with a head phone cord and a shoelace tied around his/her neck and were cut off. Patient #25 was allowed to return to the bedroom without supervision and " shortly " after, a staff member entered the bedroom and found the patient sitting on the floor, head down, with another set of headphone wires tied around the neck that needed to be cut off and left a reddened area at the site of the cord. Staff again left the patient unsupervised in the bedroom and when staff returned found the patient banging his/her head against a heater in the bedroom causing an area of swelling and broken skin. Following the 11/9/15 incidents, a nursing risk assessment form was completed. However, the assessment draws no conclusion or that interventions were reviewed and/or revised.
Interview with MD #8 on 12/10/15 at 1:16 PM identified that he/she provided close supervision and did not intervene during the 10/31/15 incident. Interview with the Nurse Manager #3 on 12/10/15 at 10:10 AM and the DNS on 12/14/15 at 1:10 PM identified that Patient #25 should have been supervised on 11/9/15 after the first self-strangulation/self-harm attempt and then again after the second attempt.
A facility policy for assessment and reassessment identified in part that the plan of care and evaluation protocols for each discipline is such that each member of the team understands clearly the elements of the youth ' s assessment and it is reflected in the ITP.
A sample review of clinical records and interviews with MD #1 on 12/10/15, BHU Supervisors #1 and #2 on 12/15/15 and Nurse Manager #2 on 12/7/15 identified that a Safety Plan was developed on admission. However, neither the medical nor nursing risk assessments were noted on patients ' Safety Plans.

2. Patient #5 was admitted on 09/14/2015 with diagnoses that included attention deficit hyperactivity disorder (ADHD), PTSD, polysubstance abuse, rule out (R/O) autism spectrum disorder and oppositional defiant disorder. The patient was transferred from a shelter on a 30 day, court ordered, evaluation with a state agency as his/her legally appointed guardian. An initial psychiatric evaluation dated 09/14/15 identified that Patient #5 had approximately 6 previous psychiatric hospitalizations and was referred for evaluation of behavioral disorganization including property damage, substance abuse, and future treatment recommendations. A medical data sheet identified an initial height of six feet two inches and weight of three hundred sixty one pounds. Initial physician ' s orders included standard precautions (every 30 minute observational checks), building mobility status (may not leave the facility building), no take downs or floor holds due to BMI (body mass index) greater than 45.

i. Review of the clinical record identified that Patient #5 exhibited self-injurious behaviors (punching walls, other surfaces, and windows) on 09/15/15, 09/20/15, 09/21/15, and 09/23/15. Additionally, Patient #5 exhibited destruction of property on 09/23/15 when he/she became agitated breaking a staff chair as well as punching a wall requiring a Show of Concern (gathering of staff from other units) for 20 minutes. Patient #5 was noted to have numerous, self-inflicted superficial scratches on his/her left forearm on 09/24/15. A milieu note dated 09/24/15 at 10:00 PM identified that while out in the courtyard adjoining the unit, the patient picked up a large metal bench and attempted to break down the door leading into the unit. An acute nursing note dated 09/24/15 identified that close checks would be conducted until Patient #5 fell asleep and that the treatment team would be notified of self-injurious behaviors in the morning. A physician ' s order dated 09/25/15 at 2:15 PM directed to conduct a room search for unsafe objects. Review of the clinical record failed to identify that close checks and/or a room search were conducted. Review of the Interdisciplinary Treatment Plan (ITP) identified problems of maintaining safe behaviors and learning coping skills for feelings of stress and anger, however, interventions failed to address self injurious behaviors (scratching self and/or destruction of property).

ii. Review of an incident report dated 09/29/15 at 4:15 PM and corresponding physician's orders, progress notes, and milieu notes identified that Patient #5 became agitated and broke off a metal door plate with several screws attached (1.25 inches (in) wide and 8 in long) and began pacing the unit, refusing to give the metal plate to the staff. The patient would not contract for safety. The patient proceeded to the main entrance door and began to strike the glass window panels on the side of the door, chipping away at the glass as well as the window to the kitchen. He/she also attempted to pry off the wooden trim around each window. Carrying the metal plate, the patient kicked open the secure courtyard door, entered the courtyard, threw the metal plate on the roof and returned to the unit. The patient then kicked open the exit door to the exterior of the building, but did not exit the building, instead, he/she again kicked open the courtyard door and retrieved the metal plate from the roof. With staff encouragement, Patient #5 surrendered the metal plate. Review of the clinical record identified that a progress noted was not documented by any discipline regarding this incident until 10/06/15, when an out of sequence acute nursing progress note was documented by RN #2. The patient remained on standard q 30 min observation status with building mobility and no other special precautions and no revisions to the ITP. A work order dated 09/29/15 at 11:15 AM identified that the door leading to the courtyard had been kicked until it broke and no longer fully closed. On 9/30/15 the door closer was replaced using longer screws. A work order dated 09/29/15 at 11:00 PM identified that the metal plate with screws attached on the side of the door was torn off. The plate was replaced with new screws on 09/30/15 at 8:51 PM. Review of work orders identified that repairs were requested on 09/29/15 to both window panels by the side of the main door, as well as one kitchen window that were cracked and chipped. Broken glass and debris was removed from the hallways and bedrooms and temporary plywood was placed over broken windows and new, double laminated glass was ordered to replace the single laminated glass. The work was completed by 09/30/15 at 8:00 AM. The new glass was delivered and installed on 11/12/15.

iii. Review of a Significant Incident Form dated 09/30/15 at 3:15 PM and 5:20 PM documented by supervising nurse, RN #3, identified that Patient #5 became angry without apparent triggers and kicked the exterior door out on the end of the hallway. He/she left the unit and began walking toward the main road outside the facility. The police were notified and the patient was returned to the facility when he/she reached the main road. Upon return to the unit, the patient continued to threaten the staff and broke a metal phone off the wall threatening to use it as a weapon. The police were called for support at 5:20 PM. Review of the clinical record identified that physician's ordered dated 09/30/15 at 3:30 PM directed to administer Thorazine 200 mg one time orally and at 4:30 PM administer Thorazine 100 mg intramuscularly if PO refused. Additional physician's orders dated 09/30/15 at 6:00 PM directed self harm precautions and/assault precautions with q 15 minute checks and unit mobility status for 24 hours. Review of an Emergency Safety Intervention (ESI) for a face up hold (5:15 PM to 5:40 PM), Escort from 5:40 PM to 5:41 PM, and Seclusion from 5:41 PM to 6:15 PM identified that Patient #5 required restraint and seclusion after threatening to harm staff with the metal phone. The patient had banged his/her head on the wall, refused oral medications and presented an immediate danger to him/her and others. Interim Plan of Care included medical observation, self-harm and assault precautions. The staff initiated a face up hold for 25 minutes which was prohibited for this patient due to BMI>45, however, it was validated by a physician and reviewed and approved by the Medical Director. Review of the ITP failed to identify the patient ' s out of control behaviors and destruction of property and failed to indicate a review and/or revision to the plan of care or interventions to address patient safety.
A facility policy for Emergency Safety Interventions included, in part, that the RN will document the interim plan of care on the youth's ITP.

iv. Review of a Report of Incident dated 10/06/15 at 5:40 PM and corresponding ESI identified that Patient #5 was upset when he/she returned from the cafeteria, became agitated and kicked the courtyard door open. He/she ran from the unit and started to throw rocks, breaking 7 courtyard windows and used the glass to cut his/her arms and threaten staff. The police were called 6:00 PM and the patient was escorted from the courtyard into his/her room. After the police left, the patient escalated, and again, began to kick the courtyard door creating a danger to him/her and others as the courtyard was covered with broken glass. With staff support, Patient #5 was placed in locked seclusion in his/her bedroom at 8:05 PM and was released at 8:10 PM as he/she was standing on a desk in the bedroom creating an additional safety risk. The patient continued with agitation and threatening behaviors for an additional 30 min. An interim plan of care included continuation of assault precautions and for the treatment team to discuss any changes to treatment plan. On 10/06/15 at 7:00 PM, MD #5 identified that he had assessed Patient #5 and directed administration of Thorazine 200 mg PO. MD #5 also spoke with the patient's family member who encouraged the staff to call him/he when the patient was agitated or upset as he/she was able to calm the patient. A behavioral consultation was requested on 10/09/15 and a support plan for responding to Patient #5's aggression was developed and implemented on or about 10/21/15 and was not included in the clinical record at time of review. The ITP failed to reflect the option of calling the family member to assist with de-escalation and/or the new support plan. Observation of the courtyard on 12/09/15 at 2:30 PM identified that multiple small rocks/stones were visible and accessible in the spaces between the asphalt and cement blocks. A facility policy for Emergency Safety Interventions included, in part, that the RN will document the interim plan of care on the ESI form and the youth's ITP.

v. Review of a Report of Incident dated 11/05/15 at 7:45 PM and corresponding documentation in the clinical record identified that Patient #5 became was increasingly agitated upon return from a supervised walk with peer. He/she broke a heavy wooden chair and used the leg to break 2 interior kitchen windows. He/she then continued striking the broken windows with both hands, causing lacerations on both arms and the right hand contaminated with shards of glass. RN #4 cleansed the lacerations and notified the on-call psychiatrist and maintenance (to fix windows) and contacted the pediatrician to evaluate the patient ' s injury in the morning. The patient de-escalated with staff support. A physician note (psychiatrist) dated 11/05/15 at 8:15 PM identified that, upon examination of the injuries, the site might have a piece of glass lodged in the wound. Plan included wound care and ice pack on right hand and change status to unit mobility status, assault precautions and every 15 minute checks. A work order completed 11/06/2015 at 7:00 AM identified that the contaminated broken safety glass was vacuumed up and the area was cleaned the night of 11/05/15 and the windows were replaced with Plexiglas to make the area safe. Patients were on the unit during the incident. The ITP failed to reflect the incident of self harm, destruction of property, wound care, assessment of imminent risk and/or change in mobility and/or observational status. Patient #5 was discharged to a Psychiatric Residential Treatment Facility (PRFT) on 11/06/15 at 9:30 AM following safety assessment conducted by the psychiatrist, and MD #6.
Interview with the Superintendent on 12/10/15 identified that in situations of threatened or actual self-harm, assault, or destruction of property he/she would expect the RN to assess the situation for imminent danger to the patient, staff, or property without intimidating or threatening the patient and other patients on the unit should be protected from the emotional and/or physical effects of the patient's behaviors. The staff should not approach the dysregulated patient, physically, until absolutely necessary. The superintendent further identified that this was a very difficult concept to teach and, although the facility and staff have been very successful at reducing the frequency, duration and restrictive features of physical restraint usage, in some situations, staff may need to move in sooner in order to ensure safety.
A facility policy for self-harm precautions identified that any time a youth is observed to engage in self-harming behaviors (an emergency safety situation) and there is imminent (immediate) risk of injury to the youth, it is the responsibility of the staff members to intervene immediately in order to prevent injury.
Review of the facility policy titled Treatment Planning Process identified, in part, that each patient receives a comprehensive interdisciplinary evaluation that serves as the starting point for developing evolving individualized treatment planning and treatment delivery. The plans direct the staff as to what steps should be taken in the evaluation and treatment of the youth. The ITP is reviewed and revised according to the evaluation recommendation. The ITP shall incorporate diagnoses that are actively treated, identify problems to be treated, and address treatment modalities. The ITP will be modified will be modified based on conclusions of the treatment reviews.

3. Patient #4 was admitted to the in-patient adolescent behavioral health facility on 08/21/15 on a thirty day court order with diagnoses that included mood disorder. Review of admission psychiatric evaluation dated 08/24/15 identified a history of auditory hallucinations and self-harm behaviors including cutting of the forearm. Review of a Report of Incident dated 11/05/15 at 7:45 PM and corresponding documentation in the clinical record identified that Patient #4 became was increasingly agitated upon return from a supervised walk with peer. He/she broke a heavy wooden chair and used the leg to break 2 interior kitchen windows. He/she then continued striking the broken windows with both hands, causing lacerations on both arms and the right hand contaminated with shards of glass. A work order completed 11/06/2015 at 7:00 AM identified that the contaminated broken safety glass was vacuumed up and the area was cleaned the night of 11/05/15 and the windows were replaced with Plexiglas to make the area safe.
An acute nursing note dated 11/07/15 at 6:30 AM documented by RN #5 identified that Patient #4 reported that he/she had been walking barefoot on the unit and had gotten a something stuck in his/her foot. Upon examination, an open area with a small amount of bleeding was identified, a small piece of glass was removed and a dressing was placed. RN #5 documented that a peer (Patient #5) had broken on window on the unit on 11/05/15.
Review of a Report of Incident dated 11/13/15 at 10:00 PM identified that Patient #4 stated that he/she had cut his/herself with a piece of glass that he/she had gotten from a peer (Patient #5) earlier in the month. Three superficial 2.5 centimeter scratches were observed on the left side of his/her cheek and the patient surrendered the piece of glass. Notification of guardian, physician, and administrator was not documented. Review of corresponding acute progress notes, physician ' s orders, risk assessment, a milieu notes and ITP identified that the physician and supervisor were notified and a suicidal risk assessment was completed by RN #4 that identified low risk. An interim plan of care was initiated to monitor patient on self harm precautions.
The facility failed to ensure that the broken glass was thoroughly removed from the patient area to prevent further injuries.

The Condition of Participation for Nursing Services has not been met.

Based on review of the clinical records, review of facility policies, review of facility documentation and staff interviews identified that patient admission safety risk assessments failed to reflect that the medical and nursing assessments were analogous (re: self-harm and violence admission risk assessments) and/or that assessment information was identified on the patients' Safety Plans, failed to reflect that the patients' self-harm and violence admission risk assessments were utilized to develop initial treatment plans and/or interdisciplinary treatment plans (ITP) and failed to reflect that ITP's were revised after a change in condition. In addition, the facility failed to ensure adequate Registered Nurse (RN) staffing was immediately available for bedside care
Please see A392, A395, A396

Based on review of facility staffing, unit specific assignment sheets, facility incident report, and interview with the Director of Nursing, the facility failed to ensure adequate Registered Nurse (RN) staffing to be immediately available for bedside care when both RN's assigned to a unit left the unit leaving no RN for a period of time. The findings include:

Patient #17 was admitted on 7/20/15 with diagnoses of PTSD, mood disorder and a history of aggression escalating to homicidal and suicidal ideation with gestures and intent. According to facility documentation of an incident on 7/31/15 Patient #17 was being escorted outdoors by one of two RN's from the unit. While outdoors, Patient #17 began making unsafe statements about jumping in front of a car. The police were called and the patient was escorted back to the unit. While the incident was occurring outdoors, it was identified that there were no licensed nursing staff on the patient unit. Interview with the DNS on 12/9/15 at 1:00 PM and on 12/14/15 at 1:10 PM identified that both RN's assigned to the unit left the unit unattended (1 outdoors with Patient #17 and the other left for a lunch break). The DNS identified that the units were to be staffed at all times with at least one RN and that the assignment sheets for that day were incomplete and that he/she would be looking at this closer in the future.

Based on review of the clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for 7 of 10 patients (Patients #A1, 9, 10, 17, 20 and 25) who were admitted to the hospital, documentation and interviews failed to reflect that the medical and nursing assessments were analogous (re: self-harm and violence admission risk assessments) and/or that assessment information was identified on the patients' Safety Plans. The findings include:

1. Patient A1 was admitted to the hospital on 9/25/15 with PTSD and Bipolar disorder. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 9/25/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 1.0= intermittently acute, and assessed for danger to others: 1.0= intermittently acute. However, the nursing admission risk assessment for self-harm and violence indicated no risk factors.

Review of a sampling of clinical records and interviews with MD #1 on 12/10/15, BHU Supervisors #1 and #2 on 12/15/15 and Nurse Manager #2 on 12/7/15 identified that a Safety Plan was developed on admission. However, neither the medical nor nursing risk assessments were noted on patients' Safety Plans.

2. Patient #9 was admitted to the hospital on 1/22/15 with mood disorder, post-traumatic stress disorder (PTSD) and autism disorder by history. The patient has had multiple inpatient admissions since the age of 5. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 1/22/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 1= intermittently acute. Patient #9 was assessed for danger to others: 0.5 which is not a component of the risk scale. However, the nursing admission risk assessment for self-harm indicated no risk factors and family dysfunction for violence risk.

3. Patient #10 was admitted to the hospital on 7/8/15 with PTSD, major depressive disorder and ADHD. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 7/8/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 2.0= chronic, non-acute and assessed for danger to others: 2.0=chronic, non-acute. However, the nursing admission risk assessment for self-harm noted that the patient verbalized suicide with a plan and history of self-injurious behavior. The violence risk factors noted a history of substance abuse and verbal aggression towards peers.

4. Patient #17 was admitted on 7/20/15 with diagnoses of PTSD, mood disorder and a history of aggression escalating to homicidal and suicidal ideation with gestures and intent. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 7/20/15 identified that the patient was assessed for danger to self: 2.0 = chronic non-acute, and assessed for danger to others: 1.0= intermittently acute. However, the nursing admission risk assessment for self-harm indicated no risk factors. In addition, the patient's safety plan dated 7/20/15 failed to address the patient's history of aggression escalating to homicidal and suicidal ideation with gestures and intent.

6. Patient #20 was admitted on 8/10/15 with diagnoses of PTSD, reactive attachment disorder, sexual and physical abuse towards other child with behaviors of aggression and poor boundaries. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 8/10/15 identified that the patient was assessed for danger to self: 2.0 = chronic non-acute, and assessed for danger to others: 1.5 = which is not a component of the risk scale. The nursing admission risk assessment for risk factors identified a recent history of violence but did not indicate what the nature of the violence. In addition, the patient's safety plan dated 8/10/15 failed to address the patient's history of aggression or violence towards others.

7. Patient #25 was admitted on 1/16/15 with diagnoses of oppositional defiant disorder, mood disorder, PTSD, with behaviors of self-injury. Review of the severity of risk profile noted on the Utilization Review Form dated 10/26/15 identified that the patient was assessed for danger to self: 1.5 = which is not a component of the risk scale and assessed for danger to others: 1.5 = which is not a component of the risk scale. Review of the clinical record identified that on 10/31/15 at 1:45 PM MD #8 observed Patient #25 with a cord around his/her neck and the patient was pulling the cord tightly causing the patient's face becoming erythematous over a five (5) minute period, when Patient #25 eventually stopped. MD #8 identified 2 demarcated reddened linear marks around the patient's entire neck. Review of the interdisciplinary treatment plan failed to identify Patient #25's self-strangulation/self-harm attempt and did not identify a review or revision for Patient #5's safety interventions. Subsequently, a review of facility documentation and Patient #25's clinical record identified on 11/9/15 at 6:40 PM Patient #25 came out of the bedroom and into the milieu with a head phone cord and a shoelace tied around his/her neck and were cut off. Patient #25 was allowed to return to the bedroom without supervision and "shortly" after, a staff member entered the bedroom and found the patient sitting on the floor, head down, with another set of headphone wires tied around the neck that needed to be cut off and left a reddened area at the site of the cord. Staff again left the patient unsupervised in the bedroom and when staff returned found the patient banging his/her head against a heater in the bedroom causing an area of swelling and broken skin. Following the 11/9/15 incidents, a nursing risk assessment form was completed. However, the assessment draws no conclusion or that interventions were reviewed and/or revised.
Interview with MD #8 on 12/10/15 at 1:16 PM identified that he/she provided close supervision and did not intervene during the 10/31/15 incident. Interview with the Nurse Manager #3 on 12/10/15 at 10:10 AM and the DNS on 12/14/15 at 1:10 PM identified that Patient #25 should have been supervised on 11/9/15 after the first self-strangulation/self-harm attempt and then again after the second attempt.

Based on review of the clinical records, review of hospital policies, review of facility documentation and interviews with hospital personnel for 5 (Patients #A1, 5, 9, 10 and 25) of 10 patients admitted admitted to the facility, documentation and interviews failed to reflect that the patients' self-harm and violence admission risk assessments were utilized to develop the patients' initial treatment plans and/or the patients' interdisciplinary treatment plans (ITP) and failed to reflect the patient's ITP was revised after a patient's change in condition. The findings include:


1. Patient A1 was admitted to the hospital on 9/25/15 with PTSD and Bipolar disorder. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 9/25/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 1.0= intermittently acute and assessed for danger to others: 1.0 = intermittently acute. Review of the patient's initial treatment plan failed to reflect the self-harm and violence risks and/or interventions. Review of the patient's ITP failed to reflect the self-harm and violence risk factors with appropriate interventions.

Review of the clinical records and interviews with MD #1 on 12/10/15, BHU Supervisors #1 and #2 on 12/15/15 and Nurse Manager #2 on 12/7/15 identified that a patient Safety Plan was developed on admission along with the initial treatment plan. A patients ' ITP is developed within 2 weeks of admission. Review of the initial treatment plans failed to reflect the admission risk assessments for self-harm and violence. In addition, Patient 1A ' s ITP failed to reflect self-harm and violence risk (noted on the Utilization Review Forms completed every 2 weeks). Interventions including the patients' mobility and precaution status' (to address the risk assessments) were not identified in the ITP's, but were noted in the physician orders.

2. Patient #5 was admitted on 09/14/2015 with diagnoses that included attention deficit hyperactivity disorder (ADHD), PTSD, polysubstance abuse, rule out (R/O) autism spectrum disorder and oppositional defiant disorder. The patient was transferred from a shelter on a 30 day, court ordered, evaluation with a state agency as his/her legally appointed guardian. An initial psychiatric evaluation dated 09/14/15 identified that Patient #5 had approximately 6 previous psychiatric hospitalizations and was referred for evaluation of behavioral disorganization including property damage, substance abuse, and future treatment recommendations. A medical data sheet identified an initial height of six feet two inches and weight of three hundred sixty one pounds. Initial physician's orders included standard precautions (every 30 minute observational checks), building mobility status (may not leave the facility building), no take downs or floor holds due to BMI (body mass index) greater than 45.

i. Review of the clinical record identified that Patient #5 exhibited self-injurious behaviors (punching walls, other surfaces, and windows) on 09/15/15, 09/20/15, 09/21/15, and 09/23/15. Additionally, Patient #5 exhibited destruction of property on 09/23/15 when he/she became agitated breaking a staff chair as well as punching a wall requiring a Show of Concern (gathering of staff from other units) for 20 minutes. Patient #5 was noted to have numerous, self-inflicted superficial scratches on his/her left forearm on 09/24/15. A milieu note dated 09/24/15 at 10:00 PM identified that while out in the courtyard adjoining the unit, the patient picked up a large metal bench and attempted to break down the door leading into the unit. An acute nursing note dated 09/24/15 identified that close checks would be conducted until Patient #5 fell asleep and that the treatment team would be notified of self-injurious behaviors in the morning. A physician's order dated 09/25/15 at 2:15 PM directed to conduct a room search for unsafe objects. Review of the clinical record failed to identify that close checks and/or a room search were conducted. Review of the Interdisciplinary Treatment Plan (ITP) identified problems of maintaining safe behaviors and learning coping skills for feelings of stress and anger, however, interventions failed to address self-injurious behaviors (scratching self and/or destruction of property).

ii. Review of an incident report dated 09/29/15 at 4:15 PM and corresponding physician's orders, progress notes, and milieu notes identified that Patient #5 became agitated and broke off a metal door plate with several screws attached (1.25 inches (in) wide and 8 in long) and began pacing the unit, refusing to give the metal plate to the staff. The patient would not contract for safety. The patient proceeded to the main entrance door and began to strike the glass window panels on the side of the door, chipping away at the glass as well as the window to the kitchen. He/she also attempted to pry off the wooden trim around each window. Carrying the metal plate, the patient kicked open the secure courtyard door, entered the courtyard, threw the metal plate on the roof and returned to the unit. The patient then kicked open the exit door to the exterior of the building, but did not exit the building, instead, he/she again kicked open the courtyard door and retrieved the metal plate from the roof. With staff encouragement, Patient #5 surrendered the metal plate. Review of the clinical record identified that a progress noted was not documented by any discipline regarding this incident until 10/06/15, when an out of sequence acute nursing progress note was documented by RN #2. The patient remained on standard q 30 min observation status with building mobility and no other special precautions and no revisions to the ITP. A work order dated 09/29/15 at 11:15 AM identified that the door leading to the courtyard had been kicked until it broke and no longer fully closed. On 9/30/15 the door closer was replaced using longer screws. A work order dated 09/29/15 at 11:00 PM identified that the metal plate with screws attached on the side of the door was torn off. The plate was replaced with new screws on 09/30/15 at 8:51 PM. Review of work orders identified that repairs were requested on 09/29/15 to both window panels by the side of the main door, as well as one kitchen window that were cracked and chipped. Broken glass and debris was removed from the hallways and bedrooms and temporary plywood was placed over broken windows and new, double laminated glass was ordered to replace the single laminated glass. The work was completed by 09/30/15 at 8:00 AM. The new glass was delivered and installed on 11/12/15.

iii. Review of a Significant Incident Form dated 09/30/15 at 3:15 PM and 5:20 PM documented by supervising nurse, RN #3, identified that Patient #5 became angry without apparent triggers and kicked the exterior door out on the end of the hallway. He/she left the unit and began walking toward the main road outside the facility. The police were notified and the patient was returned to the facility when he/she reached the main road. Upon return to the unit, the patient continued to threaten the staff and broke a metal phone off the wall threatening to use it as a weapon. The police were called for support at 5:20 PM. Review of the clinical record identified that physician's ordered dated 09/30/15 at 3:30 PM directed to administer Thorazine 200 mg one time orally and at 4:30 PM administer Thorazine 100 mg intramuscularly if PO refused. Additional physician's orders dated 09/30/15 at 6:00 PM directed self-harm precautions and/assault precautions with q 15 minute checks and unit mobility status for 24 hours. Review of an Emergency Safety Intervention (ESI) for a face up hold (5:15 PM to 5:40 PM), Escort from 5:40 PM to 5:41 PM, and Seclusion from 5:41 PM to 6:15 PM identified that Patient #5 required restraint and seclusion after threatening to harm staff with the metal phone. The patient had banged his/her head on the wall, refused oral medications and presented an immediate danger to him/her and others. Interim Plan of Care included medical observation, self-harm and assault precautions. The staff initiated a face up hold for 25 minutes which was prohibited for this patient due to BMI>45, however, it was validated by a physician and reviewed and approved by the Medical Director. Review of the ITP failed to identify the patient's out of control behaviors and destruction of property and failed to indicate a review and/or revision to the plan of care or interventions to address patient safety.

A facility policy for Emergency Safety Interventions included, in part, that the RN will document the interim plan of care on the youth's ITP.

iv. Review of a Report of Incident dated 10/06/15 at 5:40 PM and corresponding ESI identified that Patient #5 was upset when he/she returned from the cafeteria, became agitated and kicked the courtyard door open. He/she ran from the unit and started to throw rocks, breaking 7 courtyard windows and used the glass to cut his/her arms and threaten staff. The police were called 6:00 PM and the patient was escorted from the courtyard into his/her room. After the police left, the patient escalated, and again, began to kick the courtyard door creating a danger to him/her and others as the courtyard was covered with broken glass. With staff support, Patient #5 was placed in locked seclusion in his/her bedroom at 8:05 PM and was released at 8:10 PM as he/she was standing on a desk in the bedroom creating an additional safety risk. The patient continued with agitation and threatening behaviors for an additional 30 min. An interim plan of care included continuation of assault precautions and for the treatment team to discuss any changes to treatment plan. On 10/06/15 at 7:00 PM, MD #5 identified that he had assessed Patient #5 and directed administration of Thorazine 200 mg PO. MD #5 also spoke with the patient's family member who encouraged the staff to call him/he when the patient was agitated or upset as he/she was able to calm the patient. A behavioral consultation was requested on 10/09/15 and a support plan for responding to Patient #5's aggression was developed and implemented on or about 10/21/15 and was not included in the clinical record at time of review. The ITP failed to reflect the option of calling the family member to assist with de-escalation and/or the new support plan. Observation of the courtyard on 12/09/15 at 2:30 PM identified that multiple small rocks/stones were visible and accessible in the spaces between the asphalt and cement blocks. A facility policy for Emergency Safety Interventions included, in part, that the RN will document the interim plan of care on the ESI form and the youth's ITP.

v. Review of a Report of Incident dated 11/05/15 at 7:45 PM and corresponding documentation in the clinical record identified that Patient #5 became was increasingly agitated upon return from a supervised walk with peer. He/she broke a heavy wooden chair and used the leg to break 2 interior kitchen windows. He/she then continued striking the broken windows with both hands, causing lacerations on both arms and the right hand contaminated with shards of glass. RN #4 cleansed the lacerations and notified the on-call psychiatrist and maintenance (to fix windows) and contacted the pediatrician to evaluate the patient's injury in the morning. The patient de-escalated with staff support. A physician note (psychiatrist) dated 11/05/15 at 8:15 PM identified that, upon examination of the injuries, the site might have a piece of glass lodged in the wound. Plan included wound care and ice pack on right hand and change status to unit mobility status, assault precautions and every 15 minute checks. A work order completed 11/06/2015 at 7:00 AM identified that the contaminated broken safety glass was vacuumed up and the area was cleaned the night of 11/05/15 and the windows were replaced with Plexiglas to make the area safe. Patients were on the unit during the incident. The ITP failed to reflect the incident of self-harm, destruction of property, wound care, assessment of imminent risk and/or change in mobility and/or observational status. Patient #5 was discharged to a Psychiatric Residential Treatment Facility (PRFT) on 11/06/15 at 9:30 AM following safety assessment conducted by the psychiatrist, and MD #6.

Interview with the Superintendent on 12/10/15 identified that in situations of threatened or actual self-harm, assault, or destruction of property he/she would expect the RN to assess the situation for imminent danger to the patient, staff, or property without intimidating or threatening the patient and other patients on the unit should be protected from the emotional and/or physical effects of the patient ' s behaviors. The staff should not approach the dysregulated patient, physically, until absolutely necessary. The superintendent further identified that this was a very difficult concept to teach and, although the facility and staff have been very successful at reducing the frequency, duration and restrictive features of physical restraint usage, in some situations, staff may need to move in sooner in order to ensure safety.

A facility policy for self-harm precautions identified that any time a youth is observed to engage in self-harming behaviors (an emergency safety situation) and there is imminent (immediate) risk of injury to the youth, it is the responsibility of the staff members to intervene immediately in order to prevent injury.

Review of the facility policy titled Treatment Planning Process identified, in part, that each patient receives a comprehensive interdisciplinary evaluation that serves as the starting point for developing evolving individualized treatment planning and treatment delivery. The plans direct the staff as to what steps should be taken in the evaluation and treatment of the youth. The ITP is reviewed and revised according to the evaluation recommendation. The ITP shall incorporate diagnoses that are actively treated, identify problems to be treated, and address treatment modalities. The ITP will be modified will be modified based on conclusions of the treatment reviews.

3. Patient #9 was admitted to the hospital on 1/22/15 with mood disorder, PTSD and autism disorder by history. The patient has had multiple inpatient admissions since the age of 5. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 1/22/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 1= intermittently acute. Patient #9 was assessed for danger to others: 0.5 which is not a component of the risk scale. Review of the patient ' s initial treatment plan failed to reflect the self-harm and violence risks and/or interventions. Review of the patient's ITP failed to reflect the self-harm and violence risk factors with appropriate interventions.

4. Patient #10 was admitted to the hospital on 7/8/15 with PTSD, major depressive disorder and ADHD. Review of the severity of risk profile noted on the Admission Utilization Review Form dated 7/8/15 (completed by the admitting physician) identified that the patient was assessed for danger to self: 2.0 = chronic, non-acute and assessed for danger to others: 2.0=chronic, non-acute. Review of the clinical record and hospital documentation identified that while being moved from the unit during a unit crisis involving another patient, Patient #10 punched walls, wall fixtures and kicked doors. The patient yelled and destroyed property for 1.5 hours on 11/12/15 at 8:15 PM and sustained injury to the right arm and wrist. The Nursing Risk Assessment dated 11/12/15 indicated that Patient #10 was assessed at moderate risk of self-harm. Although physician orders directed a change in the patient's mobility status after the incident, the record failed to reflect any revisions to the ITP.

5. Patient #25 was admitted on 1/16/15 with diagnoses of oppositional defiant disorder, mood disorder, PTSD, with behaviors of self-injury. Review of the severity of risk profile noted on the Utilization Review Form dated 10/26/15 identified that the patient was assessed for danger to self: 1.5 = which is not a component of the risk scale and assessed for danger to others: 1.5 = which is not a component of the risk scale. Review of the clinical record identified that on 10/31/15 at 1:45 PM MD #8 observed Patient #25 with a cord around his/her neck and the patient was pulling the cord tightly causing the patient's face becoming erythematous over a five (5) minute period, when Patient #25 eventually stopped. MD #8 identified 2 demarcated reddened linear marks around the patient's entire neck. Review of the interdisciplinary treatment plan failed to identify Patient #25's self-strangulation/self-harm attempt and did not identify a review or revision for Patient #5's safety interventions. Subsequently, a review of facility documentation and Patient #25's clinical record identified on 11/9/15 at 6:40 PM Patient #25 came out of the bedroom and into the milieu with a head phone cord and a shoelace tied around his/her neck and were cut off. Patient #25 was allowed to return to the bedroom without supervision and "shortly" after, a staff member entered the bedroom and found the patient sitting on the floor, head down, with another set of headphone wires tied around the neck that needed to be cut off and left a reddened area at the site of the cord. Staff again left the patient unsupervised in the bedroom and when staff returned found the patient banging his/her head against a heater in the bedroom causing an area of swelling and broken skin. Following the 11/9/15 incidents, a nursing risk assessment form was completed. However, the assessment draws no conclusion or that interventions were reviewed and/or revised.

Interview with MD #8 on 12/10/15 at 1:16 PM identified that he/she provided close supervision and did not intervene during the 10/31/15 incident. Interview with the Nurse Manager #3 on 12/10/15 at 10:10 AM and the DNS on 12/14/15 at 1:10 PM identified that Patient #25 should have been supervised on 11/9/15 after the first self-strangulation/self-harm attempt and then again after the second attempt.

Based on observation and interview, the facility failed to ensure that lead vests from the dental exam room were tested for integrity. The finding includes:

Observation during tour of the dental exam room on 12/17/15 at 9:05am with the ADNS identified 1 lead vest hanging on a hanger. Interview with the ADNS at that time identified that dental services ceased in November 2015 and failed to provide documentation that the lead vest(s) that were used in the room prior to that date were tested for integrity.

Based on review of the Utilization Review Committee meeting minutes and interviews, the facility failed to ensure that there were at least two physician members present at the meetings. The finding includes:

Review of the Utilization Review Committee meeting minutes from 8/3/15 to 11/9/15 failed to identify that there were at least two physician members present at the meetings. Interviews with the Clinical Associate Intake Coordinator and the Intake Nurse Manager on 12/17/15 and review of the Utilization Review Committee meeting sign-in sheets identified that there was only one physician present on 8/3/15 and 11/9/15. Interviews further identified that there was a second physician who telephoned into the meeting on 11/9/15 but there was no documentation to reflect that he/she was present.

Based on observation, review of facility documentation and staff interviews the hospital failed to ensure that the physical environment of the hospital was maintained in a safe manner and in compliance with NFPA 101. Please refer to A 0701, A709 and A724 and also refer to the life safety survey K 025, K 50, K 062, K130 and K144.

Based on clinical record reviews and interviews with staff, for 2 of 10 patients reviewed for safe environment (Patients #4 and 14) the facility failed to ensure that the environment was safe for the care of the psychiatric patient. The findings include:

1. Patient #4 was admitted to the in-patient adolescent behavioral health facility on 08/21/15 on a thirty day court order with diagnoses that included mood disorder. Review of admission psychiatric evaluation dated 08/24/15 identified a history of auditory hallucinations and self-harm behaviors including cutting of the forearm. An acute nursing note dated 11/07/15 at 6:30 AM documented by RN #5 identified that Patient #4 reported that he/she had been walking barefoot on the unit and had gotten a something stuck in his/her foot. Upon examination, an open area with a small amount of bleeding was identified, a small piece of glass was removed and a dressing was placed. RN #5 documented that a peer (Patient #5) had broken on window on the unit on 11/05/15.

Review of a Report of Incident dated 11/13/15 at 10:00 PM identified that Patient #4 stated that he/she had cut his/herself with a piece of glass that he/she had gotten from a peer (Patient #5) earlier in the month. Three superficial, 2.5 centimeter scratches were observed on the left side of his/her cheek and the patient surrendered the piece of glass. Notification of guardian, physician, and administrator was not documented. Review of corresponding acute progress notes, physician ' s orders, risk assessment, a milieu notes and ITP identified that the physician and supervisor were notified and a suicidal risk assessment was completed by RN #4 that identified low risk. An interim plan of care was initiated to monitor patient on self-harm precautions.

The facility failed to ensure that the broken glass was thoroughly removed from the patient area to prevent further injuries.

2. Patient #14 was admitted on 9/2/15 with diagnoses of Post-Traumatic Stress Disorder (PTSD), depressive disorder, borderline traits and a history of aggression, assaultive and self-injurious behaviors. On 11/2/15 at 5:30 PM Patient #14 climbed a wall in the unit hallway and was able to pull down multiple ceiling tiles from the drop-ceiling. Once the ceiling tiles were down, the patient attempted to pull out multiple (electrical) wires. Post incident the patient had bruising on the left 3rd and 4th fingers. Patient #14 ' s safety plans dated 10/3/15 and 11/5/15 were reviewed with the DNS on 12/9/15 at 1:00 PM and noted that it failed to address the incident of climbing the wall and gaining access to dangerous electrical wires.





17921


Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the facility failed to identify and ensure that the facility was maintained in such a manner that the safety and well-being of patients are assured. The findings include:


On 12/07/15 and 12/08/15 while accompanied by the Plant Facilities Engineer 1 and Environment of Care Coordinator and subsequent document review, the following was observed:

a. The facility had either not identified and or took corrective action to safeguard all patient room windows to prevent injury and/or elopment i.e. while some windows were covered with a lexann sheet, most were not and the windows had exposed lock handles that could be utilized as a ligature point.
b. The ceilings in the patient rooms are fibrous lay in tiles that if broken could permit access to electrical wiring and ligature points.
c. The facility fire protection sprinklers heads throughout the patient care environment are of an ordinary type, not designed for use in an institutional environment.

d. The Arcadia unit shower/bath had had faucets and paper towel dispensers that were not designed for use in an institutional environment and posed a ligature and or sharps hazard.

e. The floors walls and ceiling throughout the patient care environment had peeling paint, missing cove base, and or damage that had been partially repaired, but not finished.

f. The door handles, door hinges and wardrobes throughout the patient care environment, posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard.

Based on observation, tour, interview and review of facility documentation on 12/07/15 and 12/08/15, the facility failed to ensure compliance with National Fire Protection Association, "Life Safety Code" (NFPA 101, 2000 edition) as referenced in 42 CFR Part 482.41 (b).


Refer to CMS form 2567, life safety survey K 025, K 50, K 062, K130 and K144

Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the facility failed to identify and ensure that the physical environment was safe. The findings include:


On 12/07/15 and 12/08/15 while accompanied by the Plant Facilities Engineer 1 and Environment of Care Coordinator and subsequent document review the following was observed:

a. The electrical receptacles throughout he facility were not designed for use in an institutional setting, were not hospital grade, and were not tamper resistant in compliance with the requirements of NFPA 70 " National Electrical Code " and NFPA 99 " Health Care Facilities " .
b. Documentation was not provided that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program.

Based on observation and interview, the facility failed to maintain a sanitary environment in the dental rooms and/or failed to ensure that dental instruments were appropriately processed to ensure they were sterilized. The findings include:

1. Observation during tour of the dental instrument reprocessing and cleaning room on 12/17/15 at approximately 9:05am identified that soiled instruments were cleaned in this room as well and repackaging the instruments. Further observation identified an autoclave on the countertop, an ultrasonic cleaner sitting on the edge of the counter with a drainage tube draining into the sink, x-ray developing solutions/equipment, cleaners and equipment stored on shelves along with lidocaine injectable medication, instrument repackaging materials, and gallon jugs of distilled water. There were clean and soiled supplies mixed in one room. Interview with the Dental Assistant on 12/17/15 at 1:10pm identified that he/she cleaned dirty instruments and packaged clean instruments one room in this same room which also housed the autoclave. Interview with the Infection Control Practitioner on 12/17/15 at 10:05am identified that he/she did not conduct environmental rounds in the dental area and his/her only involvement was to replace sharps containers when full.

2. Observation of the dental instruments in the dental exam room on 12/17/15 at approximately 9:05am with the ADNS identified about 60% of the processed dental instruments stored in the drawers of the dental exam room failed to contain an internal chemical indicator inside the packs. Further observation failed to identify any availability of the internal chemical indicator strips. Interview with the Dental Assistant on 12/17/15 at 1:10pm identified he/she reprocessed and packaged the dental instruments and there were no internal chemical strips available at the hospital. He/she further identified that some of the packaging envelopes had internal indicators as part of hte packaging and some did not. According to Guidelines for Infection Control in Dental Health Care Settings 2003, an internal chemical indicator should be placed in each package. The autoclave's operation and maintenance manual directed to place a sterilization indicator in each tray or inside each pack. Interview with the ADNS on 12/17/15 identified that the dental exam room had been closed since November 2015. Review of facility policies failed to reflect a policy and procedure on cleaning and sterilizing instruments in the dental clinic.

Based on observation, review of facility policies and procedures, and interviews for one of four seclusion rooms the facility failed to ensure that the seclusion room was cleaned after each use in accordance with facility. The findings include:

1. Tour of 4 patient units on 12/07/15 at 10:00 AM identified one of four seclusion rooms, room F43 with a streak of a greyish brown substance on the back wall of the room approximately 5.5 feet (ft.) above the floor. Revisit to the room on 12/07/15 at 1:10 PM identified that the substance remained on the wall.

Interview and review of the restraint log with RN #7 on 12/08/15 identified that Patient #8 was the last patient documented as having required seclusion in the particular seclusion room on 11/27/15 from 6:45 PM through 7:10 PM.

Patient 38 was admitted to the facility voluntarily following a previous hospitalization on11/04/15 with diagnoses that included disruptive mood dysregulation disorder, major depression, and anxiety. He/she had a history of suicide attempts including cutting him/herself. Review of an Emergency Safety Intervention dated 11/27/15 identified that he/she required a standing hold, followed by a hard escort into seclusion. The patient had been banging his/her head in the courtyard and became combative with staff intervention, ultimately requiring locked seclusion. Patient was observed banging his/her hand on the wall of the seclusion room and while processing the incident identified that he/she had cut his/her forearm superficially.

Interview with RN #7 on 12/07/15 at 1:15 PM identified that the seclusion room was cleaned daily by the housekeeping staff.

The policy for cleaning the time out room (seclusion) included, in part, that after a patient is removed from the room between 7:00 AM and 2:00 PM Monday through Friday, the housekeeping department will be notified to clean the room. If the room is visibly soiled with body fluids, the unit staff will be required to clean the room per standard precautions procedure protocol. General cleaning is done on a weekly basis.


2. Based on observation, review of facility policies and procedures, manufacturer recommendations, and interviews for one of four patient units that utilized a single patient use glucometer for emergency blood glucose monitoring, the facility failed to ensure that the glucometer was cleaned after each use and/or weekly in accordance with Center for Disease Control (CDC) guidelines and/or facility policy. The findings include:

Tour of the unit (Passaic) and observation of the unit glucometer with RN #7, on 12/08/15 at 10:20 AM identified that each patient who required routine finger sticks for blood glucose monitoring was issued their own, single use glucometer. Additionally, the unit maintained one glucometer for emergency use. RN #7 identified that the glucometer was cleaned with an alcohol wipe after each use. Review of the manufacturer instructions identified that the meter should be cleaned with bleach germicidal wipes containing 0.55% sodium hypochlorite (bleach)

Based on clinical record review, facility incident reports, policies and procedures, and interviews for 2 of 10 patients (Patient #5 and 12) reviewed for discharge the facility failed to ensure that the patients were discharged with necessary medical information to ensure necessary follow-up care. The findings include:

1. Patient #5 was admitted on 09/14/2015 with diagnoses that included ADHD, PTSD, polysubstance abuse, and R/O ASD and ODD. Review of a Report of Incident dated 11/05/15 at 7:45 PM and corresponding documentation in the clinical record identified that Patient #5 sustained lacerations on both arms and the right hand with contaminated shards of glass. RN #4 cleansed the wounds and contacted the pediatrician via e-mail to request that he/she evaluate the patient ' s injury in the morning prior to the patient ' s discharge to a lower level of care. Although the wound was assessed by the psychiatrist on 11/05/15, the wound was not assessed further for the need to remove possible shards of glass prior to discharge on 11/06/15 at 9:30 AM.

Interview with pediatrician, MD #7, on 12/10/15 at 11:30 AM identified that Patient #5 should have been assessed by the pediatrician prior to being discharged.

2. Patient #12 was admitted to the facility on 10/0815 with diagnoses that included unspecified bipolar and related disorder and ADHD. A medical examination dated 10/08/15 identified a recent diagnosis of streptococcus pharyngitis with ongoing antibiotic treatment, and recurrent eczema with no evidence of active infection. On 10/11/15 an infected, draining abscess was noted on the patient ' s right buttock. The patient was assessed by the pediatrician, MD #7. A culture was obtained and an oral and topical antibiotics, as well as, warm soaks were ordered. On 10/15/15, the culture results identified Methicillin Resistant Staphylococcus Aureus (MRSA) and the topical antibiotic was changed and the sensitive oral antibiotic was continued. On 10/15/15, an Interim Care Plan for MRSA infection was developed and implemented along with education provided for the patient and guardian. A Physician ' s Order dated 11/03/15 directed to discharge to court on 11/04/15 and send with available medications and prescriptions. Review of the ITP progress note dated 11/03/15, Discharge Plan dated 10/22/15, Discharge/Aftercare Form dated 11/04/15, Medication Transfer Sheet, and Juvenile Inter-Agency Patient Referral Report failed to identify MRSA history. Review of the Psychiatric Clinical Discharge Summary received, typed, and formatted on 12/08/15 (35 days after discharge), identified that although the MRSA infection, treatment, and progress was addressed, the documentation lacked evidence that the recent MRSA history was communicated to the discharge providers at the time of discharge.

Interview with the treating pediatrician, MD #7 and the Infection Preventionist, RN #3, on 12/14/15 at 11:05 PM identified that MRSA status was not documented on the discharge paper work.

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


I. Ensure that the Master Treatment Plan (MTPs) for one (1) of eight (8) active sample patients (A5) was revised when the patient failed to cooperate with needed assessments or participate in the prescribed treatment. The Master Treatment Plan (MTP) was not revised to provide alternative treatment modalities to address the patient's refusal of needed physical assessments, prescribed medications, and ordered laboratory studies. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)


II. Assess and provide active psychiatric and medical treatment for one (1) of eight (8) active sample patients (A5) who refused to participate in psychiatric and medical assessments, participate in assigned treatment groups and individual therapies, or accept prescribed medications for psychiatric and medical conditions. The lack of cooperation and refusal of assessments and treatments by patients results in a delay in treatment and potential delay in improvement and risk to the health and lives of patients. (Refer to B125)

III. Ensure social work assessments were available for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7) in a timely fashion. As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Please refer to B103)


IV. Provide Master Treatment Plans (MTP) that identified shortterm (ST) and long term (LT)
goals stated in individualized, observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients who were in the long enough to complete a master treatment plan (A1, A5, B1, B9, C7, C8, D3, D7). This failure impacts treatment for patients who do not have goals which are individualized, measurable or based on desired patient care outcomes. (Please refer to B121)

V. Ensure that the Master Treatment Plans (MTP) included psychiatry, primary clinician, (rehabilitation) Therapist/OT (occupational therapist), co-counselor and primary nurse interventions for eight (8) of eight (8) active patients who had been in the hopital long enough to complete a Master Treatment Plan (A1, A5, B1, C7, C8, D3, D7). Interventionss listed on the "Interdisciplilnary Treatment Plan", "Initial Treatment Plan", and "Treatment Plan Addendum" did not reflect individualized, intergrated and comprehensive multidisciplinary treatment planning, with specific interventions. (Please refer to B122)

VI. Ensure that the name of the psychiatrist, pediatrician, registered nurse, practical nurse, mental health worker, social worker, recreation therapist, art therapist, music therapist, occupational therapist responsible for carrying out interventions listed on the Master Treatment Plan (MTP) for 8 or 8 active sampled patients (A1, A5, B1, B9, C7, C8, D3, D7). Interventions were to be carried out by "All Staff".

Without this differentiation 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 accoutablility, and potentially, failure to deliver all required interventions to meet peatients' identified needs. (Please refer to B123)

VII. Provide progress notes by the psychiatrist that were legible for two (2) of eight (8) active sample patients (A1) and A5). The failure to communicate psychiatric progress in a legible and coherent fashion prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric condition and from addressing patient prgress for safe discharge planning. (Please refer to B126)

Based on record review, document review, and interview, the facility failed to provide social work assessments for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7) in a timely fashion. As a result, the treatment team did not have necessary social information and evaluation of social functioning level documented to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The Psychosocial Assessments (dates in parentheses) were not documented prior to the date of the current MTPs (dates in parentheses) for the following sample patients:

Patient A1: date of admission (9/25/15), date of MTP (9/25/15), date of Psychosocial Assessment (11/23/15). Patient A5: date of admission (10/23/15), date of MTP (10/23/15), date of Psychosocial Assessment (11/4/15). Patient B1: date of admission (11/25/15), date of MTP (11/25/15), no Psychosocial Assessment was documented on 12/8/15. Patient B9: date of admission (11/9/15), date of MTP (11/9/15), no Psychosocial Assessment was documented on 12/8/15. Patient C7: date of admission (10/7/15), date of MTP (10/7/15), date of Psychosocial Assessment (10/27/15). Patient C8: date of admission (7/13/15), date of MTP (7/13/15), date of Psychosocial Assessment (7/27/15). Patient D3: date of admission (11/6/15), date of MTP (11/6/15), date of Psychosocial Assessment (12/8/15). Patient D7: date of admission (7/13/15), date of MTP (7/13/15), date of Psychosocial Assessment (8/5/15).

B. Document Review

The "Treatment Planning Process" policy, dated 8/05, revised 8/12, stated "Evaluation Conference For Acute Settings: An evaluation Conference is held within fourteen (14) days of the youth's admission and the treatment plan is reviewed and revised according to the evaluation recommendations." The "Completion of Reports" document, dated 1/09, presented as the timeframe for completing Psychosocial Assessments stated "Psychosocial is due within 5 working days from the day of the [Psychiatric Conference Evaluation] conference." "The Psychiatric Evaluation/Psychiatric Conference held within 14 days of admission." This process does not ensure that Psychosocial Assessments are completed prior to the development of the MTP.

C. Staff Interview

During an interview with the Clinical Program Manager (supervisor of social work services) on 12/9/15 at 9:00 a.m., she acknowledged that the Psychosocial Assessments were not documented prior to the MTPs for these patients.

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

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

I. Ensure that the Master Treatment Plan (MTPs) for one (1) of eight (8) active sample patients (A5) was revised when the patient failed to cooperate with needed assessments or participate in the prescribed treatment. The Master Treatment Plan (MTP) was not revised to provide alternative treatment modalities to address the patient's refusal of needed physical assessments, prescribed medications, and ordered laboratory studies. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient A5 was admitted 10/23/15. The Admission Note/Psychiatric Evaluation dated 10/23/15 stated the reason for admission was "for stabilization and treatment due to recent medication refusal. [S/he] has been presenting as more disorganized, sexualized and paranoid." The diagnoses included "Unspecified schizophrenia spectrum and other psychotic disorder," "Unspecified Depressive Disorder," "Posttraumatic Stress Disorder," "Selective Mutism," and "Infection in toes secondary to chronic picking."

2. The MTP for Patient A5 was dated 10/23/15, revised 12/9/15. For the problem of "Paranoia," the following interventions were listed: "Will seek coach to get needs met," "Will help team to develop effective safety plan," "Will take medications as prescribed and will raise any concerns/issues about medication to staff," "Pt will bring up any thoughts/feelings around mom's pregnancy," "Meet with youth at least twice per week to develop rapport," "Will express [his/her] thoughts [and] feelings in individual [and] group meetings," "Pt will support visits w/ [with] mom 1 x [time] week and encourage talk about baby/pregnancy," "Support youth to feel safe," "Add to development of effective safety plan," "Milieu staff will assess [Patient A5] current ADL [activity of daily living] ability," "MD will assess need to adjust dosage of meds [medications] [and] and monitor for S/E [side effects]," The intervention, and "Peds [pediatrician] will examine [his/her] feet for infection [and] manage accordingly," The intervention, "P [Psychiatrist] will submit paperwork for court mandated medication administration," was added during the survey. For the problem of "Bilateral Toe Infection," the following interventions were listed: "Pt. will cooperate [with] foot soaks and other treatments prescribed," "Pt. will respond to 1:1 redirection of picking [at] toes," "PC [Primary Clinician] will encourage [Patient A5] to not pick [at] [his/her] toes and identify 2-3 things he can do in place of picking," "Staff will encourage [Patient A5] to comply [with] foot soaks and refrain from picking," "1:1 staff to observe for and redirect if pt is picking," "RN will assess toes (both feet) q [each] shift for signs/ Sx [symptoms] of infection and notify pediatrics," "Encourage [Patient A5] to wear open toe shoes (flip-flops) in order to expose toes to air," "Provide med teaching (Keflex) and provide infection prevention teaching, as tolerated," "Consult [with] pediatrics with any signs/Sx [symptoms] of infection," and "Passive recs [recreation] per pediatrics."

3. A review of the medical record for Patient A5 on 12/8/15 indicated that Patient A5 had refused all active psychiatric treatments including participation in individual and group therapies and all doses of prescribed medications since 10/25/15.

4. A review of the MTP dated 10/23/15 indicated that the MTP had not been revised to address Patient A5's refusal to cooperate with needed assessments, refusal of medications, and lack of participation in group and individual interventions. The refusal to participate in active treatments and to accept prescribed medications as well as the refusal to cooperate with needed assessments and laboratory studies was not identified as problems on the MTP to be addressed.

B. Interviews

1. During an interview with MD 1 on 12/8/15 at 11:00 a.m., he acknowledged that the MTP for Patient A5 had no been revised despite continued refusal of medical and psychiatric assessments, examinations, and treatments for a serious psychiatric condition and potentially serious medical condition.

2. During an interview with the acting Medical Director on 12/9/15 at 8:00 a.m., she acknowledged that the MTP for Patient A5 had no been revised despite continued refusal of medical and psychiatric assessments, examinations, and treatments for a serious psychiatric condition and potentially serious medical condition.

II. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7). Specifically, the MTPs were missing patient oriented goals written in observable and behavioral terms (Refer to B121), the plans were missing individualized and specific treatment interventions to address each patient's presenting psychiatric problems (Refer to B122), and the plans failed to identify specific staff responsible for providing each interventions (Refer to B123). Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans (MTP) that identified short term (ST) and long term (LT) goals stated in individualized, observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients who had been in the hospital long enough to complete a master treatment plan (A1, A5, B1, B9, C7, C8, D3, D7). This failure impacts treatment for patients who do not have goals which are individualized, measurable or based on desired patient care outcomes.

Findings include:

A. Policy/Document Review

Facility Treatment Services, Treatment Planning Process Approved by Executive Committee 8-2005, Rev (Revised) 8-12: 1) Interdisciplinary Treatment Plan. The Interdisciplinary Treatment Plan identifies, for each admitting diagnosis, the most pressing problems requiring treatment. The Plan Specifies: Key goals, Measurable Treatment Objectives, Time-frames for goal achievement, Staff responsibilities (page 156). 2) Treatment Plan Reviews, Acute. Treatment plan review shall consist of a review of: The goals and formulation, Progress in treatment, Efficacy of treatment modalities, Progress toward discharge (page 157). 3) The Interdisciplinary Treatment Plan. The Interdisciplinary Treatment Plan shall: Identify problems to be treated during treatment and establish appropriate goals and measurable objectives to resolve those problems. Have goals and objectives stated in positive terms and include developing and/ or using the youth's assets and strengths (page 159). 4) At the time of admission the admitting psychiatrist shall: Develop the Initial Treatment Plan (page 158). Relevant findings from the above evaluations (Social Work Department, Psychologists, Nursing, Rehabilitation, Work Skill-Life Skill, Clinical Dietitian, Speech and Language Pathologist, Pediatrician, School Psychologist) shall be presented at the Evaluation Conference. The Youth's psychiatrist shall: Review and revise psychotropic medication as needed, Evaluate medical problems, Update the mental status, Present relevant findings at the Evaluation Conference, Chair the Interdisciplinary Evaluation Conference within fourteen (14) days of admission and shall provide a written summary of the conference (page 158).

B. Record Review

1. Patient A1 (admitted 9/25/15, Interdisciplinary Treatment Plan 9/25/15).

"Interdisciplinary Treatment Plan: Date of Plan: 9/24/15, Target Behavior # and Goal 1: Mood Lability [sic]. Learn and practice emotions in a safe and verbal manner. Objective 1: Start Date 9/25/15, Pt. [patient] will report any thoughts/ urges to SI/ SIB [Suicide Ideation/ Self Injurious Behavior]. [Patient] will help staff build a helpful & [and] effective safety plan that helps pt. cope w/ [with] stress. [Patient] will bring 1 topic to discuss in individual therapy. [Patient] will educate review DBT [Dialectic Behavior Therapy] skill w/ [with] coach and PC [Primary Clinician]."

"Target Behavior # and Goal 2: Relational Conflicts. Improve communication skills and relations in and out of home. Objective 1: Start Date 9/25/15, Pt. will talk about her family issues + [and] concerns during individual therapy and/ or during coaching sessions. [Patient] will have positive peer interactions in milieu groups and rehab [rehabilitation] groups once per shift."

The Interdisciplinary Treatment Plan did not identify the Long Term Goals that were individualized, observable and measurable. Short Term Goal, labeled "Objective" did not reflect observable, measurable criteria - including expected frequency, time span, and criteria for evidencing that the patient has progressed to sufficiently meet the desired outcomes.

2. Patient A5 (admitted 10/23/15, Interdisciplinary Treatment Plan 10/23/15).

"Interdisciplinary Treatment Plan: 10/23/15, Target Behavior # and Goal 1: Paranoia. Will take medications consistently. Objective 1) Start date: (blank on form): Will seek coach to get needs met. Will help team to develop effective safety plan. Will take medications as prescribed and raise any concerns/issues about medication to staff. Will bring up thoughts /feelings around mom's pregnancy."

"Target Behavior # and Goal 2: Bilateral Toe Infection. Goal: Toes will remain free of infection. Objective 1) Start date: (blank on form): Pt. will refrain from picking (at) toes to prevent further infection and allow healing. Pt. will cooperate [with] foot soaks and other treatments prescribed. Pt. will respond to 1:1 redirection of picking [at] toes."

The Interdisciplinary Treatment Plan did not identify Long Term Goals that were individualized, observable and measurable. The identified "Target Behavior, Paranoia" would be expected to have a specific goal related to stabilizing paranoid ideation, thereby reducing symptoms, not simply medication compliance, "will take medications consistently". Short Term Goals, labeled "Objective" did not reflect a start date (this section was left blank on the form). The Goals listed in the Interdisciplinary Treatment Plan did not include measurable criteria, including expected frequency, time span, and criteria for evidencing that the patient has progressed to sufficiently meet the desired outcomes. The Treatment Goals failed to address the patient's refusal to participate in treatment since admission.

3. Patient B1 (admitted 11/25/15, Initial Treatment Plan 11/25/15).

"Initial Treatment Plan: 11/25/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Remain safe; communicate urges for unsafe behaviors; follow rules."

"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team."

"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences."

A standardized, pre-printed form was used to identify Goal 1: Safety, Goal 2: Youth and Family Engagement, and Goal 3: Assessment of Youth and Family Needs/ Strengths. The plan of treatment failed to specify individualized long term and short term goals. This same Goal and Objective was present for all sample patients admitted after November 1, 2015, using a standardized, pre-printed form with standard objectives for Goal 2 and Goal 3.

4. Patient B9 (admitted 11/9/15, Initial Treatment Plan 11/9/15).

"Initial Treatment Plan: 11/9/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: I will communicate my triggers."

"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team.

"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences." A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. The plan of treatment failed to specify individualized long term and short term goals. This same Goal and Objective was present for all sample patients admitted after November 1, 2015, using a standardized, pre-printed form with standard objectives for Goal 2 and Goal 3.

5. Patient C7 (admitted 10/7/15, Interdisciplinary Treatment Plan 10/7/15).

"Interdisciplinary Treatment Plan 12/7/15, Long Term Goal # __ (blank on form) Include Target Date (blank on form): Patient will remain safe with self and others. Objective #__ (blank on form) Include Target Date: (blank on form): C7 (Pt name) will demonstrate consistent safety and achieve on grounds mobility."

"Interdisciplinary Treatment Plan 10/7/15, Target Behavior # and Goal 1: Mood dysregulation (goal blank on form). Objective 1: Start Date (blank on form), Decrease reactive bx. [behavior] when feeling overwhelmed by - [negative] thoughts [and] feelings, verbalize internal thoughts (and) feelings."

"Target Behavior # and Goal 2: Decrease suicidal ideation [and] self harm [behavior]. Objective 1: Start date: (date blank on form), Decrease suicidal ideation and improve [positive] thinking. Begin to identify precipitants, context [and] demonstrate knowledge for use of at least 3 [positive] coping skills. Learn staff [and] peers names, review mobilities [sic], transition to (and) from school/program safely."

The Interdisciplinary Treatment Plan did not identify the Long Term Goals that were individualized, observable and measurable. Goal 1, Mood dysregulation was the target behavior and a Goal was not specified. The start dates for Goals and Objectives were not documented, left blank on the form for Goal 2. Short Term Goals, labeled "Objective" did not reflect observable, measurable criteria- including expected frequency, time span, and criteria for evidencing that the patient has progressed to sufficiently meet the desired outcomes.

6. Patient C8 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

"Interdisciplinary Treatment Plan 7/13/15: Target Behavior # and Goal 1: Decrease unsafe [behavior] i.e. [self injurious behavior and suicidal ideation]. Objective 1: Start Date (date blank on form): Decrease [self injurious behavior and suicidal ideation] thoughts [and] feelings [and] [behavior]. Begin to identify precipitants, context, [and] demonstrate knowledge for use of at least 5 [positive] coping skills."

"Target Behavior # and Goal 2: Improve mood [and] increase verbalization of internal thoughts/ feelings. Objective 1: Start Date (date blank on form): Decrease reactive [behavior] when begin to feel overwhelmed, id [identify] precipitant [and] demonstrate acceptance through use of [positive] [and] appropriate coping skills [and] verbalize."

The Interdisciplinary Treatment Plan did not identify the Long Term Goals that were individualized, observable and measurable. The documentation failed to list the Target Behavior and Goal. The start dates for the Objectives was not documented (left blank on the form), for Goal 1 and Goal 2. Short Term Goal, labeled "Objective" did not reflect observable, measurable criteria- including expected frequency, time span, and criteria for evidencing that the patient has progressed to sufficiently meet the desired outcomes.

7. Patient D3 (admitted 11/6/15, Initial Treatment Plan 11/6/15).

"Interdisciplinary Treatment Plan 11/23/15, Long Term Goal # 1 Include Target Date: 12/7/15 Patient: D3 (Patient Name) will be seizure free. Objective # 1 (Short Term Goal) Include Target Date: 12/7/15: (Pt name) will identify stressors which have been contributing to pseudo seizures and work toward a desire of getting better."

"Long Term Goal # 2 Include Target Date: 12/21/15 Patient: D3 (Patient Name) Safety. Objective # 1 (Short Term Goal) Include Target Date: 12/14/15: (Pt name) will identify her thoughts and feelings prior to becoming emotionally distressed."

"Initial Treatment Plan 11/6/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Not engage in aggressive behaviors [and] self injurious behaviors."

"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team."

"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences".
A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. This same Goal and Objective was present for all sample patients admitted after November 1, 2015, using a standardized, pre-printed form with standard objectives for Goal 2 and Goal 3. The numbering of the goals changed from the Initial Treatment Plan to the Interdisciplinary Treatment Plan, making it difficult to follow patient progress. Safety was goal #1 in the Initial Treatment Plan (11/16/15) and Safety was Long Term Goal #2 in the Interdisciplinary Treatment Plan (11/23/15).

8. Patient D7 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

"Interdisciplinary Treatment Plan 7/13/15, Target Behavior # and Goal 1: Increase ability to assist in own defense as well as understanding of charges, court personnel, [and] procedures, and cartroom behaviors [sic]. Objective 1: Start Date (7/13/15), Complete a baseline assessment of D7 (Patient Name) knowledge [and] understanding of the above. Objective 2: (Patient Name) will participate in any psychological testing to assist with identifying barriers to restoration as well as most effective approach to competency education. 11/23/15 Objective 2: (Patient name) will engage during restoration education sessions. Objective 1: complete competency assessment at least 1x [time]/month to monitor progress over time."
The Interdisciplinary Treatment Plan did not identify the Long Term and Short Term Goals. The Interdisciplinary Treatment Plan did not identify Goals that were individualized, observable and measurable. The documentation failed to list the Target Behavior and Goal. Short Term Goal, labeled "Objective" did not reflect observable, measurable criteria- including expected frequency, time span, and criteria for evidencing that the patient has progressed to sufficiently meet the desired outcomes. The Interdisciplinary Treatment Plan focused to the Court Order for restoration and did not reflect target behaviors/goals related to the patient's admitting diagnosis ("Axis I Learning Disorder, NOS; Rule out Mathematics Disorder; Rule out Attention Deficit Hyperactivity Disorder; Axis II Borderline IQ, Rule Out Mild Mental Retardation").

C. Staff Interviews

1. In an interview on 12/8/15 at 1:30 p.m., after reviewing the interdisciplinary treatment plans, the Nursing Director acknowledged that the sample patient Individualized Treatment Plans reviewed did not include both long term (LT) and short term (ST) goals, that the goals were generic and not measurable both for the previous plans and the revised treatment plans implemented November 1, 2015. She said the revised plans with the three standardized goals "Safety, Youth and Family Engagement, and Assessment of Youth and Family Needs/Strengths" were implemented "after recommendation from a consultant we hired prior to our Joint Commission Survey." She said the executive leaders "went back and forth on using standard goals with check boxes for interventions" since they "don't become individualized". She said, "I agree with you with your concerns". She said "we switched away from nursing doing these in the past" stating that "it will take some time for our staff to develop the skills and the competencies. I understand that the interdisciplinary planning is best practice."

2. In an interview with the acting Medical Director on 12/9/15 at 8:00 a.m., she acknowledged that the sample patient Individualized Treatment Plans reviewed did not include both LT and ST goals, that the goals were generic and not measurable both for the previous plans and the revised treatment plans implemented November 1, 2015.

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTP) included psychiatry, primary clinician, (rehabilitation) therapist/OT (occupational therapist), co counselor, and primary nurse interventions for eight (8) of eight (8) active patients who had been in the hospital long enough to complete a master treatment plan (A1, A5, B1, B9, C7, C8, D3, D7). Interventions listed on the "Interdisciplinary Treatment Plan", "Initial Treatment Plan", and "Treatment Plan Addendum" did not reflect individualized interventions/care planning rather include a list of staff modalities with frequency of the modality, without identification of specific interventions and did not specify the focus of individual and group treatment modalities. Interventions on the previous "Interdisciplinary Treatment Plan" and "Initial Treatment Plans" listed monitoring and assessment interventions that would be expected to be regularly provided to all patients. The interventions on the revised "Initial Treatment Plans" were completed on generic forms that listed interventions to check off that would be expected to be regularly provided for all patients, including monitoring and assessments. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning, specifically interventions necessary to provide active treatment.

Findings include:

A. Policy/Document Review

Facility Treatment Services, Treatment Planning Process Approved by Executive Committee 8-2005, (Rev) 8-12: 1) Interdisciplinary Treatment Plan. Treatment Planning Process: The Interdisciplinary Treatment Plan identifies, for each admitting diagnosis, the most pressing problems requiring treatment. The plan specifies: Key goals, Measurable treatment Objective, Time-frames for goal achievement, Staff responsibilities (page 156). Treatment Planning Process: The Interdisciplinary Treatment Plan shall: List treatment modalities which are appropriate, positively reinforcing and non-punitive. Identify, by name, staff responsible for carrying out treatment for each interventions.

B. Record Review

1. Patient A1 (admitted 9/25/15, Interdisciplinary Treatment Plan 9/25/15).

"Interdisciplinary Treatment Plan 9/25/15, Target Behavior # and Goal 1: Mood Lability [sic]. Learn and practice emotions in a safe and verbal manner. Review date 10/13/15, Objective 1: Start Date: 9/25/15: [Patient] will cooperate [with] evaluations. [Patient] will report any thoughts/ urges to [Suicidal Ideation/ Self Injurious Behavior]. Patient will learn names of Acadia staff/ youth as well as unit rules. [Patient] will help staff build a helpful and effective safety plan that helps [Patient] cope [with] stress. Interventions listed: Individual and Group Therapies: [Primary Clinician] will meet [with] [patient] [at] least 2[time's] /[week] to develop trust and rapport. [Recreation Therapist] will administer leisure/ interest survey to determine what rehab groups to prescribe. Milieu: All Staff will monitor for signs/ symptoms of [Self Injurious Behavior/ Suicidal Ideation]. All Staff will teach [patient] names, rules and expectations. All Staff will help create [and] update safety plan to prevent/ decrease unsafe actions. Medical: [Psychiatrist] will prescribe medication according to symptoms/ diagnosis. [Psychiatrist, Pediatrician, Primary Nurse] will monitor for medication efficacy and side effects by monitoring weights, vitals, etc. Notation on top of Interdisciplinary Treatment Plan form (10/13/15) discontinued 10/16/15. Review Date: 10/16/15, 11/5/15, 11/9/15 and 11/24/15 Target Behavior # and Goal 1: Mood Lability [sic]. Learn and practice emotions in a safe and verbal manner. Objective 1: Start Date 9/25/15, Pt. [Patient] will report any thoughts/ urges to SI/SIB [Suicide Ideation/ Self Injurious Behavior]. Pt. will help staff build a helpful [and] effective safety plan that helps Pt. cope [with] stress. Pt. will bring 1 topic to discuss in individual therapy. Pt. will educate review DBT [Dialectic Behavior Therapy] skill [with] coach and PC [Primary Clinician]. Individual and Group Therapies: [Primary Clinician] will meet [with] patient 2x/week to conduct individual therapy/ practice DBT [review assignments]. RT will facilitate [at] least 2x/wk [week] [rehabilitation] groups include: active games, art therapy, fitness room, pottery class. Clinical staff [with] facilitate DBT group 1x/[week]. Milieu: All staff will monitor for signs and symptoms of SIB/SI/ mood lability [sic] and provide coaching. All staff will help create [and] update safety plan to prevent/decrease unsafe actions. Coach will review and discuss [with] [patient] DBT work/ assignments. All staff will follow through [with] snack box plan to motivate [patient] to attend classes. Medical: P [Psychiatrist] will prescribe medications according to symptoms/diagnosis. P Ped & N [Psychiatrist, Pediatrician and Nurse] will monitor for medication efficacy and side effects by monitoring weight, vital signs, etc. [Psychiatrist, Pediatrician] will follow up [with] endocrine testing results and next steps.

"Target Behavior # and Goal 2: Relational Conflicts: Improve communication skills and relations in and out of home. Review Date: 10/13/15: Objective 1 Start date: 9/25/1, [Patient] will talk about her family issues [and] concerns during individual therapy. [Patient] will positive peer interactions in milieu groups and [rehabilitation] groups once per shift [sic]. Individual and Group Therapies: [Primary Clinician] will engage in family therapy meeting to further assess/ understand family dynamics. Milieu: All staff will observe [Patient's] interactions during visits [and] phone calls and document remarkable observations. Staff will honor temporary allowance of phone calls as needed to father w/in [within] reason. Notation on top of form: Discontinued 10/16/15." Review Date 10/16/15, 11/5/15, 11/9/15 and 11/24/15: "Target Behavior # and Goal 2: Relational Conflicts. Improve communication skills and relations in and out of home. Objective 1: Start Date 9/25/15, [Patient] will talk about her family issues + [and] concerns during individual therapy and/ or during coaching sessions. [Patient] will have positive peer interactions in milieu groups and rehab [rehabilitation] groups once per shift." Individual and group therapies: [Primary Clinician] will engage in family therapy/ meeting to further assess/understand family dynamics [with] a focus on improving communication skills and problem solving techniques. [Primary Clinician] will meet [with] [patient] and father 1[time]/week to have family therapy. [Primary Clinician] will attempt to engage stepmother in family therapy. Milieu: All staff will observe [patient's] interactions during visits [and] phone calls and document remarkable observations. Staff/ Coach can process [with] [Patient Name] before or after phone calls that are more emotionally charged in order to reflect or use skills."
Interventions listed on the "Interdisciplinary Treatment Plan" did not reflect individualized interventions/care planning rather include a list of staff modalities with frequency of the modality, without identification of specific interventions. Interventions did not specify the focus of individual and group treatment modalities. Interventions listed monitoring and assessment that would be expected to be regularly provided to all patients, i.e. Individual and Group Therapies...meet [with] [patient] [at] least 2[times]/[week] to develop trust and rapport. [Recreation Therapist] will administer leisure/ interest survey to determine what rehab groups to prescribe. Milieu: All Staff will monitor for signs/ symptoms of [Self Injurious Behavior/ Suicidal Ideation]. All Staff will teach [Patient] names, rules and expectations. All Staff will help create [and] update safety plan to prevent/ decrease unsafe actions. Medical: [Psychiatrist] will prescribe medication according to symptoms/ diagnosis. [Psychiatrist, Pediatrician, Primary Nurse] will monitor for medication efficacy and side effects by monitoring weights, vitals, etc."

2. Patient A5 (admitted 10/23/15, Interdisciplinary Treatment Plan 10/23/15).

"Interdisciplinary Treatment Plan 10/23/15, Target Behavior # and Goal 1: Paranoia. Will take medications consistently. Objective 1: start date: (blank on form): Will seek coach to get needs met. Will help team to develop effective safety plan. Will take medications as prescribed and raise any concerns/ issues about medication to staff. Will bring up thoughts /feelings around mom's pregnancy [sic]. Review date: 11/9/15 and 12/9/15 Individual and Group Therapies: Meet with youth at least twice per week to develop rapport. Will express his thoughts and feelings in individual and group meetings [sic]. [Primary Clinician] will support visits [with] mom 1[time]/week and encourage talk about baby/ pregnancy. Milieu: Support youth to feel safe. Add to development of effective safety plan. Milieu staff will assess (Patient name) current ADL [activity of daily living] ability. Medical: MD will assess need to adjust dosage of meds [medications] [and] and monitor for S/E [side effects]. [Pediatrician] will examine his feet for infection [and] manage accordingly. [Psychiatrist] will submit paperwork for court mandated medication administration.

"Target Behavior # and Goal 2: Bilateral Toe Infection. Goal: Toes will remain free of infection. Objective 1: Start date: (blank on form): Pt. will refrain from picking [at] toes to prevent further infection and allow healing. Pt. will cooperate [with] foot soaks and other treatments prescribed. Pt. will respond to 1:1 redirection of picking [at] toes. Review date: 12/9/15, 12/15/15. Individual and group therapies: [Primary Clinician] will encourage (Patient name) to not pick [at] his toes and identify 2-3 things he can do in place of picking. Milieu: Staff will encourage [patient] to comply [with] foot soaks and refrain from picking. 1:1 staff to observe for and redirect if [patient] is picking. RN will assess toes (both feet) [each] shift for signs/[symptoms] of infection and notify pediatrics. Encourage (Patient name) to wear open toe shoes (flip-flops) in order to expose toes to air. 11/2/15: Provide med teaching (keflex) and provide infection prevention teaching, as tolerated. Consult [with] pediatrics with any signs/[symptoms] of infection. Passive recs [recreation] per pediatrics.

Interventions listed on the "Interdisciplinary Treatment Plan" did not reflect individualized interventions/care planning rather include a list of staff modalities with frequency of the modality, without identification of specific interventions, i.e. Meet with youth at least twice per week to develop rapport. Interventions listed routine monitoring and assessment that would be expected to be regularly provided to all patients, i.e. Milieu: Support youth to feel safe. Add to development of effective safety plan. Milieu staff will assess (Patient name) current ADL [activity of daily living] ability. Medical: MD will assess need to adjust dosage of meds [medications] [and] and monitor for S/E [side effects]. An intervention was added during the survey to "submit paperwork for court mandated medication administration" to address the patient's refusal to participate in treatment. Interventions related to identified Goals to treat: paranoia and bilateral foot infection, however it was not clear how the Interdisciplinary Treatment Plan provided interventions related to the patient's admission diagnosis (Unspecified psychotic disorder, unspecified depressive disorder, PTSD, Parent Child Relational Problem, Selective Mutism, Bilateral toe infections from chronic picking, and exposure to trauma).

3. Patient B1 (admitted 11/25/15, Initial Treatment Plan 11/25/15).

"Initial Treatment Plan 11/25/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Remain safe; communicate urges for unsafe behaviors; follow rules. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked. Psychiatry: Preprinted form, Check box interventions (all checked): Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed. Will identify and implement Medication interventions as indicated. Will meet with youth to assess response to prescribed medication. Will meet with youth to assess degree of functional impairment. Will meet with team to assess/ review youth's progress/ response to interventions. Will assess knowledge of medications to provide a basis of teaching. Will meet with youth weekly to assess mental status. Clinical: Will meet with youth within 1 working day to establish a therapeutic rapport. Will assess youth's current coping strategies. Will meet with youth to develop/ reinforce strategies to replace unhealthy choices. Will assist youth in attending all scheduled group and activities. Will collaborate with youth and family to develop and implement Safety Plan.

"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked. Psychiatry: Preprinted form, Check box interventions (all boxes checked): Will meet with youth to assess current level of functioning. Will meet with youth to assess appropriate medication interventions. Will meet with family to provide assessment of functioning. Will be available to family for questions regarding youth's functioning, diagnosis, medication, or other aspects of care. Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment. Will identify barriers to participation in treatment and develop plan to address. Clinical: Will meet with youth within 1 working day to establish therapeutic rapport. Will connect with family/ guardian within 1 day to schedule initial family session. Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment. Will identify barriers to participation in treatment and develop plan to address."
"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked. Psychiatry: Preprinted form, Check box interventions (all boxes checked): Will meet with youth to assess response to past and current prescribed medications. Will meet with youth to assess degree of functional impairment. Will meet with team to assess/ review youth's progress/ response to interventions. Will assess knowledge of medications to provide a basis of teaching. Will meet with youth weekly to assess mental status. Will refer youth for participation in specific evaluations: OT [occupational therapy] box checked. Clinical: Will complete a psychosocial assessment within 2 weeks. Will complete psychological assessment within 2 weeks. Will complete Ohio scales and review with youth and family. Will identify additional clinical psycho-educational groups.
A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. Interventions pre-printed on the form for each goal were standardized using check boxes. There were no nursing interventions checked for any of the three standardized goals on the first date of survey (12/7/15). The patient was admitted on 11/25/15. The interventions focused on assessing the patient and monitoring the patient responses. Disciplines were listed by "department" providing interventions, however there were no therapeutic modalities or types of groups the patient would benefit from listed on the Initial Treatment Plan form. The interventions checked were identical or similar for other patients admitted to the facility after November 1, 2015 and did not differentiate interventions related to the individual patient needs.

4. Patient B9 (admitted 11/9/15, Initial Treatment Plan 11/9/15).

"Initial Treatment Plan 11/9/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: I will communicate my triggers. Interventions: We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will initiate regular and positive interactions to establish therapeutic rapport. Will provide coaching to assist in identifying triggers for behavior. Will meet with youth to assess response to prescribed medication. Will assess knowledge of medications to provide basis for teaching. Psychiatry: Preprinted form, Check box interventions (all checked): Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed. Will identify and implement Medication interventions as indicated. Will meet with youth to assess response to prescribed medication. Will meet with youth to assess degree of functional impairment. Will meet with team to assess/ review youth's progress/ response to interventions. Will assess knowledge of medications to provide a basis of teaching. Will meet with youth weekly to assess mental status. Clinical: Will meet with youth within 1 working day to establish a therapeutic rapport. Will assess youth's current coping strategies. Will meet with youth to develop/ reinforce strategies to replace unhealthy choices. Will collaborate with youth and family to develop and implement Safety Plan.
"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team. Interventions: We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will review facility handbook with youth. Will initiate regular and positive interactions to establish therapeutic rapport. Will connect with family/ guardian within 24 hours to provide update on adjustment and functioning. Will meet with youth and family to discuss their questions and concerns and to provide education about their care and treatment. Psychiatry: Preprinted form, Check box interventions (all checked): Will meet with youth to assess current level of functioning. Will meet with youth to assess appropriate medication interventions. Will meet with family to provide assessment of functioning. Will be available to family for questions regarding youth's functioning, diagnosis, medication, or other aspects of care. Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment. Will identify barriers to participation in treatment and develop plan to address. Clinical: Will meet with youth within 1 working day to establish therapeutic rapport. Will find out from youth and family who are the people in their support network and whom they would like to include as part of their extended treatment team. Will identify barriers to participation in treatment and develop plan to address."
"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked. Psychiatry: Preprinted form, Check box interventions (all boxes checked): Will meet with youth to assess response to past and current prescribed medications. Will meet with youth to assess degree of functional impairment. Will meet with team to assess/ review youth's progress/ response to interventions. Will assess knowledge of medications to provide a basis of teaching. Will meet with youth weekly to assess mental status. Will refer youth for participation in specific evaluations: OT [occupational therapy] box checked. Clinical: Will complete a psychosocial assessment within 2 weeks. Will complete psychological assessment within 2 weeks. Will complete Ohio scales and review with youth and family.
A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. Interventions pre-printed on the form for each goal were standardized using check boxes. There were no nursing interventions checked for goal 3, Assessment of Youth and Family Needs/ Strengths, on the first date of survey (11/7/15). Disciplines were listed by "department" providing interventions, however there were no therapeutic modalities or types of groups the patient would benefit from listed on the Initial Treatment Plan form. The interventions checked were identical or similar for other patients admitted to the facility after November 1, 2015 and did not differentiate interventions related to the individual patient needs.

5. Patient C7 (admitted 10/7/15, Interdisciplinary Treatment Plan 10/7/15).

"Interdisciplinary Treatment Plan 12/7/15, Long Term Goal # (blank) Patient will remain safe with self and others. Target date: (blank) Objective # (blank) (Patient name) will demonstrate consistent safety and achieve on grounds mobility. Interventions: (we will...) Nursing: Nursing will assess patient's mental status on a daily basis. Psychiatry: Psychiatrist will monitor medications for effectiveness and side effects. Psychiatrist will monitor mental status. Clinical: Therapist will support client in identifying and using coping skills to decrease self harm and aggress behaviors and verbalizations. Children's Services: Coach will encourage (Patient name) to seek out support 1[time]/shift. Rehabilitation (include OT as applicable): (blank, no interventions listed). Other (e.g. Education, Dietary, Medical, Life Skills) (Can be specific activities to be implemented by the family): (blank, no interventions listed).
"Interdisciplinary Treatment Plan 10/7/15, Target Behavior # and Goal 1: Mood dysregulation (goal blank on form). Objective 1: Start Date (blank on form), Decrease reactive bx. [behavior] when feeling overwhelmed by - [negative] thoughts [and] feelings, verbalize internal thoughts [and] feelings. Individual and Group Therapies: Review date: (blank): Meet [with] clinician 1[times]/wkly [weekly] [and] participate in prescribed groups, assess internal thoughts [and] feelings, identify triggers [and] stressors. [Rehabilitation] will include but is not limited to 5-7 groups per week, including art therapy, music therapy, music and art, board games, and work crew. Milieu: Participate in prescribed [treatment programs], identify at least 2 supports [and] how to access them. Begin to identify triggers [and] ways to resolve conflict without unsafe [behavior]. [Patient] encouraged to ask staff to help her resolve issues with peers to help her develop skills to eventually successfully resolve issues on her own. Medical: Review date: (blank): Comply with prescribed medication regime. Demonstrate knowledge of reason for medication. RN [Registered Nurse] to monitor rash to bottom of feet. RN to educate and review [patient's] medication uses and side effects. RN to educate to Bactroban ointment."
"Target Behavior # and Goal 2: Decrease suicidal ideation [and] self harm [behavior]. Objective 1: Start date: (date blank on form), Decrease suicidal ideation and improve [positive] thinking. Begin to identify precipitants, context [and] demonstrate knowledge for use of at least 3 [positive] coping skills. Learn staff [and] peers names, review mobilities [sic], transition to [and] from school/program safely. Individual and Group Therapies: Review Date: (blank): Meet with clinician at least [weekly] [and] in groups to routinely assess risk, safety plan (and) review stressors, id. [identify] warning signs and [negative] feelings and thoughts. Begin to establish therapeutic rapport. [Rehabilitation] will include but is not limited to 5-7 groups per week including music therapy, art therapy, music and art, gym, games and work. Anger management group [times]1/ week star team [sic]. Milieu: In milieu demonstrate active participation in prescribed [treatment] program. Identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts. Medical: Review date: (blank) Comply [with] assessment, demonstrate knowledge of reason for medication."
Interventions listed on the Interdisciplinary Treatment Plan form for each goal were similar or identical to interventions for patients with diagnosis of depression or mood disorder. Disciplines were listed by "department" providing interventions, however interventions were general expectations of care that would be provided, i.e. "meet with the clinician and participate in prescribed groups..." demonstrate active participation in prescribed treatment program", "comply with prescribed medication regime..." The interventions were identical or similar for other patients with similar diagnosis, i.e. "In milieu demonstrate active participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts" and did not differentiate interventions related to the individual patient needs.

6. Patient C8 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

"Interdisciplinary Treatment Plan 7/13/15, Target Behavior # and Goal 1: Decrease unsafe [behavior] i.e. [self injurious behavior and suicidal ideation]. Objective 1: Start Date (date blank on form): Decrease [self injurious behavior and suicidal ideation] thoughts [and] feelings [and] [behavior]. Begin to identify precipitants, context, [and] demonstrate knowledge for use of at least 5 [positive] coping skills. Inter-Discipline Interventions: Individual and Group Therapies: Review Date: 8/4/15: Meet with clinician at least 2 weeks [and] in groups to routinely assess risk, safety, plan [and] review stressors, [identify] warning signs [and] identify [negative] feelings [and] thoughts. Pt. was referred to Anger management group. Pt. was referred to DBT. [Patient name] will participate in walking group, emotion reg. [regulation] group, women's group, issues group and art group. (Patient name) to attend anger management weekly-star team. Milieu: Review date: (blank) In milieu demonstrate participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts. Medical: Review date: (blank): Comply with assessments, demonstrate acceptable of [and] knowledge of rationale for prescribed medication, review side effects if any [and] response to [medications]. [registered nurse] will educate patient) on all mediations."
"Target Behavior # and Goal 2: Improve mood [and] increase verbalization of internal thoughts/ feelings. Objective 1: Start Date (date blank on form): Decrease reactive [behavior] when begin to feel overwhelmed, id [identify] precipitant [and] demonstrate acceptance through use of [positive] [and] appropriate coping skills [and] verbalize. Inter-Discipline Interventions: Individual and Group Therapies: Review Date: 8/4/15: Meet [with] clinician [times]2/ [weekly] [and] in groups to routinely assess internal thoughts [and] feelings, identify triggers [and] stressors [and] responses to each, identify warning signs [and] ways to cope [with] feelings. Patient referred to anger management [and] [Dialectic Behavior Therapy] groups. [Rehabilitation treatment] programming to include but not limited to 3-5 groups/week, music therapy, open leisure, aquatics [and] group games, art therapy, zumba, work crew, run/weights. Milieu: Review Date: (blank): Milieu demonstrate participation in prescribed [treatment] program; identify at least 2 supports [and] how to access them if overwhelmed by intense/ [negative] emotions or feelings. Medical: Review Date (blank): Comply [with] assessment, demonstrate acceptance of [and] knowledge of rationale for prescription medication Review side effects (if any) [and] responses to [medications].
Interventions listed on the Interdisciplinary Treatment Plan form for each goal were similar or identical to interventions for patients with diagnosis of depression or mood disorder. Disciplines were listed by "department" providing interventions, however interventions were general expectations of care that would be provided, i.e. "meet with the clinician and participate in prescribed groups..." demonstrate active participation in prescribed treatment program", "comply with prescribed medication regime..." The interventions were identical or similar for other patients with similar diagnosis, i.e. "In milieu demonstrate active participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts" and did not differentiate interventions related to the individual patient needs.

7. Patient D3 (admitted 11/6/15, Initial Treatment Plan 11/6/15).

"Interdisciplinary Treatment Plan 11/23/15, "Long Term Goal # 1 Include Target Date: 12/7/15 Patient: D3 (Patient Name) will be seizure free. Objective # 1 (Short Term Goal) Include Target Date: 12/7/15: (Pt name) will identify stressors which have been contributing to pseudo seizures and work toward a desire of getting better."
"Long Term Goal # 2 Include Target Date: 12/21/15 Patient: D3 (Patient Name) Safety. Objective # 1 (Short Term Goal) Include Target Date: 12/14/15: (Pt name) will identify her thoughts and feelings prior to becoming emotionally distressed."" Initial Treatment Plan: 11/6/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Not engage in aggressive behaviors [and] self injurious behaviors. We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will initiate regular and positive interactions to establish therapeutic rapport. Will monitor signs of increased agitation or distress. Will provide positive encouragement for youth's identification of strengths. Will encourage youth in therapeutic activities, groups and milieu to promote verbalization of feelings. Will meet with youth to assess response to prescribed medication. Will assess knowledge of medications to provide basis for teaching. Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed. Will collaborate with youth and family to develop and implement Safety Plan. Will implement specific interventions related to medical condition(s); (blank on form). Other: Will assess and monitor for seizure type symptoms (please call mom if she has a seizure). Psychiatry: Preprinted form, Check box interventions: Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed. Will identify and implement medication interventions as indicated. Will meet with youth to assess response to prescribed medication. Will meet with youth to assess degree of functional impairment. Will meet with youth weekly to assess mental status. Other: Will monitor for psychological seizures. Clinical: Will assess youth's current coping strategies. Will assist youth in attending all scheduled groups and activities. Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions a

Based on policy review, record review and interview, the facility failed to identify the name of the psychiatrist, pediatrician, registered nurse, practical nurse, mental health worker, social worker, recreation therapist, art therapist, music therapist, occupational therapist responsible for carrying out interventions listed on the Master Treatment Plan (MTP). Each plan for sample patient's (A1, A5, B1, B9, C7, C8, D3, D7) had a signature for staff persons who participated in the planning meeting, however did not specify staff responsible for carrying out the interventions. Interventions were listed by staff discipline or interventions to be carried out by "All Staff." Without this differentiation 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 accountability, and potentially, failure to deliver all required interventions to meet patients' identified needs.

Findings Include:

A. Policy/Document Review

1. The hospital policy: Treatment Planning Process: Interdisciplinary Treatment Plan Approved by Executive Committee 8-2005, (Rev) 8-12: "The Interdisciplinary Treatment Plan shall: List treatment modalities which are appropriate, positively reinforcing and non-punitive. Identify, by name, staff responsible for carrying out treatment for each interventions."

B. Record Review

1. Patient A1 (admitted 9/25/15, Interdisciplinary Treatment Plan 9/25/15).

The MTP included problems related to Mood Lability [sic] and Relational Conflicts. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Medical" section for interventions. The treatment modalities: Individual and Group Therapies, Milieu, Medical was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The staff was listed by discipline or job title, i.e. "Clinical staff" - DBT group, Recreation Therapist, or "All Staff" in milieu section. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

2. Patient A5 (admitted 10/23/15, Interdisciplinary Treatment Plan 10/23/15).

The MTP included problems related to Paranoia and Bilateral Toe Infection. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Medical" section for interventions. The treatment modalities: Individual and Group Therapies, Milieu, Medical was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The staff was listed by discipline or job title, i.e. "Milieu staff" in milieu section, "MD", "Psychiatrist", or "Peds" [sic] in the Medical section. In the Individual and Group Therapies section the first intervention was listed without identifying a discipline to carry out the intervention and the second intervention listed to occur "in individual [and] group meetings." Without differentiation, it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

3. Patient B1 (admitted 11/25/15, Initial Treatment Plan 11/25/15).

The MTP included problems related to Safety, Youth and Family Engagement, and Assessment of Youth and Family Needs/ Strengths. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Psychiatry" and "Nursing (includes milieu and medical) sections for prescribed interventions." The treatment modalities: "Nursing (includes milieu and medical), Psychiatry, and Clinical" was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The Interventions were listed in a check off fashion designating that the "Discipline will" i.e. complete admission assessment, meet with youth to assess degree of functional impairment, assess the need for modifications to the safety plan, monitor and assess response to treatment interventions, arrange for youth to receive physical examination, etc. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

4. Patient B9 (admitted 11/9/15, Initial Treatment Plan 11/9/15).

The MTP included problems related to Safety, Youth and Family Engagement, and Assessment of Youth and Family Needs/ Strengths. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Psychiatry" and "Nursing (includes milieu and medical) sections for prescribed interventions". The treatment modalities: "Nursing (includes milieu and medical), Psychiatry, and Clinical" was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The Interventions were listed in a check off fashion designating that the "Discipline will" i.e. complete admission assessment, meet with youth to assess degree of functional impairment, assess the need for modifications to the safety plan, monitor and assess response to treatment interventions, arrange for youth to receive physical examination, etc. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

5. Patient C7 (admitted 10/7/15, Interdisciplinary Treatment Plan 10/7/15).

The MTP included problems related to Patient will remain safe with self and others and Mood Dysregulation. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Medical" section for interventions. The treatment modalities: Individual and Group Therapies, Milieu, Medical was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The staff was referred to by discipline or job title, i.e. "Clinician", "(Rehabilitation)", or "Staff " in milieu section. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

6. Patient C8 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

The MTP included problems related to Unsafe [Behaviors] [Self Injurious Behavior and Suicidal Ideation] and Improve Mood [and] [increase] verbalization of internal thoughts/ feelings. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Medical" section for interventions. The treatment modalities: Individual and Group Therapies, Milieu, Medical was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The staff was listed by discipline or job title, i.e. "Clinician", "RN" or interventions were listed as types of groups, i.e. DBT, Anger Management Group, Issues Group, Wellness Group, "treatment programs" in the milieu section. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions

7. Patient D3 (admitted 11/6/15, Initial Treatment Plan 11/6/15). ).

The MTP included problems related to Safety, Youth and Family Engagement, Assessment of Youth and Family Needs/ Strengths, and Will be seizure free [sic]. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Psychiatry" and "Nursing (includes milieu and medical) sections for prescribed interventions, or in Intervention sections" Nursing, Psychiatry, Clinical, Children's Services, Rehabilitation (Include OT as applicable), Other (e.g. Education, Dietary, Medical, Life Skills). The treatment modalities: "Nursing (includes milieu and medical), Psychiatry, and Clinical" was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. Without differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

8. Patient D7 (admitted 7/13/15. Interdisciplinary Treatment Plan 7/13/15).

The MTP included problems: Increase ability to assist in own defense as well as understanding of charges, court personnel, [and] procedures, and cartroom behaviors [sic]. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient in the "Medical" section for interventions. The treatment modalities: Individual and Group Therapies, Milieu, Medical was listed in the MTP, however staff names were not included to identify the patient's specific staff assigned responsibility for carrying out the plan and monitoring effectiveness. The staff was referred to by discipline or job title, i.e. "Primary Clinician", "Psychiatrist", or by treatment modality, i.e. "group therapy", "prescribed rehabilitation groups". Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered.

C. Staff Interview

1. In an interview on 12/8/15 at 1:30 p.m., after reviewing "Interdisciplinary Treatment Plans", the Nursing Director acknowledged that the Interventions on the sample patient Individualized Treatment Plans did not identify the specific staff responsible for carrying out the interventions. She said "I agree with you with your concerns", the plan does not assign staff person accountability for the interventions.

2. In an interview with the Medical Director on 12/9/15 at 8:00 a.m., the Medical Director acknowledged that the sample patient Individualized Treatment Plans reviewed did not specify specific staff persons responsible for carrying out the interventions.

Based on interview and record review, the facility failed to assess and provide active treatment for psychiatric and medical treatment for one (1) of eight (8) active sample patients (A5) who refused to participate in psychiatric and medical assessments, participate in assigned treatment groups and individual therapies, and accept prescribed medications for psychiatric and medical conditions. The lack of cooperation and refusal of assessments and treatments by patients results in a delay in treatment and potential delay in improvement and risk to the health and lives of patients.

Findings include:

Patient A5

A. Record Review

1. Psychiatric Condition

a. Patient A5 was admitted 10/23/15. The Admission Note/Psychiatric Evaluation dated 10/23/15 stated the reason for admission was "for stabilization and treatment due to recent medication refusal. [S/he] has been presenting as more disorganized, sexualized and paranoid." The diagnoses included "Unspecified schizophrenia spectrum and other psychotic disorder," "Unspecified Depressive Disorder," "Posttraumatic Stress Disorder," "Selective Mutism," and "Infection in toes secondary to chronic picking."

b. The "Psychiatric Evaluation Conference Note" dated 12/1/15 stated "As [s/he] refused [his/her] medications, it was reported that [s/he] became very disorganized, sexualized and paranoid...[S/he] also began to refuse to eat and was increasingly picking [his/her] toes to the point of causing them to bleed." "Recommendations" from this conference included "within the hospital, as [s/he] is not taking medications and has shown dispensation that is placing [his/her] medical and mental health at risk..."

c. A review of the "Physician's Medication Orders" for Patient A5 indicated that Trilifon 24 mg per day orally was prescribed at the time of admission and increased to 48 mg orally per day on 11/6/15. A review of the "Medication Records" on 12/8/5 indicated that all doses of these medications were refused by Patient A5 since 10/25/15.

d. The psychiatric progress note dated 11/10/15 at 9:00 p.m. stated "Pt. continues with symptoms of acute psychosis with behaviors that put [him/her] at medical risk."

e. A review of the document provided by the facility as the attendance and participation of Patient A5 in the assigned individual and group therapy sessions from 11/7/15 to 12/7/15 indicated that Patient A5 refused to attend all group therapies and refused individual sessions or responded with only nods of [his/her] head.

2. Medical Conditions

a. A review of the "Pediatric Admission Orders" dated 10/24/15 at 1:15 p.m. indicated the following laboratory evaluations were ordered: "Admission Profile," "Urinalysis complete," TSH [thyroid stimulating hormone], ferritin, "Hepatitis Panel Acute," urine G/C [gonococcal], chlamydia, prolactin, "lipid profile," "Quaniferon Gold TB [tuberculosis]," and "HIV [human immuno virus] titer with reflex." An EKG [echocardiogram] was also ordered. A review of the medical record for Patient A5 on 12/8/15 indicated that none of these tests were obtained and had not been discontinued.

b. The only past laboratory studies available in the medical record were collected prior to admission on 2/4/15. The results were significant for a white blood count = 3.4 [normal reference range 5.0 to 10.0 K/uL [thousand per microliter]] and absolute neutrophil count = 1.59 K/uL [reference range 2.5-7.0 K/uL]. No documented follow-up of these abnormalities was available.

c. A review of the "CT DPH Vaccine Administration Record for Children and Teens" stated "refused completion of vaccines."

d. The "Medical History/Physical Exam" dated 10/24/15 stated that Patient A5 "will not allow me to examine [him/her]. [S/he] has been picking at [his/her] toenails..." The "Assessment" section included "Paronychia, reports of self injury to feet."

e. The progress note by MD 2, a pediatrician, dated 11/2/15 at 1:00 p.m. stated "[Patient A5] has been unable to cooperate [with] a physical exam. [S/he] has been noted to continue to pick [his/her] toenails [with] bloody show on [his/her] socks. [with] help of OT [occupational therapy], [Patient A5] allowed me to examine [his/her] toes." "On exam [left] foot - swollen great toe [with] erythema from top of toe to ½ down toe past the nail. There is blood/clot on each side of nail. [Right] toe - again blood bilaterally around nail [with] [illegible] extend only the ½ way of toenail. Minimal swelling." "P [plan] - Keflex 500 q [every] 8 A [a.m.] [and] 8 P [p.m.] But I am concerned that [Patient A5] will not take meds [medications]. [S/he] continues to refuse all medications. Will need to observe closely." A review of the "Physician's Medication Orders" for Patient A5 indicated that Keflex 500 mg orally was prescribed on 11/2/15 for 10 days. A review of the "Medication Records" on 12/8/5 indicated that all doses of Keflex were refused by Patient A5. The progress note by MD 2 on 11/9/15 at 8:30 a.m. stated "Pt [patient] continues to refuse physical exam." No further assessment of the condition of Patient A5's toe infection was documented by MD 2 despite Patient A5's continued refusal of antibiotic treatment.

f. The nursing progress note on 11/8/15 at 1:15 a.m. stated "[Right] great toe is swollen [with] exudate on inner aspect of nail bed. There is bloody drainage present. [Left] great toe has drainage on both sides of nail bed [with] drainage on both sides of nail bed [with] drainage that is bloody. Toes were cleaned [with] H2O as [Patient A5] refused anything else...Both toes are swollen [and] inflamed. Both feet smell foul in odor." A review of the medical record on 12/8/15 indicated no other assessment of the infection of Patient A5's toe by nursing staff was documented during this admission.

g. A review of the "Weekly Medical Data Sheet" on 12/8/15 indicated that Patient A5 had refused all ordered vital signs since 10/28/15.

B. Interviews

1. During an interview with MD1 on 12/8/15 at 11:00 a.m., he stated that Patient A5 had begun refusing medication in October 2015 prior to admission and had continued to refuse medications since admission. MD 1 stated Patient A5's mental status and behaviors were not improved since admission and that he believed Patient A5 was psychotic. MD 1 stated that Patient A5 had not had laboratory studies completed during this hospitalization and no vital signs were obtained since admission. MD 1 acknowledged that Patient A5's refusal of an examination of his/her infected toes and refusal of the prescribed antibiotic could lead to a worsening medical condition including spread of the infection. MD 1 stated that he was following the steps according to state policy to gain approval to force psychiatric medications but that it could be "a couple of weeks" longer. MD 1 stated that legal approval would probably happen "quickly" after state approvals were obtained.

2. During an interview with the acting Medical Director on 12/9/15 at 8:00 a.m., she acknowledged that Patient A5 required psychiatric and medical medications but had refused needed assessments, medications, and treatments since admission. She stated that state policy required multiple procedures and approvals outside the facility to administer psychotropic medication which "can take up to six months." She stated that the use of contingency reinforcement techniques to encourage a patient to take psychotropic medications was viewed as "coercive." The acting Medical Director stated that medical procedures, such as laboratory studies, vital signs, medical examinations, could be forced by the facility without outside approval. She stated that she did not know why these evaluations and procedures had not been forced for Patient A5. She acknowledged that the unexamined and untreated infection of Patient A5's toe could potentially become medically serious.

Based on record review and interview the facility failed to provide progress notes by the psychiatrist that could be assessed due to illegibility for two (2) of eight (8) active sample patients (A1 and A5). The failure to communicate psychiatric progress in a legible and coherent fashion prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric condition and from addressing patient progress for safe discharge planning.

Findings include

A. All of the psychiatric progress notes written by the attending psychiatrist were illegible as follows: dated 10/26/15 at 2:30 [no notation of time of day], 11/5/15 at 3:30 p.m., 11/6/15 at 11:30 [no notation of time of day], 11/9/15 [no notation of time of day], 11/9/15 at 3:30 p.m., 11/12/15 at 3:45 p.m., 11/13/15 at 4:00 p.m., 11/25/15 at 11:30 [no designation of time of day], 12/3/15 at 4 p.m., and 12/8/15 at 2:00 p.m. were all illegible. No assessments by a psychiatrist to assess Patient A5's progress, justification of psychiatric interventions, or plans for further treatment were legibly documented in a progress note.

B. Interview

During an interview with the acting Medical Director on 12/9/15 at 8:00 a.m., she stated that all of the progress notes written by the attending psychiatrist for Patients A1 and A5 were illegible. She acknowledged that the inability to read the progress notes could lead to a failure to communicate psychiatric progress or deterioration to other members of the treatment staff.

Based on observation, interview and record review, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Ensure that the Master Treatment Plan (MTPs) for one (1) of eight (8) active sample patients (A5) was revised when the patient failed to cooperate with needed assessments or participate in the prescribed treatment. The Master Treatment Plan (MTP) was not revised to provide alternative treatment modalities to address the patient's refusal of needed physical assessments, prescribed medications, and ordered laboratory studies. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 I)

II. Ensure the provision of comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7). Specifically, the MTPs were missing patient oriented goals written in observable and behavioral terms (Refer to B121), the plans were missing individualized and specific treatment interventions to address each patient's presenting psychiatric problems (Refer to B122), and the plans failed to identify specific staff responsible for providing each interventions (Refer to B123). Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met. (Refer to B118 II.)

III. Ensure that treatment plan interventions by psychiatrists were specific to patient treatment needs for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7). The listed interventions for psychiatrists on the Master Treatment plans [MTPs] were stated as generic, discipline functions. This failure results in a lack of safe coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient A1

The MTP, dated 9/25/15, listed the following generic and routine psychiatrist functions for the problem of "Mood Lability [sic]:" "[Psychiatrist] will prescribe medication according to symptoms/ diagnosis," "[Psychiatrist, Pediatrician, Primary Nurse] will monitor for medication efficacy and side effects by monitoring weights, vitals, etc.,"
and "[Psychiatrist, Pediatrician] will follow up [with] endocrine testing results and next steps." For the problem of "Relational Conflicts," no interventions were listed to be performed by the psychiatrist.

2. Patient A5

The MTP, dated 9/25/15, listed the following generic and routine psychiatrist functions for the problem of "Paranoia:" "MD will assess need to adjust dosage of meds [medications] [and] and monitor for S/E [side effects]." For the problem of "Bilateral Toe Infection," no interventions were listed to be performed by the psychiatrist.

3. Patient B1

The MTP, dated 11/25/15, listed the following generic and routine psychiatrist functions for the goal of "Safety:" "Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed," "Will identify and implement Medication interventions as indicated," "Will meet with youth to assess response to prescribed medication," "Will meet with youth to assess degree of functional impairment," "Will meet with team to assess/ review youth's progress/ response to interventions," "Will assess knowledge of medications to provide a basis of teaching," and "Will meet with youth weekly to assess mental status." For the goal of "Youth and Family Engagement," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess current level of functioning," "Will meet with youth to assess appropriate medication interventions," "Will meet with family to provide assessment of functioning," "Will be available to family for questions regarding youth's functioning, diagnosis, medication, or other aspects of care," "Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment," and "Will identify barriers to participation in treatment and develop plan to address." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess response to past and current prescribed medications," "Will meet with youth to assess degree of functional impairment," "Will meet with team to assess/ review youth's progress/ response to interventions," "Will assess knowledge of medications to provide a basis of teaching," "Will meet with youth weekly to assess mental status," and "Will refer youth for participation in specific evaluations: OT [occupational therapy] box checked."

4. Patient B9

The MTP, dated 11/9/15, listed the following generic and routine psychiatrist functions for the goal of "Safety:" "Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed," "Will identify and implement Medication interventions as indicated," "Will meet with youth to assess response to prescribed medication," "Will meet with youth to assess degree of functional impairment," "Will meet with team to assess/ review youth's progress/ response to interventions," "Will assess knowledge of medications to provide a basis of teaching," and "Will meet with youth weekly to assess mental status." For the goal of "Youth and Family Engagement," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess current level of functioning. Will meet with youth to assess appropriate medication interventions," "Will meet with family to provide assessment of functioning," "Will be available to family for questions regarding youth's functioning, diagnosis, medication, or other aspects of care," "Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment," and "Will identify barriers to participation in treatment and develop plan to address." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess response to past and current prescribed medications," "Will meet with youth to assess degree of functional impairment," "Will meet with team to assess/ review youth's progress/ response to interventions," "Will assess knowledge of medications to provide a basis of teaching," "Will meet with youth weekly to assess mental status," and "Will refer youth for participation in specific evaluations: OT [occupational therapy] box checked."

5. Patient C7

The MTP, dated 10/7/15, listed the following generic and routine psychiatrist functions for the Long Term Goal of "Patient will remain safe with self and others:" "Psychiatrist will monitor medications for effectiveness and side effects" and "Psychiatrist will monitor mental status." For the problem of "Mood dysregulation," the following generic and routine social work functions were listed: "Comply [with] assessment, demonstrate knowledge of reason for medication." For the goal of "Decrease suicidal ideation [and] self harm [behavior]" the following generic and routine psychiatrist functions were listed: "Comply [with] assessment, demonstrate knowledge of reason for medication."

6. Patient C8

The MTP, dated 7/13/15, listed the following generic and routine psychiatrist function for the Long Term Goal of "Decrease unsafe [behavior] i.e. [self injurious behavior and suicidal ideation]:" "Comply with assessments, demonstrate acceptable of [and] knowledge of rationale for prescribed medication, review side effects if any [and] response to [medications]. [Registered nurse] will educate patient on all mediations." For the goal of "Improve mood [and] increase verbalization of internal thoughts/feelings:" the following generic and routine psychiatrist function was listed: "Comply [with] assessment, demonstrate acceptance of [and] knowledge of rationale for prescription medication Review side effects (if any) [and0responses to [medications]."

7. Patient D3

The MTP, dated 11/6/15, listed the following generic and routine psychiatrist functions for the goal of "Safety:" "Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed," "Will identify and implement medication interventions as indicated," "Will meet with youth to assess response to prescribed medication," "Will meet with youth to assess degree of functional impairment," "Will meet with youth weekly to assess mental status," and "Other: Will monitor for psychological seizures." For the goal of "Youth and Family Engagement," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess current level of functioning," "Will meet with youth to assess appropriate medication interventions," "Will meet with family to provide assessment of functioning," "Will be available to family for questions regarding youth's functioning, diagnosis, medication, or other aspects of care," "Will identify barriers to participation in treatment and develop plan to address," and "Other: Will review previous records/ work up for seizures." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine psychiatrist functions were listed: "Will meet with youth to assess response to past and current prescribed medications," "Will meet with youth to assess degree of functional impairment," "Will meet with team to assess/ review youth's progress/ response to interventions," "Will assess knowledge of medications to provide a basis of teaching," "Will meet with youth weekly to assess mental status," "Will refer youth for participation in specific evaluations: OT [occupational therapy] box checked," and "Other: Cognitive assessment."

8. Patient D7

The MTP, dated 7/13/15, listed the following generic and routine psychiatrist functions for the goal of "Increase ability to assist in own defense as well as understanding of charges, court personnel, and cartroom [sic] behaviors:" "(Patient name) will comply with prescribed medication regime if needed," "[Psychiatrist], [Primary Nurse], [Pediatrician] will prescribe (if needed), monitor compliance [and] assess efficacy of current medications," and "[Psychiatrist], [Primary Nurse], [Pediatrician] will monitor for side effects of medication including but not limited to monitoring weight, vital signs [and] thyroid function per mental status, patient report, [and] staff observation signs/[symptoms] of infection."

C. Staff Interview:

In an interview with the Medical Director on 12/9/15 at 8:00 a.m., she acknowledged that the sample patient Individualized Treatment Plans reviewed did not include individualized interventions or focus of the interventions provided by the staff responsible for the individual/ group modalities.

IV. Ensure the assessment and provision of active psychiatric and medical treatment for one (1) of eight (8) active sample patients (A5) who refused to participate in psychiatric and medical assessments, participate in assigned treatment groups and individual therapies, or accept prescribed medications for psychiatric and medical conditions. The lack of cooperation and refusal of assessments and treatments by patients results in a delay in treatment and potential delay in improvement and risk to the health and lives of patients. (Refer to B125)

IV. Ensure the provision of progress notes by the psychiatrist that could be assessed due to illegibility for two (2) of eight (8) active sample patients (A1 and A5). The failure to communicate psychiatric progress in a legible and coherent fashion prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric condition and from addressing patient progress for safe discharge planning. (Refer to B126)

Based on record review and staff interview, it was determined that the Director of Nursing (DON) does not have sufficient education and experience for her current administrative position as Director of Nursing in the facility. This deficient practice can result in lack of quality nursing care for the patients.

Findings include:

A. Document Review

1. Review of the Director of Nursing's curriculum vitae revealed that the Director of Nursing (hired to these duties in 2004) received an Associate Degree in Nursing 1986. Work experience highlighted the DON's work in Psychiatric Mental Health Nursing since starting at the current facility in June 1995 and included work as a Charge Nurse on an Adolescent unit, Head Nurse, Nursing Supervisor (2001-2004) and promotion to Director of Nursing 2004.

B. Staff Interview

During an interview on 12/17/2014 at 2:00 p.m., the Director of Nursing (DON) stated that she has a Bachelor Degree since 1983. She said the facility functioned previously as a Psychiatric Residential Treatment Facility (PRTF), until a recent transition which prompted the request for an initial survey as a hospital (current survey). She said she continues to be the Nursing Director for one on site PRTF in addition to the hospital (Albert J Solnit Children's Center). She said that the hospital shift ("house") supervisors all have a Master's Degree. She added that, the Infection Control Nurse has a Master's Degree and that one of the previous Directors of Nursing now in their central office has a Master's Degree. The Director of Nursing said that she is in regular communication with each of these nurses. There was no documented consultation with nurses having a Masters Degree in Psychiatric Mental Health Nursing. The surveyor requested to review any additional education/ training specific to psychiatric mental health nursing. The Director of Nursing said she would be able to show ongoing training provided at the hospital. The training submitted was for mandatory and annual training updates, i.e. fire extinguisher, policy and procedure review, ethics training, code of conduct, CMS Hospital Conditions of Participation, Nursing Best Practice, Lab Requisition, etc. She said that she did not have documented continuing education for psychiatric mental health nursing beyond the ongoing annual and mandatory training provided by the hospital. She said that since beginning in the DON position in 2004, she did not have any documented consultation with a Nurse Specialist having a Master's Degree in Psychiatric Mental Health Nursing.

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 the Master Treatment Plan (MTP) The MTP's for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3, D7). This was evident based on deficiency of short term and long term goals, individualized and measurable nursing interventions, and identification of specific assigned nursing personnel to carry out the MTP.

A. Record Review: Lack of Individualized Nursing Interventions on the MTPs

1. Patient A1 (admitted 9/25/15, Interdisciplinary Treatment Plan 9/25/15).

"Review Date: 10/16/15, 11/5/15, 11/9/15 and 11/24/15 Target Behavior # and Goal 1: Mood Lability [sic]. Learn and practice emotions in a safe and verbal manner. Objective 1: Start Date 9/25/15, (Patient) will report any thoughts/ urges to SI/SIB [Suicide Ideation/ Self Injurious Behavior]. Pt. will help staff build a helpful [and] effective safety plan that helps pt. cope [with] stress. Milieu: All staff will monitor for signs and symptoms of SIB/SI/ mood lability [sic] and provide coaching. All staff will help create [and] update safety plan to prevent/decrease unsafe actions. Coach will review and discuss [with] [patient] [Dialectic Behavior Therapy] work/ assignments. All staff will follow through [with] snack box plan to motivate [patient] to attend classes."
"Review Date 10/16/15, 11/5/15, 11/9/15 and 11/24/15: Target Behavior # and Goal 2: Relational Conflicts. Improve communication skills and relations in and out of home. Objective 1: Start Date 9/25/15, [Patient] will talk about her family issues [and] concerns during individual therapy and/ or during coaching sessions. (Patient) will have positive peer interactions in milieu groups and (rehabilitation) groups once per shift. Milieu: All staff will observe [patient ' s] interactions during visits [and] phone calls and document remarkable observations. Staff/ Coach can process [with] (Patient Name) before or after phone calls that are more emotionally charged in order to reflect or use skills."
The Nursing-Milieu section listed three (3) of four (4) interventions carried out by "All Staff" and the names of staff members designated to carry out the plans were not listed. Other interventions listed "coach" or the title for assigned nursing personnel. Nursing care interventions were generic for patients having similar problems and did not reflect individual care needs, i.e. frequency of patient safety monitoring, etc.

2. Patient A5 (admitted 10/23/15, Interdisciplinary Treatment Plan 10/23/15).

"Interdisciplinary Treatment Plan 10/23/15, Target Behavior # and Goal 1: Paranoia. Will take medications consistently. Objective 1: start date: (blank on form): Will seek coach to get needs met. Will help team to develop effective safety plan. Will take medications as prescribed and raise any concerns/ issues about medication to staff. Will bring up thoughts /feelings around mom's pregnancy [sic]. Review date: 11/9/15 and 11/9/15 Milieu: Support youth to feel safe. Add to development of effective safety plan. Milieu staff will assess (Patient name) current ADL [activity of daily living] ability."
"Target Behavior # and Goal 2: Bilateral Toe Infection. Goal: Toes will remain free of infection. Objective 1: Start date: (blank on form): Pt. will refrain from picking [at] toes to prevent further infection and allow healing. Pt. will cooperate [with] foot soaks and other treatments prescribed. Pt. will respond to 1:1 redirection of picking [at] toes. Review date: 12/9/15, 12/15/15, Milieu: Staff will encourage [patient] to comply [with] foot soaks and refrain from picking. 1:1 staff to observe for and redirect if [patient] is picking. [Registered Nurse] will assess toes (both feet) [each] shift for signs/ [symptoms] of infection and notify pediatrics. Encourage (Patient name) to wear open toe shoes (flip-flops) in order to expose toes to air. 11/2/15: Provide med teaching (keflex) and provide infection prevention teaching, as tolerated. Consult [with] pediatrics with any signs/[symptoms] of infection. Passive recs [recreation] per pediatrics."
The Nursing-Milieu sections listed interventions were to be carried out by "Staff" or "Coach" and the names of staff members designated to carry out the plans were not listed. Nursing care interventions for paranoia were generic for patients new to a unit, i.e. support youth to feel safe, develop safety plan, take prescribed medications, etc. and did not reflect individual care needs. Interventions for the patient's toe infection did not identify staff responsible for carrying out the interventions, or interventions to address the patient's resistance to participation in treatment since being hospitalized.

3. Patient B1 (admitted 11/25/15, Initial Treatment Plan 11/25/15).

"Initial Treatment Plan 11/25/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Remain safe; communicate urges for unsafe behaviors; follow rules. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked.
Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked.
Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences. Interventions: we will ... in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked."
A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. Interventions pre-printed on the form for each goal were standardized using check boxes. There were no nursing interventions checked for any of the three standardized goals on the first date of survey (11/7/15).

4. Patient B9 (admitted 11/9/15, Initial Treatment Plan 11/9/15).

"Initial Treatment Plan 11/9/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: I will communicate my triggers. Interventions: We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will initiate regular and positive interactions to establish therapeutic rapport. Will provide coaching to assist in identifying triggers for behavior. Will meet with youth to assess response to prescribed medication. Will assess knowledge of medications to provide basis for teaching.
"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team. Interventions: We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will review facility handbook with youth. Will initiate regular and positive interactions to establish therapeutic rapport. Will connect with family/ guardian within 24 hours to provide update on adjustment and functioning. Will meet with youth and family to discuss their questions and concerns and to provide education about their care and treatment."
"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences. Interventions: we will... in order for youth to be/ feel safe: Nursing (includes milieu and medical) 13 check box interventions listed, none checked."
A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. Interventions pre-printed on the form for each goal were standardized using check boxes. There were no nursing interventions checked for goal 3, Assessment of Youth and Family Needs/ Strengths on the first date of survey (11/7/15). The interventions checked included routine nursing staff duties, i.e. "review facility handbook", "initiate regular and positive interactions to establish therapeutic rapport". The interventions checked were identical or similar for other patients admitted to the facility after November 1, 2015 and did not differentiate interventions related to the individual patient needs.

5. Patient C7 (admitted 10/7/15, Interdisciplinary Treatment Plan 10/7/15).

"Interdisciplinary Treatment Plan 12/7/15, Long Term Goal # (blank) Patient will remain safe with self and others. Target date: (blank) Objective # (blank) (Patient name) will demonstrate consistent safety and achieve on grounds mobility. Interventions: (we will...) Nursing: Nursing will assess patient's mental status on a daily basis.
"Interdisciplinary Treatment Plan 10/7/15, Target Behavior # and Goal 1: Mood dysregulation (goal blank on form). Objective 1: Start Date (blank on form), Decrease reactive bx. [behavior] when feeling overwhelmed by - [negative] thoughts [and] feelings, verbalize internal thoughts [and] feelings. Milieu: Participate in prescribed [treatment programs], identify at least 2 supports [and] how to access them. Begin to identify triggers [and] ways to resolve conflict without unsafe [behavior]. Pt. encouraged to ask staff to help her resolve issues with peers to help her develop skills to eventually successfully resolve issues on her own. Medical: Review date: (blank): Comply with prescribed medication regime. Demonstrate knowledge of reason for medication. RN [Registered Nurse] to monitor rash to bottom of feet. RN to educate and review [patient's] medication uses and side effects. RN to educate to Bactroban ointment."
"Target Behavior # and Goal 2: Decrease suicidal ideation [and] self harm [behavior]. Objective 1: Start date: (date blank on form), Decrease suicidal ideation and improve (positive) thinking. Begin to identify precipitants, context (and) demonstrate knowledge for use of at least 3 [positive] coping skills. Learn staff [and] peers names, review mobilities [sic], transition to [and] from school/program safely. Milieu: In milieu demonstrate active participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts. Medical: Review date: (blank) Comply [with] assessment, demonstrate knowledge of reason for medication."
Interventions listed on the Interdisciplinary Treatment Plan form for each goal were similar or identical to interventions for patients with diagnosis of depression or mood disorder. Disciplines were listed by "department" providing interventions and did not specific staff responsible to carry out the interventions. Interventions were general expectations of care that would be provided, i.e. "demonstrate active participation in prescribed treatment program" and "comply with prescribed medication regime." The interventions were identical or similar for other patients with similar diagnosis, i.e. "In milieu demonstrate active participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts" and "did not differentiate interventions related to the individual patient needs."

6. Patient C8 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

"Interdisciplinary Treatment Plan 7/13/15: Target Behavior # and Goal: 1) Decrease unsafe [behavior] i.e. [self injurious behavior and suicidal ideation]. Objective 1: Start Date (date blank on form): Decrease [self injurious behavior and suicidal ideation] thoughts [and] feelings [and] [behavior]. Begin to identify precipitants, context, [and] demonstrate knowledge for use of at least 5 [positive] coping skills. Inter-Discipline Interventions: Individual and Group Therapies: Review Date: 8/4/15: Meet with clinician at least 2 weeks [and] in groups to routinely assess risk, safety, plan [and] review stressors, [identify] warning signs [and] identify [negative] feelings [and] thoughts. Pt. was referred to Anger management group. Pt. was referred to DBT. (Patient name) will participate in walking group, emotion reg. [regulation] group, womens group, issues group and art group. (Patient name) to attend anger management weekly-star team. Milieu: Review date: (blank) In milieu demonstrate participation in prescribed tx. [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts. Medical: Review date: (blank): Comply with assessments, demonstrate acceptable of [and] knowledge of rationale for prescribed medication, review side effects if any [and] response to [medications]. [Registered nurse] will educate patient on all mediations."
"Target Behavior # and Goal 2: Improve mood [and] increase verbalization of internal thoughts/ feelings. Objective 1: Start Date (date blank on form): Decrease reactive [behavior] when begin to feel overwhelmed, id [identify] precipitant [and] demonstrate acceptance through use of [positive] [and] appropriate coping skills [and] verbalize. Inter-Discipline Interventions: Individual and Group Therapies: Review Date: 8/4/15: Meet [with] clinician 2[times]/ [weekly] [and] in groups to routinely assess internal thoughts [and] feelings, identify triggers [and] stressors [and] responses to each, identify warning signs [and] ways to cope [with] feelings. Patient referred to anger management [and] [Dialectic behavior therapy] groups. [Rehabilitation treatment] programming to include but not limited to 3-5 groups /week, music therapy, open leisure, aquatics [and] group games, art therapy, zumba, work crew, run/weights. Milieu: Review Date: (blank): Milieu demonstrate participation in prescribed [treatment] program; identify at least 2 supports [and] how to access them if overwhelmed by intense/ [negative] emotions or feelings. Medical: Review Date (blank): Comply [with] assessment, demonstrate acceptance of [and] knowledge of rationale for prescription medication Review side effects (if any) [and] responses to [medications].
Interventions listed on the Interdisciplinary Treatment Plan form for each goal were similar or identical to interventions for patients with diagnosis of depression or mood disorder. Disciplines were listed by "department" providing interventions, however interventions were general expectations of care that would be provided, i.e. "meet with the clinician and participate in prescribed groups..." "demonstrate active participation in prescribed treatment program", "comply with prescribed medication regime..." The interventions were identical or similar for other patients with similar diagnosis, i.e. "In milieu demonstrate active participation in prescribed [treatment] program, identify at least 2 supports [and] how to access them if overwhelmed by intense feelings/ thoughts" and did not differentiate interventions related to the individual patient needs.

7. Patient D3 (admitted 11/6/15, Initial Treatment Plan 11/6/15).

"Interdisciplinary Treatment Plan 11/23/15, "Long Term Goal # 1 Include Target Date: 12/7/15 Patient: D3 (Patient Name) will be seizure free. Objective # 1 (Short Term Goal) Include Target Date: 12/7/15: (Pt name) will identify stressors which have been contributing to pseudo seizures and work toward a desire of getting better."
"Long Term Goal # 2 Include Target Date: 12/21/15 Patient: D3 (Patient Name) Safety. Objective # 1 (Short Term Goal) Include Target Date: 12/14/15: (Pt name) will identify her thoughts and feelings prior to becoming emotionally distressed."
"Initial Treatment Plan: 11/6/15, Goal 1: Safety. Initial Objective: Youth will remain safe and feel safe. Specifically this means: Not engage in aggressive behaviors (and) self injurious behaviors. We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will initiate regular and positive interactions to establish therapeutic rapport. Will monitor signs of increased agitation or distress. Will provide positive encouragement for youth's identification of strengths. Will encourage youth in therapeutic activities, groups and milieu to promote verbalization of feelings. Will meet with youth to assess response to prescribed medication. Will assess knowledge of medications to provide basis for teaching. Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed. Will collaborate with youth and family to develop and implement Safety Plan. Will implement specific interventions related to medical condition(s); (blank on form). Other: Will assess and monitor for seizure type symptoms, please call mom if she has a seizure."
"Goal 2: Youth and Family Engagement. Initial Objective: Youth and family will feel connected to the treatment team and unit community, and will feel they are equal partners in the treatment team. Interventions: We will...in order for youth to be/ feel safe): Nursing (includes milieu and medical) check box interventions: Will review facility handbook with youth. Will initiate regular and positive interactions to establish therapeutic rapport. Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment. Will identify and respond to concrete needs related to clothing, toiletries, etc. Other: Please call mom if she has a seizure.
"Goal 3: Assessment of Youth and Family Needs/ Strengths. Initial Objective: Youth, family and team will work together to develop a better understanding of youth and family strengths, struggles, preferences and needs. Youth, family, and team will identify potential ways to respond to these struggles and needs, building upon their strengths and preferences. Interventions: we will...in order for youth to be/ feel safe: Nursing (includes milieu and medical) check box interventions: Will complete admission assessment on the day of admission. Will complete nursing evaluation within 14 days of admission. Will assess youth and family knowledge of medical conditions(s) and provide appropriate education. Will arrange for youth to receive physical examination. Will arrange for youth to receive dental screening. Will arrange for youth to receive Dietary consultation. Will arrange for assessments of the following medical condition(s): Other: Seizures, please call mom.

A standardized, pre-printed form was used to identify Goal 1 Safety, Goal 2 Youth and Family Engagement, and Goal 3 Assessment of Youth and Family Needs/ Strengths. This same Goal and Objective was present for all sample patients admitted after November 1, 2015, using a standardized, pre-printed form with standard objectives for Goal 2 and Goal 3. The numbering of the goals changed from the Initial Treatment Plan to the Interdisciplinary Treatment Plan, making it difficult to follow patient progress. Safety was goal #1 in the Initial Treatment Plan (11/16/15) and Safety was Long Term Goal #2 in the Interdisciplinary Treatment Plan (11/23/15). Interventions pre-printed on the form for each goal were standardized using check boxes. Disciplines were listed by " department " providing interventions, however there were no therapeutic modalities or types of groups the patient would benefit from listed on the Initial Treatment Plan form. The interventions checked were identical or similar for other patients admitted to the facility after November 1, 2015 and did not differentiate interventions related to the individual patient needs. The interventions included reviews (i.e. facility handbook), assessments (i.e. current level of functioning), referrals (i.e. to receive physical examination) and monitoring (i.e. signs of increased agitation or distress) expected to be provide for all patients. Responsible staff were identified by discipline or modality, however no specific staff person was assigned responsible to carry out the interventions.

8. Patient D7 (admitted 7/13/15, Interdisciplinary Treatment Plan 7/13/15).

"Interdisciplinary Treatment Plan Review Date 11/23/15, Target Behavior # and Goal 1: Increase ability to assist in own defense as well as understanding of charges, court personnel, and cartroom behaviors [sic]. Objective 1: Start Date (7/13/15), Complete a baseline assessment of D7 (Patient Name) knowledge (and) understanding of the above. Objective 2: (Patient Name) will participate in any psychological testing to assist with identifying barriers to restoration as well as most effective approach to competency education. Notation on form: 8/20/15 (objective 1 (and) 2 met. 11/23/15 Objective 2: (Patient name) will engage during restoration education sessions. Objective 1: complete competency assessment at least 1x [time]/month to monitor progress over time. Milieu: Review date: 11/23/15, continued: [co-counselor 1], [co-counselor 2], and [primary nurse] will review and update safety plan on a regular bases or as needed. (Patient name) will attend school [and] off unit programming on a daily basis. Medical: Review date: 11/23/15, continued: (Patient name) will comply with prescribed medication regime if needed. [Psychiatrist], [Primary Nurse], [Pediatrician] will prescribe (if needed), monitor compliance [and] assess efficacy of current medications. [Psychiatrist], [Primary Nurse], [Pediatrician] will monitor for side effects of medication including but not limited to monitoring weight, vital signs [and] thyroid function per mental status, patient report, [and] staff observation.
Disciplines were listed by "department" or "job title" of staff providing interventions, however failed to identify a specific staff person responsible to carry out the interventions. The stated interventions were general expectations of care that would be provided, i.e. "review and update safety plan on a regular bases or as needed. (Patient name) will attend school (and) off unit programming on a daily basis. Assess efficacy of current medication including but not limited to monitoring weight, vital signs...Patient will comply with prescribed medication regime if needed" and did not differentiate interventions related to the individual patient needs.

C. Staff Interview

In an interview on 12/8/15 at 1:30 p.m., the Nursing Director agreed that the sample patient Individualized Treatment Plans included generic check boxes for interventions, did not differentiate interventions related to individual patient needs, and did not identify the specific staff responsible for carrying out the interventions. She said "I agree with you with your concerns", the plan does not assign staff person accountability for the interventions and is not individualized.

Based on document review and interviews, the facility failed to provide or have available adequate registered nurse staffing on the midnight shift to meet the needs of active, behaviorally/cognitively impaired patients. This omission compromises the facility's ability to address all the patient's nursing care needs in a timely manner.

Findings include:

A. Document Review

Review of the Direct Nursing Staffing forms for 11/1/15-11/7/15 and 12/1/15-12/7/15 showed that one to four registered nurses were assigned to staff the four patient units on the midnight (MN) shift. The units that did not have a registered nurse (RN) were staffed with a practical nurse assigned. The practical nurses had access to phone call contact to request RN assistance by the registered nurse shift (house) supervisor. The number of MN shift RN staff included: date (# MN shift RN's assigned for 4 units) patient census: 11/1/15(3RN/4 units) census: 38 patients; 11/2/15(1RN/4 units) census:39 patients; 11/3/15(2RN/4 units) census:38 patients; 11/4/15(2RN/4 units) census:37 patients; 11/5/15(3RN/4 units) census:37 patients; 11/6/15(1RN/4 units) census:36 patients; 11/7/15(1RN/4 units) census:34 patients; 12/1/15(2RN/4 units) census:42 patients; 12/2/15(2RN/4 units) census:43 patients; 12/3/15(3RN/4 units) census:42 patients; 12/4/15(2RN/4 units) census:40 patients; 12/5/15(3RN/4 units) census:38 patients; 12/6/15(2RN/4 units) census:36 patients; 12/7/15(4RN/4units) census:41 patients.

B. Staff Interviews

In an interview on 12/8/15 at 2:30 pm, the Director of Nursing (DON) confirmed that the facility did have a nurse assigned on each unit on the a.m. and p.m. shifts, however the midnight shift varied from this staffing pattern and there could be between one to four nurses assigned to the four units on the midnight shift. Units that did not have an RN assigned had a Practical Nurse assigned, and additional registered nurse needed coverage would be obtained by contacting the supervising RN/house supervisor on duty. A master's level supervising RN/house supervisor was assigned on duty each shift (a.m. shift, p.m. shift, and the midnight shift) seven days a week. The DON said that the midnight unit registered nurse duties included "direct nursing care as needed, auditing and chart reviews; auditing orders; a 24 hour check of all chart; assisting with medical record audits; authentication of orders; follow up to be sure our pain assessments are completed; renewals due, mediation room audits, etc. stating there were a list of assigned midnight shift registered nurse duties." She said the registered nurse house supervisors were responsible as "Shift supervisors responsible for the patient care on the units, operations, staffing, emergency maintenance; contacting the administrator on call (24/7 on call coverage, the managers rotate this responsibility)." She agreed that the hospital was providing treatment to youth with significant acuity, i.e. risks for injury to self or others and that there were incidents reported to occur on all three shifts. She said there was currently "about a 6% rate of vacant nursing positions." She said that she had "several vacant registered nurse positions and that there was a hiring freeze." Several registered nurse positions also had been recently 'revoked', which means that the positions were "no longer there". She said the facility had "one registered nurse on a worker compensation leave" and that the facility also "utilized per-diem registered nurses with the same training as unit registered nurses, to assist with registered nurse staffing."

Based on record review and interviews, the Director of Social Services failed to:

A. Ensure social work assessments for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7) in a timely fashion. As a result, the treatment team did not have necessary social information and evaluation of social functioning level documented to utilize in developing treatment goals and interventions. (Refer to B108)

B. Ensure that treatment plan interventions by social work staff were specific to patient treatment needs for eight (8) of eight (8) active sample patients (A1, A5, B1, B9, C7, C8, D3 and D7). The listed interventions on the Master Treatment plans [MTPs] were stated as generic, discipline functions. This failure results in a lack of safe coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient A1

The MTP, dated 9/25/15, listed the following generic and routine social work functions for the problem of "Mood Lability [sic]:" "[Primary Clinician] will meet [with] [patient] [at] least 2[time's] /[week] to develop trust and rapport," "Pt. will bring 1 topic to discuss in individual therapy," "Pt. will educate review DBT [Dialectic Behavior Therapy] skill [with] coach and PC [Primary Clinician]," and "[Primary Clinician] will meet [with] patient 2 [times]/week to conduct individual therapy/practice DBT (review assignments)." For the problem of "Relational Conflicts," the following generic and routine social work functions were listed: "[Patient] will talk about [his/her] family issues [and] concerns during individual therapy. [Patient] will positive peer interactions in milieu groups and [rehabilitation] groups once per shift [sic]. [Primary Clinician] will engage in family therapy meeting to further assess/understand family dynamics. Notation on top of form: Discontinued 10/16/15." Review Date 10/16/15, 11/5/15, 11/9/15 and 11/24/15: for the problem of "Relational Conflicts," the following generic and routine social work functions were listed: "[Patient] will talk about [his/her] family issues + [and] concerns during individual therapy and/or during coaching sessions," "[Primary Clinician] will engage in family therapy/meeting to further assess/understand family dynamics [with] a focus on improving communication skills and problem solving techniques," "[Primary Clinician] will meet [with] [patient] and father 1[time]/week to have family therapy," and "[Primary Clinician] will attempt to engage stepmother in family therapy."

2. Patient A5

The MTP, dated 10/23/15, listed the following generic and routine social work functions for the problem of "Paranoia:" "Meet with youth at least twice per week to develop rapport," "Will express [his/her] thoughts and feelings in individual and group meetings [sic]," and "[Primary Clinician] will support visits [with] mom 1[time]/week and encourage talk about baby/pregnancy."

3. Patient B1

The MTP, dated 11/25/15, listed the following generic and routine social work functions for the goal of "Safety:" "Will meet with youth within 1 working day to establish a therapeutic rapport," "Will assess youth's current coping strategies," "Will meet with youth to develop/reinforce strategies to replace unhealthy choices," "Will assist youth in attending all scheduled group and activities," and "Will collaborate with youth and family to develop and implement Safety Plan." For the goal of "Youth and Family Engagement," the following generic and routine social work functions were listed: "Will meet with youth within 1 working day to establish therapeutic rapport," "Will connect with family/guardian within 1 day to schedule initial family session," "Will review with youth and family their past experience of treatment, what was helpful and what was not helpful, and identify their concerns about current treatment," "Will identify barriers to participation in treatment and develop plan to address." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine social work functions were listed: "Will complete a psychosocial assessment within 2 weeks," and "Will identify additional clinical psycho-educational groups."

4. Patient B9

The MTP, dated 11/9/15, listed the following generic and routine social work functions for the goal of "Safety:" "Will meet with youth within 1 working day to establish a therapeutic rapport," "Will assess youth's current coping strategies," "Will meet with youth to develop/reinforce strategies to replace unhealthy choices," and "Will collaborate with youth and family to develop and implement Safety Plan." For the goal of "Youth and Family Engagement," the following generic and routine social work functions were listed: "Will meet with youth within 1 working day to establish therapeutic rapport," "Will find out from youth and family who are the people in their support network and whom they would like to include as part of their extended treatment team," and "Will identify barriers to participation in treatment and develop plan to address." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine social work function was listed: "Will complete a psychosocial assessment within 2 weeks."

5. Patient C7

The MTP, dated 10/7/15, listed the following generic and routine social work functions for the Long Term Goal of "Patient will remain safe with self and others:" "Therapist will support client in identifying and using coping skills to decrease self harm and aggress behaviors and verbalizations." For the problem of "Mood dysregulation," the following generic and routine social work functions were listed: "Meet [with] clinician 1[time] /[weekly] [and] participate in prescribed groups, assess internal thoughts [and] feelings, identify triggers [and] stressors." For the goal of "Decrease suicidal ideation [and] self harm [behavior]" the following generic and routine social work functions were listed: "Meet with clinician at least [weekly] [and] in groups to routinely assess risk, safety plan [and] review stressors, id [identify] warning signs and [negative] feelings and thoughts," and "Begin to establish therapeutic rapport."

6. Patient C8

The MTP, dated 7/13/15, listed the following generic and routine social work functions for the Long Term Goal of "Decrease unsafe [behavior] i.e. [self injurious behavior and suicidal ideation]:" "Meet with clinician at least 2 weeks [and] in groups to routinely assess risk, safety, plan [and] review stressors, [identify] warning signs [and] identify [negative] feelings [and] thoughts." For the goal of "Improve mood [and] increase verbalization of internal thoughts/feelings:" the following generic and routine social work function was listed: "Meet [with] clinician 2 [times[/ [weekly] [and] in groups to routinely assess internal thoughts [and] feelings, identify triggers [and] stressors [and] responses to each, identify warning signs [and] ways to cope [with] feelings."

7. Patient D3

The MTP, dated 11/6/15, listed the following generic and routine social work functions for the goal of "Safety:" "Will assess youth's current coping strategies," "Will assist youth in attending all scheduled groups and activities," "Will review with youth and family past unsafe behaviors, identify current risk of these behaviors, and implement supports and precautions as needed," "Will meet with team to assess/review youth's progress/response to interventions," "Will collaborate with youth and family to develop and implement Safety Plan," and "Other: Will explores stressors [and] family dynamics." For the goal of "Youth and Family Engagement," the following generic and routine social work functions were listed: "Will meet with youth within 1 working day to establish therapeutic rapport," "Will connect with family/guardian within 1 working day to schedule initial family session," "Will find out from youth and family who are the people in their support network and whom they would like to include as part of their extended treatment team," "Will review with youth and family their past experience of treatment, what was helpful and what was not, and identify their concerns about current treatment," "Will identify barriers to participation in treatment and develop plan to address," "Will introduce youth to members of their educational team, who will assess and respond to their academic/learning needs," and "Other: We will explore scheduling medcab for mom [sic]." For the goal of "Assessment of Youth and Family Needs/Strengths," the following generic and routine social work functions were listed: "Will complete a psychosocial assessment within 2 weeks" and "Will identify additional clinical psycho-educational groups."

8. Patient D7

The MTP, dated 7/13/15, listed the following generic and routine social work functions for the goal of "Increase ability to assist in own defense as well as understanding of charges, court personnel, and cartroom [sic] behaviors:" "[Primary Clinician] will schedule individual sessions at least 3 [times]/week to complete competency restoration education" and "(Patient name) will attend group therapy at least 5x/week (competency, musical mindfulness, problem solving, occupational therapy, nursing education)."

B. Staff Interview

During an interview with the Clinical Program Manager (supervisor of social work services) on 12/9/15 at 9:00 a.m., she acknowledged that the interventions to be provided by social work staff were generic and not specific to individual patient needs.