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Based on review of facility documents, staff interviews, and observations, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient's Rights
CFR 482.28 Dietary Services
CFR 482.41 Physical Environment
CFR 482.56 Rehabilitation Services

Based on medical record reviews, observations, reviews of facility documents, and staff interviews, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to trend complaints and grievances, and report the data to a QAPI committee. (Refer to Tag A-0119).

2. The facility failed to ensure all patient rights were implemented for all patients. (Refer to Tag A-0129).

3. The facility failed to provide patient education regarding the patient's right to formulate an advance directive or psychiatric advance directive. (Refer to Tag A-0132).

4. The facility failed to provide patient care in a safe setting. (Refer to Tag A-0144).

5. The facility failed to ensure that the use of restraints was in accordance with a written modification to the patients' plan of care. (Refer to Tag A-0166).

6. The facility failed to ensure the use of physical restraints was in accordance with facility policy for all of the patients. (Refer to Tag A-0168).

Based on review of facility documents and staff interview it was determined that the facility failed to aggregate data from their complaints and grievances, and report the data to a quality assurance performance improvement committee (QAPI).

Findings include:

1. On 4/2/14 at 1:40 PM, the complaints and grievance process was reviewed in the presence of Staff #45, Staff #46, and Staff #47. There was no evidence that the complaints and grievances were trended and reported to a QAPI committee.

2. This was confirmed by Staff #45.

Based on a review of medical records, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that all Patient Rights were implemented.

Findings include:

Reference: Facility document "Mental Health Advocacy Services and Your Rights" (the description of patient rights and responsibilities given to all patients) states, "ADVOCACY AND YOUR RIGHTS: When you receive mental health services in a New Jersey State Psychiatric Hospital, your rights are guaranteed by state laws, hospital policy and the Patient's Bill of Rights. ... [These rights include] 9. To keep and use your personal possessions. ... Statement on pain management: All patients have a right to appropriate pain relief. ..."

1. Patient #12 was admitted on 2/21/14. An initial nursing assessment, completed the same date, states, "Patient wears glasses but they are at his old center [name of facility]."

a. There was no evidence in the Treatment Team Meeting notes that the patient did not have his eyeglasses in his possession.

b. There was no evidence in the medical record of any effort to retrieve the glasses for the patient.

c. There was no evidence that a referral or a consult was written to replace the patient's glasses.

d. These findings were confirmed by Staff #40.

2. Patient #12 was admitted on 2/21/14. An initial nursing assessment, completed the same date, states, "Patient c/o [complained of] back pain 5 of 10."

a. There was no evidence in the Treatment Team Meeting notes that the patient had any issue with pain.

b. There was no evidence in the medical record of any evaluation or treatment of pain for the patient.

c. There was no evidence that a referral or a consult was written to evaluate and treat the patient's pain.

d. These findings were confirmed by Staff #40.

3. Patient #33 was admitted on 9/18/13. An initial nursing assessment, completed the same date, states, "Patient asked about his belongings left at his previous residence."

a. There was no evidence in the Treatment Team Meeting notes that any effort was made to recover the patient's possessions.

d. These findings were confirmed by Staff #34.

4. Patient #33 was admitted on 9/18/13. An initial nursing assessment, completed the same date, states, "Patient c/o [complained of] pain 7 of 10."

a. There was no evidence in the Treatment Team Meeting notes that the patient had any issue with pain.

b. There was no evidence in the medical record of any evaluation or treatment of pain for the patient.

c. There was no evidence that a referral or a consult was written to evaluate and treat the patient's pain.

d. These findings were confirmed by Staff #34.

Based on facility document review, it was determined that the facility failed to provide patient education regarding the patient's right to formulate an advance directive or psychiatric advance directive.

Findings include:

1. On 4/2/14, the facility's 'Family Handbook', and the 'Mental Health Advocacy Services and Your Rights' pamphlet, provided to patients, lacked information about the patient's right to formulate an advance directive or psychiatric advance directive.

Based on observations and staff interview, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

1. During a tour of Birch Hall A Dorm 111, conducted at approximately 10:30 AM on 4/1/14 in the presence of Staff #40 and #55, the battery back-up for the exit sign failed.

a. The sign, at the door leaving the dorm and going back into the unit, was tested.

b. Upon testing, the sign flashed red-red.

c. Per the key provided on the sign, this indicated a failure of the battery back-up.

d. This finding was confirmed by Staff #40.

2. During a tour of Birch Hall A Dorm 116, conducted at approximately 10:45 AM on 4/1/14 in the presence of Staff #40 and #55, numerous non-vandal proof screws were found in patient bedrooms.

a. Several non-vandal proof screws were found in patient bedroom #116G, securing the electrical conduit to the wall.

b. Several non-vandal proof screws were found in patient bedroom #116C, securing the electrical conduit to the wall.

c. These findings were confirmed by Staff #40.

3. A Treatment Team note, dated 3/28/14 at 11:40AM, states, "Pt [Patient] on 2:1 for assault of peer in LHC [Larch Hall C] tx [treatment] groups. Pt on 2:1 because it took 4 staff to separate him from victim during 3/27/14 attack. Pt is unpredictably violent and fixated on his victim. He has physically attacked victim twice this month and continues to verbalize desire aggress [sic] against particular peer. Tx team has attempted to separate pt from victim (they both live on LHD) but administration has yet to make a decision to move one of them. ..."

a. The Treatment Team determined that the "victim" was not safe on the same unit as Patient #34 and wanted one of the patients moved to another unit.

b. The inaction of administration caused the "victim" in these attacks to continue to receive care in an unsafe setting.

c. This finding was confirmed by Staff #34.

Based on medical record review and staff interview it was determined that the facility failed to ensure written modifications to the patients' plan of care are made when patients are physically restrained.

Findings include:

1. Review of Medical Record #12 indicated the patient was placed in restraints eight times between 3/7/14 to 3/24/13.

a. There was no evidence in the medical records that a written modification to the plan of care was made.

b. This finding was confirmed by Staff #40.


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2. Review of Medical Record #36 indicated the patient was placed in restraints seven times between 11/13/12 to 2/4/13.

a. There was no evidence in the medical record that a written modification to the plan of care was made.

b. This finding was confirmed by Staff #8.

3. Review of Medical Record #37 indicated the patient was placed in restraints five times between 11/15/12 to 2/13/14.

a. There was no evidence in the medical record that a written modification to the plan of care was made.

b. This finding was confirmed by Staff #8.

4. Review of Medical Record #38 indicated the patient was placed in restraints three times between 7/30/13 to 3/3/13.

a. There was no evidence in the medical record that a written modification to the plan of care was made.

b. This finding was confirmed by Staff #8.

A. Based on a review of facility policy and the medical records of three patients who were physically restrained for violent behaviors, it was determined that the use of physical restraint was not in accordance with facility policy for all patients.

Findings include:

Reference: The "Procedures" section of policy titled "Restraint Use for Behavioral Management" stated: "... C. Procedure for the Use of Mechanical Restraint ... 1. Procedure for the Use of Mechanical Restraint ... a. The order is written on page one of the Restraint Record (NURS-N-302) and must include the date and time of the order, whether the order is a verbal order, the type of restraint, duration of the intervention, the rationale for the intervention, specific behavioral criteria for the release of the patient, and whether medication was ordered at the time of initiation of restraint. ... d. If the criteria for discontinuation of mechanical restraint have not been met 15 minutes before the time of the expiration of the order, the patient is to be seen and assessed by the physician before the restraint order has expired, to give an additional restraint order. A verbal order can be given for continuation of mechanical restraint only in the case of a concurrent emergent situation that prevents the physician from seeing the patient immediately and notification of this will be made to the Chief of Psychiatry during regular working hours and to the AOC during other than regular working hours. ..."

1. Review of Medical Record #11 indicated:

a. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 3/9/14 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 10:15 AM. The order was not time limited.

b. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 3/10/14 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 6:20 PM. The order did not include the rationale for the intervention.

c. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 3/11/14 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 8:00 AM. The order was not time limited.

d. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 3/11/14 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 10:00 AM. The order was not time limited.

2. Review of Medical Record #39 indicated:

a. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 1/24/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 10:38 AM. The order was not time limited and did not include specific behavioral criteria for the release of the patient.

b. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 1/24/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 11:38 AM. The order did not include specific behavioral criteria for the release of the patient.

c. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 1/28/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 2:00 PM. The order did not include specific behavioral criteria for the release of the patient.

d. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 1/28/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 3:00 PM. The order did not include specific behavioral criteria for the release of the patient.

e. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 2/15/13 indicated that the patient was ordered to be placed in 4-point mechanical wrist restraints at 4:20 PM. The order was not time limited and did not include specific behavioral criteria for the release of the patient.

f. A RESTRAINT RECORD dated 3/7/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 10:25 AM. The order was time limited to 60 minutes. The "Required changes in mental status and/or behavior for release" section of the order stated: "Absence of agitation and threatening behavior for at least 30 minutes." At 11:10 AM, with 15 minutes remaining in the order, the patient was documented as having not yet met the criteria for release. The physician was documented as having been notified, but there was no documentation that an additional order was obtained or that the criteria for release was changed by the physician. The patient was documented on the RESTRAINT RECORD as having met the criteria at 11:25 AM - the expiration time of the order, at which time he/she was released from the restraints.

g. A RESTRAINT RECORD dated 5/10/13 indicated that the patient was ordered to be placed in 2-point mechanical wrist restraints at 12:55 AM. The order was time limited to 60 minutes. The "Required changes in mental status and/or behavior for release" section of the order stated: "Improved reality testing and absence of anger [sic] aggression [sic] hostility and threatening behavior x (for) 30 min (minutes)." At 1:35 PM, with 15 minutes remaining in the order, the patient was documented as having not yet met the criteria for release. The physician was documented as having been notified, but there was no documentation that an additional order was obtained or that the criteria for release was changed by the physician. The patient was documented on the RESTRAINT RECORD as having met the criteria at 1:50 PM - the expiration time of the order, at which time he/she was released from the restraints.

3. The PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 2/15/13 in Medical Record #40, indicated the patient was ordered to be placed in 2-point mechanical wrist restraints at 7:58 PM. The order was not time limited.

B. Based on a review of the medical records of three patients who were physically restrained for violent behaviors it was determined that the use of physical restraint was not in accordance with the order of a physician or other licensed independent practitioner for one patient (Medical Record #39).

Findings include:

1. Review of Medical Record #39 indicated, per the PHYSICIAN RESTRAINT ORDER section of a RESTRAINT RECORD dated 1/29/13, that the patient was ordered to be placed in a "Physical Hold" at 9:15 AM. The order was time limited to 1 minute. The INTERIM ASSESSMENT sections of the RESTRAINT RECORD indicated that the patient was in mechanical restraint for at least 45 minutes - between 9:30 AM and 10:15 AM. There was no evidence of an order for the use of mechanical restraint during that time frame in the medical record.

Based on a review of medical staff bylaws, interview with administrative staff, and a review of related documentation it was determined that not all medical records were completed no later than 30 days after discharge.

Findings include:

Reference: The "Medical Records" section of ARTICLE XII - RULES AND REGULATIONS of the medical staff bylaws stated: "A. ... The Active Medical Staff member shall be obligated to complete relevant sections of medical records in a legible and timely manner. Documentation requirements shall adhere to policies and procedures in the Medical Records Documentation/Treatment Plan Protocol Manual as follows: ... 2. Discharge Summaries not dictated within five days shall be considered "past due". [sic] Discharge Summaries not dictated within twenty days of discharge shall be considered "outstanding" and shall appear on the "Outstanding Discharge Summary List". [sic] Discharge Summaries not dictated by thirty days after discharge shall be considered "delinquent" and referred to the Department Head. ..."

1. A review of the most current BACKLOG LIST of outstanding Discharge Summaries indicated that 34 medical records were more than 30 days past discharge.

2. Administrator #13 agreed with the findings on the afternoon of April 4, 2014.

Based on observation, policy review, and staff interview, it was determined that the facility failed to ensure that outdated or otherwise unusable drugs were not available for patient use.

Reference #1: Facility policy titled "Medication: Administration Guidelines Addendum A" (NURS 5.35) states, "... Injectables: Once opened, multi-dose vials are used for up to 28 days unless otherwise specified by the manufacturer."

Reference #2: United States Pharmacopoeia Chapter 797 (USP-797) states, "The BUD [beyond-use date] after initially entering or opening (e.g., needle puncturing) multiple-dose containers is 28 days unless otherwise specified by the manufacturer."

Findings include:

1. On 4/1/14 at 1:30 PM, in the presence of Staff #7, two opened Fluphenazine 25 mg (milligram)/ml (milliliter) and Fluphenazine 2.5 mg/ml multiple dose vials were found in a medication cart on the F-1 Unit with no open date or beyond-use date indicated.

2. On 4/2/14 at 11 AM, in the presence of Staff #2, one opened Levemir 100 unit/ml multiple dose vial was found in the medication refrigerator on the Cedar B Unit labeled "Date Opened...3/31...Exp Date...5/2".

a. The calculated "Exp Date" indicated on the label exceeds the allowable 28 day beyond-use date according to facility policy (Reference #1) and USP-797 (Reference #2).

b. Upon request, Staff #14 was unable to provide documentation from the manufacturer of Levemir supporting the beyond-use date calculated by the facility staff.

3. On 4/2/14 at 2:30 PM, the following outdated drugs were found in the Pharmacy Unit:

a. Forty-six Ziprasidone 40 mg capsules, expired 1/14

b. One bottle of Diclofenac Delayed-Release 50 mg tablets, expired 1/14

c. Ten Lorazepam 40mg/10ml injection vials, expired 5/13

d. One bottle of Dronabinol 5 mg capsules, expired 5/13

e. One Byetta 5 mcg (microgram) injection pen, expired 3/14

f. Twenty-five Ipratropium 0.02% inhalation vials, expired 3/14

g. Five Vitamin K injection 10 mg/ml ampules, expired 3/1/14

h. One Flovent Diskus 100 mcg inhalation device, expired 1/14

i. One box of Nicotine gum 4 mg, expired 1/14

j. Upon request, Staff #14 could not provide evidence of unit inspections for the Pharmacy Unit to ensure that drugs were checked for expiration dates.

k. Upon interview, Staff #14 and #15 stated that expiration dates for drugs in the Pharmacy Unit are checked during the monthly inventory.

l. Upon request, Staff #14 stated that the facility did not have a policy addressing unit inspections for outdated medications.

Based on medical record review, observation, review of facility documents, and staff interview, it was determined that the facility failed have an organized dietary service that is directed and staffed by qualified personnel.

1. The facility failed to ensure the director of food services provided effective daily management of the food services, and failed to ensure that all Food Service Training policies and procedures are implemented. (Cross Refer Tag 0620).

2. The facility failed to ensure that the therapeutic diet manual is approved by the dietitian and medical staff. (Cross Refer Tag 0631).

A. Based on document review, staff interview and observation, it was determined that the facility failed to ensure that the director of food services provided effective daily management of the food services department in accordance with the "Food Services Supervisor 1" job specifications and job expectations.

Findings include:

Reference #1: "Food Services Supervisor 1" job specifications states: "Has charge of the facilities and staff associated with the storage, preparation and service of all food ... Maintains and controls the proper health, sanitary and safety conditions and standards and inspects all areas where food supplies are received, handled, stored, refrigerated, prepared and served ... Knowledge of health, sanitary and safety standards for kitchen personnel, equipment, appliances and routines ... oversee food preparation service and storage areas are maintained in clean, orderly and safe condition."

1. On 4/3/14, the "Food Services Supervisor 1" personnel file, for Staff #20, was reviewed and indicated Staff #20's date of hire was 4/11/11. The file contained Staff #20's "Certified ServSafe Instructor & Registered ServSafe Examination Proctor Certificate." The date of approval on the certificate is 3/30/2009 and the date of expiration is 3/30/2014. The certificate contains a notation that "This is NOT a ServSafe Food Protection Manager Certification and should not be conveyed as one. You must maintain a current ServSafe Food Protection Manager Certification."

a. During observations on 4/1/14 at 11:00 AM, Staff #20 stated the he/she is a Certified ServSafe Instructor & Registered ServSafe Examination Proctor Certificate," inferring that this is the equivalent of the "ServSafe Food Protection Manager Certification."

b. Staff #20 did not provide evidence of current "ServSafe Food Protection Manager Certification" and training.

2. The above was confirmed by Staff #20 on 4/3/14 at 3:00 PM.

B. Based on staff interview and document review, it was determined that the "Food Services Supervisor 1" failed to ensure that all Food Service Training policies and procedures are implemented.

Findings include:

Reference #1: The "Training" policy and procedure states: "Training in the specific job related responsibilities of the Food Service Department is accomplished by monthly in-servicing as well as hands on job specific orientation."

Reference #2: The "Monthly Food Service Training" policy and procedure states: "In-servicing of the Head Cook 1, Area Operations Managers and Cooks is conducted on a monthly basis ... The Head Cook 1 and the Area Operations Managers will then train/inservice their respective staff on the monthly topic ... training rosters will be signed by all Food Service workers who received training ... Training rosters will be compiled and placed in the Food Service Training Manual by the Food Service Supervisor."

1. On 4/1/14 at 11:30 AM, Staff #20 stated that the Monthly Food Service training was not implemented. Staff #20 stated that the staff are trained on an individual, as needed basis.

a. On 4/1/14 at 11:30 AM, Staff #20 provided for review, the Food Service Training Manual. The most recent documented training rosters were dated July, 2008. Current rosters documenting Food Service Training were requested by the surveyor, but not provided for review.

b. On 4/3/14 at 10:45 AM the personnel training file for food service, Staff #64, Staff #67, Staff #68, and Staff #69 lacked documentation of monthly and individual Food Service Training.

2. The above was confirmed by Staff #1 on 4/3/14 at 11:45 AM.

C. Based on staff interview and document review, it was determined that the "Food Services Supervisor 1" failed to ensure that Food Service "Storage" policies and procedures are implemented.

Findings include:

Reference #1: The Food Service "Storage" policy and procedure states: "The ingredient room must be ventilated and temperature controlled (Temperature not below 42 or above 70 degrees Fahrenheit).

1. On 4/3/14 at 12:15 PM Staff #20 provided for review, the ingredient room temperature monitoring logs for the Month of December indicating the temperatures ranged between 70 and 80 degrees F. The temperature log contained temperatures recorded on 15 of 31 days above 70 degrees F. Temperatures were not recorded on 10 of 31 days.

2. On 4/3/14 at 12:15 PM, Staff #20 provided for review, the ingredient room temperature monitoring log for the Month of April indicating the temperature log contained temperatures recorded on 4/1/14 at 72 degrees F, 4/2/14 at 72 degrees F, 4/3/14 at 73 degrees F and 4/4/14 at 74 degrees F. Four of the four temperatures recorded were above the maximum of 70 degrees F as written in the facility "Storage" policy and procedure.

a. Two temperatures recorded with the date of 4/3/14 PM and 4/4/14 AM were recorded before the actual date and time.

3. The above was confirmed by Staff #21 on 4/3/14 at 1:45 PM.


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D. Based on observation, it was determined that the dietary service failed to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24).

Findings include:

Reference #1: N.J.A.C. 8:24-2.3 (f) states, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, "

Reference #2: N.J.A.C. 8:24-6.7(o) states, "A handwashing facility may not be used for purposes other than handwashing."

Reference #3: N.J.A.C. 8:24-4.7 (a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7 (b) states "Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning."

Reference #4: N.J.A.C. 8:24-3.5(f)(2) states, "Except during preparation, cooking, or cooling, ... potentially hazardous food shall be maintained: ... 2. At refrigeration temperatures."

Reference #5: N.J.A.C. 8:24-2.4 (a)(2) states, "The following shall apply to eating, drinking, or using tobacco: ... 2. A food employee may drink from a closed beverage container if the container is handled to prevent contamination of the employee's hands, the container, exposed food, clean equipment, utensils, linens, or unwrapped single-service or single-use articles."

Reference #6: N.J.A.C. 8:24-3.3(m)(2)(ii) states, "Requirements for wiping cloths shall include the following: ... 2. Cloths used for wiping food spills shall be: ... ii. Wet and cleaned as specified under N.J.A.C. 8:24-4.10(b)4, stored in a chemical sanitizer at a concentration specified in N.J.A.C. 8:24-4.8(j)1, and used for wiping spills from food-contact and non-food contact surfaces of equipment."

Reference #7: N.J.A.C. 8:24-4.2(c)(2) states, "Temperature measuring devices shall meet the following requirements: ... 2. A temperature measuring device with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin foods such as meat patties and fish filets."

Reference #8: N.J.A.C. 8:24-4.5(a) states, "Equipment and equipment components shall be maintained in a state of repair and condition that meets the requirements specified under N.J.A.C. 8:24-4.1 and 4.2."

Reference #9: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately measures the concentration in mg/L of sanitizing solutions shall be provided."

Reference #10: N.J.A.C. 8:24-6.3(c)(2) states, " Dressing area and locker requirements include the following: ... 2. Lockers or other suitable facilities shall be provided for the orderly storage of employees' clothing and other possessions."

Reference #11: N.J.A.C. 8:24-6.3(d)(1) states, "Designated area requirements include the following: 1. Areas designated for employees to eat, drink, and use tobacco, in compliance with the New Jersey Smoke-Free Air Act at N.J.S.A. 26:3D-55 through 3D-64 and the rules promulgated thereunder, shall be located so that food, equipment, linens, and single-service and single-use articles are protected from contamination."

Reference #12: N.J.A.C. 8:24-6.5(f) states, "After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies."

Reference #13: N.J.A.C. 8:24-6.7(m) states, "A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees."

1. On 4/9/14, a routine inspection of the facility's food and nutrition department and associated food pantries was completed in the presence of Staff #36, and the following observations were made:

a. In the Snack Prep Room (Old Tray Line) an employee was observed leaving the prep area with gloves on, and came back with the same pair of gloves and continued to prep fruit in single service articles. The employee did not wash his/her hands when entering into the prep area to continue the task of preparation, and the employee did not put on a new set of gloves. After stating to Staff #36 the violation, Staff #36 had the employee discard his/her gloves and wash his/her hands properly, and place a new set of gloves on to complete the task, as per Reference #1.

b. In the Patient Cafeteria, Large Side, there was a hand sink with serving spoons and wiping cloths in buckets laying inside the basin of the hand wash sink. Obstructing the hand wash sink may cause employees not to use the sink for hand washing purposes. This is not in accordance with Reference #2. Washing hands is a key component of preventing a food borne outbreak. Staff #36 removed the serving spoons and wiping cloths from this hand washing station during inspection.

c. In the Anchorage/Canteen, an employee was observed wiping a prep area with a dry wiping cloth and using the wiping cloth to wipe the sandwich knife. This is not in accordance with Reference #3. No sanitizer was used on the food contact surfaces during shifts, until closing. Staff #36 had the employee change the cloth and use a bleach sanitizer for the food contact surfaces for clean up.

d. In the Patient Cafeteria - Small Side, the salad bar side had tuna fish with a temperature of 67 degrees F; Egg Salad temperature of 50 degrees F; and Cottage Cheese temperature of 51 degrees F. Ice was under each tray, but not high enough near the rim to chill the products near 41 degrees F. This is not in accordance with Reference #4.

e. In the Employee Cafeteria, the salad bar needed more ice under the tuna fish 51 degrees F, pasta salad 54 degrees F, egg salad 53 degrees F, and potato salad 52 degrees F. This is not in accordance with Reference #4. The food products are out less than two hours, but more ice is needed to keep these potentially hazardous foods at safe temperatures.

f. In the Patient Cafeteria- Small Side, employees were observed leaving drinks without lids or straws in food serving areas. This is not in accordance with Reference #5. This can lead to possible food contamination and cause a potential outbreak if a food worker is ill. Staff #36 removed the drinks from the serving area and educated the employees on eating and drinking in the kitchen.

g. Dry wiping cloths were observed throughout the establishment, not submerged in a wet sanitizer bucket. This is not in accordance with Reference #6. Dry wiping cloths can be a vehicle of contamination for microorganisms to grow and contaminate food contact surfaces and possibly cause a food borne outbreak. Staff #36 removed all dry used wiping cloths and placed them in a sanitizer bucket with chlorine bleach as a sanitizer solution.

h. Staff #36 could not show proof of a thin probe thermometer on-site during inspection. This is not in accordance with Reference #7. According to the menu hamburgers are served and a thin probe thermometer can check the temperature of a well done hamburger when cooked. Staff #36 explained that this venue had a thermometer, but could not locate it. This is a repeat violation.

i. In the Main Food Service Area, a cleaning unit that was not in use was observed located in the dumping area, which is not in accordance with Reference #8. The Food Service Supervisor explained that this equipment is for a garbage can cleaner. The surfaces on this equipment were filled with heavy rust and debris. The item is unused and should be removed. Unused equipment with rust and debris can cause contamination and pests can harbor inside and near this equipment.

j. In the Back Kitchen, a possible blockage in the condensation pipe, located in walk in cooler #8, was observed, which is not in accordance with Reference #8. During inspection condensate was spitting out of the condenser and hitting the floor. No food was contaminated during inspection, however, contamination may occur when this violation exists. Staff #36 contacted maintenance to check the drain lines for leaks.

k. Sanitizer test strips were missing in the ware washing area which check the strength of chlorine bleach. This is not in accordance with Reference #9. The strips are necessary to give employees the correct reading of the strength of the sanitizer used, to prevent food borne outbreaks.

l. An employee's purse and jacket was lying on the prep table inside the Tray Room, where trays are loaded with food to be delivered to patient units. This is not in accordance with Reference #10. Personal belongings can cause contamination of food surfaces in food prep areas. Employees must have a designated area to place their belongings. Staff #36 corrected this violation immediately.

m. An employee's lunch was observed inside Continental Refrigerator #1 with the patients' food. This is not in accordance with Reference #11, and may cause contamination of food. Employee food storage must be kept separate from patient food storage. Staff #36 removed the employee's food from this refrigerator and discarded it.

n. The mop bucket station contained the mop bucket which was filled with excessively dirty water, and the mop soaking inside the water. This is not in accordance with Reference #12. Staff #36 was educated on how to properly hang the mop to air dry, and not cause contamination of the mop which could potentially spread to the kitchen floor.

o. A hand wash station is set up in an old three compartment sink, however this hand sink does not have a sign stating it is for employees to wash their hands. This is not in accordance with Reference #13. Staff #36 stated that a sign will be hung at this sink to designate this area for employees to wash their hands.

Based on staff interview and document review, it was determined that the facility failed to ensure that the therapeutic diet manual is approved by the dietitian and medical staff.

Findings include:

1. On 4/1/14 at 1:45 PM, Staff #21 stated that the "Manual of Clinical Nutrition" was not reviewed and approved by the facility medical staff.

2. The above findings were confirmed by Staff #21 on 4/1/14 at 1:45 PM.

Based on observation, it was determined that the facility failed to ensure the safety of patients.

Findings include:

1. The facility failed to ensure that the physical plant was developed and maintained in such a manner that the safety and well-being of patients is assured. (Cross refer Tag 0701).

2. The facility failed to the facility failed to ensure that supplies and environmental surfaces were maintained at an acceptable level of safety and quality. (Cross Refer Tag 0724).

Based on observation, it was determined that the facility failed to ensure that the physical plant was developed and maintained in such a manner to ensure the safety and well-being of patients.

Findings include:

1. On 4/3/14 at 9:45 AM, in the presence of Staff #76, in Room # M123 the wall surfaces were not finished. The unfinished wall surfaces are not a cleanable surface.

2. On 4/3/14 at 10:00 AM, in the presence of Staff #76, in Room # M145 the surface mounted electrical line was pulled away from the wall.

3. On 4/3/14 at 10:50 AM, in the presence of Staff #76, in Room # BHC B211 the surface mounted telephone line was pulled away from the wall.

4. On 4/3/14, in the presence of Staff #76, in the patient units, the patient room doors had door hinges that were not of an anti-ligature design type. The Main Building has approximately 125 doors equipped with these hinges and the Ward Buildings have approximately 40 in each of the 16 Wards.

5. On 4/3/14, in the presence of Staff #76, in the patient units, the patient room doors had corridor side door handles that were not of an anti-ligature design type. The Main Building has approximately 63 of these door handles and the Ward Buildings have approximately 237.

A. Based on tours of five patient care units, in the presence of Administrator #7, and interview with administrative staff, it was determined that the facility failed to ensure that supplies were maintained at an acceptable level of safety and quality in three units.

Findings include:

1. A tour of the Admissions Unit on April 1, 2014, was conducted in the presence of Staff #7. In the Examining Room, the middle drawer of the examining table contained one 5-0 suture pack with an expiration date of 2013-09 (9/30/2013)and one 5-0 suture pack with an expiration of 2012-06 (6/30/2012).

2. A tour of Unit F1 on April 1, 2014, accompanied by administrative staff indicated the following in the Medication Room:

a. The top drawer to the right of the sink contained thirty-three Lifestyles Ultra lubricated condoms with expiration dates of 7/2012 (7/31/2012), one 3-0 suture pack with an expiration date of 2012-06, one 5-0 suture pack with an expiration date of 2013-09, and a bottle of LifeScan SureStepPro test strips with an expiration date of 12/2013 (12/31/2013).

b. The top drawer to the left of the sink contained three Hemoccult Sensa Slides with expiration dates of 11/2010 (11/31/2010).

c. A cabinet above the sink, to the right, contained one 3-0 suture pack with an expiration date of 2012-06 and one 5-0 suture pack with an expiration date of 2013-02 (2/28/2013).

3. A tour of Unit F2 on April 2, 2014, accompanied by administrative staff indicated in the Medication Room, a metal cabinet above the sink that contained one Cytocare Latex 18 Ch/Fr (Charriere / French) urinary catheter with an expiration date of 2013-06 (6/30/2013).

4. Staff #7 agreed with the findings.

B. Based on tours of five patient care units, in the presence of Staff #7, and interview with administrative staff, it was determined that not all equipment and environmental surfaces were kept clean to sight and touch.

Findings include:

1. A tour of the Admissions Unit on April 1, 2014, accompanied by administrative staff indicated the following observations:

a. In the Team Room: An air conditioning unit in a window had seven dirty, folded paper towels stuck between the unit and a sheet of Plexiglass cut out to fit the unit. Desiccated beetles, flying insects, and mosquitos were behind the Plexiglass.

b. In the Admissions Office: The counter on which the card printer was placed was dusty behind the printer. The floor behind the counter had a heavy accumulation of dust, cobwebs, and grit.

c. In the Examining Room:

i. The Examining table had heavy dust on surgical tape stuck under the head of the table. Tape residue was found on the side of the table with dust stuck to it. The middle drawer of the table had dust and hair on the interior bottom.

ii. A stained ceiling tile was found above the door to the clothing closet.

iii. Desiccated bugs and spider webs were between a piece of Plexiglass and the interior side of a window.

d. In the Clothing Closet (old bathroom):

i. A shower control panel cover was heavily rusted.

ii. Heavy scale was noted on wall tiles.

iii. Heavy dust was noted atop a metal cabinet.

2. A tour of Unit F1 on April 1, 2014, accompanied by administrative staff indicated the following observations:

a. In the Nurses Station, there was heavy dust on the floor and heavy dust accumulation on the countertop beneath, and behind machines, the telephone, and computers.

b. In the Code Cart Room there was heavy dust on top of the code cart and suction canister.

c. In the Storage Room there was a heavy accumulation of dust, dust clumps, paper scraps, shoes, and shoe boxes on the floor.

d. In the Day Room (F144) there were three stained ceiling tiles. One ceiling tile was observed with a black, mold-like substance on it.

e. In the Medication Room the following was observed:

i. There were reddish, tacky stains on the exterior of the metal cabinets, under the sink, and on the inside of the bottom of the cabinet on the left side of the sink.

ii. A metal cabinet with books atop it was heavily rusted.

iii. A 'Non-Controlled Drugs Disposal Box' atop the refrigerator was heavily rusted.

iv. The medication cart had a large piece of paper with the words DO NOT USE taped over holes containing medication wrappers, soiled paper towels, dust, grit, and other forms of refuse. The tape on the paper was dusty and dirty.

v. The refrigerator had three dead flying insects inside of it. The interior had various types of stains and food particles inside. The freezer section had dust inside of the door. A dead flying insect was inside of the freezer. There were red stains inside of the ice cube tray and the bottom of the freezer.

f. In the Pantry:

i. The refrigerator had heavy, raised reddish stains on the bottom of the bottom, right drawer. Brown, raised stains were beneath both bottom drawers. The butter bin on the interior of the door had hair and milky, white stains in it. Drip stains and brown stains were on the interior of the door. The shelves had various types of stains on them. The freezer part of the refrigerator had heavy, raised, white and pink stains on all interior surfaces.

ii. The floor beneath and behind the refrigerator had an accumulation of dust, grit, paper scraps, crumpled aluminum foil, food particles, and other refuse.

iii. A drawer in the metal cabinet to the left of the refrigerator had scraps of paper, an accumulation of spilled salt and pepper, crumbs, and rust inside of it.

iv. Drawers under the stainless steel counter near the sink had an accumulation of spilled salt and pepper, and tacky stains.

v. The ice machine had heavy mineral scale on the catch basin and behind the machine.

3. A tour of Unit Holly D on April 2, 2014, accompanied by administrative staff indicated:

a. In the Laundry Room, a metal supplies cabinet and employee file cabinet had dust atop them.

b. The Code cart had surgical and cellophane tape, and tape residue, on its surface.

c. In the Medication Room, there was dust on the rails, muntins, catches, and stiles of two windows. Cobwebs were observed between the two windows. The Venetian blinds had various types of stains on them.

d. In the Nurses Station:

i. There was an accumulation of dust, grit, chads, and hair behind the letter holder.

ii. The refrigerator under the counter had dust atop it. Under and behind the refrigerator were clumps of dust, dust, paper scraps, and grit.

iii. There was heavy dust on the counter behind the computer and under the counter. The floor behind and beneath the confidential paper collection bin. There was heavy dust and stains on the counter behind the fax machine.

e. In Room D, there was a heavy accumulation of dust on the curtains.

4. A tour of Unit F2 on April 2, 2014, accompanied by administrative staff indicated the following:

a. In the Observation Room, the restraint chair had food pieces, a dried alcohol pad, grit, and paper scraps between the seat cushion and the wooden sides.

b. In Room F-219 (the Program Room), the four light covers had multiple dead beetles, lady bugs, and flying insects atop them.

c. In the Serving Pantry (Room F-221), the freezer section of the refrigerator had brown stains on the sides and base of its interior.

d. In the Dayroom (Room F-228), one light cover had stains on the exterior, two light covers had dead beetles atop them and stains on the exterior.

e. In the Dayroom (Room F-227), four light covers had dead bugs atop them. One ceiling tile was stained.

f. In the Woman's bathroom (Room F-230) the window curtain had heavy dust on it.

g. In the Pantry, a drawer had grit and stains under a piece of Plexiglass set inside of it.

h. In the Medication Room the following was observed:

i. A drawer in the medication cart had stains on the interior with unwrapped plastic spoons inside of the drawer touching the stains.

ii. A metal cabinet above the sink, to the left, had dust, rust, and raised stains on the shelves. The center metal cabinet above the sink had tape and tape residue on the edges of the shelves.

iii. A metal lock box inside of the refrigerator had raised, dried white stains and particulate on the interior and exterior. The bottom shelf of the refrigerator had raised yellow and white stains on the bottom shelf.

iv. A large plastic water cooler containing ice water had a black piece of particulate on the interior of the cover.

v. The inside of the windows looking out to the hallway had heavy dust, tape, tape residue, hair, and grit on the rails, muntins, catches, and stiles.

5. A tour of Unit Birch A on April 3, 2014, accompanied by administrative staff indicated the following:

a. In the Medication Room:

i. The Medication cart's Eye Drops drawer had raised brownish stains, paper scraps, and hair at the bottom of the interior of the drawer. The Injectables drawer had surgical tape, paper scraps, and stains on the inside of the drawer. The Oral Meds drawer and the Miralax drawer had an accumulation of old patient medication stickers stuck to the interior of the drawers.

ii. There was dust on the window rails of the lower sashes.

b. In the Nurses Station:

i. There was heavy tape residue and tape on the Formica shelf above the counter top.

ii. There was heavy dust, paper scraps, chads, grit, paper clips, and clumps of dust beneath and behind the confidential paper destruction box. There was also heavy dust atop the container which was set under the counter top.

iii. A wall cabinet across from the counter contained a tethered pair of leather leg restraints with a white cream on them. The restraints were unwrapped in a plastic container with spilled red sparkles at the bottom of it.

iv. The wall cabinets across from the counter had rusted surfaces with dust and grit inside of the sliding door tracks.

c. In the Day Room:

i. An insulation cover around a pipe was ripped in the middle and near the floor, exposing the Fiberglass insulation.

ii. The light covers all had dead bugs atop them.

6. Administrator #7 agreed with the above findings.

C. Based on tours of five patient care units and the medical records department, in the presence of Staff #7, and interview with administrative staff, it was determined that not all facilities and environmental surfaces were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. A tour of the Admissions Unit on April 1, 2014, accompanied by administrative staff indicated the following:

a. In the Admissions Office, a raw wooden stand was beneath the air conditioner. This surface cannot be properly cleaned.

b. In the Clothing Closet (old bathroom), the ceiling paint was chipped.

2. A tour of Unit F1 on April 1, 2014, accompanied by Staff #7, indicated the following:

a. In the Observation Room, the mattress on the bed frame had two approximately one-inch slits in it.

b. In the Storage Room, a metal cabinet had a raw wood stand. This surface cannot be properly cleaned.

c. In the Medication Room, the top drawer in the desk had no handle. The lock on the narcotics drawer in the medication cart was broken.

3. A tour of Unit Holly D on April 2, 2014, accompanied by administrative staff indicated the following:

a. In the Medication Room, the edge of the countertop was delaminated.

b. In the Hallway, there were 5 plastic pails on the floor under ceiling tiles between Rooms D and H. Staff #43 stated that the ceiling was leaking.

4. A tour of Unit F2 on April 2, 2014, accompanied by administrative staff indicated:

a. Two ceiling tiles in the hallway outside of Room F-220 were missing.

b. In the Serving Pantry (Room F-221), the internal temperature of the refrigerator was 68 degrees Fahrenheit.

c. Two vertically placed drop ceiling tiles were observed to have fallen inside of the frame leaving open spaces.

5. A tour of Unit Birch A on April 3, 2014, accompanied by administrative staff indicated the following:

a. In the Medication Room, the paint was chipping on the window frame, and the ceiling and walls had chipping paint.

b. In the Main female bathroom (Room 109), the paint was chipped in one of the stalls.

c. In the Day Room, an insulation cover around a pipe was ripped in the middle and near the floor, exposing the Fiberglass insulation.

6. A tour of the Medical Records Department on April 4, 2014, accompanied by administrative staff indicated there were 23 floor tiles missing in the back right corner of the room as one enters it, and a radiator had chipping paint.

7. Staff #7 agreed with the above findings.

Based on observation, policy review and staff interview, it was determined that the facility failed to implement infection control measures to maintain a sanitary environment.

Findings include:

Reference: Facility policy titled "Glucose Monitoring" (NURS 5.21) states, "... 8. The external surface of the glucometer is cleaned and disinfected with an EP-registered [sic] agent prior to and between patient use."

1. On 4/2/14 at 11:50 AM, Staff #58 was observed performing blood glucose fingerstick testing on Patient #15 at the medication window of the nursing station on the Cedar B Unit.

a. Staff #58 failed to clean and disinfect the glucometer prior to performing the blood glucose fingerstick testing. After obtaining the blood sample, Staff #58 placed the glucometer back into its case without cleaning and disinfecting the device with an EPA-registered agent in accordance with facility policy. (Reference)

i. Upon interview, when questioned on the facility's practice for cleaning and disinfecting the glucometer, Staff #58 stated, "We use a 10% bleach solution wipe but we're out of it and need to order more."

b. After obtaining the blood sample, Patient #15 was given an alcohol swab to press against the site where the blood sample was obtained. After a few seconds, Patient #15 placed the blood soiled alcohol swab onto the counterspace ledge of the medication window. Staff #58 discarded the soiled alcohol swab into the trash and proceeded to the next patient.

i. Staff #58 failed to clean and disinfect the counterspace ledge area of the medication window prior to the next patient coming to the window for medication.

c. These findings were confirmed by Staff #2, #3 and #58.

Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure their policy and procedure for organ donation is in accordance with the contracted OPO and CMS requirements.

Findings include:

Reference: Facility policy and procedure # APH EXEC 4.7, titled 'Procedure in the Event of Death' states "... II. Procedure for Death on Hospital Grounds: ... F. If the patient has a valid organ donor card, the physician contacts donor agencies, as identified on the donor card/driver's license, as soon as possible."

1. On 4/2/14 review of the facility's contract with their OPO indicated the Donor Institution [the facility] shall "3.3 establish a procedure for notification to Gift of Life at or near the time of death of every patient at Donor Institution, except as otherwise required by law;".

a. Review of the above referenced policy and procedure lacks a procedure for notification to the OPO of every patient's death. The policy indicates the physician will notify the OPO only if the patient has a valid donor card/driver's license. This is not in accordance with their contracted OPO agreement, or with CMS that stipulates the OPO determines medical suitability for organ, tissue, and eye donation.

i. Per Staff #2, on 4/1/14 at 11 AM, the facility has not had any patient deaths on site in 2012, 2013, or 2014.

2. Further review of the facility's contract with their OPO indicated at 3.2, that the Donor Institution shall "conduct professional and community education programs regarding organ and tissue donation and transplantation ..."

a. Staff #1 confirmed in interview on 4/2/14 at 1:15 PM that the facility has not provided any community education program for organ/tissue donation.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that physical therapy treatment is provided to patient's in accordance with physician orders.

Findings include:

The facility failed to ensure that treatment for physical therapy was ordered by the physician. (Refer to Tag A-1132).

Based on medical record review and staff interview, conducted on 4/3/14, it was determined that the facility failed to ensure that physical therapy treatment was delivered in accordance with physicians' orders in 5 of 5 medical records reviewed (#9, #10, #26, #27, #28).

Findings include:

1. Review of Medical Record #9 revealed the following:

a. A physician order dated 3/24/14 at 10:35 AM, "PT Consult-deconditioning/strengthening exercise."

b. According to the "Physical Therapy Evaluation Addendum," dated 3/24/14, the plan was documented as "Recommend PT [Physical Therapy] 2x/wk [2 times a week] for 4-6 wks for strengthening, endurance, balance, amb [ambulation] and stair negotiation to tol [tolerance]. Treatment to include ... safety awareness."

c. The Physical Therapy "Treatment Log" indicated the patient received physical therapy treatment on 3/25/14, 3/27/14 and 3/31/14.

d. The "Ancillary Rehabilitation Services Consultations" form was not signed by the physician, therefore it is not clear if he/she agreed to the treatment recommended by the Physical Therapist.

e. These findings were confirmed by Staff #77 on 4/3/14 at 1:55 PM.

2. Review of Medical Record #10 revealed the following:

a. A physician order dated 9/11/13 at 10:50 AM, "Resume PT for gait training/ambulation."

b. According to the "Physical Therapy Evaluation Addendum," dated 9/12/13, the plan was, "Recommended PT 5x/wk to tol for ROM, strengthening, wound monitor, standing tol and amb training and bed mobility training."

c. The Physical Therapy "Treatment Log" indicated the patient received physical therapy treatment sporadically from 9/12/13 through 3/12/14.

d. There was no evidence in the medical record that the treatment for physical therapy was ordered by the physician.

e. These findings were confirmed by Staff #77 on 4/3/14 at 2:20 PM.

3. Review of Medical Record #26 revealed the following:

a. A physician order dated 3/3/14 at 3:45 PM, "Refer to physical therapy for gait eval [evaluation]. Reason: Rt [right] knee pain leading to gait imbalance."

b. According to the "Physical Therapy Evaluation Addendum," dated 3/11/14, the plan was, "PT 2-3x's / week ... RLE [lower extremity] strengthening program ... manual stretch, for r knee ext [extension].

c. The Physical Therapy "Treatment Log" revealed the patient received physical therapy treatment on 3/18/14, 3/20/14, 3/26/14, 3/28/14 and 3/31/14.

d. The "Ancillary Rehabilitation Services Consultations" form was signed by the physician on 4/2/14, that he/she agreed to the treatment. This was 16 days after physical therapy treatment began.

e. These findings were confirmed by Staff #77 on 4/3/14 at 1:50 PM.

4. Review of Medical Record #28 revealed the following:

a. A physician order dated 2/26/14 at 11:05 AM, "Refer to PT for gait evaluation and treatment. Reason: unwitnessed fall with h/o [history of] Diabetes and diabetic neuropathy."

b. According to the "Physical Therapy Evaluation Addendum," dated 3/3/14, the plan was, "PT 3X per week, modalities for pain, there ex [therapeutic exercises] for core and lower extremity strengthening ..."

c. The Physical Therapy "Treatment Log" revealed the patient received physical therapy treatment on 3/4/14, 3/7/14, 3/10/14, 3/17/14, 3/19/14 and 3/21/14.

d. The "Ancillary Rehabilitation Services Consultations" form was signed by the physician on 4/2/14, that he/she agreed to the treatment. This was 33 days after physical therapy treatment began.

e. These findings were confirmed by Staff #77 on 4/3/14 at 1:45 PM.

5. Review of Medical Record #27 revealed the following:

a. A physician order dated 2/11/14 at 2:40 PM, "PT Consult - acute back pain management."

b. According to the "Physical Therapy Evaluation Addendum," dated 2/20/14, the plan was, "PT 2 to 3x's per week ... for strengthening and stretching ..."

c. The Physical Therapy "Treatment Log" revealed that the patient received physical therapy treatment on 2/21/14, 2/24/14, 2/28/14, 3/5/14, 3/7/14, 3/10/14, 3/12/14, 3/17/14 and 3/19/14.

d. The "Ancillary Rehabilitation Services Consultations" form was signed by the physician on 4/2/14, that he/she agreed to the treatment. This was 41 days after physical therapy treatment began.

e. These findings were confirmed by Staff #77 on 4/3/14 at 1:40 PM.

Based on observation, medical record review, and staff interview, it was determined that the facility failed to:

1. Establish Treatment Plans that were individualized and focused on specific psychiatric problems, and that for the first 14 days of hospitalization there was present a multidisciplinary treatment plan with individualized treatment interventions and that when interventions were described they were simply routine, generic, discipline functions for 16 of 16 sample patients. (Patients A1, A2, A3, A4, B5, B6, B7, B7, C9, C10, C11, C12, E13, E14, E15, and F16). (Refer to B118, B119, and B122)

2. Provide active treatment for two (2) of 16 sample patients (Patients C9 and C12). (Refer to B125)

Based on medical record review and staff interview, it was determined that the facility failed to ensure that Psychiatric Evaluations contained an assessment of patient assets in descriptive and not interpretive fashion for six (6) of 16 sample patients. (Patients A2, B8, C9, C11, C12 and E14). This failure results in the treatment team not having available individualized descriptions of patient assets that could be utilized in therapeutic endeavors. The findings are as follows:

I. Medical Record Review:

1.Patient A2: The Psychiatric Evaluation dated 1/27/2014 contained the sole asset "Has steady income/ financial resources".

2. Patient B8: The Psychiatric Evaluation dated 6/14/2013 lacked any assessment of patient assets.

3. Patient C9: The Psychiatric Evaluation dated 3/08/2014 lacked any assessment of patient assets.

4. Patient C11: The Psychiatric Evaluation dated 3/04/2014 lacked any assessment of patient assets.

5. Patient C12: The Psychiatric Evaluation dated 2/21/2014 lacked any assessment of patient assets.

6. Patient E14: The Psychiatric Evaluation dated 5/07/2012 lacked any assessment of patient assets.


I. Staff Interviews:

1. On 3/25/2014 at 4:00 p.m. the facility's Quality Assurance Co-coordinator was interviewed. She was shown the Psychiatric Evaluation of Patient B8. After reviewing the material she agreed that there was not present an assessment of assets that would describe this patient.

2. On 3/25/2014 at 10:30 a.m. the clinical director was interviewed. When Patient E14's Psychiatric Evaluation was reviewed with the surveyor, the clinical director agreed that there was no assessment of patient assets noted.

Based on record review, document review, and staff interview, the hospital failed to ensure that Initial Treatment/Stabilization Plans (ITSP) were updated for four (4) of 16 active sample patients (A2, A3, E4, and E6). The treatment plans for these patients were not updated to reflect their needs. Failure to review and revise treatment plans hampers staff's ability to provide needed treatment.

Findings Include:

A. Record Review:
The ITSPs for the following patients were reviewed (dates of plans in parentheses): A2 (1/27/14), A3 (1/30/14), E4 (5/7/12), and E6 (8/3/11). Results revealed that a review of assessments and the ITSP did not occur within the hospital's established time frame.

B. Document Review:

The hospital Documentation/Treatment Plan Manual, dated 10/20/10 and revised 11/26/13, stated, "Within one business day of admission, the patient and other core members of the patient's treatment team meet to review the initial assessments, and ITSP, interview, reassess, the patient, identify discharge needs, and update the patient's ITSP on the Update Treatment Plan/ Interdisciplinary Team Note, checking off Update Initial Treatment/Stabilization Plan".

C. Interview:

During interview on 3/25/14 at 2:45 p.m. with the Director of Health Information Management, Initial Treatment/Stabilization Plans (ITSP) were reviewed. She agreed that ITSP updates were not present for patients A2, A3, E4, and E6.

Based on record review and staff interviews, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs) for 13 of 16 active sample patients (A1, A2, A3, A4, B5, B6, B7, B8, C9, C11, C12, E13, and E16). Problem statements were not based on each patient's presenting symptoms that had to be resolved or reduced prior to discharge. Instead, the stated problems on treatment plans included diagnostic terms, evaluative statements regarding symptoms, and/or a generalized quote by the patient. This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/7/14), A2 (updated 2/19/14), A3 (updated 3/5/14), A4 (1/2/14), B5 (12/4/13, updated 3/19/14), B6 (12/12/13), B7 (1/2/14), B8 (1/21/14, C9 (3/21/14), C10 (update 3/6/14), C11 (3/18/13), C12 (3/7/2014), E13 (1/7/14), E14 (1/3/14), E15 (updated 1/7/14), and A16 (12/31/13). This review revealed that the MTPs had the following problem statements that had no supporting documentation to reflect how presenting symptoms were manifested for each patient.

1. Patient A1 was admitted 1/24/14 with a diagnosis of "Psychotic Disorder, NOS [Not Otherwise Specified]." The psychiatric problems listed on the MTP were: (1) Patient Quote - "There is a parasite in my face." Staff - "Delusional Thought Process." (2) Patient Quote - "I can't do anything about it (parasite in facial skin) and I'm tired." Staff Formulated: "Depression with attempts at suicide." There was no content included in the psychiatric problem statements formulated by staff that clearly outlined behavioral descriptions of how the patient manifested the "Depression and suicide" symptoms identified.

2. Patient A2 was admitted 1/27/14 with a diagnosis of "Bipolar Disorder, NOS [Not Otherwise Specified]." One of the psychiatric problems listed on the MTP was: Patient Quote - "I got manic from the medicine they gave at [Agency name]." Staff Formulated - "Mood Lability with anxiety." There was no content included in the psychiatric problem statement formulated by staff that outlined behavioral descriptions of how the patient individually manifested the symptom identified.

3. Patient A3 was admitted 1/30/14 with a diagnosis of "Bipolar I Disorder, Most Recent Episode Mixed, Unspecified." The psychiatric problem statement listed on the MTP was: Patient Quote - "I have at least 38 suicide attempts in my life." Staff Formulated - "Depressed Mood with Suicide." There was no content included in the psychiatric problem that clearly outlined behavioral descriptions of how the patient manifested the "Depression and suicide" symptoms identified.

4. Patient A4 was admitted 11/3/12 with a diagnosis of "Schizoaffective Disorder." The psychiatric problems listed on the MTP were: (1) "Alcohol Intoxication." (2) "Medication and treatment non-compliance in the community by history." There was no content included in the these problem statements that described how the patient manifested his/her alcohol use and no content that described the behaviors associated with the medication non-compliance, such as not able to obtain medications (transportation and/or financial problems), stopped taking medications because of side effects, lack of knowledge, etc.

5. Patient B5 was admitted on 3/5/14 and the diagnosis on the Psychiatric Evaluation dated 3/5/14 was "Braels j6 [sic] mixed" (handwriting unintelligible). The psychiatric problem statements listed on the MTP updated 3/19/14 were: (1) Patient Quote - "I need to be on the night meds [medications]" Staff Formulated - "[Patient's name] was involuntarily committed on detainer status after [s/he] attempted to hand himself." (2) Patient Quote - "I am not suicidal & I haven't heard voices [sic] a while." There was no staff formulated problem for this statement. Although there was content stating attempted suicide, there was no content related to circumstances related to the attempt such stopped taking medications, hearing command hallucinations, etc.

6. Patient B6 was admitted 10/29/97 with a diagnosis of "Schizoaffective Disorder, Bipolar Type." One of the psychiatric problem statements listed on the MTP was: Patient Quote - "I am doing everything I have to do." Staff Formulated - "Physically aggressive behaviors/Mood lability. [Patient's name] has a long history of labile affects, as well as both imp [sic]. " There was a description of the physical aggression in a separate problem statement however, there was no content included in the psychiatric problem statement formulated by staff that outlined behavioral descriptions of how the patient manifested the "mood lability" identified.

7. Patient B7 was admitted 8/5/13 with a diagnosis of "Schizophrenia, Undifferentiated." One of the psychiatric problem statements listed on the MTP was: "Depression, leading to angry outburst, records indicate [Patient's name] has difficulty managing [his/her] emotions in the community." There was no content included in the psychiatric problem statement that described the depressive behaviors evidenced by the patient.

8. Patient B8 was admitted 11/22/94 with a diagnosis of "Schizophrenia, Paranoid Type, Continuous." One of the psychiatric problem statements listed on the MTP was: Patient Quote - "I don't want witch craft used on me." Staff Formulated - "[Patient's name] demonstrates with a poor thought disorder, psychosis, violence, suspicion and grandiose feelings." There was no content included in the psychiatric problem statement formulated by staff that clearly outlined behavioral descriptions of how the patient manifested the "psychosis, violence, and grandiose feelings" identified.

9. Patient C9 was admitted 3/8/14 with a diagnosis of "Bipolar I Disorder, Most Recent Episode Manic...." The psychiatric problem on the MTP was: "As pr [sic] record, [Patient's name] non-compliance with medication and aftercare results in rehospitalization." There was no content included in the psychiatric problem statement that described psychiatric behaviors resulting from medication non-compliance nor behaviors associated with medication non-compliance, such as not able to obtain medications (transportation, finances), stopped taking medications because of side effects, lack of knowledge, etc.

10. Patient C11 was admitted 3/4/14 with a diagnosis of "Mood Disorder, NOS [Not Otherwise Specified]." One of the psychiatric problem statements listed on the MTP was: "Mood instability, admitted for suicidal thoughts." There was no content included in the psychiatric problem statement that outlined behavioral descriptions of how the patient manifested the "mood instability and suicidal thoughts" identified.

11. Patient C12 was admitted 2/21/14 with a diagnosis of "Psychotic Disorder, NOS [Not Otherwise Specified]." One of the psychiatric problem statements listed on the MTP was: "Delusional thoughts, auditory hallucinations, labile mood and poor insight." There was no content included in the psychiatric problem statement that outlined behavioral descriptions of how the patient manifested the symptoms identified.

12. Patient E13 was admitted 5/12/06 with a diagnosis of "Cyclothymia." Two of psychiatric problem statements listed on the MTP were: (1) Patient Quote: "They agitated me." Staff Formulated - "[Patient's name] copes with emotions by engaging in behaviors that warrant precaution status." (2) Patient Quote - "I don't like 3rd shift nurses." Staff Formulated - "[Patient's name] was non-complaint with her medications at times." There was no content included in the psychiatric problem statement formulated by staff that outlined behavioral descriptions of how the patient manifested the "emotions and non-compliance with medications" identified.

13. Patient E16 was admitted 8/3/11 with a diagnosis of "Bipolar I Disorder, Most recent Episode, Mild." One of the psychiatric problem statements listed on the MTP was: "Pt [Patient] has Suicidal Thoughts, Self injurious Behavior." There was no content included in the psychiatric problem statement formulated by staff that outlined behavioral descriptions of how the patient manifested the "suicidal thoughts and self-injurious behavior" identified.

B. Interviews

1. During interview on 3/25/14 at 11:50 a.m., Program Coordinator #1 acknowledged that problems on the MTPs were not behaviorally descriptive and not individualized for each patient and stated, "We recognize we have a problem with this [problem statements]." Program Coordinator #1 also noted that quotes from patients were on the MTPs because of the hospital's current initiative to create more "patient-centered" treatment plans.

2. During interview on 3/26/14 at 9:50 a.m. with Clinical Director, Associate Hospital Director, and Director of Quality Improvement, the Master Treatment Plans were reviewed. The Clinical Director agreed that problem statements were not individualized and did not contain behavioral descriptions of each patient's presenting symptoms.

Based on medical record reviews and staff interviews it was determined that that facility failed to ensure that Treatment Plans contained individualized interventions for 14 of 16 active sample patients. That when interventions were listed they were more than generic, discipline specific functions. This failure results in no information about what exactly each discipline will be attempting in their therapeutic endeavors. Patients (A1, A2, A3, A4, B5, B8, C9, C10, C11, C12, E13, E14, E15, and E16).

The findings are as follows:

I. Medical Record reviews:

1. Patient A1: The Treatment Plan dated 3/24/2014 had the following interventions for the Problem "DELUSIONAL THOUGHT PROCESS" the following interventions "Wellness Group Mon @ 10:15 AM; Team Solutions Mon @ 1:30 PM; Wellness Group Tue @ 10:15 AM; Team Solutions Tue @ 1:30 PM; Wellness Group Wed @ 10:15 AM; Team Solutions Wed @ 1:30 PM; Wellness Group Thu @ 10:15AM; Team Solutions Thu @ 1." For the Problem "DEPRESSION WITH ATTEMPTS AT SUICIDE" the following interventions were listed "Wellness Group Mon @ 10:15 AM; Team Solutions Mon @ 1:30 PM; Wellness Group Tue @ 10:15 AM; Team Solutions Tue @ 1:30 PM; Wellness Group Wed @ 10:15 AM; Team Solutions Wed@1:30PM; Wellness Group Thu @ 10:15AM; Team Solutions Thu @ 1."

2. Patient A2: The Treatment Plan dated 2/19/2014 for the Problem "MOOD LABILITY WITH ANXIETY" had the following interventions listed "THERP ART (Rehab) 0 0 0 1/Per Week/45 minutes/ Art Therapy Group A2 Tue @ 1:15 PM", and "THERP ART (Rehab) 0 0 02/Per Week/40 minutes/ IMR A2 Mon @ 10:15 AM; IMR A2 Wed @ 10:15 AM", CLIN PSYCHOL 2 (Psychology) 0 0 01/ Per Week/45 minutes/Managing Anxiety and Panic A/B Thu @ 1:15:00 PM", and "CHARGE NURSE( Nursing) 0 0 01/Per Week/40 inutes/Medication Education 4 Mon @ 9:30 AM" and for the psychiatrist "CLIN PSYCH BRD ELIGIBLE (Psychiatry) 0 0 0 1/ Per Week/ 10 minutes/ MEDICATION/ MONITORING".

3. Patient A 3: The Treatment Plan dated 3/05/2014 had listed as interventions for the Problem "DEPRESSIVE MOOD WITH SUICIDE ATTEMPTS" the following "Charge Nurse (Nursing) 0 0 0 1/Per Week/ 45 minutes/ Medication Education 3 Mon@ 2:05:00 PM", "CLIN PSYCHOL 2 (Psychology) 0 0 01/Per Week/45 minutes/Woman's Emotions Grp Tue @ 1:15:00 PM", and "CLIN PSYCH BRD ELIGBLE 9 Psychiatry) 0 0 01/Per Week/ 10 minutes/ MEDICATION/MONITORING" and "CHARGE NURSE (Nursing) 0 0 02/ Daily/5 minutes/MEDICATION ADMINISTRATION/ASSESS."

4. Patient A4: The Treatment Plan dated 1/2/2014 had no interventions listed by the psychiatrist.

5. Patient B5: The Treatment Plan dated 12/4/2013 had the following interventions for the issue of previous suicide attempt for nursing staff "Nursing will educate (Patient B5) on the importance of his medications and reinforce his coping skills to reduce his depression FREQUENCY: 1 times Per Shift for 5 minutes" and for the psychiatrist "Medication to provide (Patient B5) with medication for his depression, psychosis and mood liability. FREQUENCY: 1 times Per Week for 20 minutes", and for Social Services "Social Worker will inform (Patient B5) of his court dates and status as needed. FREQUENCY: 1 times Per Week for 20 minutes."

6. Patient B8: The Treatment Plan dated 1/21/2014 stated as Nursing intervention "Nursing to educate, monitor and counsel (Patient B8) about side effects of his medications. FREQUENCY: 1 times Per Shift for 5 minutes", and there were no interventions listed for the psychiatrist.

7. Patient C9: The Treatment Plan dated 3/10/2014 for the problem described "As pr(sic) record, (Patient C9) non-compliance with medication and aftercare results in rehospitalization" has no interventions listed to be provided by the psychiatrist, for Social Services "SOC WK 1 (PSYCH)(Social Services) 0 0 0 0/Per Week/45m/Community Re-entry A/B Tue@1:15:00 PM", and there are no interventions listed for the nursing staff.

8. Patient C10: The Treatment Plan dated 3/06/2014 has no interventions listed for the psychiatrist, no interventions for the social service clinician and no interventions for nursing staff directed at the psychiatric problem "...psychotic depressed and anxious state..."

9. Patient C11: The Treatment Plan dated 3/18/2014 for the problem of "Mood instability, admitted for suicidal thoughts" has for the psychiatrist "To evaluate the pts mental status to determine if medications need adjustments. To evaluate the pts mental status to determine if medications need adjustments. (sic) FREQUENCY: 1 times Per Week for 15 minutes", and for nursing services "Nursing-To administer medications as prescribed by the psychiatrist daily. To provide supportive counseling for depression throughout the day as needed. To administer medications as prescribed by the psychiatrist daily. To provide supportive counseling throughout the day as needed. (sic) FREQUENCY: as needed times Daily for 5 minutes."

10. Patient C12: The Treatment Plan dated 2/25/2014 for the problem "Delusional thoughts, intermittent auditory hallucinations, labile mood and poor insight" had for the psychiatrist intervention "CLIN PSYCH BRD ELIGIBLE(Psychiatry) 0 0 0 1/Per Week/15 minutes/Psychiatry-To evaluate the pts mental status to determine if medications need adjustments", and for nursing "CHARGE NURSE(Nursing) as needed/ Daily/5 minutes/Nursing to administer medications as prescribed by the psychiatrist daily. To provide a PRN when the pt is escalated."

11. Patient E13: The Treatment Plan dated 1/07/2014 for the problem described as "(Patient E13) copes with her emotions by engaging in behaviors that warrant precaution status" for the psychiatrist "To monitor psychotropic medications for effectiveness and side effect- by engaging her in short conversation once a week for 15 minutes. To improve trust and rapport", and for psychology "To improve coping skills. When demonstrating safe behavior", and for nursing "To counsel and redirect her. Offer to put helmet on if counseling is ineffective and escort (Patient E13) to the quiet room.", and for social services "SOCIAL SERVICES supportive interaction. To aid (Patient E13) in identifying coping skills to utilize when feeling upset."

12. Patient E14: The Treatment Plan dated 1/03/2014 for the problem "Alcohol dementia-resulting in confusion, intrusive behavior and at times, physical aggression" has the psychiatrist interventions as "Prescribe Medications: Depakote Ativan and Seroquel To assist in the stabilization of (Patient E14)'s mood and decrease his agitation and aggressive outburst FREQUENCY: 1 times Per Month", and for nursing "comfort and reassurance with ADL's Nursing will provide comfort and reassurance during assistance with activities of daily living FREQUENCY: Daily".

13. Patient E 15: The Treatment Plan dated 1/07/2014 has for the major psychiatric problem "I want to be out of here" no interventions listed by the psychiatrist, there, also, are no interventions by nursing and for the Social Services "Social Worker will meet with (Patient E15) monthly. To ascertain reasons why he wants to stay in the hospital. FREQUENCY: 1x times Per Month for 10-15 mins."

14. Patient E16: The Treatment Plan dated 12/31/2013 has for the psychiatrist intervention "Prescribe medications to (Patient E16) in order to stabilize her mood. Monitor same for side effects and efficacy FREQUENCY: 1 times Per Month for 20 minutes", and "PRECAUTIONS WHEN NECESSARY 1:1 Observation To prevent (Patient E16) from engaging in self harming behaviors. FREQUENCY: 1 times As needed", and for the nursing staff the sole intervention was "Contraband check To ensure that no items are in possession that she could use to injure self. FREQUENCY: Q times Per Shift."

II. Staff Interview:

On 3/25/2014 at 10:00 a.m. the clinical director and the surveyor examined the charted materials of Patients E13, E14, E15, and E16 with a focus on the psychiatric evaluations and current treatment plans. The clinical director agreed the interventions on Treatment Plans were generic in nature and that they were not individualized.

During an interview on 3/25/14 at 10:50 a.m. with the Program Specialist 4 and the Associate Nursing Officer, the Master Treatment Plans (MTPs) were discussed. They agreed the nursing interventions on the MTPs, such as "administering medications as prescribed" were clinical tasks that the RN would perform regardless of the patient's need and/or presenting symptoms. Program Specialist 4 stated, "The Joint Commission found this too and we are addressing this in our POC [Plan of Correction]."

During an interview on 3/25/13 at 4:30 p.m. with the Chief Nursing Officer (CNO), Patient's C12's non-attendance in group was discussed. She noted that they were aware of the need to provide alternative programming for patients not participating in the Treatment Mall. She stated, "We are aware of this and we have discussed ways to address that population of patients not participating in the Mall Program."

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

I. Provide active treatment, including purposeful alternative interventions for two (2) of 4 patients active sample patients in the main building (C9 and C12). Specifically, all patients were expected to attend the Treatment Mall. However, patients who were unwilling, unable due to their condition, or were not motivated to attend the group treatment program, were not offered alternative active treatment measures. Rather than providing individual sessions to meet these patients' specific needs at the present time, they were encouraged to attend groups in the Treatment Mall. These patients spent most of the day either lying on their beds or sitting in the dayroom or hallway. Despite, inconsistent or lack of regular attendance in groups, Master Treatment Plans were not formulated or revised to reflect individual active treatment sessions instead of group treatment. Failure to provide active and appropriate treatment for patients results in patients being hospitalized without all intervention for recovery being provided to them, potentially delaying their improvement.

II. Based on record review and staff interview, the facility failed to ensure the appropriate documentation of restraints for three (3) of 4 non-sample patients (T1, T2, and T4) added to the sample to review episodes of restraint. Specifically, these patients had multiple restraint episodes without comprehensive revised Master Treatment Plans (MTPs) reflecting interventions to address and reduce the number of restraint episodes. This deficiency results in MTPs that failed to provide guidance to staff regarding the specific non-physical interventions to use before and after the patients become aggressive thereby exposes patients to potential harm from unnecessary restraint and jeopardizes patients' rights to safe treatment in the least restrictive manner possible.

Findings include:

I. Failure to Provide Active Treatment

A. Patient C9

1. During observation on 2/25/14 at 1:20 p.m., it was reported that all patients on Unit F1 were attending groups in the Treatment Mall. However, the staff in the Mall stated that Patient C9 was on the unit. When the surveyor arrived on the unit, the patient was observed in his/her room in bed and assigned to a staff that was outside the door for one-to-one observation. His/her "Individual Patient Program Schedule" showed that s/he should have been attending a "Solution for Wellness" group.

2. During interview 3/24/14 at 1:35 p.m., the patient stated that s/he was admitted to get help to stay on her medications and started to sing remarking that s/he likes to sing and loves music. S/he also stated that s/he was not going to the Mall and stated, "I am planning to leave today."

3. During discussion on 3/24/14 at 1:45 p.m., while interviewing Patient C9, the HST #1 assigned to observe Patient C9 one-to-one was asked if the patient had been attending groups and what type of activities did the patient participate in during the day on the unit. HST #1 stated that s/he was from another unit and did not know the patient very well.

4. The "Update Treatment Plan/Interdisciplinary Team Note" form dated 3/10/14 noted that Patient C9 was admitted on 3/8/14 for the third time and during interview with the treatment team was, "loud, singing, agitated, aggressive...flight of ideas, racing thoughts..." This plan assigned Patient C9 to 15 groups in the Treatment Mall and one (1) on ward group.

5. A review of the "Special Monitoring Sheets" from 3/17/14 through 3/21/14 and on 3/24/14 and 3/25/14 were reviewed. During the period of 3/17/14 to 3/21/14, from 9:15 a.m. to 11:00 a.m. and 1:15 p.m. to 3:00 p.m. when all patients were expected to attend the Treatment Mall Program, the patient was recorded as being on the unit, despite being assigned to groups during this period. "Special Monitoring Sheets" from 3/17/14 through 3/21/14 showed that the patient was either in the "Dorm" [patient bedroom] in bed, hallway, sitting in the "pantry" area [room where patients eat and watch television], or sitting in the Dayroom.

6. The MTP dated 3/21/14 and formulated 14 days after the patient's admission also assigned the patients to 15 groups offered in the Treatment Mall and one (1) on ward group. This MTP assigned the patient to group treatment despite his/her non-attendance in the Treatment Mall Program. Additionally, the MTP failed to identify alternative individual sessions to engage the patient based on his/her present level of functioning. There was no documentation found that the patient participated in any on ward active treatment measures. This was despite the stipulation regarding 1:1 observation outlined in the facility's "Special Observation" Policy revised 1/27/2012. This policy stated, "The Charge Nurse shall ensure that the assigned persons are intervening therapeutically and encourage more adaptive functioning in accordance with the treatment plan and specific team recommendations." The MTP provided no guidance for staff to engage the patient while on 1:1 observation.

7. The "Special Monitoring Sheets" from3/24/14 to 3/25/14 showed that during the Treatment Mall Program, the patient was on the unit and s/he continued to spend time sitting in the dayroom, sleeping, or watching television.

8. During interview on 2/24/13 at 2:30 p.m. with RN #1 the patient's involvement in active treatment was discussed. RN #1 stated that Patient C9 had not been attending the Mall program and acknowledged that there was no on unit program for him/her.

9. During interview on 3/26/14 at 9:50 a.m. with the Clinical Director, Associate Hospital Director, and Director of Quality Improvement, the Clinical Director acknowledged that some patients were not ready for the group program in the Treatment Mall and alternative programs should be made available. He stated, "I know this patient and [Patient's name] is not group material at this time." He also agreed that the patient's MTP was not formulated to reflect individual instead of group treatment.

B. Patient C12

1. During observation on 2/24/14 at 2:00 p.m., Patient C12 was observed sitting alone in the dayroom with his/her jacket over his/her head. The "Individual Patient Schedule" showed that s/he should have been attending a "Group Readiness" in the Treatment Mall.

2. During interview 3/24/14 at 2:10 p.m., Program Coordinator #2 stated that the patient had not been attending group for one month. Program Coordinator #2 also stated that the patient refuses to be interviewed every day and acknowledged that the MTP had not been revised to reflect the patient's present level of functioning.

3. The "Update Treatment Plan/Interdisciplinary Team Note" dated 2/25/14 noted that Patient C12 was admitted on 2/25/14and reported that the patient was, "...brought to the ER [emergency room] after displaying, 'acute exacerbated psychosis, A/H [auditory hallucinations], easily agitated, and noncompliant with medications." This plan only contained routine psychiatrist and registered nurse tasks and failed to identify active treatment measures to be offered until the Master Treatment Plan (MTP) was developed. The MTP was not completed per hospital policy until 14 days after the patient's admission.

4. Patient C12's MTP dated 3/7/14 listed the following active treatment group: "Group Readiness" three times a day on Mondays, Wednesdays, and Thursdays and 2 times a day on Fridays; "12 Steps & Recovery," "Healthy Living", "Addictions Education B," and "Recovery Process." Despite the patient's non-attendance in these groups, the MTP failed to identify individual active treatment sessions to be implemented based on the patient's current level of functioning.

5. A review of the "Ward Census/Count Status Check" sheets from 3/10/14 through 3/14/14, 3/17/14 through 3/21/14, and 3/24/14 through 3/25/14were reviewed. Expect for 3/17/14, these sheets showed that the patient was not checked and located for safety every 15 minutes which was in violations of the facility's "Special Observation" Policy revised 1/27/14. The Director Nursing acknowledged that patients remaining on the unit should be checked and their location documented every 15 minutes. A review of the "Ward Census/Count Status Check" sheets recorded in the Treatment Mall showed the patient did not attend the Mall program during this period.

6. During interview on 3/25/13 at 4:30 p.m. with the Chief Nursing Officer (CNO), Patient's C12's non-attendance in group was discussion. She noted that they were aware of the need to provide alternative programming for patients not participating in the Treatment Mall. She stated, "The Joint Commission found this too" and plans were underway to address this problem.

7. During observation on 3/26/14 at 10:15 a.m., Patient C12 was observed sitting in the hallway with his jacket over his/her head. His/her "Individual Patient Program Schedule" showed that s/he should be attending "Group Readiness" in the Treatment Mall.

8. During interview with RN #1 on 3/26/14 at 10:25 a.m., alternative active treatment measures for Patient C12 were discussed. RN #1 acknowledged formalized active treatment measures, such as planned individual sessions to interact with the patient on a regular basis, had not been implemented for this patient.

II. Lack of Comprehensive MTPs for Patients with Multiple Restraint Episodes

A. Record Review

1. Patient T1 - The Restraint Report for the period 2/1/13 - 2/28/13 showed that Patient T1 had 24 episodes of restraint. A review of the last "Update Treatment Plan/Interdisciplinary Team Note" Form dated 1/28/13 which was formulated to address the patient's aggressive problem of "SIB [Self Injurious Behavior]" revealed only the following interventions unrelated to the patient's aggression:

Psychiatry - "... 1/ per week/20 minutes / Medication/Monitoring"

Nursing - "... 2/ Daily/10 minutes / Medication Administration."
The interventions on this updated MTP failed to identify appropriate interventions to provide guidance for staff. There were no supportive or directive interventions described that would be useful in avoiding confrontations and reducing the use of restraints. Additionally, there were no individual and/or group interventions included aimed at directing the patient away from the self-injurious behavior and/or developing non-harmful behaviors.

2. Patient T2: The Restraint Report for the period 2/1/13 - 2/28/13 showed that Patient T1 had 29 episodes of restraint. A review of "Update Treatment Plan/Interdisciplinary Team Note" Form dated 2/15/13revealed no interventions to address the patient's aggressive behavior.

3. Patient T4: The Restraint Report for the period 2/1/13 - 2/28/13 showed that Patient T1 had eight (8) restraint episodes. A review of the "Update Treatment Plan/Interdisciplinary Team Note" Form dated 2/25/13 which was formulated to address the patient's problem of aggression identified as "Aggressive and threatening behavior toward staff," revealed only the following interventions which were unrelated to the patient's aggression:

Psychiatry - "... Prescribe psychotropic medication (see medication)."

Nursing - "... Administer prescribed medication, check for efficacy, provide supportive counseling and medication education."

Psychology - "...Life Management Meeting." "... Assess patient and complete psychological assessment."

Social Work - "... Continue to provide support, act as liason [sic] to between family and patient, and contact mother to assess for further treatment."

The interventions on this updated MTP failed to identify appropriate interventions to provide guidance for staff related to the patient's aggression. There were no supportive or directive interventions described what would be useful in avoiding confrontations and reducing use of restraints. Additionally, there were no individual and/or group interventions included aimed at directing the patient away from aggressive and/or developing non-harmful behaviors.

B. During interview on 3/26/14 at 9:50 a.m. with the Clinical Director, Associate Hospital Director, and Director of Quality Improvement, the revision of treatment plans for patients who had had multiple restraint episodes was discussed. The Clinical Director and Associate Hospital Director agreed that the treatment plans revised for these patients did not provide guidance for staff regarding non-physical interventions to be used to handle patients' aggressive behavior.

Based on record review and interview, the facility failed to ensure that registered nurse progress notes included information about each patient's progress or lack of progress toward treatment goals for one (1) of 4 sample patients (C9) located in the main building. This failure potentially impedes the treatment team's ability to assess each patient's response to treatment provided by registered nurses.

Findings include:

A. Record Review

Patient C9 was admitted 3/8/14 with diagnosis of "Bipolar I Disorder, Most Recent Episode Manic..." There were no weekly progress notes by registered nurses for the weeks ending 3/15/14 and 3/22/14 that reflected the patient's progress or lack of progress toward treatment objectives and/or presenting problems. The registered nurse notes reviewed were incidental notes about events during the shift and did not contain a statement regarding the patient's improvement or lack of improvement.

B. Interview

During interview on 3/25/14 at, RN #3 and the Associate Nursing Officer (ANO) confirmed that there were no weekly progress notes for the patient. RN#3 noted that there was a tracking glitch resulting in no RN being assigned to complete the weekly progress notes for this patient.

Based on record review, policy review and interview, the hospital failed to assure that:

I. Social Worker Progress Notes for 12 out of 16 active sample patients (A1. A2, A3, A4, C9, C10, C11, C12, E13, E14, E15, and E16) did not contain information which specifically addressed patient progress towards treatment goals and discharge planning. Lack of social work documentation of patient progress impedes the treatment team's ability to evaluate the patient's response to treatment.

II. Social Work Progress Notes for 4 of 16 active sample patients (A1, A2, A3, and A4) had missing weekly and /or monthly social work progress notes. This failure results in a lack of social work input in treatment planning.

Findings include:

I. Incomplete Social Work Progress Notes

A. Record Review

1. Patient A1 was admitted on 1/24/14. There was not sufficient documentation to measure patient progress in seven weekly progress notes from 1/31/14 to 3/14/14.

2. Patient A2 was admitted on1/27/14. There was not sufficient information to measure patient progress in seven weekly progress notes from 1/5/14 to 3/5/14.

3. Patient A 3was admitted on 1/30/14. There was not sufficient information to measure patient progress in three weekly progress notes from 2/27/14 to 3/21/14.

4. Patient A4 was admitted on 11/3/12. There was not sufficient information to measure patient progress in four weekly progress notes from 12/6/13 to 3/3/14.

5. Patient C9 was admitted on 3/8/14. There was not sufficient information to measure patient progress in two weekly progress notes dated 3/21/14.

6. Patient C10 was admitted on 7/9/89. There was not sufficient information to measure patient progress in two monthly progress notes from 1/9/14 to 2/9/14.

7. Patient C11was admitted on 3/4/14. There was not sufficient information to measure patient progress in three weekly progress notes from 3/11/14 to 3/25/14.

8. Patient C12 was admitted on 2/21/14 there was not sufficient information to measure patient progress in four weekly progress notes from 2/28/14 to 3/20/14.

9. Patient E13 was admitted on 5/12/06. There was not sufficient information to measure patient progress in three monthly progress notes from 1/10/14 to 3/11/14.

10. Patient E14 was admitted on 5/7/12. There was not sufficient information to measure patient progress in three monthly progress notes from 1/1/14 to 3/1/14.

11. Patient E15 was admitted on 8/10/10. There was not sufficient information to measure patient progress in two monthly progress notes from 12/10/13 to 1/10/14.

12. Patient E16 was admitted on 8/3/11. There was not sufficient information to measure patient progress in three monthly progress notes from 12/3/13 to 3/3/14.

B. Policy Review

The hospital Social Service Policy NO.: Soc. Serv. Section 5.2; sub-section B.1. "A Social Work Progress Note must be written weekly for the first 8 weeks following admission (or re-admission), and monthly thereafter. Required Progress Notes may not be combined (e.g., "3rd + 4th Weekly Note "), nor may a Team Note signed by the Social Worker substitute for his /her weekly or monthly Progress Note."

C. Staff Interview

1. In an interview on 3/25/14 at 12:15 pm with SW3, after reviewing 3 weekly progress notes for patient #A3, she confirmed there was not enough information to measure patient progress towards treatment goals and discharge planning.

2. In an interview on 3/25/14 at 3:10 pm with the Deputy CEO of Clinical Services, the Acting Director of Social Work (SWS I) and SW1, after reviewing the records cited in Part I and II, Section A, confirmed there was not sufficient information to measure patient progress in social work progress notes . The Deputy CEO of Clinical Services stated, "This has gone on too long and this is not acceptable."

II. Missing Social Work Progress Notes

A. Record Review

1. Patient A1 was admitted on1/24/14. There was one missing weekly social work progress note for week of 3/21/14.

2. Patient A2 was admitted on 1/27/14. There was one missing weekly social work progress note for week of 2/19/14.

3. Patient A3 was admitted on 1/30/14. There were four missing weekly social work progress notes from 2/6/14 to 3/21/14.

4. Patient A4 was admitted on 11/3/12. There was one missing monthly social work progress note for 12/3/13.

B. Policy Review

The hospital Social Service Policy NO.: Soc. Serv. Section 5.2; sub-section B.1. "A Social Work Progress Note must be written weekly for the first 8 weeks following admission (or re-admission), and monthly thereafter. Required Progress Notes may not be combined (e.g., "3rd + 4th Weekly Note"), nor may a Team Note signed by the Social Worker substitute for his /her weekly or monthly Progress Note."

C. Interview
.
In an interview on 3/25/14 at 3:20 pm with the Deputy CEO of Clinical Services, the Acting Director of Social Work (SWS I) and SW1, after reviewing the records cited in Part I and II, Section A, confirmed there were missing weekly and /or monthly progress notes. The Acting Director of Social Work (SWSI) stated "perhaps the missing notes had not yet been filed I don't know what happened."

Based on medical record review, observation and staff interview it was determined that the clinical failed to:

1. Ensure that treatment plans were descriptive of individual patient needs, and how the staff were going to address them in an informative not generic manner by the multidisciplinary treatment team members. (See B118, B119 and B122)

2. Ensure that Psychiatric Evaluations contained an assessment of patient assets. (See B117)

3. Ensure active treatment measures are pursued when current interventions have failed. (See B125)

Based on record review, interview and observation, the Chief Nursing Officer (CNO) failed to provide adequate oversight to ensure quality nursing services. Specifically, the CNO failed to:

I. Ensure that Master Treatment Plans (MTPs) contained individualized nursing interventions for 14 of 16 active sample patients (A2, A3, A4, B5, B6, B7, B8, C9, C10, C11, C12, E13, E14, and E16). Specifically, when nursing interventions were listed they were actually generic and routine nursing functions. Additionally, MTPs failed to include how the intervention would be delivered for eight (8) of 16 active sample patients (A3, A4, B5, B7, B8, C11, E13, and E16) and there were no nursing interventions identified at all for three (3) of 16 active sample patients (B6, C9, and C10). This failure results in having no information about what exactly nursing staff will be attempting in their therapeutic endeavors.

Findings include:

A. Record Review

1. Patient A2: The Master Treatment Plan updated 2/19/14, for the problem "MOOD LABILITY WITH ANXIETY," had the following nursing interventions: "...01/Per Week/ 40 minutes/ Medication Education 4 Mon @ 9:30 AM"; and "... 02/Daily/5 minutes/ Medication administration/Assess." The former intervention failed to include a delivery method (group or individual sessions).The latter intervention was a routine nursing function that would be performed regardless of the patient's problem.

2. Patient A3: The Master Treatment Plan updated 3/5/14,for the problem "DEPRESSIVE MOOD WITH SUICIDE ATTEMPTS," had the following nursing interventions: "...01/Per Week/ 45 minutes/ Medication Education 3 Mon [Monday] @ 2:05 PM"; and "...02/ Daily/5 minutes/MEDICATION ADMINISTRATION/ASSESS." The former intervention failed to include a delivery method (group or individual sessions). The latter intervention was a routine nursing function that would be performed regardless of the patient's problem.

3. Patient A4: The Master Treatment Plan dated 1/2/14, for the problem "Medication and treatment non-compliance in the community by history," had the following nursing interventions: "Milieu Therapy. Therapeutically interact with the client to discuss and encourage [him/her] to continue to practice strategies and skills that maintain... healthy living" "... 2 times Daily for 5 [sic]"; and "Medication Education 4 Mon [Monday] @ 9:30 AM; to teach [Patient's name] the benefits of medications... 1 times Per Week for 40 minutes." These two interventions failed to include a delivery method (group or individual sessions).

4. Patient B5: The Master Treatment Plan dated 12/4/13 and updated 3/19/14,for the problem "[Patient's name] attempted to hand himself/herself in [location]," had the followingnursing intervention: "Nursing will educate [Patient's name] on the importance of [his/her] medications and reinforce his coping skills to reduce his depression... 1 times Per Shift for 5 minutes." This intervention failed to include a delivery method (group or individual sessions).

5. Patient B6: The Master Treatment Plan dated 12/12/13, for the psychiatric problem "Physically aggressive behaviors/Mood lability. [Patient's name] has a long history of labile affects...," there were no nursing interventions included.

6. Patient B7: The Master Treatment Plan dated 1/2/14, for the problem "Depression, leading to angry outburst, records indicate [Patient's name] has difficulty managing [his/her] emotions in the community," had the following generic and routine nursing intervention: "Administer prescribed medication, check for efficacy, provide supportive counseling and medication education. To reduce symptoms of psychosis..." This was a routine nursing function that would be performed regardless of the patient's problem. There was no delivery method included for the "supportive counseling and medication education listed."

7. Patient B8: The Master Treatment Plan dated 1/21/14, for the problem "... demonstrates with a poor thought disorder, psychosis, violence, suspicious and grandiose feeling," had the following nursing intervention: "Nursing will hold a reality based conversation with [Patient's name] to reduce [his/her] psychosis and non-adherence with [his/her] medications... 1 times Per Shift for 5 minutes." There was no delivery method included for this intervention.

8. Patient C9: The Master Treatment Plan dated 3/21/14, for the problem "As pr [sic] record, (Patient C9) non-compliance with medication and aftercare results in rehospitalization." There were no interventions listed for the nursing staff to address this problem.

9. Patient C10: The Master Treatment Plan updated 3/06/14 had no interventions listed for nursing staff directed at the psychiatric problem "...psychotic depressed and anxious state..."

10. Patient C11: The Master Treatment Plan dated 3/18/14, for the problem of "Mood instability, admitted for suicidal thoughts," had the following generic and routine nursing intervention: "To administer medications as prescribed by the psychiatrist daily. To provide supportive counseling for depression throughout the day as needed... as needed times Daily for 5 minutes."

11. Patient C12: The Master Treatment Plan dated 3/7/14, for the problem "Delusional thoughts, intermittent auditory hallucinations, labile mood and poor insight" had the following generic and routine intervention for nursing: "...as needed/ Daily/5 minutes/Nursing to administer medications as prescribed by the psychiatrist daily. To provide a PRN when the pt [Patient] is escalated." This intervention was a routine nursing function that would be performed regardless of the patient's problem.

12. Patient E13: The Master Treatment Plan dated 1/7/14, for the problem "[Patient's name] copes with her emotions by engaging in behaviors that warrant precaution status," had the following generic and routine nursing intervention: "To counsel and redirect [him/her]. Offer to put helmet on if counseling is ineffective and escort [Patient ' s name] to the quiet room." The former intervention failed to include a delivery method (group or individual sessions). The latter intervention was an instruction for staff to ensure patient safety instead of an intervention related to the problem, such as an approach to assist the patient to learn non-harmful behavior.

13. Patient E14: The Master Treatment Plan dated 1/3/14, for the problem, "Alcohol dementia-resulting in confusion, intrusive behavior and at times, physical aggression," had the following generic and routine nursing intervention: "Comfort and reassurance with ADL's. Nursing will provide comfort and reassurance during assistance with activities of daily living ... Daily." These were routine nursing functions that would be performed regardless of the patient's problem.

14. Patient E16: The Master Treatment Plan dated 12/31/13,for the problem "... Suicidal Thoughts, Self Injurious Behavior," had the following nursing interventions: "Review progress with the [Patient's name] and offer consistent firm positive feedback and encouragement to manage [his/her] negative emotions in a [sic] acceptable manner...1 times Per shift for 10 minutes." "Contraband check to ensure that no items are in possession that she could use to injure self...Q times Per Shift." The former intervention failed to include a delivery method (group or individual sessions). The latter intervention was a routine nursing function that would be performed regardless of the patient's problem.

B. Interviews

1. During interview on 3/25/14 at 10:50 a.m. with the Program Specialist 4 and the Associate Nursing Officer, the Master Treatment Plans (MTPs) were discussed. They agreed the nursing interventions on the MTPs, such as "administering medications as prescribed" were clinical tasks that the RN would perform regardless of the patient's need and/or presenting symptoms. Program Specialist 4 stated, "The Joint Commission found this too and we are addressing this in our POC [Plan of Correction]."

2. During interview on 3/25/13 at 4:30 p.m. with the Chief Nursing Officer (CNO), Patient C12's non-attendance in group was discussion. She noted that they were aware of the need to provide alternative programming for patients not participating in the Treatment Mall. She stated, "We are aware of this and we have discussed ways to address that population of patients not participating in the Mall Program."

3. Ensure that registered nurse progress notes included information about each patient's progress or lack of progress toward treatment goals for one (1) of 4 sample patients (C9) located in the main building. This failure potentially impedes the treatment team's ability to assess each patient's response to treatment provided by registered nurses.

Based on record review, interview and policy review, it was determined that the Director of Social Work failed to:

I. To assure that Social Worker Progress Notes for 12 out of 16 active sample patients (A1, A2, A3, A4, C9, C10, C11, C12, E13, E14, E15, and E16) did not contain information which specifically addressed patient progress towards treatment goals and discharge planning. Lack of social work documentation of patient progress impedes the treatment team's ability to evaluate the patient's response to treatment. (Refer to B108)

II. To assure that Social Work Progress Notes for 4 of 16 active sample patients (A1, A2, A3, and A4) had missing weekly and /or monthly social work progress notes. This failure results in a lack of social work input in treatment planning. (Refer to B108)

III. To assure that the Master Treatment Plans of 6 of 16 active sample patients (A2, A3, B5, C9, E13, and E15) included social work interventions listed as generic role functions. The absence of individualized interventions on master treatment plans potentially hampers the staff's ability to provide individualized care to patients.

Findings include:

A. Record Review

1) Patient A2, MTP dated 2/19/14 the Problem "I want to live by my church in Tom's River (LACKS DISCHARGE HOUSING)", Social Work generic interventions included "SOC WK1 (PSYCH) (SOCIAL SERVICES) 0 0 0 1 /Per Week /40 minutes /Community Connections A/ B Thu@10:15 a.m."

2) Patient A3, MTP dated 3/5/14 the Problem "My first plan didn't work out, I do need a place to stay, HOMELESS", Social Work generic interventions included, "SOC WK 1(PSYCH) SOCIAL SERVICES) 0 0 0 1/Per Week/40 minutes/Community Connections A/B 4 FRI @ 9:30 a.m."

3) Patient B5 , MTP dated 12/2/13 the Problem described as the issues of previous suicide attempt with nursing staff, Social Work generic interventions included "Social Worker will inform( Patient B 5 ) of his court dates and status as needed. FREQUENCY: 1 times Per Week for 20 minutes."

4) Patient C9, MTP dated 3/10/14 the Problem "Non -compliance with medication and aftercare results in rehospitalization", Social Work generic interventions included "SOC WK 1 (PSYCH) (SOCIAL SERVICES) 0 0 0 0 Per Week /45 m/Community Re-entry A/B Tues @1:15 :00 p.m."

5) Patient E13, MTP dated 1/7/14 the Problem "(Patient E13) copes with her emotions by engaging in behaviors that warrant precaution status"; Social Work generic interventions included "SOCIAL SERVICES supportive interaction. To aid (Patient E13) in identifying coping skills to utilize when feeling upset."

6) Patient E15, MTP dated 1/7/14 the Problem "I want to be out of here", Social Work generic interventions included "Social Worker will meet with (Patient E15) monthly . To ascertain reasons why he wants to stay in the hospital. FREQUENCY: 1 x times Per Month for 10-15 mins."

B. Interview

1. In an interview on 3/25/14 at 12:05 p.m. with SW 3, after reviewing the MTP on Patient A2 she agreed the social work intervention was a generic social work role function and not individualized for this patient.