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Based on record review, observation and interview, the facility failed to provide sufficient individualized programming to assure that patients progressed in treatment. Specifically the facility failed to:


1. Develop Master Treatment Plans for 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27) that evidenced sufficient individualized planning of modalities, with specific purpose and focus, to reasonably assure patient progress in treatment. Review of the plans revealed that the only modalities listed for all six patients were one or two "Core" groups which were the same for all patients on a unit; and for 4 patients (B10, B28, C2, C11), one or two "Special" groups (those that focused on specific patient problems such as substance abuse) which were held once or twice a week. Staff interviews revealed that each unit had a daily schedule of unit activities, amounting to about 9 "Core" groups which all patients were expected to attend. However, the majority of those groups were not listed on the plans; therefore there was no evidence that those modalities had specific purpose and individualized focus for any patient. Instead, they were a series of disconnected modalities, which staff admitted patients could choose to attend or not. Failure to be specific and inclusive in group selections for each patient results in a lack of depth and intensity in the provision of treatment measures, leading to hours of patient idleness on the unit. (Refer to B122)


2. Ensure that staff provided sufficient individualized modalities for patients, and assessed the appropriateness and usefulness of modalities, in such a way to assure sufficient treatment focused on the specific needs of 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27). None of the 6 active sample patients had individual activity schedules, beyond the "special" groups (those focusing on specific problems such as alcoholism, competency to stand trial, etc. to which specific patients were assigned by the treatment team) listed on the treatment plans. With the exception of the "special" groups each patient had each week, all patients were expected to attend all groups listed on their unit's schedule, very few of which were included in the patients' Master Treatment Plans, and when listed did not include any individualized focus. The lack of development of sufficient individualized modalities and failure to document the focus of the groups and patients' responses in each patient ' s record makes it difficult for the facility to determine whether the patients are making progress, and what revisions in care are needed for goal achievement. (Refer to B125)

Based on record review, policy review and interview, it was determined that the facility failed to assure the reporting of memory, orientation, or intellectual functioning in measurable, behavioral terms that clearly reflected the patients' ability to function in those areas for 4 of 6 active sample patients (Patients B10, B28, D5 and D27.). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions can be measured.


Findings include:


A. Record Review


1. Patient B10: (admitted 8/13/10). The Mental Status Examination dated 8/13/10 made no mention of memory or intellectual functioning.


2. Patient B28 (admitted 10/6/10). The Mental Status Examination dated 10/8/10 made no mention of memory or intellectual function.


3. Patient D5 (admitted 10/17/10). The Mental Status examination dated 10/17/09 referred to intellectual function as "Limited intellectually." There was no mention of memory.


4. Patient D27 (admitted 3/04/10). The Mental Status examination dated 3/8/10 made no mention of memory or intellectual functioning.


B. Document (Policy) Review


1. "Hospital System Medical Staff Bylaws Georgia Regional Hospital-Savannah," Appendix I, Item I. "Professional Performance and Standards and Scope of Assessment for the Medical Staff." Page 65 - 66 states "Mental Status Examination (will include)" "Cognitive Function" "Level of Consciousness," orientation," "immediate recall," "recent memory," "remote memory."


2. "Information Management and Record of Care Committee Documentation Guideline for Clinical Staff; Subject: Assessment of Consumers." (Revision 9/1/09) "Procedures #5: Psychiatric Assessment" states "The scope of the assessment will include mental status exam (orientation, memory, concentration, intellectual functioning, and insight."


C. Interview


In an interview with the Medical Director and the Program Director on November 11, 2010 between 3:30p.m. and 4:30p.m., the above findings were presented. Both Directors acknowledged the missing information in the Mental Status exams.

Based on record review, observation and interview, the facility failed to develop Master Treatment Plans for 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27) that evidenced sufficient individualized planning of modalities, with specific purpose and focus, to reasonably assure patient progress in treatment. Review of the plans revealed that the only modalities listed for all six patients were one or two "Core" groups which were the same for all patients on a unit; and for 4 patients (B10, B28, C2, C11), one or two "Special" groups (those that focused on specific patient problems such as substance abuse) which were held once or twice a week. Staff interviews revealed that each unit had a daily schedule of unit activities, amounting to about 9 "Core" groups which all patients were expected to attend. However, the majority of those groups were not listed on the plans; therefore there was no evidence that those modalities had specific purpose and individualized focus for any patient. Instead, they were a series of disconnected modalities, which staff admitted patients could choose to attend or not. Failure to be more specific and inclusive in group selections for each patient resulted in a lack of depth and intensity in the provision of treatment measures, leading to hours of patient idleness on the unit.


Findings include:


1. Facility policy no.18.104, dated 11/18/08, titled " Individualized Treatment Planning," states under the section on "Guidelines for Documenting Active Treatment" that "regarding group and activity therapy, specify group by title, frequency, provider, purpose on the treatment plan and when progress notes are written. Progress notes should reference the consumer's level of participation, progress toward goal."


2. Active sample patient B10 on Unit 4 had only one "Special" group, the "Wellness" group, on his Master Treatment Plan (MTP) dated 10/4/10. The "Wellness" group was held on the unit one day per week on Mondays at 10:00a.m. Other interventions listed on the plan were: "Psychologist will assess severity of depression every two weeks"; "Social worker will meet with patient bi-weekly for up to 30 minutes --- providing him with coping skills he can use after discharge." B10 was electing not to attend unit activities: a review of B10's progress notes for the period of 11/1/10 to 11/10/10 documented only two references to him attending unit groups. A nursing note on 11/5/10 at 10:30p.m. stated "He [patient] attended community - current events - listened to music therapy group. He achieved his goal today of finishing his resume." The nursing note dated 11/10/10 stated- "Attended/participated at community - current event - music therapy groups." Since B10 was electing not to attend unit activities, the infrequency of the "Special" group and 1:1 meetings with clinical staff caused many idle hours of inactivity for this patient; the frequency and intensity of the modalities on the plan would not be expected to lead to improvement and movement to a less restricted environment.


3. Active sample patient B28 on Unit 4 had one "Special" group (Competency) listed on his MTP dated 10/6/10. The group was held one time per week on Wednesdays at 2:00 p.m. The other groups listed were "Task/Activities" (no description on plan of what this meant) and "Group Activities" once a day. Another intervention was: "Doctor will meet with patient 2 x [times] week to assess presence of psychotic symptoms." There were no registered nurse or social work interventions listed on the plan. Per unit staff, the patient was attending most of the groups on the unit. However, the unit groups the patient attended and the focus of each for this patient were not included in the MTP.


4. Active sample patient C2 on Unit 6 had only one "Special" group listed on her MTP, dated 8/13/10. It was "Leisure group that enhance [sic] social skill building". Other interventions included: "Psychiatrist will assess for mood, mental status M - F [Monday through Friday]"; Social Worker will meet weekly with [name of patient] to discuss aggression"; and "nursing staff will engage [name of patient] in recovery - inspire conversation." This patient, by her own admission, was attending most of the unit groups, but they were not listed on her treatment plan. Therefore without the group leaders' knowledge of the specific focus for the patient in each group, they were not able to direct their attention toward meeting the patient's individualized needs.


5. Active sample patient C11 on Unit 6 had two groups listed on his MTP, dated 10/26/10. They were "Special" group, "Wellness," (the unit schedule said the group met twice a week on Tuesdays and Thursdays) and "Core" group: "Recreation, Music and Crafts" held daily to "redirect attention to task at hand." The other 7or 8 "Core" groups that the patient was expected to attend were not listed on the MTP.


6. Active sample patient D5 on Unit 3 had only one reference to a group activity on her MTP dated 10/9/10. It read "Will participate in art, music, and recreational therapy 4 days a week." Patient D5, by her own admission, was attending groups held on the unit, but they were not included on the plan. She stated she attended most groups because they gave her something to do during the day.


7. Active sample patient D27 on Unit 3 had no activities from the unit schedule listed on his MTP dated 8/3/10. There was a social work intervention which stated, "Social worker will meet with patient at least one time a week to work toward placement." Per unit Health Services Technician (HST) staff, patient D27 attended all groups on the unit, but they were not incorporated and individualized on the plan.


8. In an interview with RN #3 on 11/10/10 at 10:30a.m., he was asked why "Core" groups from the unit schedule were not listed on the MTPs. He stated that the topics presented in these groups were so varied that it would be hard to have a specific focus for each patient.


9. In an interview with the facility's Program Director on 11/10/10 at 3:30 p.m., the lack of inclusion on the MTPs of the groups patients were expected to attend was discussed. Also discussed was the difficulty of trying to evaluate patient care without all the available information on the groups each patient attended and what the focus was for each patient He agreed that this problem currently existed.

Based upon record review and interview, it was determined that the facility failed to identify the responsible team member by name for the treatment modalities recorded on the Master Treatment Plans for 5 of 6 active sample patient records reviewed (Patients B10, C2, C11, D5 and D27). This resulted in the inability to determine what staff member was responsible for ensuring compliance with the various aspects of treatment, thus compromising a coordinated treatment process for the patient.


Findings include:


A. Record Review


1. Active sample patient B10 was admitted 8/13/10. Updated Master Treatment Plan (MTP) dated 10/04/10 listed no responsible provider for nursing modalities.


2. Active sample patient C2 was admitted 11/03/10. MTP dated 8/13/10 designated no person as "responsible provider" for "Doctor," "SW [social worker]", "AT [activity therapy]," or "Nurse" modalities.


3. Active sample patient C11 was admitted 10/12/10. MTP updated 10/26/10 listed no "responsible provider" for "Attending Physician," "Nursing Staff," "Activity Therapy" or "Social Worker" modalities.


4. Active sample patient D5 was admitted 10/17/09. Updated MTP dated 10/9/10 listed no "responsible provider" for "Social Work" and "Nursing" modalities.


5. Active sample patient D27 was admitted 3/4/10. MTP updated 8/3/10 listed no "responsible provider" for "Nursing Staff" or "Attending Physician."


B. Interview


1. In an interview with the Nursing Director on 11/10/10 at 1:30p.m., the lack of a specific nurse being listed by name as the person accountable for nursing interventions on the sample patients' Master Treatment Plans was discussed. The Director stated that she had thought that naming one nurse for each nursing intervention was impossible because so many nurses were involved in patient care. She also stated that she now sees the need for accountability.


2. During an interview with the Medical Director and the Program Director on November 11, 2010 between 3:30p.m. and 4:30p.m., the above findings were presented. Both Directors acknowledged the findings.

Based on record review, observation, and interviews, the facility failed to ensure that staff provided sufficient individualized modalities for patients, and assessed the appropriateness and usefulness of modalities in such a way to assure that treatment focused on the specific needs of 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27). None of the 6 active sample patients had individual activity schedules, beyond the "special" groups (those focusing on specific problems such as alcoholism, competency to stand trial, etc. to which specific patients were assigned by the treatment team), listed on the treatment plans. With the exception of the "special" groups each patient had each week, all patients were expected to attend all groups listed on their unit's schedule, very few of which were included in the patients' Master Treatment Plans. When listed on the MTPs, the groups did not include any individualized focus. Failure to develop individualized treatment modalities, and document the focus of groups and patients' responses to treatment in each patient's record, hampers the staff's ability to determine whether the patients are making progress, and what revisions in care are needed for goal achievement. It also can lead to hours of patient idleness on the unit.


Findings include:


A. Unit Programming Review


1. The three patient units (Unit 3 - Chronic Adults, Unit 4 - Forensic, and Unit 6 - Acute Adult Admission) offered activity groups approximately 9 to 10 times per day, depending on the unit, Monday through Friday between the hours of 8:00a.m. and 11:00a.m., and between the hours of 1:00p.m. and 6:00 p.m. Four to five groups were offered on the weekends. The length of the week day groups varied anywhere from 15 to 45 minutes. With the exception of 2 to 3 "special" groups on some patient units, the groups offered on the schedules of the 3 units were the same. Only the times of some of the groups differed. Some "core" or routine groups, such as goals group, were held twice a day. Many "special" groups such as "substance abuse education" were held at the same time as the "core" groups. The following 7 "core" groups were listed on Unit 3 and 4 ' s Activity schedule: "Daily Goal Setting and Community Meeting", "Life/Social Skills", "Enhanced Health and Wellness", "Stress/Relaxation Group", "Medication Education", "Daily Goal Review and Community Meeting", and "Current Events." Unit 6, had 5 of the "core" groups listed above on its schedule; it did not have the "Life/Social Skills" and "Current Events" groups. Unit 6 had more "special" groups than Unit 4; Unit 3 had no "Special" groups in its unit schedule for a current census of 28 patients. The length of stay for the current patients ranged from about one month to two years.


2. In an interview on 11/9/10 at 12:50p.m., RN #1 stated that there was only one schedule for each unit and all patients were expected to attend all the "Core" groups listed on the schedule.


3. In an interview on 11/10/10 at 9:30a.m., RN #2 was shown the ward schedule for Unit 3 and asked to identify any special groups that only specific patients attended. She stated "There are no special groups offered on this unit. The groups offered here are for everybody on the unit."


4. In an interview with MD #1 on 11/10/10 at 10:10a.m., the problem of patients not attending groups was discussed. He stated that patients were expected to go to all groups, but admitted that he saw many patients just sitting around the unit all day.


5. During an interview with active sample C11 from Unit 6 on 11/10/10 at 9:40a.m., the patient stated "Compared to other hospitals I have been in, this one has nothing to do. No groups, except AT [activity therapy]. We sit and watch TV all day." Patient C11 was observed sitting in the Day Room of Unit 6 forty minutes later at 10:30 a.m., reading a book. There were 8 non-sample patients sitting in the same room. They were watching TV. Patient C11 was asked if there had been any organized groups that morning. He stated that they rarely had any groups other than recreation. He stated that they (patients) mostly watched TV/or sat around. Unit 6's schedule showed 2 groups that should have been held that morning: the "Daily Goals Setting" group at 8:00a.m and the "Stress Management" group at 10:00a.m.


6. During the two morning groups (same as above) on Units 3 and 4 on 11/10/10, 4 to 5 non-sample patients were observed either wandering around the unit or outside in the screened in areas. Since the groups were opened to all patients, the group leaders had no idea how many patients would be coming to a group or what the specific focus was for each patient that did come. Staff was observed asking patients to come to a group, but if the patient said "no", the staff walked away without making any further effort to get them to go to the group It was difficult to count the number of patients in each group because they wandered in and out at will. Staff made no effort to stop this behavior. It was observed, however, that the Goals group on the female side of Unit 3 started at 10:50a.m. on 11/10/10 instead of 8:00a.m. Staff said the breakfast was late. Sixteen females were housed on that side; 10 attended the group which lasted 10 minutes. One patient was still eating at 10:50a.m. Approximately 9 to 10 patients were just sitting or walking around the day room.


7. A "Stress/Relaxation" group was observed on the female side of Unit 6 on 11/10/10 at 10:15a.m. Non-sample patient C26 approached the writer and stated that the group being observed did not ordinarily take place at that time. Unit 6's group/activity daily schedule was checked. The group listed on the schedule at the 10:00 a.m. time was "Enhanced health and wellness". The "Stress/Relaxation" group was scheduled for 1:00p.m.


B. Individual Patient Findings:


1. Active sample patient B10 on Unit 4 had a Master Treatment Plan (MTP) dated 10/4/10. The identified problems were: "Suicidal Ideation", "Substance Abuse" and "Hypertension." The only groups listed on the MTP were "Activity will provide MT [music therapy]", "RT ["Recreation Therapy"]" and other group activities 1x [time] per day for 20 minutes on the unit for the problem of "Suicidal Ideations," and "Wellness" group 1x weekly for 30 minutes for the problem of "Substance Abuse."


In an interview on 11/9/10 at 11:45a.m., active sample patient B10 stated that he did not attend groups, most of which were held in the day room of the unit. He stated that he spent his time reading books provided by his doctor.


In an interview on 11/10/10 at 10:10a.m., Patient B10's doctor (MD #1) said that the patient had slept on a cot in the dayroom of Unit 4 for the 3 weeks up to the survey as a result of an almost fatal suicide attempt by hanging. He (patient) was found unconscious, hanging from a sheet attached to a ceiling ventilator in his room. Patient B10 was currently on line of sight precautions.


Patient B10 was observed "attending" the "Stress/Relaxation" group on 11/9/10 at 10:00a.m.in the same dayroom where he resided. He sat with his head down and did not verbally participate. He was also observed attending the "Goals" group in the day room on 11/10/10 at 8:00a.m. Neither of these groups was included in his Master Treatment Plan. The patient sat at a table in the group area. When asked about his goal for the day, patient B10 said, "Sleep."


2. Active sample patient B28 on Unit 4 had a MTP dated 10/6/10. The identified problems were: "Thought and Mood Disorder", "Aggression/Hostility" and "Incompetent to stand trial." The "Task/Structural Activities "x6 per week was the group listed for the problem of "Aggression/Hostility." For the problem of "Incompetency to stand trial," the "Competency" group on Wednesday at 2:00p.m. was provided. There was no specific intervention for the problem of "Thought and Mood Disorder."


Patient B28 attended most of the groups. However, there was little documentation in the progress notes about what groups the patient was attending and what, if any goals were being achieved by attending these groups.


3. Active sample patient C2 on Unit 6 had a MTP dated 8/13/10. The identified problems were: "Disorganized Thought Process," and "Agitation and Aggression." For the problem of "Disorganized Thought Process," the group was "Leisure activities when [name of patient] can express her thought..." Leisure activities were also listed for the problem of "Agitation any Aggression." During the survey, active sample patient C2 was observed wandering around Unit 6, yelling and rambling incoherently at times. She was seen walking in and out of the "Stress Management" group which was being held on 11/10/10 at 10:00a.m. on the screened-in area of Unit 6. She was never observed actually participating in a group.


4. Active sample patient C11 on Unit 6 had a MTP dated 10/26/10. The identified problems were: "Manic Behavior," "Impaired Thought process" and "Non-adherent [sic] with medication." For the problem of " Impaired Thought," the plan listed "Daily session of recreation, music, and Crafts." There were no specific activities listed for the other two problems.


During an interview with patient C11 on 11/10/10 at 9:40a.m., the patient complained about the lack of groups on the unit, causing him to have too few things to do. He said Except for AT [activity therapy], we just watch TV all day." The patient was observed 11/10/10 at 10:20a.m., sitting in the dayroom on the male side of Unit 6, reading and watching TV. During this time, a "Stress Management" group was taking place on the female side. C11 was asked if there had been any organized activities on his side in the past hour. He said "No, but I have my books to read."


During an interview on 11/10/10 at 3:30p.m., the Program Director was told about the lack of a group on Unit 6 at 10:00a.m. that morning while one had taken place on the female side as scheduled. The Program Director stated that the therapist assigned to conduct a similar group on the male side of Unit 6 was absent from work at that time.


5. Active sample patient D5 on Unit 3 was admitted 10/17/09. She had a MTP dated 10/9/10. The identified problems on the MTP were: "Thought Disorder", "Aggressive Behavior" and "Self Injurious Behavior." For the problem of Thought Disorder, the plan stated: "Will participate in Art, Music and Recreation Therapy 4 days a week." No special groups were listed for the other 2 problems. According to the unit staff, patient D5 attended most of the unit groups; these groups were not included on her MTP. There was little or no information about the groups this patient was attending and what, if any, goals were being achieved by her attending these groups.


6. Active sample patient D27 on Unit 3 had a MTP dated 8/3/10. The identified problems were: "Schizoaffective Disorder Bipolar type as evidenced by hyper verbal rapid speech, flight of ideas", and "Poly-pharmacy." There were no specific groups listed for Poly-pharmacy or the Schizoaffective Disorder Bipolar Type. According to the unit staff, Patient D27 attended most of the unit groups; these groups were not on his MTP.There was little or no information about the groups this patient was attending and what , if any, goals were being achieved by him attending these groups.


C. Staff assessment of patient progress


1. In an interview on 11/10/10 at 9:30a.m., RN #2 was asked how one can tell whether a patient attended a group or not. RN #2 stated that the Health Services Technicians (HST's) made daily notes in each patient's record of whether he or she participated in groups.


2. None of the HST/FST's daily Progress Notes for the 6 active sample patients (B10, B28, C2, C11, D5 and D27) consistently included documentations regarding what groups each patient had attended, the specific focus of the groups for each patient, or whether each patient ' s goals were achieved.


3. During an interview on 11/10/10 at 1:15p.m., the Nursing Director was told by the surveyor that the nursing Progress Notes did not consistently include the specific groups patients attended. The DON stated that she expected the nursing staff to document what patients were doing in groups as well as what groups they attended.


4. In an interview on 11/10/10 at 3:30p.m. with the Program Director, the lack of an inclusion in the MTP of the specific groups patients were attending and the focus of the groups for each patient were discussed. The Program Director stated that he understood the importance of documenting this information.

Based on observation, record review and interview, the facility failed to assure that all treatment measures/activities offered to 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27) and other patients on the 3 certified bed units (Units 3, 4, and 6) were conducted by qualified clinical staff rather than non-professional personnel who did not have the education and skills to perform these treatment functions. This failure results in a lack of comprehensive active treatment measures, based on the presenting needs of patients.


Findings include:


1. In an interview on 11/10/10 around 10:30a.m., RN #5 she was asked what training the Health Services technicians received for running groups. She stated that they were given pre-printed material which they were to use as a script when leading groups. She provided copies of some of the materials.


2. A "Stress/Relaxation" group was observed on 11/9/10 at 1:00p.m. in the dayroom on the co-ed side of Unit 4. Active sample patient B10 sat at one of the tables in the dayroom where he resides and sleeps, but he did not verbally participate in the group. The group was conducted by a Forensic Service Technician (FST) who stood in front of the patients in attendance and read some information from a sheet of paper on how stress affects people. Non-sample patient (B8) repeatedly interrupted the reading by telling the Group Leader that the staff needed to practice some of the coping skills they kept "throwing out" at the patients. At first, the Group Leader did not respond verbally to patient B8. However, the more B8 was ignored by the Group Leader, the louder B8 became. After a few minutes, the Group Leader told patient B8 she understood what she (Patient) was saying, but she (the Group Leader) wanted to continue with the topic. B8 did not stop the interruptions. The charge nurse, who was present in the room at the time, took over the group leadership at that point and continued conducting the group.


3. A "Stress/Relaxation" group was observed on the female side of Unit 6 on 11/10/10 at 10:15a.m. It was held in a screened outside area of the unit. The Group Leader, a Health Services Technician, read from some pre-printed material. During this time, about 8 other patients were talking loudly and walking about in the same area, including active sample patient C2. They appeared to be inattentive to the fact that a group was going on as evidenced by their behavior. Active sample patient C2 was taken back inside the unit because she was disruptive in the group. She was not observed to be encouraged by staff to join the group again.


4. Non-sample patient C26 approached the writer and complained that there was no order on the unit. She had been observing the "Stress/Relaxation" group in the screened area and was referring to the distraction taking place as several patients wandered about near the group, talking in loud voices. The HST group leader continued to read from her pre-printed material without doing anything to quiet the disrupting patients.


5. In an interview on 11/10/10 around 1:30p.m., group leader MHT #1 was asked why she stopped conducting the group "Stress/Relaxation" on unit 4 at 1:00p.m. She stated that she just froze up at the interaction between her and patient B8. She also acknowledged that she had felt uncomfortable with a surveyor present. When asked if she had ever had any training in running groups, she stated "No."


6. In an interview on 11/10/10 around 10:45 a.m., MHT #2 was asked if he conducted patient groups. He stated "Yes." When asked about his training to run groups, he stated that he and the other technicians were provided printed material on many topics. He stated that they (MHTs) choose a topic of choice from this available material when assigned to run a group. He also stated that the charge nurse of the unit assigns a technician to run a group on a given date, and that the assignments are rotated among the HST [Health Services Technicians] and FST [Forensic Services Technicians] staff.


7. In an interview on 11/10/10 at 1:15p.m., the Nursing Director confirmed that the non-professional nursing staff (Health and Forensic Services Technicians) had not had any formal training on how to run groups prior to one week preceding the survey.

Based upon record review, observation and interview, it was determined that the Medical Director failed to:


I. Assure the reporting of memory, orientation, or intellectual functioning in measurable, behavioral terms which clearly reflected the patients' ability to function in those areas for 4 of 6 active sample patients (B10, B28, D5 and D27). This failure compromises the database from which diagnoses are determined and from which patient changes in response to treatment interventions may be measured. (Refer to B 116)


II. Ensure that Master Treatment Plans were developed for 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27) that included all the activities/groups necessary for patient improvement. The unit modalities consisted of about 9 "Core" groups (those open to all patients who wanted to attend) and "Special" groups (those that focused on specific problems such as substance abuse). Patients were expected to attend the "Core" groups. Patients were assigned by the treatment team to the "Special" groups, which were mostly held once or twice a week. Failure to be specific and inclusive in group selections for each patient results in a lack of depth and intensity in the provision of treatment measures, potentially leading to hours of patient idleness on the unit. (Refer to B122)


III. Ensure that the responsible team member is listed by name on the Master Treatment Plans for the treatment modalities selected for 5 of 6 active sample patients (B10, C2, C11, D5 and D27). Inability to determine what staff member is responsible for ensuring compliance with various aspects of treatment leads to lack of staff accountability, potentially resulting in poor coordination of treatment for the patient. (Refer to B123)


IV. Ensure that staff provided sufficient individualized modalities for patients, and assessed the appropriateness and usefulness of modalities, in such a way to assure sufficient treatment focused on the specific needs of 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27). None of the 6 active sample patients had individual activity schedules beyond the "special" groups (those focusing on specific problems such as alcoholism, competency to stand trial, etc. to which specific patients were assigned by the treatment team) listed on their treatment plans. With the exception of the "special" groups each patient had each week, all patients were expected to attend all groups listed on their unit's schedule, very few of which were included in the patients' Master Treatment Plans. When listed on the MTPs, the groups did not include any individualized focus. Failure to develop individualized treatment modalities, and document the focus of groups and patients' responses to treatment in each patient's record hampers the staff's ability to determine whether the patients are making progress and what revisions in care are needed for goal achievement. (Refer to B125)

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


I. Ensure that nursing staff responsible for specific aspects of care were listed by name on the Master Treatment Plans for 5 of 6 active sample patients (B10, C2, C11, D5 and D27. This practice results in the Nursing Director's inability to monitor nursing staff accountability for specific treatment modalities.


II. Ensure that Health/Forensic Services Technicians consistently included in their daily progress notes information on whether patients were attending groups or not, the names of the specific groups patients attended, and whether individualized patient goals were achieved for 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27). Lack of this information impedes the treatment team's ability to assess and/or evaluate the patient response to the treatment measures provided. This failure also results in an absence of consistent monitoring of patients ' responses to interventions (groups) provided.


III. Ensure that Health/Forensic Services Technicians who conducted treatment measures/activities offered to 6 of 6 active sample patients (B10, B28, C2, C11, D5 and D27) and all other patients on the units received formal training by qualified clinical staff prior to performing these treatment functions. This failure results in a lack of knowledge and skills by technicians in providing active treatment measures for patients.


Findings include:


I. Failure to include names of nursing staff responsible for seeing that nursing interventions included on the treatment plans are carried out.


A. Record Reviews


1. Patient B10 (admitted 8/13/10). The updated Master Treatment Plan (MTP) dated 10/04/10 listed no responsible provider for nursing modalities.


2. Patient C2 (admitted 11/03/10) The MTP dated 8/13/10 designated no person as "responsible provider" for "Nurse" modalities.


3. Patient C11 (admitted 10/1210). The MTP Review updated 10/26/10 listed no "responsible provider" for "Nursing Staff" modalities.


4. Patient D5 (admitted 10/17/09). The updated MTP of 10/9/10 listed no "responsible provider" for " nursing" modalities.


5. Patient D27 (admitted 8/05/10). The MTP dated 8/13/10 listed no "responsible provider" for "Nursing Staff" modalities.


B. Interview


In an interview with the Nursing Director on 11/10/10 at 1:30p.m., the lack of a specific nurse being listed by name as the person accountable for nursing interventions was discussed. The DON stated that she had thought that naming one nurse for each nursing intervention was impossible because so many nurses were involved in patient care. She also said that she now saw the importance of nurses consistently being identified by name for the nursing interventions on the Master Treatment Plan.


II. Failure of the Health/Forensic Services Technicians (HST/FST) to consistently include in their daily progress notes specific information regarding patients attendance in groups and the individual focus of the group for each patient. (Note: Mental health technicians working with patients on the Adult psychiatric unit in this facility are called Health Services Technicians. Those working on the Forensic units are called Forensic Services Technicians.)


1. None of the HST/FST's daily Progress Notes in the 6 active sample patients (B10, B28, C2, C11, D, and D27) consistently included what groups each patient attended, the specific focus of the group for each patient, and whether each patient's goals were achieved. The absence of this information makes it difficult to ascertain which groups each patient is actually attending.


2. In an interview with the Nursing Director on 11/10/10 at 1:15p.m., the absence of detailed information about patients' attendance at groups in the HST/FST's daily progress notes was discussed. The DON stated that nursing staff were expected to document what patients were doing in groups. The DON said "That information should have been present in the progress notes."


III. Lack of formal training for Health/Forensic Services Technicians who conduct patient groups.


1. A "Stress/Relaxation" group was observed on 11/9/10 at 1:00p.m. in the dayroom on the co-ed side of Unit 4. Active sample patient B10 sat at one of the tables, but did not verbally participate. The group was conducted by a Forensic Service Technician (FST) who stood in front of the patients in attendance and read some information from a sheet of paper on how stress affects people. Non-sample patient (B8) repeatedly interrupted the reading by telling the Group Leader that the staff needed to practice some of the coping skills they kept "throwing out" at the patients. At first, the Group Leader did not respond verbally to patient B8. However, the more B8 was ignored by the Group Leader, the louder she became. After a few minutes, the Group Leader told patient B8 she understood what she (patient) was saying, but that she (the Group Leader) wanted to continue with the topic. B8 did not stop the interruptions. The charge nurse, who was present in the room at the time, took over the group leadership at that point and continued conducting the group.


2. A "Stress/Relaxation" group was observed on the female side of Unit 6 on 11/10/10 at 10:15a.m. It was held in a screened outside area of the unit. The Group Leader, a Health Services Technician, read from some pre-printed material. During this time, many other patients were talking loudly and walking about in the same area. They appeared to be inattentive to the fact that a group was going on as evidenced by their behavior. Active sample patient C2 remained inside and was not observed to be encouraged by staff to join the group. Non-sample patient C26 approached the writer and complained that there was no order on the unit. She stated that the group being observed did not ordinarily take place at that time. Unit 6's group/activity daily schedule was checked. The group listed on the schedule at the 10:00a.m. time was "Enhanced health and wellness." The "Stress/Relaxation" group was scheduled for 1:00p.m.


3. In an interview on 11/10/10 around 1:30p.m., group leader MHT #1 was asked why she stopped conducting the group "Stress/Relaxation" on unit 4 at 1:00p.m. She stated that she just froze up at the interaction between her and patient B8. She also admitted that she had felt uncomfortable with a surveyor present. When asked if she had ever had any training in running groups, she stated "No."


4. In an interview on 11/10/10 around 10:30a.m., RN #5 she was asked what training the Health Services technicians received for running groups. She stated that they were given pre-printed material which they were to use as a script when leading groups. She provided copies of some of the material.


5. In an interview on 11/10/10 around 10:45a.m., MHT #2 was asked if he conducted patient groups. He stated "Yes." He confirmed that he and the other technicians were provided printed material on many topics. He stated that they (the MHTs) choose a topic of choice from this available material when assigned to run a group. He also stated that the charge nurse of the unit assigns a technician to run a group on a given date, and that the assignments are rotated among the HST and FST staff.


6. In an interview on 11/10/10 at 1:15p.m., the Nursing Director confirmed that the non-professional nursing staff (Health and Forensic Services Technicians) had not had any formal training on how to run groups prior to one week preceding the start of the sur