HospitalInspections.org

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

I. Ensure that the master treatment plans for 4 of 8 sample patients (A32, B10, B14, and B24) were revised based on the presenting needs of the patients. These patients displayed cognitive limitations, psychosis, and/or language limitations that prevented participation in the prescribed treatment. The only psychiatric treatments prescribed on the master treatment plans for these patients, other than medications, were group therapy sessions. These patients were incapable of benefiting from these groups and these master treatment plans were not revised to include modalities from which these patients could benefit. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients. (Refer to B118)

II. Ensure necessary interpreter services for 2 of 8 active sample patients (B10 and B14) who were not proficient in the English language. This failure compromised the patients' ability to understand and participate in treatment. (Refer to B125 Part I)

III. Ensure the provision of alternative treatment modalities for the specialized needs for 2 of 8 active sample patients (A32 and B24) in order to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125 Part II)

IV. Ensure that 4 of 8 active sample patients (A30, A35, B10 and B14) who had reached their maximum level of treatment were discharged. This resulted in patients being retained in the facility who were not receiving treatment based on their treatment needs.
(Refer to B125 Part III)

V. Ensure patients were provided needed therapeutic programs and interventions during evening hours and weekends. A review of the schedule of programming for patients revealed that the facility failed to provide active therapeutic programs for patients by licensed/certified professional staff other than in the Recovery Center (Monday through Friday from 9:00 a.m. to 3:15p.m.). All other scheduled activities were leisure oriented and conducted by untrained staff without professional supervision. This practice results in delay of improvement in patients' condition and prolongs hospitalization. (Refer to B125 IV)

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

I. Ensure that registered nurses were given the responsibility and authority for the delegation and supervision of patient care provided by unlicensed Human Service Workers/Certified Nursing Assistants (mental health technicians). All nursing care functions provided by these technicians for patients on 2 of 2 wards (M1 and W1) were delegated and supervised by mental health technician supervisors. These technician supervisors reported to the Unit Treatment Rehabilitation Director who was not a registered nurse. The technician staff made patient assessments (physical, emotional and behavioral) and provided behavioral/psychiatric care to the patients without direction and supervision from a registered nurse. The mental health technicians (including supervisiors) and the Unit Treatment Rehabilitation Director do not have the education and licensure in nursing to make nursing assessments or to direct and supervise nursing care. This failure resulted in lack of authority for the quality of nursing care by the Department of Nursing and potential harm to patients. (Refer to B148 Part I)

II. Ensure that the Director of Social Work monitored and evaluated the quality and appropriateness of discharge planning and aftercare arrangements for 8 out of 8 sample patients (A1, A30, A32, A35, B10, B14, B15, and B24). (Refer to B152 Part II)

III. Ensure that social work staff participated in discharge planning, arranging for follow-up care, and developed mechanisms for exchange of appropriate information with sources outside the hospital for 8 out of 8 active sample patients (A1, A30, A32, A35, B10, B14, B15, and B24) including 4 of 8 active sample patients (A30, A35, B10, and B14) who had reached their maximum level of treatment but were not discharged. (Refer to B155)

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

I. Ensure that the master treatment plans for 4 of 8 sample patients (A32, B10, B14, and B24) were revised based on the presenting needs of the patients. These patients displayed cognitive limitations, psychosis, and/or language limitations that prevented participation in the prescribed treatment. The only psychiatric treatments prescribed on the master treatment plans for these patients, other than medications, were group therapy sessions. These patients were incapable of benefiting from these groups and these master treatment plans were not revised to include modalities from which these patients could benefit. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients.

II. Ensure that the master treatment plan for 1 of 8 sample patients (A32) was based on a completed psychosocial assessment. This failure allows master treatment plans to be developed without all required discipline assessments completed.

Findings include:

I. Master treatment plans were not revised to include modalities from which these patients could benefit:

A. Patient A32

1. Patient A32 was admitted to the facility on 8/3/11. The Psychiatric Evaluation for Patient A32 dated 8/4/11 stated that his/her diagnoses included "Dementia (not otherwise specified)" and "History of Antisocial Acts." S/he was admitted on "forensic status, Incompetent to Proceed." According to this evaluation "on 8/1/09 the patient shot one woman who eventually died..." and "also shot another woman...prior to 2009 he had no history of psychiatric illness or treatment." Findings on the Psychiatric Evaluation included disorientation to place, time, and date.

2. The Psychosocial Assessment dated 8/12/11 stated that Patient A32 was "suffering from cognitive decline, memory deficits, impaired capacity to care for himself and gross impairment of judgment. [A32] has difficulty understanding and responding to questions."

3. According to the master treatment plan dated 8/10/11, for the problem of "Dementia-NOS/Major Depressive Disorder/History of anti-social acts, Patient A32 was scheduled for the following therapy groups each weekday: "Social Skills group," "Anger/Stress Management group," "Spiritual Issues group," and " General Leisure group."

4. A review of the "Rehabilitation Service Monthly Summary" notes for Patient A32 from 8/8/11 to 8/26/11 showed that he attended only 1 of 13 scheduled therapeutic groups during this time.

5. Further review of the master treatment plan for Patient A32 dated 8/10/11 revealed that, as of 9/13/11, there was a failure to address the inability of Patient A32 to participate in or benefit from group therapy or programming activities. No revisions were documented on the plan to include treatment interventions/modalities based on his/her decreased level of cognitive functioning.

6. During an interview on 9/13/11 at 9:00a.m. with MD 1, s/he agreed that Patient A32 was offered no active psychiatric treatment other than group therapy and medication and that Patient A32 did not usually attend group therapies. S/he acknowledged that Patient A32 had displayed minimal improvement since admission. S/he agreed that Patient A32 appeared unlikely to respond to group therapies and that the master treatment plan had not been revised to address the lack of response to the documented interventions.

7. During an interview on 9/13/11 at 12:00 noon with SW 1, s/he stated that s/he was unaware of any alternative treatments provided for Patient A32 when s/he did not attend prescribed group therapy. S/he acknowledged that Patient A32 had displayed minimal improvement since admission and that the master treatment plan had not been revised to address the lack of response to the documented interventions.

8. During an interview on 9/13/11 at 11:20a.m. with Treatment Team Coordinator 1, s/he stated that Patient A32 "refuses group." S/he stated that Patient A32 "has nothing to learn from groups." S/he acknowledged that Patient A32 was offered no active psychiatric treatment other than group therapy and that the master treatment plan had not been revised to address the lack of response to the documented interventions.
B. Patient B10

1. Patient B10 was admitted to the facility on 11/14/02. The face sheet documented the primary language as Spanish. The Annual Psychiatric Evaluation dated 10/15/10 stated that his/her diagnoses included "Schizophrenia Disorder" and "Dementia (not otherwise specified)." This evaluation stated that the psychiatrist was unable to evaluate memory, ability to calculate, ability to abstract or intelligence for Patient B10.

2. As documented in the Annual Psychosocial Addendum (10/22/10), Patient B10 had a diagnosis of "Dementia" and presented with confusion and wandering the halls. "[B10] remains confused for the most part...[B10] no longer attends the Recovery Center due to dementia..."

3. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 stated, "[Patient B10's] main issue is dementia. [B10] gets no benefit out of almost any interaction. I do not even get a response."

4. According to the Recreational Therapy monthly progress notes from April through August, 2011, the only activity offered to Patient B10 was an "Enrichment Program" which consisted of going outside the building to sit or walk in the yard.

5. According to the master treatment plan, revised 8/11/11, one of the interventions for the problems, "Schizophrenia" and "Dementia", was "Encourage participation in R.C. (Recovery Center) and on-unit enrichment activities". A review of the "Rehabilitation Service Monthly Summary" notes for Patient B10 from 8/8/11 to 8/26/11 indicated that s/he attended only 1 of 13 scheduled therapeutic groups during that time.

6. Further review of Patient B10's master treatment plan on 9/13/11 revealed failure to include treatment interventions/modalities based on the patient's level of cognitive functioning; there was a failure to address the inability of Patient B10 to participate in or benefit from group therapy or programming activities. No revisions were documented on the plan to include treatment interventions/modalities based on his/her decreased level of cognitive functioning.

C. Patient B14

1. Patient B14 was admitted to the facility on 5/12/05. The Annual Psychiatric Evaluation dated 5/12/11 stated that the diagnoses included "Vascular Dementia," "Psychotic Disorder (Not Otherwise Specified)," and "Depressive Disorder (Not Otherwise Specified)." According to this evaluation, Patient B14 "is scheduled to attend the following Recovery Center groups Music & Relaxation, Creative Activities, Music & Sensory, and fitness for Fun....attendance has been good but...participation is poor except for Fitness for Fun group..."

2. During an observation of the "Spiritual" group on 9/12/11 from 1:25p.m. to 1:40p.m., Patient B14 was observed sitting in the group. During this period s/he did not interact with the group leader or other group members. During an interview with the leader of this group on 9/12/11 at 2:00p.m., s/he stated that Patient B14 did not interact during the Spiritual group. S/he stated that Patient B14 always responded "yes" to attempts to verbally engage Patient B14 in the group. The group leader stated that s/he had attempted to engage Patient B14 previously but was unsuccessful. S/he agreed that Patient B14 did not appear to understand verbal interactions with the group leader.

3. During an interview on 9/13/11 at 11:45a.m., Treatment Team Coordinator 2 stated that Patient B14 spoke Haitian French Creole. S/he stated that there was a staff member who had translated for Patient B14 in the past but the last time was "about two months ago." S/he agreed that the majority of the groups offered were English language-based and that Patient B14 responded "minimally" in the groups.

4. A review of the master treatment plan for Patient B14 dated 8/11/11 revealed that, as of 9/13/11, there was a failure to address the inability of Patient B14 to participate in or benefit from group therapy or programming activities and a failure to address this patient's language barrier and need for an interpreter. No revisions were documented on the plan to include treatment interventions/modalities based on the inability of Patient B14 to benefit from the documented interventions.

D. Patient B24

1. Patient B24 was admitted to the facility on 6/22/98. The Annual Psychiatric Evaluation for Patient B24 dated 5/13/11 stated that his/her diagnoses included "Schizophrenic, Paranoid Type." According to this evaluation, Patient B24's "scheduled groups and activities at the Recovery Center include Activity Therapy, Cognitive Skills, Relaxation & Leisure, General Leisure, and the Forensic Group."

2. During an interview on 9/12/11 at 1:00p.m., RN B1 stated that this patient was religiously preoccupied and had a delusion that God talks to him/her. S/he reported that Patient B24 "sometimes refuses to go to the Recovery Program and does absolutely nothing. On these days [B24] stays in the ward lobby (dayroom)."

3. During observations on Ward W1 on 9/12/11 at 1:25p.m., Patient B24 was observed quietly sitting in a corner of the dayroom with seven other patients. A mental health technician was sitting outside the door. During an interview at that time, Patient B24 stated "I sit in this room most of the time. I read my Bible."

4. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 stated that Patient B24 "has refused to go to all groups recently."

5. A review of the master treatment plan for Patient B24, updated 6/23/11, revealed that, as of 9/13/11, there was a failure to address the lack of attendance to the prescribed group therapies. No revisions were documented on the plan to include treatment interventions/modalities based on his/her lack of attendance.

II. Master treatment plans developed without all required discipline assessments completed:

A review of the Comprehensive Psychosocial History for Patient A32 indicated that the date of completion for this assessment was 8/12/11. A review of the Master Treatment Plan for Patient A32 indicated that the Master Treatment Plan was completed on 8/10/11, two days prior to the completion of the psychosocial assessment.

Based on record review and interview, the facility failed to develop master treatment plans that identified nursing and social work interventions to address the specific treatment needs of 7 of 8 active sample patients (A1, A30, A32, A35, B10, B15, and B24). Many of the nursing interventions were routine, generic nursing functions.

In addition, for 6 of 8 active sample patients (A1, A30, A35, B10, B15 and B24), social work interventions were generic, role functions. The absence of individualized interventions on master treatment plans hampers staff's ability to provide individualized care to patients.

Findings include:

A. Nursing Interventions

1. Patient A1 (master treatment plan revision dated 7/13/11):

For problem, "Psychosis-poor insight/anti-social/non-compliance/aggressive," a generic nursing intervention was listed as "Administer medications as ordered, monitoring for effectiveness." The interventions delegated to the mental health technicians were generic without specifics documented as "Encourage (patient) to take his medications, complete ADLs, and comply with ward routine. Approach (patient) in a friendly manner and explain procedures prior to attempting them."

2. Patient A30 (master treatment plan revision dated 7/6/11):

For problem, "Cognitive Deficit/Mental Retardation/Disorganized thoughts/hallucinations," generic nursing interventions were documented as, "Assess (patient) for needs, ability to perform ADLs, and to make needs known. Administer medications as ordered, monitoring for effectiveness." An inappropriate delegation to mental health technicians was stated as "Assess (patient for needs, ability to perform ADLs and to make needs known, rather than given technicians directions for care,"

3. Patient A32 (master treatment plan revision dated 8/10/11):

For problem, "Dementia," a generic intervention was stated as "Administer medications as ordered, monitoring for effectiveness." There were no specific interventions to address this patient's confusion and impaired memory.

4. Patient A35 (master treatment plan revision dated 7/13/11):

For problem, "Delusions/Hallucinations," generic nursing interventions were stated as "Administer medications as ordered, monitoring for effectiveness. Document inappropriate behaviors including interventions and outcomes."

5. Patient B10 (master treatment plan revision dated 8/11/11):

a. For problem, Schizophrenia causing alteration in thought processes, a generic nursing intervention was listed as "Administer psychotherapeutic medications as ordered by (doctor)." Patient B24 had severe dementia and did not speak English and was unable to attend most groups (especially process oriented groups and without an interpreter). An intervention delegated to the mental health technicians was "Encourage participation in R.C. [Recovery Center] and on-unit enrichment activities." There were no specific directions for the technicians to provide care to Patient B10 even though this patient remained in bed or wandered the halls. There were no interventions in B10's master treatment plan to direct technicians to relate to this patient even though s/he was not fluent in English.

b. For problem, "Dementia NOS causing confusion, socially inappropriate behavior, and inability to care for self," a general nursing intervention was "Administer psychotherapeutic medications per order of (doctor)." A nursing intervention delegated to the technicians without specific directions was "Maintain a stable, consistent environment to help (patient) achieve optimal functioning." There were no specific interventions to address this patient's confusion and impaired memory.

6. Patient B15 (master treatment plan revision dated 8/11/11):

For problem, "Paranoia, Hallucinations," a generic nursing intervention was listed as "Administer psychotherapeutic meds [medications] per order of (doctor)." A nursing intervention delegated to the technicians without specific directions was "Maintain a stable, consistent environment to help (patient) achieve optimal functioning."

7. Patient B24 (master treatment plan revision dated 6/13/11):

For problem, "Delusional ideation," a generic nursing intervention was listed as "Administer psychotherapeutic medication per order of (doctor)." A nursing intervention delegated to mental health technicians was listed as "Counsel (patient) as to alternate, pro-social responses." Specific direction to the technicians was not identified.
Another intervention delegated to the mental health technicians was "Encourage participation in R.C. [Recovery Center] and on-unit enrichment activities." Patient B24 was acutely psychotic and unable to attend most groups (especially process oriented groups). There were no specific directions for the technicians as to how to respond to this patient frequently talking about his/her delusions, nor what to do with him/her on a 1:1 level, since s/he was not attending the treatment programs.

8. During an interview with the Director of Nursing on 9/13/11 at 3:15p.m., s/he acknowledged that the nursing interventions on the treatment plans were generic nursing functions.

B. Social Work Interventions:

1. Patients A1 (master treatment plan review dated 7/13/11) and A30 (master treatment plan review dated 7/6/11):

For the problem of "Placement," the same generic interventions were listed as follows: "Monitor and assess level of (patient's) functioning and behavior for future discharge potential especially regarding discharge barrier(s). Maintain contact with the family, guardian or guardian advocate; provide updates regarding treatment and progress towards discharge. Be available to provide updates to community liaision (sic) or case managers. When approved for discharge, the treatment coordinator will complete with assistance of the treatment team, the 7001 form. After completion submit to the social services department for processing. Social worker will submit request for med pack to unit clerk. The discharge planner and community contact will make discharge arrangements with involvement from the resident, family, guardian or guardian advocate."

2. Patient A35 (master treatment plan review dated 7/13/11):

For the problem of "Placement," generic interventions were listed as follows "Monitor and assess level of functioning and behavior for future discharge potential. Maintain contact with the family, guardian or guardian advocate to provide updates regarding treatment progress. Be available to provide updates to community liaisons or case managers. SW [social worker] will work closely with discharge planner, family and community liaisons in an effort to find best possible placement."

3. Patient B10 (master treatment plan review dated 6/11/11) and B15 (master treatment plan review dated 7/14/11):

For the problem of "Placement," generic interventions were listed as follows "Observe and assess for level of functioning. Continue to engage in a dialogue-problem solving. Provide updates to the treatment team. Provide updates to the Community Liaison. Provide updates to the Social Services Dept. Discharge Unit. The Discharge Unit, in conjunction with the unit Social Worker and Case Manager Community Liaison, to make discharge arrangements as per the aftercare plan. Involve family in the discharge planning process for their input and decisions."

4. Patient B24 (master treatment plan review dated 6/23/11):

For the problem of "Appropriate transition to the community-Placement," generic interventions were listed as follows: "Continue to monitor and assess for current level of functioning and behavior. Continue to facilitate involvement of family updating them on [Patient B24's] progress and treatment. Continue to be available to the community liaison for updates. When approved by the psychiatrist and treatment team, the team coordinator will schedule the discharge planning meeting to place [Patient B24] on discharge ready status. Then the Discharge Unit social worker and community liaison will make discharge arrangements as detailed on the Aftercare Plan."

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

I. Ensure necessary interpreter services for 2 of 8 active sample patients (B10 and B14) who were not proficient in the English language. This failure compromised the patients' ability to understand and participate in treatment.

II. Ensure the provision of alternative treatment modalities for the specialized needs for 2 of 8 active sample patients (A32 and B24) in order to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement.

III. Ensure that 4 of 8 active sample patients (A30, A35, B10 and B14) who had reached their maximum level of treatment were discharged. This practice results in patients being retained in the facility who were not receiving treatment based on their treatment needs.

IV. Ensure patients were provided needed therapeutic programs and interventions during evening hours and weekends. A review of the schedule of programming for patients revealed that the facility failed to provide active therapeutic programs for patients by licensed/certified professional staff other than in the Recovery Center (Monday through Friday from 9:00a.m. to 3:15p.m.). All other scheduled activities were leisure oriented and conducted by untrained staff without professional supervision. This practice results in delay of improvement in patients' condition and prolongs hospitalization.

Findings include:

I. Failure to ensure necessary interpreter services:

A. Patient Findings

1. Patient B10 was a 72 year old patient admitted to the facility on 11/14/02. The current diagnoses were "Schizophrenia Disorder" and "Dementia (not otherwise specified)."

a. As documented on Patient B10's medical record face sheet (revised 9/8/11), "Fluent Language: Spanish."

b. As documented in the psychiatric evaluation (10/15/10), Patient B10 was "withdrawn from groups (Recovery Center) in March 2010." This document added, "...[B10] will continue to be encouraged to attend the Recovery Center groups when [B10]is lucid."

c. The comprehensive Psychosocial History (12/2/02) stated, "does not speak English and requires an interpreter when assessing...would benefit from therapy either group or individual with a Spanish speaking staff."

d. During rounds on 9/12/11 at 1:20p.m., Patient B10 was observed in his/her assigned room asleep under the bedcovers in the dark. At this time s/he turned half way over in bed when approached, but failed to respond to verbal engagement. RN B1 stated that Patient B10 did not understand the surveyor's questions. During an interview with MHT A1 on 9/12/11 at 2:10p.m., s/he stated that Patient B10 was allowed to remain in his/her bed during the day because Patient B10 entered other patients' rooms when not in his/her own room.

e. During an interview on 9/12/11 at 12:45p.m., RN B1 stated that Patient B10 was "non-English speaking. Mostly s/he spends the day in bed, or wanders around and can't keep still. At one time s/he had an interpreter who spent time with him/her. S/he was not receptive and has not had an interpreter for awhile. An interpreter (hospital staff member) is present once a month for the treatment team meeting." S/he reported that if an interpreter was needed, a staff member was called to come to the ward, or staff talked to the interpreter by telephone. When asked if Patient B10 could let the staff know what s/he needed, s/he replied, "Sometimes (s/he) can, other times (s/he) does not even respond to questions." "There is a problem with placement. (S/he) is hard to place because (s/he) cannot speak English. S/he is ready to go if we could find a placement."

f. During an interview on 9/13/11 at 10:20a.m., the Mental Health Technician Behavior Analyst stated that Patient B10 had attended some groups but usually walked out of group and "wanders around." The Mental Health Technician Behavior Analyst added, "But, I don't speak Spanish."

g. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 stated, "(Patient B10) gets no benefit out of almost any interaction. (S/he) constantly wanders." When asked if an interpreter had worked with Patient B10, (s/he) reported that s/he did not know that an interpreter "ever worked with (him/her)."

h. During an interview on 9/13/11 at 12:00p.m., SW B3 stated, "(Patient B10) is not scheduled for any groups. I don't think (s/he) understands much at all." SW B3 reported that s/he had asked Patient B10 to sign a consent form for eye surgery and the patient refused. S/he then added, "We then called for an interpreter." When asked if the patient understood what s/he was being asked to sign, SW B3 replied, "I'm not 100 per cent sure that (s/he) understood."

i. There was no evidence that qualified language interpreters had been provided during Patient B10's hospitalization.

2. Patient B14 was a 72 year old patient who was admitted on May 12, 2005 with diagnoses of "Vascular dementia," "Psychotic Disorder (not otherwise specified)," and "Depressive disorder (not otherwise specified)."

a. As documented on the medical record face sheet for Patient B14 (revised 9/8/11), "Fluent Language: Creole."

b. During an observation of the "Spiritual" group on 9/12/11 from 1:25p.m. to 1:40p.m., Patient B14 was observed sitting in the group. During this period s/he did not interact with the group leader or other group members. During an interview with the leader of this group on 9/12/11 at 2:00p.m., s/he stated that Patient B14 did not interact during the Spiritual group. S/he stated that Patient B14 always responded "yes" to attempts to verbally engage him/her in the group. The group leader stated that s/he had attempted to engage Patient B14 previously but was unsuccessful. S/he agreed that Patient B14 did not appear to understand verbal interactions with the group leader.

c. During an interview on 9/13/11 at 11:45a.m., Treatment Team Coordinator 2 stated that Patient B14 spoke Haitian French Creole. S/he stated that there was a staff member who had translated for Patient B14 in the past but the last time was "about two months ago." S/he agreed that the majority of the groups offered were English language-based and that Patient B14 responded "minimally" in the groups.

d. A review of the Annual Psychiatric Assessment dated 4/6/11 stated the "Problem List and Challenges" as "1. Language barrier."

e. A review of the Annual Nursing Assessment for Patient B14 dated 4/20/11 stated "Primary Language Spoken: French Creole...Individual's Treatment Preferences.. .: refused to participate r/t [related to] language barrier. Individual's Discharge Plan/Aftercare Expectations (In their words): unable to determine r/t language. Hx [history] of Suicidal/Homicidal Ideation/Gesture:...Unable to converse - language barrier. Medication Education:...language barrier. Speech: language barrier. Reviewed Findings and Discussed Plan of Care with Individual: Attempted Indiv [individual] [with] limited language understanding. Summary of Individual's Input Regarding Findings and Plan of Care: Cont [continue] [with] current POC [plan of care] indiv [individual] had no input - language barrier."

f. A review of the Annual Psychosocial Addendum for Patient B14 dated 5/9/11 stated "Her [Patient B14] communication is poor due to her language barrier."

g. There was no evidence that qualified language interpreters had been provided during Patient B14's hospitalization even though this patient understood little or no English.

B. Policy Review:

Policy: The policy guiding services by this facility was titled "Operating Procedure No.60-10," Chapter 3 (dated 6/1/10) "Auxiliary aids and services plan for persons with disabilities and persons with limited-English proficiency." This policy states, "...will provide at no cost...qualified foreign-language interpreter to persons with Limited-English Proficiency (LEP) where necessary to afford such persons an equal opportunity to participate in or benefit from the Department of Children and Families' programs and services."

II. Failure to provide active individualized treatment measures and care based on assessed needs:

A. Patient A32

1. Patient A32 was admitted to the facility on 8/3/11. The Psychiatric Evaluation for Patient A32 dated 8/4/11 stated that his/her diagnoses included "Dementia (not otherwise specified)" and "History of Antisocial Acts." He was admitted on "forensic status, Incompetent to Proceed." Findings on the Psychiatric Evaluation included disorientation to place, time, and date. The Psychosocial Assessment dated 8/12/11 stated that Patient A32 was "suffering from cognitive decline, memory deficits, impaired capacity to care for himself and gross impairment of judgment. He has difficulty understanding and responding to questions."

2. A review of the master treatment plan dated 8/10/11, revealed that for the problem of "Dementia-NOS/Major Depressive Disorder/History of anti-social acts," Patient A32 was scheduled for the following therapy groups Monday through Friday: "Social Skills group," "Anger/Stress Management group," "Spiritual Issues group," and "General Leisure group."

3. A review of the "Rehabilitation Service Monthly Summary" notes for Patient A32 from 8/8/11 to 8/26/11 indicated that he attended only 1 of 13 scheduled therapeutic groups during this time.

4. During an interview on 9/13/11 at 9:00a.m. with MD 1, s/he stated that Patient A32 did not usually attend group therapies. He agreed that Patient A32 was offered no active psychiatric treatment other than group therapy and medication. S/he acknowledged that Patient A32 had displayed minimal improvement since admission. S/he agreed that Patient A32 appeared unlikely to respond to group therapies.

5. During an interview on 9/13/11 at 12:00 noon with SW A3, s/he stated that s/he was unaware of any alternative treatments provided for Patient A32 when s/he did not attend prescribed group therapy. S/he acknowledged that Patient A32 had displayed minimal improvement since admission and that the master treatment plan had not been revised to address the lack of response to the documented interventions.

6. During an interview on 9/13/11 at 11:20a.m. with Treatment Team Coordinator 1, s/he stated that Patient A32 "refuses group." S/he stated that Patient A32 "has nothing to learn from groups." S/he acknowledged that Patient A32 was offered no active psychiatric treatment other than group therapy.

7. Even though Patient A32 did not attend most of his/her scheduled treatment groups, there was no documented evidence that alternative treatment was provided for Patient A32.

B. Patient B24

1. Patient B24 was admitted to the facility on 6/22/98 with a diagnosis of "Schizophrenic, Paranoid Type." According to the Annual Psychiatric Evaluation dated 5/13/11, Patient B24's "scheduled groups and activities at the Recovery Center include Activity Therapy, Cognitive Skills, Relaxation & Leisure, General Leisure, and the Forensic Group."

2. During an interview on 9/12/11 at 1:00p.m., RN B1 stated that Patient B24 was religiously preoccupied and had a delusion that God talks to her. S/he reported that Patient B24 "sometimes refuses to go to the Recovery Program and does absolutely nothing. On these days (s/he) stays in the ward lobby (dayroom). The (mental health technician) stays with them (patients) in case they need something, but does not do anything with them."

3. During observations on Ward W1 on 9/12/11 at 1:25p.m., Patient B24 was observed quietly sitting in a corner of the dayroom with seven other patients. A mental health technician was sitting outside the door. During an interview at this time, Patient B24 stated, "God tells me not to go to the Recovery Center." When asked when s/he last went to the recovery programs, s/he replied, "It's been a long time. I sit in this room most of the time. I read my bible."

4. During an interview on 9/13/11 at 10:20a.m., the Mental Health Technician Behavior Analyst stated that s/he sometimes met with Patient B24 to "try to get her to come back to the recovery mall." When asked if s/he does any other work with this patient, s/he replied "No."

5. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 stated that Patient B24 "has refused to go to all groups recently."

6. During an interview on 9/13/11 at 12:00p.m., when asked if alternative treatment approaches have been used with Patient B24 since s/he had refused groups, SW B3 responded "No, but we encourage [B24] to go to groups."

7. A review of the master treatment plan for Patient B24, dated 6/23/11, revealed assignment of groups in the Recovery Center even though his/her illness had prevented attendance in this type of treatment.



III. Failure to discharge in a timely manner:

A. Patient A30 was a 54 year old patient admitted to the facility on 4/6/81. The diagnoses for Patient A30 were "Schizophrenia, Undifferentiated Type" and "Cognitive Deficit due to suspected moderate mental retardation."

1. As documented in the Annual Psychiatric Evaluation dated 2/7/11, Patient A30 had been treated previously with several medications and was currently prescribed Lexapro and Clozapine. The evaluation documented the following: "we believe that [A30] has auditory hallucinations although [A30] will not or would not answer the questions."

2. During an interview with the Director of Social Work and MD1 on 9/13/11 at 9:00a.m., the Director of Social Work stated that the "Discharge Status List" was a list of patients who were felt to be ready for discharge. S/he stated that if the treatment team and psychiatrist for the patient believed that the patient could function in a less restrictive environment, the patient's name was placed on the "Discharge Status List" and they "start looking for an appropriate placement." A review of the facility "Discharge Status List" revealed that Patient A30 had been on this list since 4/6/11.

3. During an interview on 9/13/11 at 9:10a.m., MD1 stated that Patient A30 "has been here a long time. We have worked with [A30] on his medications. [A30] has received maximum benefit from this hospital. We have pursued a group home placement and are now looking at a nursing home placement."

4. During an interview on 9/13/11 at 12:15p.m., SW A3 stated that Patient A30 had been on the "Discharge Status List" since 4/6/11. S/he stated that s/he thought that this patient was ready for discharge.

5. During an interview on 9/13/11 at 1:45p.m., RN A5 stated that Patient A30 was ready for discharge if it was to "a safe placement."

B. Patient A35 was an 83 year old patient admitted to the facility on 4/18/89. The diagnoses for Patient A35 included "Schizophrenia, Paranoid Type" and "Alcohol-induced persistent dementia."

1. As documented in the Annual Psychiatric Evaluation (1/25/11), Patient A35 had been treated over the years with multiple psychotropic medication trials, most recently Geodon. This evaluation stated, "at this point, he does not seem to be experiencing a lessening or improvement of his symptoms."

2. During an interview with MD 1 on 9/13/11 at 9:00a.m., s/he stated that Patient A35 had a dementia but that it was stable and not progressive. S/he stated that Patient A35 also had a history of pedophilia. MD 1 stated that Patient A35's needs were "security and supervision" and that Patient A35 had "met the maximum benefit of hospitalization." S/he stated that Patient A35 could function in a nursing home setting but that s/he was "too healthy" to qualify for a nursing home.

3. During an interview with Treatment Team Coordinator 1 on 9/13/11 at 11:30a.m., Treatment Team Coordinator 1 stated that Patient A35 was "stable to go to an outside facility if not for his/her pedophilia" and that Patient A35 was "very stable" psychiatrically.

4. During an interview on 9/13/11 at 12:00 noon, SW A3 agreed that Patient A35 had received his/her maximum benefit from hospitalization and that a community placement was needed at that time.

C. Patient B10 was a 72 year old patient admitted to the facility on 11/14/02. The current diagnoses were "Schizophrenia Disorder" and "Dementia (not otherwise specified)."

1. As documented in the Annual Psychiatric Evaluation (10/15/10), Patient B10 "has been on Discharge Status for the last four years but has not been able to be discharged due to (his/her) immigration status. S/he does not have aggression or agitation and can be well taking (sic) care of in a nursing home but at this time due to (his/her) immigration status, it is impossible to discharge (him/her)."

2. As documented in the Annual Psychosocial Addendum (10/22/10), Patient B10 had a diagnosis of Dementia and presented with confusion and wandering the halls. "(S/he) remains confused for the most part...(S/he) no longer attends the Recovery Center due to dementia..."

3. During an interview with the Director of Social Work and MD 1 on 9/13/11 at 9:00a.m., the Director of Social Work stated that Patient B10 did not have behaviors that would prevent his/her from being discharged. S/he stated that Patient B10 could not be discharged to a nursing home because of his/her immigrant status. MD1 stated that Patient B10's behavior is not preventing (him/her) from going (being discharged)."

4. During an interview on 9/13/11 at 10:55a.m. SW 10 reported that his/her role was to work on resolving immigration problems for this patient so that s/he would be eligible for financial benefits for placement outside the hospital. SW 10 reported that Patient B10 had been referred to him/her in July 2010.

5. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 stated, "[Patient B10's] main issue is dementia. (S/he) gets no benefit out of almost any interaction. I do not even get a response. (S/he) is on Discharge Status. (S/he) could go if we could find a placement."

D. Patient B14 was a 72 year old patient admitted to the facility on 5/12/05. The diagnoses were "Vascular dementia," "Psychotic Disorder (not otherwise specified)," and "Depressive disorder (not otherwise specified)."

1. The Annual Psychiatric Evaluation (4/6/11) for Patient B14 stated "[B14] has no major behavioral problems except for refusing to drink and not eating well. [B14] has been on Discharge Status for nursing home placement for several years but due to (his/her) immigration status (s/he) has not been able to be discharged." Patient B14 "will be continued on (his/her) current medications which have kept (him/her) somewhat stable....In my clinical opinion, this patient has sufficiently improved to be placed on Discharge Status to a total care facility. However, because of (his/her) immigration status, appropriate community disposition has been has been hindered."

2. The Annual Psychosocial Addendum dated 5/9/11 stated that Patient B14 "has zero discharge barriers, besides his/her immigration problems. (His/Her) behavior is stable. (S/he) is compliant with (his/her) treatment and medication...Discharge discussed monthly. [Patient B14] remains on Discharge Status. Upon discharge resident would require a Nursing Home. Barriers to discharge include: immigration problems."

3. The most recent review of the master treatment plan dated 8/11/11 stated that Patient B14 "remains essentially stable. (His/Her) immigration status remains (his/her) main barrier to discharge."

4. A review of the facility "Discharge Status List" revealed that Patient B14 had been on "Discharge Status" since 6/13/06.

5. During an interview with MD 1 on 9/13/11 at 9:00a.m., s/he stated that Patient B14 was behaviorally stable and that his/her behaviors would not prevent him/her from being treated in a nursing home if one were available. S/he stated that Patient B14 did not have a source of funding for nursing home care because of his/her illegal immigrant status.

IV. Failure to provide therapeutic treatment during evenings and week-ends:

A. During an interview on 9/13/11 at 2:20p.m., the Director of Programming Services(certified recreational therapist) reported that s/he developed the schedule (all leisure oriented; not directed toward individualized treatment) for groups/activities to be held on the wards after Recovery Center hours and on weekends. S/he stated that these activities were conducted by unlicensed mental health technicians. S/he stated that the supervision for these workers was provided by the mental health technician supervisors and not by nurses or other licensed clinical staff.

B. A review of the evening and week-end activity calendar for Wards M1 and W1 revealed that all programming activities were leisure-oriented groups such as Current Events and Reminiscing, and were not therapeutically oriented..

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

I. Ensure that the master treatment plans for 4 of 8 sample patients (A32, B10, B14, and B24) were revised based on the presenting needs of the patients. These patients displayed cognitive limitations, psychosis, and/or language limitations that prevented participation in the prescribed treatment. The only psychiatric treatments prescribed on the master treatment plans for these patients, other than medications, were group therapy sessions. These patients were incapable of benefiting from these groups and these master treatment plans were not revised to include modalities from which these patients could benefit. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients. (Refer to B118)

II. Ensure necessary interpreter services for 2 of 8 active sample patients (B10 and B14) who were not proficient in the English language. This failure compromised the patients' ability to understand and participate in treatment. (Refer to B125 Part I)

III. Ensure the provision of alternative treatment modalities for the specialized needs for 2 of 8 active sample patients (A32 and B24) in order to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125 Part II)

IV. Ensure that 4 of 8 active sample patients (A30, A35, B10 and B14) who had reached their maximum level of treatment were discharged. This practice results in patients being retained in the facility who were not receiving treatment based on their treatment needs.
(Refer to B125 Part III)

V. Ensure patients were provided needed therapeutic programs and interventions during evening hours and weekends. A review of the schedule of programming for patients revealed that the facility failed to provide active therapeutic programs for patients by licensed/certified professional staff other than in the Recovery Center (Monday through Friday from 9:00a.m. to 3:15p.m.). All other scheduled activities were leisure oriented and conducted by untrained staff without professional supervision. This practice results in delay of improvement in patients' condition and prolongs hospitalization. (Refer to B125 IV)

Based on observation, interview and record review, it was determined that the Director of Nursing failed to:

I. Ensure that registered nurses were given the responsibility and authority for the delegation and supervision of patient care provided by unlicensed Human Service Workers/Certified Nursing Assistants (mental health technicians). All nursing care functions provided by these technicians for patients in 2 of 2 wards (M1 and W1) were delegated and supervised by mental health technician supervisors. These technician supervisors reported to the Unit Treatment Rehabilitation Director who was not a registered nurse. The technician staff made patient assessments (physical, emotional and behavioral) and provided behavioral/psychiatric care as to the patients without direction and supervision from a registered nurse. The mental health technicians (including supervisors) and the Unit Treatment Rehabilitation Director do not have the education and licensure in nursing to make nursing assessments or to direct and supervise nursing care. This failure resulted in lack of authority for the quality of nursing care by the Department of Nursing and potential harm to patients.

Findings include:

A. Interviews:

1. During an interview on 9/12/11 at 12:45p.m., RN B1 reported that the Unit treatment Rehabilitation Director (not a registered nurse) was "over [supervised] the mental health technicians." S/he stated "I have no control over these workers, I tell the lead worker what I need and they assign the (technician). No (technicians) report to the RN (registered nurse). If a (technician) refuses an assignment, I would talk to the supervisor (MHT Supervisor I)." S/he added, "All assignments (patient care) are made by the supervisors (technicians)." When asked if s/he was able to assign the technicians based on their individual skills and the needs of the patients, s/he responded, "No." S/he added, "The lead (technician) decides who is assigned to watch patients who are on close supervision."

2. During an interview on 9/12/11 at 2:00p.m., MHT B2 stated that s/he reports to a registered nurse when a patient was physically ill; otherwise, s/he reports to the technician supervisor.

3. During an interview on 9/12/11 at 3:20p.m., MHT B3 reported that all patient assignments were made by the Technician Supervisor I for Wards M1 and W1. S/he reported that the only time a mental health technician (MHT) reported to a registered nurse (RN) was when a "medical issue is involved." S/he stated, "Combined care (patient) is given by the RN and (mental health technicians). The RN for medical issues and the (mental health technician) for patients personal needs."

4. During an interview on 9/12/11 at 3:20p.m., MHT B4 reported that s/he reports to the Unit Treatment Rehabilitation Director through the Mental Health Technician Supervisor II. When asked about his/her relationship to the RN on duty, MHT B4 replied, "We are co-workers. I assist her in anything needed with medical treatment, [such] as getting urine specimens." MHT B4 stated that s/he made patient assignment based on the patient's needs and the mental health technician's skills, stating, "The RN may make a suggestion about assignment of staff to patients. We discuss the pros and cons. I go to my supervisor (Unit Treatment Rehabilitation Director) if needed."

5. During an interview on 9/12/11 at 3:45p.m., the Unit Treatment Rehabilitation Director for Wards M1 and W1 reported that s/he supervises the mental health technicians for these two wards.

6. During an interview on 9/13/11 at 1:45p.m., RN A5 described the duties of the RN as the administration of medications and treatments and the duties of the mental health technicians as "taking care of the patients and making patient assignments." RN A5 stated that s/he communicated to the Mental Health Technician Supervisor (MHTS) what direct patient care was needed. The MHTS then supervised the mental health technician staff in providing the direct patient care and supervision of patients. RN A5 stated that if there were a problem concerning patient care, s/he had no direct supervisory authority over the mental health technicians and would have to go to the mental health technician supervisor to inform him/her of the problem.

7. During an interview on 9/13/11 at 3:15p.m., the Director of Nursing (DON) stated that the RNs gave the nursing care assignments to the mental health technician supervisor who made the patient assignments to the individual technicians. The DON stated agreement that although the RN staff had the responsibility, non-licensed personnel had the authority for assignment and implementation of nursing care and the supervision of patients. The DON verified that mental health technicians reported out of the organizational line of nursing to the Unit Treatment Rehabilitation Director. Upon review of the "Shift Weekly Progress Note" form, the DON agreed that the mental health technicians were making patient assessments rather than reporting observations. These assessments of behavior included "suicidal behavior, sexual acting out, responding to internal stimuli, anxious, delusional statements, conceptual disorganization."

B. Policy Review:

Policy: "Operating Procedure No. 155-5" (dated 11/15/10) "Supervision of unlicensed assistive personnel performing nursing delegated tasks and activities in mental health treatment facilities," states "The assignment of a selected task or activity to a trained and competent UAP (unlicensed assistive personnel) by a nurse qualified (sic) by licensure and experience to perform the task or activity. UAPs provide resident care services through direct assignments and delegated tasks or activities under the supervision of a nurse. The nurse shall verify the training and validate the competency of the UAP prior to assigning tasks or activities. The nurse shall communicate the assignment to the UAP and verify the UAP's understanding of the assignment."

The facility failed to follow the above policy including the delegation and supervision of tasks to meet the psychiatric and behavioral needs of the patients.

II. Ensure that the master treatment plans for 4 of 8 sample patients (A32, B10, B14, and B24) were revised based on the presenting needs of the patients. These patients displayed cognitive limitations, psychosis, and/or language limitations that prevented participation in the prescribed treatment. The only psychiatric treatments prescribed on the master treatment plans for these patients, other than medications, were group therapy sessions. These patients were incapable of benefiting from these groups and these master treatment plans were not revised to include modalities from which these patients could benefit. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients

Findings include:

A. Patient A32

1. Patient A32 was admitted to the facility on 8/3/11. The Psychiatric Evaluation for Patient A32 dated 8/4/11 stated that his/her diagnoses included "Dementia (not otherwise specified)" and "History of Antisocial Acts." Findings on the Psychiatric Evaluation included disorientation to place, time, and date.

2. According to the master treatment plan dated 8/10/11, for the problem of "Dementia-NOS/Major Depressive Disorder/History of anti-social acts, Patient A32 was scheduled for the following therapy groups each weekday: "Social Skills group," "Anger/Stress Management group," "Spiritual Issues group," and "General Leisure group".

3. A review of the "Rehabilitation Service Monthly Summary" notes for Patient A32 from 8/8/11 to 8/26/11 showed that [A32] attended only 1 of 13 scheduled therapeutic groups during this time.

4. Further review of the master treatment plan for Patient A32 dated 8/10/11 revealed that, as of 9/13/11, there was a failure to address the inability of Patient A32 to participate in or benefit from group therapy or programming activities. No revisions were documented on the plan to include treatment interventions/modalities based on his/her decreased level of cognitive functioning.

5. During an interview on 9/13/11 at 11:20a.m. with Treatment Team Coordinator 1 (RN), s/he stated that Patient A32 "refuses group." S/he stated that Patient A32 "has nothing to learn from groups." S/he acknowledged that Patient A32 was offered no active psychiatric treatment other than group therapy and that the master treatment plan had not been revised to address the lack of response to the documented interventions.


B. Patient B10

1. Patient B10 was admitted to the facility on 11/14/02. The face sheet documented the primary language as Spanish. The annual psychiatric evaluation dated 10/15/10 stated that his/her diagnoses included "Schizophrenia Disorder" and "Dementia (not otherwise specified)." This evaluation stated that the psychiatrist was unable to evaluate memory, ability to calculate, ability to abstract or intelligence for Patient B10.

2. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 (RN) stated, "[Patient B10's] main issue is dementia. [B10] gets no benefit out of almost any interaction. I do not even get a response."

3. According to the Recreational Therapy monthly progress notes from April through August, 2011, the only activity offered to Patient B10 was an "Enrichment Program" which consisted of going outside the building to sit or walk in the yard.

4. According to the master treatment plan, revised 8/11/11, one of the interventions for the problems, "Schizophrenia" and "Dementia", was "Encourage participation in R.C. (Recovery Center) and on-unit enrichment activities". A review of the "Rehabilitation Service Monthly Summary" notes for Patient B10 from 8/8/11 to 8/26/11 indicated that s/he attended only 1 of 13 scheduled therapeutic groups during that time.

5. Further review of Patient B10's master treatment plan on 9/13/11 revealed failure to include treatment interventions/modalities based on the patient's level of cognitive functioning; there was a failure to address the inability of Patient B10 to participate in or benefit from group therapy or programming activities. No revisions were documented on the plan to include treatment interventions/modalities based on his/her decreased level of cognitive functioning.

C. Patient B24

1. Patient B24 was admitted to the facility on 6/22/98. The Annual Psychiatric Evaluation for Patient B24 dated 5/13/11 stated that his/her diagnoses included "Schizophrenic, Paranoid Type." According to this evaluation, Patient B24's "scheduled groups and activities at the Recovery Center include Activity Therapy, Cognitive Skills, Relaxation & Leisure, General Leisure, and the Forensic Group."

2. During an interview on 9/12/11 at 1:00p.m., RN B1 stated that this patient was religiously preoccupied and had a delusion that God talks to her. S/he reported that Patient B24 "sometimes refuses to go to the Recovery Program and does absolutely nothing. On these days [B24] stays in the ward lobby (dayroom)."

3. During observations on Ward W1 on 9/12/11 at 1:25p.m., Patient B24 was observed quietly sitting in a corner of the dayroom with seven other patients. A mental health technician was sitting outside the door. During an interview at that time, Patient B24 stated "I sit in this room most of the time. I read my Bible."

4. During an interview on 9/13/11 at 11:20a.m., Treatment Team Coordinator 2 (RN) stated that Patient B24 "has refused to go to all groups recently."

5. A review of the master treatment plan for Patient B24, updated 6/23/11, revealed that, as of 9/13/11, there was a failure to address the lack of attendance to the prescribed group therapies. No revisions were documented on the plan to include treatment interventions/modalities based on his/her lack of attendance.

III. Develop master treatment plans that identified nursing interventions to address the specific treatment needs of 7 of 8 active sample patients (A1, A30, A32, A35, B10, B15, and B24). Many of the nursing interventions were routine, generic nursing functions. The absence of individualized nursing interventions on master treatment plans hampers staff's ability to provide individualized nursing care to patients.

Findings include:

A. Patient A1 (master treatment plan revision dated 7/13/11):

For problem, "Psychosis-poor insight/anti-social/non-compliance/aggressive," a generic nursing intervention was listed as " Administer medications as ordered, monitoring for effectiveness." The interventions delegated to the mental health technicians were generic without specifics documented as "Encourage (patient) to take medications, complete ADLs, and comply with ward routine. Approach (patient) in a friendly manner and explain procedures prior to attempting them."

2. Patient A30 (master treatment plan revision dated 7/6/11):

For problem, "Cognitive Deficit/Mental Retardation/Disorganized thoughts/hallucinations," generic nursing interventions were documented as, "Assess (patient) for needs, ability to perform ADLs, and to make needs known. Administer medications as ordered, monitoring for effectiveness." An inappropriate delegation to mental health technicians was stated as "Assess (patient for needs, ability to perform ADLs and to make needs known, rather than given technicians directions for care."

C. Patient A32 (master treatment plan revision dated 8/10/11):

For problem, "Dementia," a generic intervention was stated as "Administer medications as ordered, monitoring for effectiveness." There were no specific interventions to address this patient's confusion and impaired memory in the clinical area.

D. Patient A35 (master treatment plan revision dated 7/13/11):

For problem, "Delusions/Hallucinations," generic nursing interventions were stated as "Administer medications as ordered, monitoring for effectiveness. Document inappropriate behaviors including interventions and outcomes."

E. Patient B10 (master treatment plan revision dated 8/11/11):

1. For problem, Schizophrenia causing alteration in thought processes, a generic nursing intervention was listed as "Administer psychotherapeutic medications as ordered by (doctor)." An intervention delegated to the mental health technicians was "Encourage participation in R.C. [Recovery Center] and on-unit enrichment activities." Patient B24 had severe dementia and was non-English speaking and unable to attend most groups (especially process oriented groups and without an interpreter). There were no specific directions for the technicians to provide care to Patient B10 even though this patient remained in bed or wandered the halls. There were no interventions in B10's master treatment plan to direct technicians to relate to this patient even though s/he was non-fluent in English.

2. For problem, "Dementia NOS causing confusion, socially inappropriate behavior, and inability to care for self," a general nursing intervention was "Administer psychotherapeutic medications per order of (doctor)." A nursing intervention delegated to the technicians without specific directions was "Maintain a stable, consistent environment to help (patient) achieve optimal functioning." There were no specific interventions to address this patient's confusion and impaired memory in the clinical area.

F. Patient B15 (master treatment plan revision dated 8/11/11):

For problem, "Paranoia, Hallucinations," a generic nursing intervention was listed as "Administer psychotherapeutic meds [medications] per order of (doctor)." A nursing intervention delegated to the technicians without specific directions was "Maintain a stable, consistent environment to help (patient) achieve optimal functioning."

G. Patient B24 (master treatment plan revision dated 6/13/11):

For problem, "Delusional ideation," a generic nursing intervention was listed as "Administer psychotherapeutic medication per order of (doctor)." A nursing intervention delegated in the plan to mental health technicians was listed as "Counsel (patient) as to alternate, pro-social responses." Specific types of responses to give proper direction to the technicians were not identified. Another intervention delegated to the mental health technicians was "Encourage participation in R.C. [Recovery Center] and on-unit enrichment activities." Patient B24 was acutely psychotic and unable to attend most groups (especially process oriented groups). There were no specific directions for the technicians as to responding to this patient frequent talking about his/her delusions, nor what to do with him/her on a 1:1 level since s/he was not attending the treatment programs.

H. During an interview with the Director of Nursing on 9/13/11 at 3:15p.m., s/he acknowledged that the nursing interventions on the treatment plans were generic nursing functions.

1. Ensure that adequate active individualized treatment measures and care were provided to 2 of 8 active sample patients (A32 and B24) based on assessed needs in order to move the patient to a higher level of functioning and a less restrictive environment. The facility failed to provide alternative treatment modalities for the patients' specialized needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125, Part II)

2. Ensure that patients who were cognitively impaired received the treatment based on their level of functioning for 1 of 8 active sample patients (A32). Even though this patient presented confusion and impaired memory, he was assigned to attend treatment/groups that were designed and conducted for patients who were not cognitively impaired. This practice results in inappropriate treatment for patients with low cognitive functioning and results in patients being hospitalized without all interventions for recovery being provided and potentially delaying improvement. (Refer to B125, Part III)

V. Ensure patients were provided needed therapeutic programs and interventions during evening hours and weekends. A review of the patients' schedule of programming revealed that the facility failed to provide active therapeutic programs for the patients other than in the Recovery Center (Monday through Friday from 9:00a.m. to 3:15p.m.) by licensed clinical staff. All other scheduled activities were leisure oriented and conducted by untrained staff Human Service Workers (mental health technicians) without professional direction and supervision. This practice results in delay of improvement in patient's condition and prolongs hospitalization. (Refer to B125 IV)

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

I. Ensure the development of master treatment plans that identified social work interventions to address the specific treatment needs for 6 of 8 active sample patients (A1, A30, A35, B10, B15 and B24). Social work interventions were generic, role functions. The absence of individualized interventions on master treatment plans hampers staff's ability to provide individualized care to patients.

Findings include:

A. Patients A1 (master treatment plan review dated 7/13/11) and A30 (master treatment plan review dated 7/6/11):

For the problem of "Placement," the same generic interventions were listed as follows: "Monitor and assess level of (patient's) functioning and behavior for future discharge potential especially regarding discharge barrier(s). Maintain contact with the family, guardian or guardian advocate; provide updates regarding treatment and progress towards discharge. Be available to provide updates to community liaision (sic) or case managers. When approved for discharge, the treatment coordinator will complete with assistance of the treatment team, the 7001 form. After completion submit to the social services department for processing. Social worker will submit request for med pack to unit clerk. The discharge planner and community contact will make discharge arrangements with involvement from the resident, family, guardian or guardian advocate."

B. Patient A35 (master treatment plan review dated 7/13/11):

For the problem of "Placement," generic interventions were listed as follows "Monitor and assess level of functioning and behavior for future discharge potential. Maintain contact with the family, guardian or guardian advocate to provide updates regarding treatment progress. Be available to provide updates to community liaisons or case managers. SW [social worker] will work closely with discharge planner, family and community liaisons in an effort to find best possible placement."

C. Patient B10 (master treatment plan review dated 6/11/11) and B15 (master treatment plan review dated 7/14/11):

For the problem of "Placement," generic interventions were listed as follows "Observe and assess for level of functioning. Continue to engage in a dialogue-problem solving. Provide updates to the treatment team. Provide updates to the Community Liaison. Provide updates to the Social Services Dept. Discharge Unit. The Discharge Unit, in conjunction with the unit Social Worker and Case Manager Community Liaison, to make discharge arrangements as per the aftercare plan. Involve family in the discharge planning process for their input and decisions."

D. Patient B24 (master treatment plan review dated 6/23/11):

For the problem of "Appropriate transition to the community-Placement," generic interventions were listed as follows: "Continue to monitor and assess for current level of functioning and behavior. Continue to facilitate involvement of family updating them on her progress and treatment. Continue to be available to the community liaison for updates. When approved by the psychiatrist and treatment team, the team coordinator will schedule the discharge planning meeting to place [B24] on discharge ready status. Then the Discharge Unit social worker and community liaison will make discharge arrangements as detailed on the Aftercare Plan."

II. Ensure that the master treatment plan for 1 of 8 sample patients (A32) was based on a completed psychosocial assessment. (Refer to B118 Part II)

II. Monitor and evaluate the quality and appropriateness of discharge planning and aftercare arrangements for 8 out of 8 active sample patients (A1, A30, A32, A35, B10, B14, B15, and B24).

The findings include:

1. During an interview with the Admissions/Discharge Director on 9/13/11 at 3:45p.m., s/he stated that s/he supervised a "Discharge Coordinator" who attended treatment team meetings and developed discharge plans and arranged for aftercare for patients. S/he stated that these responsibilities were not supervised by the Director of Social work and that neither s/he nor the Discharge Coordinator possessed master's level social work training or comparable experience.

2. A review of the medical records for sample patients A1, A30, A32, A35, B10, B14, B15, and B24 failed to show that a master's level social worker was involved in overseeing the psychosocial discharge planning. Staff who were not social workers or supervised by the Director of Social Work performed discharge and aftercare planning.

3. During an interview with the Director of Social services on 9/13/11 at 2:45p.m., s/he stated that discharge planning was performed by non-social work staff in the "Admissions/Discharge Department" which was not associated with or supervised by the Social Work Department. S/he stated that social workers were not responsible for discharge planning or arranging aftercare. S/he stated that oversight of these duties was not provided by the Director of Social Services or a master's level social worker.

Based on interview and record review, the facility failed to ensure that social work staff participated in discharge planning, arranging for follow-up care, and developed mechanisms for exchange of appropriate information with sources outside the hospital for 8 out of 8 sample patients (A1, A30, A32, A35, B10, B14, B15, and B24) including 4 of 8 active sample patients (A30, A35, B10, and B14) who had reached their maximum level of treatment but were not discharged.

1. During an interview with the Admissions/Discharge Director on 9/13/11 at 3:45p.m., s/he stated that s/he supervised a "Discharge Coordinator" who attended treatment team meetings and developed discharge plans and arranged for aftercare for patients. S/he stated that these responsibilities were not supervised by the Director of Social work and that neither s/he nor the Discharge Coordinator possessed master's level social work training or comparable experience.

2. A review of the medical records for sample patients A1, A30, A32, A35, B10, B14, B15, and B24 failed to show that a master's level social worker was involved in overseeing the psychosocial discharge planning. Staff who were not social workers or supervised by the Director of Social Work performed discharge and aftercare planning.

3. During an interview with the Director of Social services on 9/13/11 at 2:45p.m., s/he stated that discharge planning was performed by non-social work staff in the "Admissions/Discharge Department" which was not associated with or supervised by the Social Work Department. S/he stated that social workers were not responsible for discharge planning or arranging aftercare. S/he stated that oversight of these duties was not provided by the Director of Social Services or a master's level social worker.

4. A review of the medical records and interviews with staff indicated that for 4 of 8 active sample patients (A30, A35, B10 and B14) who had reached their maximum level of treatment, discharge and aftercare planning was not being performed by social work staff. (Refer to B125 Part IV)