HospitalInspections.org

Based on interview and record review the facility failed to complete timely face-to-face assessments for 1 of 7 patients (#15) requiring restraint application placing Patient #15 at risk for poor clinical outcomes. Findings include:

On 09/11/19 at 1015 a review of Patient #15's restraint record was completed with Registered Nurse F present. The review revealed the following information:

1. On 06/22/19 at 1025 per physician order, Patient #15 was placed into four-point mechanical restraints for exhibiting violent behaviors. Review of the record revealed no documented evidence that the face-to-face assessment was completed by a qualified practitioner within one hour of the application of the restraints. The documentation indicated the face-to-face assessment was completed on 06/24/19 at 1100.

2. A second physician order was written on 06/22/19 at 1425 for Patient #15 to continue in restraints. Review of the record revealed no documented evidence that the face-to-face assessment was completed by a qualified practitioner within one hour of the order. The documentation indicated the face-to-face assessment was completed on 06/24/19 at 1500.

During an interview with Registered Nurse F on 09/11/19 at 1030, Registered Nurse F acknowledged the face-to-face assessment times for Patient #15 were untimely.

Review of facility policy titled, "Restraint-Mechanical, Use Of" implemented on 03/17/17 indicated under Standards section, "9. When restraint is used for the management of violent or self-destructive behavior, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a physician ...", and, under the section titled "The Physician Responsible For The Patient", the physician will "6. Directly assess the patient within 60 minutes from the application of restraints, whether the patient continues in restraints or not.".

Based on document review and interview, the Medical Staff leadership failed to consistently maintain an active role in Quality Assurance Performance Improvement (QAPI) program planning and implementation resulting in the potential for missed opportunities for improvement for all patients. Findings include:

On 9/11/19 at 0900 a review of the QAPI program was conducted with the Director of Nursing (staff B) and the Director of Staff Development/Regulatory Compliance (staff C). At that time, Staff B explained the committee met monthly. She said the meetings were mandatory.

Per review of the facility's QAPI minutes and data collection records dated January 2019 through July 2019 revealed no sign in or input from the Medical Staff Leadership or Medical Staff representation on the following dates:

On 1/29/19, there was no sign in or input from the Medical Staff Leadership.
On 2/27/19, there was no sign in or input from the Medical Staff Leadership.
On 3/27/19, there was no sign in or input from the Medical Staff Leadership.
On 7/24/19, there was no input from the Medical Leadership. There was only sign in for the Medical physician.

Interview with the staff B on 9/11/19 at 0930, verified that the Medical Staff did not always attend nor provide input directly to the QAPI program. Staff B stated, "we were low on psychiatrists at the beginning of the year." Staff B stated, "I don't recall why there was no psychiatrist at the meeting on 7/24/19.

An interview was conducted with the Hospital Director (staff A) on 9/11/19 at 1250. Staff A stated, "we've been short on psychiatrists." She said, "I'll make sure they attend in the future."

Based upon observation and interview the facility failed to maintain the hospital environment to assure the health and safety of the current census of 92 patients and its staff. Findings include:

1. On 9/9/19 at approximately 1130 during inspection of cottage 27 roof, observed two roof drains that were over 50% clogged with debris. When asked, staff A explained that the facility did conduct environmental rounds but not on a scheduled basis for the roof areas. Such extreme blockage of the roof could lead to severe water ponding in heavy rain with possible roof failure.

2. On 9/9/19 at approximately 1130 during inspection of cottage 27 roof, observed several areas of the flat roof with significant amount of debris that had vegetation growing on it.

3. On 9/9/19 at approximately 1130 during inspection of cottage 27 roof, observed several section of the roof with tree branches thickly overgrown and hanging over the roof.

Staff A also confirmed that the facility did not have any routine maintenance schedule for tree trimming or cleaning roof drains and clearing debris from the flat roof of cottage 27.



32000


On 9/9/19 during a tour of the number 27, 16, and 15 cottage's kitchens between 11:10 AM- 3:19 PM the following observations took place:

On 9/9/19 damage and deterioration was observed on the walls in the number 27 cottage kitchen at 11:49 AM, in the number 16 cottage kitchen at 11:24 PM, and in the number 15 cottage kitchen at 2:43 PM. Additional damage and deterioration was observed on the windows in the number 16 cottage "left" kitchen at 11:26 AM, on the number 27 cottage's janitors closet ceiling at 2:57 PM, and on the laminate counters in the number 15 cottage kitchen at 2:39 PM.

On 9/9/19 at 1:17 PM, four taped over cabinets were observed in the number 16 left kitchen. On 9/9/19 at 1:19 PM, upon observation of the number 16 left kitchen's cabinets the Registered Dietitian, staff H, stated, "must be to keep them shut". At this time the surveyor inquired how the facility places work orders for repair work needed to which staff H stated, "the nurse manager or the maintenance supervisor handles all work orders and then maintenance takes care of them when they can".

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated September 13, 2019.
K-0291
K-0321
K-0353

Based on observation and interview the facility failed to maintain the physical plant condition and proper operation of equipment to ensure adequate ventilation resulting in potential for building safety and health issues for all patients, visitors and staff.

Findings include:

1. On 9/9/2019 at 1120 during inspection of cottage 27 roof, observed that the two exhaust fans on the west end of roof were not running and two of the three exhaust fans on the North end roof were not running.

2. On 9/9/19 at 1140, observed that the switch was off that controls the rooftop exhaust fan. The switch was located on the wall of the women's restroom. Staff S explained that the switch had been covered with a cage to prevent unauthorized people from turning off the exhaust fan; however, on the day of the survey, there was no wire cage over the switch to ensure that the exhaust fan would run continuously.

3. On 9/9/19 at approximately 1145 after the exhaust fan had been turned on the exhaust flow was checked in the men's restroom. The exhaust fan motor could be heard but no air flow identified. Maintenance electrician (Staff BB) checked the rooftop exhaust fan and reported that it had a broken fan belt.

4. On 9/9/19 at 1210, observed in the North end women's rest room that the switch was off that controls the rooftop exhaust fan. The wire cage that had covered the switch was also off so that there was no exhaust air for the restroom at the time of the survey.

5. On 9/9/19 at 1440 during inspection of cottage 15 roof, observed no exhaust was detectable in the toilet rooms. The main exhaust fan unit in the basement was inspected and found to be working. Staff A did not know why the exhaust grills did not have any discernible exhaust flow.

Staff A confirmed all of the above findings at the time of observation.

This citation has two deficient practice statements (DPS)

DPS #1

Based on observation, interview and document review, the facility failed to ensure maintenance of a sanitary physical environment with adequate water quality, resulting in the increased potential for opportunistic pathogen growth in the water systems and risk of infections for all staff and patients. Findings include:

1. On 9/9/19 at 1145, during a physical environment tour of the number 27 cottage, observed the water from the unused laundry sink in the music equipment storage room was a dark brown rust color. On 9/9/19 at 1100 Staff S had previously stated that the facility did run water in unused or low usage fixtures on a regular basis, but commented that staff must have forgotten that this sink was there. The sink was not easily visible from the room door as the room was very full of storage.

2. On 9/9/19 at 1320 during document review, staff S confirmed via phone consult with his chief plumber (Staff AA) that the facility did not have a written water management plan. Documentation of interdisciplinary water management team activity or minutes of environment of care meetings that documented evaluation of water management was requested, but was not received by survey exit.



32000

DPS 2
Based on observation and interview the facility failed to ensure sanitary conditions in the kitchen, resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents to 92 patients receiving oral foods. Findings include:

On 9/9/19 during a dietary tour of the number 27, 16, and 15 cottage's kitchens between 11:10 AM- 3:19 PM the following observations and interviews took place:

1. On 9/9/19 at 11:22 AM, an air gap of at least 1" and twice the diameter of the receiving drain was not observed present on the one-compartment food preparation sink's drain line in the number 27 cottage's kitchen. On 9/9/19 at 11:30 AM, upon interview with Registered Dietitian, staff H, the surveyor inquired if there had been any recent changes to the plumbing system to which they replied, "I don't think so, not since I've been here that I'm aware of". This same observation was made on the two-compartment food preparation sink's drain lines in the number 16 cottage's drain lines at 1:12 PM, (in the left kitchen) and at 1:43 PM, (in the right kitchen) as well as in the number 15 cottage's two-compartment food preparation sink's drain line at 2:08 PM.

2. On 9/9/19 at 2:12 PM, soiled food contact surfaces were observed as two ice dispensing scoops in the number 16 cottage were observed in a designated holding container resting in a small portion of standing water with visible floating debris. On 9/9/19 at 2:13 PM, upon interview with Registered Dietitian, staff H, the surveyor inquired on the frequency in which the ice scoops are cleaned to which they replied, "daily, but I can have maintenance drill a hole in the bottom it to help the water drain out from the ice build up". On 9/9/19 at 2:14 PM, an accumulation of mold and/or mildew was observed on stemming from the ice machine's condensate dripline. On 9/9/19 at 2:15 PM, upon interview with staff H, the surveyor inquired on the frequency in which the interior and exterior of the ice machines are cleaned to which they replied, "they are on a schedule, but I'm not sure when maintenance has done it last".

3. On 9/9/19 at 2:24 PM, the number 15 cottage's dish machine was tested using a thermolabel temperature indicating device to determine that an internal temperature of a minimum of 160 degrees Fahrenheit was reached. At this time the thermolabel did not change color, indicating that the internal temperature did not reach 160 degrees Fahrenheit. On 9/9/19 at 2:27 PM, a second test was conducted and again the thermolabel did not change color although the external temperature gauge was observed reaching 196 degrees Fahrenheit. At this time upon interview with Registered Dietitian, staff H, the surveyor inquired on what the facility would do in a situation such as this to which they replied, "we'll use paper products tonight and call our guy to come out and fix it". As this time the surveyor inquired if the facility was aware of the current state of the unit to which staff H responded, "no".

Based on record review, observation, and interview, the facility failed to ensure that active treatment measures were provided for one sample patient (A4) and two patients (A9 and A10) who were added to the sample to evaluate active treatment. Specifically, all three patients were unable or unwilling to attend the scheduled treatment groups and failed to have alternative therapeutic treatments listed in their Master Treatment Plans (MTPs). The "Individual Plans of Services (IPOS)," which was what the facility called the MTP, contained statements for all three patients that said alternative interventions would be offered the patient(s) if they refused the scheduled groups. Observations revealed that only leisure, not therapeutic alternatives, were offered. All three patients regularly refused the alternatives offered, and this was not addressed, nor were individualized interventions established. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on record review, policy review, and interview, the facility failed to provide treatment plans that identified patient-related short-term and long-term goals stated in individualized, observable, measurable, and behavioral terms for seven of eight sampled patients (A2, A3, A4, A5, A6, A7, and A8) and one of two patients added to evaluate active treatment (A10). This failure hinders the ability of the treatment team to measure changes in the patient as a result of treatment interventions and may contribute to the failure of the team to modify plans in response to patient needs. In addition, this failure could increase patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Medical Records

1. Patient A2 was admitted 7/17/19. The "Individual Plan of Service (IPOS)," which was what the facility called the Master Treatment Plan), dated 7/25/19, listed the diagnosis for the patient as "Undifferentiated schizophrenia." The Master Treatment Plan (MTP) listed the Problem, "Undifferentiated schizophrenia as evidenced by confusion, pressured speech, suspiciousness, impulsive aggressive behaviors." The non-measurable Long-Term Goal (LTG) for this problem was, "[Patient] will achieve stable behavior without acting upon delusions [false, fixed beliefs], hallucinations [seeing or hearing things that no one else sees or hears] and aggressive impulses." The non-individualized Short-Term Goal (STG) was, "[Patient] will cooperate with treatment including adherence to [his/her] medication regime, meeting with team members and attending group therapy."

2. Patient A3 was admitted on 5/2/19. The MTP Update, dated 8/12/19, listed the diagnoses for the patient as "Schizophrenia nos, [not otherwise specified], crack cocaine abuse, r/o [rule out] cognitive impairment." The MTP listed the Problem, "Schizophrenia unspecified as evidence by responding to internal stimuli, disorganized thoughts, poor insight and judgement, blocking [to stop speaking suddenly without explanation in the middle of a sentence], Tangentially [erratic thoughts], Looseness of Associations [thought disorder where sentences are not connected to one another] and poverty of Content [talking a lot but not saying anything substantive] and irritable mood." The non-measurable LTG for this problem was, "[Patient] will participate in daily activities without interference from symptoms of schizoaffective disorder." (This goal did not concur with the listed patient's diagnosis.) The non-measurable STG was, "[Patient] will adhere to treatment, including medication and AEP [Adult Enrichment Program], and converse with others in a relevant reality based manner without responding to internal stimuli, more organized thoughts, and improved insight and judgement."

3. Patient A4 was admitted 6/28/19. The MTP Update, dated 8/01/19, listed the diagnosis for the patient as "Schizoaffective Disorder, unspecified." The MTP listed the Problem, "Schizoaffective Disorder, unspecified." The non-measurable LTG for this problem was, "[Patient] will follow the daily unit routine with minimal interface of [his/her] thoughts and mood symptoms." The non-measurable STG was, "[Patient] will follow the daily unit routine with minimal interference of [his/her] thought and mood symptoms."

4. Patient A5 was admitted 5/07/19. The Admission Psychiatric Evaluation, dated 05/10/19, listed the diagnosis for the patient as "Schizoaffective d/o [Disorder] pre [sic] records h/o [history of] alcohol abuse." The MTP, dated 5/10/19, listed the Problem, "Schizoaffective disorder, bipolar type AEB [As Evidenced By] delusions 'I am the president of the country' formication [sic] 'bugs are crawling on my skin' and heightened profound irritability." The non-measurable, non-individualized LTG for this problem was, "[Patient] will participate in daily activities without interference from symptoms of schizoaffective." The STG was "[Patient] will adhere to medication and PSR [Psychosocial Rehabilitation], and converse with others in a reality-based manner without aggression."

5. Patient A6 was admitted 6/20/19. The Psychiatric Evaluation, dated 6/25/19, listed the diagnosis for the patient as "Schizophrenia." The MTP, dated 6/25/19, listed the Problem, "Schizophrenia as evidence by auditory hallucinations [hearing voices], delusions." The non-measurable, non-individualized LTG for this problem was, "[Patient] will participate in daily activities with minimal interference from symptoms of schizophrenia." The non-individualized, non-measurable STG was, "[Patient] will adhere to treatment, including medications and PSR [Psychosocial Rehab], and converse with others in a reality based manner without aggression."

6. Patent A7 was admitted 1/23/13. The Annual Psychiatric Evaluation, dated 5/16/19, listed the diagnosis for the patient as "Schizoaffective disorder, bipolar type." The MTP Update, dated 04/22/19, listed the Problem "Schizoaffective disorder, bipolar type." The non-measurable, non-individualized LTG for this problem was, "[Patient] will participate in the daily routine without interference from symptoms of schizoaffective disorder." The non-measurable, non-individualized STG was, "[Patient] will adhere to medication, attend PSR groups, converse without delusional content and interact without aggression."

7. Patient A8 was admitted 7/13/16. The Annual Psychiatric Evaluation, dated 7/09/19, listed the diagnoses for this patient as "Schizoaffective Disorder, Bipolar Type, Cannabis use disorder." The MTP Update, dated 07/11/19, listed the Problem, "Community Reintegration." The non- measurable LTG for this problem was, "[Patient] will fulfill all expectations for release to the community." The non-measurable STG was, "[Patient] will be compliant with [his/her] treatment plan, demonstration [sic] psychiatric stability and comprehend and accept the expectations of any court order for treatment ..."

8. Patient A10 was admitted on 7/30/15. The Annual Psychiatric Evaluation, dated 8/26/19, listed the diagnosis for this patient as "Schizophrenia, paranoid type ..." The MTP Update, dated 7/25/19, listed the Problem, "Schizophrenia, Paranoid Type as evidenced by delusions, isolation, flat affect [severe reduction in emotional expressiveness]." The non-measurable LTG for this problem was, "[Patient] will participate in [his/her] daily routine with minimal interference from symptoms of [his/her] thought disorder." The non-individualized STG was, "[Patient] will complete [his/her] ADLs [Activities of Daily Living] with assistance will attend AEP groups once per week, will take [his/her] prescribed medications, and be free from aggression.]"

B. Policy Review

The Hospital Policy, titled, "PERSON CENTERED PLANNING SERVICES SUITED TO CONDITION; PROCEDURE NUMBER: 3.15," stated that written goals shall be "time limited, behaviorally stated, written in measurable terms, and utilize and consider identified strengths, interests, resources and barriers for learning."

C. Interviews

1. In an interview on 9/10/19 at 10:30 a.m., RN2 concurred with findings of the lack of individualization and behavioral content of treatment goals.

2. In an interview on 9/10/19 at 1:30 p.m., the Director of Nursing concurred with the findings regarding the lack of individualizations in treatment goals.

3. In an interview on 9/10/19 at 1:55 p.m., the Director of Social Work concurred with the findings regarding the lack of individualization of treatment goals.

4. In an interview on 9/10/19 at 2:30 p.m., the Director of Psychology agreed with the findings that long and short-term goals were not individualized and measurable.

5. In an interview on 9/11/19 at 9:30 a.m., the CEO concurred with the findings regarding long and short-term goals.

6. In an interview on 9/11/19 at 10:00 a.m., the Chief of Clinical Affairs and the Clinical Director were informed about the findings with long and short-term goals. They stated that they understood the findings and did not have any questions.

Based on record review, policy review, and interview, the hospital failed to develop individualized nursing treatment interventions based on the individual needs of the patients for six of eight patients in the sample (A2, A3, A4, A5, A6, and A8). The Nursing Care Plans [part of the Master Treatment Plan (MTP)] listed identical problems for each of the reviewed patients. The nursing interventions were generic job descriptions. This failure has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Record Review

1. Patient A2's Nursing Care Plan Update, dated 9/04/19, listed for the Problem, "Thought processes altered," the generic, routine nursing interventions was, "Monitor mental state (memory, cognition, judgement, concentration) and ability to follow commands" and "Stay with [Patient] if [s/he] is agitated and likely to be injured."

2. Patient A3's Nursing Care Plan Update, dated 8/23/19, listed for the Problem, "Thought processes altered," the routine, generic nursing intervention was, "Assist [Patient] with daily hygiene as needed, encourage self-care."

3. Patient A4's Nursing Care Plan Update, dated 9/08/19, listed for the Problem, "Thought processes altered," the generic, routine nursing intervention was, "Monitor mental status (memory, cognitions, judgement concentration) and ability to follow commands."

4. Patient A5's Nursing Care Plan Update, dated 8/30/19, listed for the Problem, "Thought processes altered," the generic, routine nursing intervention was, "Monitor mental status (memory, cognitions, judgement, concentration) and ability to follow commands."

5. Patient A6's Nursing Care Plan Update, dated 8/30/19, listed for the Problem, "Thought processes altered," the generic, routine nursing intervention was, "Monitor mental status (memory, cognitions, judgement, concentration) and ability to follow commands."

6. Patient A8's Nursing Care Plan Update, dated 9/04/19, listed for the Problem, "Thought processes altered," the generic, routine nursing intervention was, "Monitor mental status (memory, cognitions, judgement concentration) and ability to follow commands."

B. Policy Review

The Hospital Policy, titled, "PERSON CENTERED PLANNING SERVICES SUITED TO CONDITION; PROCEDURE NUMBER: 3.15," stated only that planned interventions for the IPOS (Individual Plan of Service) will include the " ...rationale for their [interventions] use and specification of the person(s) responsible for the implementation including their credentials and department discipline."

Interviews

1. In an interview on 9/10/19 at 10:30 a.m., RN2 concurred with findings of the lack of individualization in nursing interventions. In addition, she concurred that the interventions frequently were routine job description and nursing duties.

2. In an interview on 9/10/19 at 1:30 p.m., the Director of Nursing concurred that nursing interventions reflected routine nursing duties rather than individualized nursing interventions.

Based on record review, observation, and interview, the facility failed to ensure that active treatment measures were provided for one sample patient (A4) and two patients (A9 and A10) who were added to the sample to evaluate active treatment. Specifically, all three patients were unable or unwilling to attend the scheduled treatment groups and failed to have alternative therapeutic treatments listed in their Master Treatment Plans (MTPs). The "Individual Plans of Services (IPOS)," which was what the facility called the MTP, contained statements for all three patients that said alternative interventions would be offered the patient(s) if they refused the scheduled groups. Observations revealed that only leisure, not therapeutic alternatives were offered. All three patients regularly refused the alternatives offered, and this was not addressed, nor were individualized interventions established. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A4 was admitted 6/28/19 from another hospital that was unable to stabilize his/her symptoms of paranoia (thinking others are out to get them and perceived threats to self) and delusions (false, fixed beliefs that do not change with facts). The Psychiatric Evaluation, dated 6/28/19, stated that Patient A4 was initially admitted to the first hospital due to aggression in the group home.

a. The MTP Review, dated 7/03/19, stated, "If [patient] declines to attend # [number] [sic] AEP [Adult Enrichment Program], [s/he] will be provided with an alternative cognitive stimulation group on the unit from 10:00 ? [sic] 10:45 a.m."

b. In an interview on 9/09/19 at 1:30 p.m., Resident Care Aide 1 (RCA1) stated that only four patients of the 26 patients on Unit 27 North went to the PSR (Psychosocial Rehab Center). Patient A4 was not one of the four patients. For those 22 patients who did not go to the PSR Center, RCA1 stated that the expectation was for those patients to go to the AEP group offered by psychologists off the dayroom. For those who didn't go to either the PSR or the AEP group, a leisure group was offered in the dayroom from 10:00 a.m.-10:45 a.m. and 11:00 a.m.-11:45 a.m. RCA1 stated that there were 10-12 patients of the 26 patients who rarely went to the EAP groups. Patient A4 was described as someone who went "some of the time."

c. In an interview on 9/09/19 at 3:00 p.m., Patient A4 stated that s/he had never been hospitalized although there had been multiple admissions over the years. When asked how s/he spent his/her days, Patient A4 stated, "Eating, sleeping, getting medication and [getting] clothes."

d. During an observation on 9/09/19 at 12:30 p.m. on Unit 27 North, Patient A4 was observed sleeping at a table in the dining room/dayroom while a Trivia Group was in session. S/he slept during most of the group and only opened his/her eyes when asked a direct question and then would appear asleep again. There were 17 patients in the group, and five patients were outside getting fresh air. Four patients were still in the PSR Center. No AEP groups were being offered since those ended for the day at 11:45 a.m.

e. During an observation on 9/09/19 at 1:30 p.m., on Unit 27 North, the schedule listed "Radio/ Electronics" from 1:15 p.m.-2:00 p.m. RCA1, when asked what the group was about, stated that it was when patients with electronics could check them out. However, only three patients had electronics to check out. When asked what the other 23 patients did during this time, RCA1 replied that they read books or watched television or napped in the dayroom. Patient A4 was asleep at a table in the dayroom during this time.

f. During an observation on 9/09/19 at 2:20 p.m., on Unit 27 North, a music group was observed. The schedule stated, "Group at assigned building" from 2:00 p.m.-2:45 p.m. A Music Therapist was leading the group, which consisted of music videos featuring rock music from the 1970s and 1980s. There were 25 patients in attendance in the dining room/dayroom (the four patients were back from PSR, which ended for the day at 1:15 p.m.) One other patient was feeling sick and was in bed. Of the 25 patients in the dining room/dayroom, six patients were asleep, and two patients were sitting out of the group and not attending to what was going on. The Music Therapist walked around from table to table, but there was no group discussion and little participation by the patients. Patient A4 was observed sitting at a table, apparently asleep.

g. During an observation on 9/09/19 from 3:00 p.m.-4:00 p.m., on Unit 27, Patient A4 was observed asleep at a table in the dining room/dayroom. Patient A4 did not have any electronics to occupy his/her time during the Radio/Electronic time on the schedule. Although going to the courtyard was offered to Patient A4, s/he declined and continued to doze. The time scheduled for Radio/Electronic was 3:00 p.m. - 4:30 p.m. The television was on "Judge Mathis" and one patient was watching. Six of the other patients were asleep.

h. During the scheduled EAP group on 9/10/19 at 9:45 a.m., on Unit 27 North, it was observed that 12 patients were in attendance. Six patients were observed sleeping during the group. There were two RCAs in the group, and they answered the majority of the questions asked by the group leader. RN4 was with the surveyor in the group and stated that she wished that the RCAs had tried to wake up the patients and interact with them. Patient A4 was observed at 10:05 a.m. sleeping at a table in the dining room/dayroom. When RN4 asked RCA3 about the leader for the Trivia group who had not arrived, RCA3 stated, "It's hit and miss with her coming. I don't know if there is a shortage [of staff]." RCA3 also stated that when no one showed up, the RCAs do something with the patients. The leader arrived minutes later and started the Trivia group. Ten patients were in the dining room/dayroom, and four were sleeping, including A4. The staff answered the majority of the trivia questions.

i. A review of Group Progress Notes from 8/30/19-9/10/19 revealed that 43 groups were scheduled. Patient A4 did not participate in 55.7% of the groups. Although alternatives were offered for several of the refused groups, the alternatives usually consisted of going into the courtyard with no planned activity. Comments included: "Refused and sat with [his/her] back to the film" (8/30 /29); "Patient ignored all staff prompts and was not receptive to this as noted to be sleeping for the duration of the group" (9/03/19); "Slept despite verbal prompts from staff. No progress towards goal" (9/04/19); " ...attempting to sleep for duration of group" (9/05/19) and "Refused and slept" (9/08/19).
2. Patient A9 was admitted on 11/08/13. The Annual Psychiatric Evaluation, dated 8/28/19, revealed that s/he was admitted from another hospital. Patient A9 was admitted due to refusing medications and becoming aggressive, delusional, and paranoid.

a. The MTP Review, dated 11/07/18, revealed that the Long-Term and Short-Term goals had "date opened" as of 7/17/15. Although the patient had not accomplished the goals for over three years, the goals had not been modified. The Long- Term goal was, "[Patient] will participate in the unit/hospital routine with minimal interference from [his/her] symptoms of Schizophrenia." The Short-Term goal was, "[Patient] will attend AEP group once per week, complete [his/her] ADLs [Activities of Daily Living], interact with staff and/or peers, comply with [his/her] prescribed medication, and remain free from aggression." The "Progress Toward Goal" stated, "[Patient] continues to be withdrawn, suspicious, and selectively mute. Continues to refuse [his/her] prescribed medications, all programming and to speak with [his/her] treatment team."

b. During an observation on 9/09/19 at 12:30 p.m. on Unit 27 North, Patient A9 was observed sitting in a chair behind a half wall segregated from the group while a Trivia Group was in session.

c. In an interview on 9/09/19 at 1:30 p.m., Resident Care Aide 1 (RCA1), when asked about Patient A9, stated: "S/he never goes to group."

d. During an observation on 9/09/19 at 1:30 p.m. on Unit 27 North, the schedule listed "Radio/ Electronics" from 1:15 p.m.-2:00 p.m. Patient A9 was sitting behind the half wall and then walking around in the dining room/dayroom. Patient A9 did not have any electronics to access.

e. During an observation on 9/09/19 at 2:20 p.m. on Unit 27 North, a music group was observed. The group consisted of music videos featuring rock music from the 1970s and 1980s. Patient A9 was sitting outside the group then walked around the dining room/dayroom shouting, "Turn off the t.v."

f. During an observation on 9/09/19 from 3:00 p.m.-4:00 p.m. on Unit 27, Patient A9 was observed sitting in a chair in the dining room/dayroom. S/he would get out of the chair and walk around the unit. The time scheduled for Radio/Electronic was 3:00 p.m. - 4:30 p.m. however, Patient A9 did not have any electronics to access.

g. During the scheduled EAP group on 9/10/19 at 9:45 a.m. on Unit 27 North, Patient A9 refused to attend and instead sat in a chair behind the half wall away from the other patients.

h. A review of Group Progress Notes from 8/26/19-9/09/19 revealed that 54 groups were scheduled. Patient A9 did not participate in 79.6% of the groups. For the groups attended, Patient A9's participation was minimal and described as "passively engaged," "sporadically engaged," and "partially attentive."

3. Patient A10 was admitted 7/30/15. The Annual Psychiatric Evaluation, dated 6/28/19, revealed that the patient was transferred from another hospital for long-term care due to aggression.

a. The MTP Review, dated 7/25/19, stated that if Patient A10 did not attend groups, s/he would be offered alternatives. The MTP did not list specific alternatives that would be offered to Patient A10. The majority of the observed alternatives offered to Patient A10 consisted primarily of going into the courtyard.

b. During an observation on 9/09/19 at 12:30 p.m. on Unit 27 North, Patient A10 was observed sitting in a chair against the wall while a Trivia Group was being held. S/he appeared to be sleeping and was not involved at all in the group.

c. In an interview on 9/09/19 at 1:30 p.m., Resident Care Aide 1 (RCA1), when asked about Patient A9, stated: "S/he never goes to group."

d. During an observation on 9/09/19 at 1:30 p.m. on Unit 27 North, the schedule listed "Radio/ Electronics" from 1:15 p.m.-2:00 p.m. Patient A10 was sleeping in a chair against the wall. Patient A10 did not have any electronics to access and was, therefore, free to read, watch television, or sleep.

e. During an observation on 9/09/19 at 2:20 p.m. on Unit 27 North, a music group was observed. The group consisted of music videos featuring rock music from the 1970s and 1980s. Patient A10 was sitting in the same chair against the wall and was sleeping during the music group.

f. During an observation on 9/09/19 from 3:00 p.m.-4:00 p.m. on Unit 27, Patient A10 was observed sitting in a chair against the wall and was sleeping. The time scheduled for Radio/Electronic was 3:00 p.m. - 4:30 p.m. however, Patient A10 did not have any electronics to access.

g. During the scheduled EAP group on 9/10/19 at 9:45 a.m. on Unit 27 North, Patient A10 refused to attend and instead sat in a chair against the wall in the dining room/dayroom. Patient A10 appeared to be sleeping.

h. A review of Group Progress Notes from 8/26/19 - 9/09/19 revealed that 54 groups were scheduled. Patient A10 did not participate in 94.7% of the groups. Although alternatives were offered for several of the refused groups, the alternatives usually consisted of going into the courtyard with no planned activity. Comments included: "[Patient] did not attend session" (8/27/19); "Slept despite prompting" (9/02/19); "Slept despite verbal prompts from staff. No progress towards goal" (9/04/19); and "Refused and slept" (9/08/19).

Based on medical record review, observation, and interview, the Medical Director failed to ensure that active treatment measures were provided for one sample patient (A4) and two patients (A9 and A10) who were added to the sample to evaluate active treatment. Specifically, all three patients were unable or unwilling to attend the scheduled treatment groups, and failed to have alternative therapeutic treatments listed in their Master Treatment Plans (MTPs). The "Individual Plans of Services (IPOS)," which was what the facility called the MTP, contained statements for all three patients that said alternative interventions would be offered the patient(s) if they refused the scheduled groups.

Observations revealed that only leisure, not therapeutic alternatives were offered. All three patients regularly refused the alternatives offered, and this was not addressed, nor were individualized interventions established. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125).

In an interview on 9/11/19 at 10:00 a.m., the Chief of Clinical Affairs and the Clinical Director were informed about the findings with active treatment on Unit 27 North. Both stated that they understood the findings and did not have any questions.

In an interview on 9/11/19 at 9:30 a.m., the CEO concurred with the findings regarding active treatment on Unit 27 North. The CEO stated that she was aware that there were issues with treatment on that unit.

Based on record review and interview, the Director of Nursing failed to ensure that nursing treatment interventions in the Nursing Care Plan (part of the Master Treatment Plan) were based on the individual needs of the patients for six of eight patients in the sample (A2, A3, A4, A5, A6, and A8). The Nursing Care Plans listed identical problems for each of the reviewed patients. The nursing interventions were generic job descriptions. This failure has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122).

In an interview on 9/10/19 at 1:30 p.m., the Director of Nursing concurred that nursing interventions reflected routine nursing duties rather than individualized nursing interventions.