HospitalInspections.org

Based on interview, the governing board failed to ensure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate.

Findings include:

1. On 05-02-13 at 1430 hours, staff #42 confirmed that the medical staff did not have a written policy & procedure for appraisal of emergencies, initial treatment, and referral when appropriate.

Based on document review and interview, the facility failed to ensure that when restraint or seclusion is used that either is used in accordance with a written modification to the patient's plan of care for 4 of 6 restraint / seclusion medical records reviewed (Patient #5, 6, 7 and 8).

Findings include:

1. Review of policy/procedure Seclusion & Restraint Policy indicated the following:
"(4) The use of restraint or seclusion must be
(i) In accordance with a written modification to the patient's plan of care"
This policy/procedure was last reviewed/revised on 06-16-08.

2. Review of patient #5's MR indicated the patient was placed in restraint on 04-04-13 from 2125 hours to 2230 hours. The patient's MR lacked documentation that the patient's Safety Plan was reviewed with the patient after the restraint incident on 04-04-13.

3. Review of patient #6's MR indicated the patient was placed in restraint on 03-12-13 at 0925 hours. The patient's MR lacked documentation that the patient's Safety Plan was reviewed with the patient after the restraint incident on 03-12-13.

4. Review of patient #7's MR indicated the patient was placed in seclusion on 03-20-13 at 0410 hours. The patient's MR lacked documentation that the patient's Safety Plan was reviewed with the patient after the seclusion incident on 03-20-13.

5. Review of patient #8's MR indicated the patient was placed in restraint on 04-01-13 from 1815 hours to 1820 hours. The patient's MR lacked documentation that the patient's Safety Plan was reviewed with the patient after the restraint incident on 04-01-13.

6. On 05-01-13 at 1530 hours, staff #42 confirmed that after a patient is restrained or placed in seclusion, the staff are to review the Safety Plan with the patient and then the Treatment Team will review the Safety Plan at the next Treatment Plan review.

Based on interview, the facility failed to ensure that physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy have a working knowledge of hospital policy regarding the use of restraint or seclusion.

Findings include:

1. On 05-01-13 at 1145 hours, staff #40 confirmed that staff use Bridge building techniques when restraining patients.

2. On 05-02-13 at 1055 hours, MD #1 confirmed that physician residents give orders for restraint and or seclusion and do not get a copy or get trained on the facility's restraint and seclusion policy/procedure. MD #1 confirmed that medical staff members who order restraint do not get training on Bridge Building physical hold techniques.

Based on document review and interview, the facility failed to ensure that unlicensed direct care staff have documented education, training, and demonstrated knowledge on the use of first aid techniques for 5 of 5 Behavioral Health Recovery Attendants (BHRA) (Staff #N2, N7, N11, N12 & N15).

Findings include:

1. Review of staff #N2, N7, N11, N12 & N15's personnel files lacked documentation of education, training, and demonstrated knowledge on the use of first aid techniques.

2. On 05-01-13 at 1145 hours, staff # 40 confirmed that BHRAs do not get first aid training.

Based on document review and interview, the facility failed to include 3 contracted services (Nursing, Pet Therapy and Radiology) in its quality assessment and performance improvement program (QAPI).

Findings:

1. Review of the hospital's QAPI program indicated it did not include the contracted services of Nursing, Pet Therapy and Radiology.

2. In interview, on 05-02-13 at 3:15 pm, employee #A1 confirmed the above and no further documentation was provided prior to exit.

Based on interview, the facility failed to directly provide or have a written contractual arrangement to provide radiological services.

Findings:

1. In interview, employee #A3, of hospital #1, indicated the hospital did not directly provide radiological services. The employee indicated these were provided by local hospital #2. The employee was requested to provide documentation of any written agreement between hospital #1 and hospital #2, whereby hospital #2 would provide radiological services for hospital #1. The employee indicated there was no written agreement and no further documentation was provided prior to exit.

Based on observation and document review, the director of the dietary services failed to assure the facility's policies and procedures were followed for the proper labeling of 3 food containers stored in a refrigerator.

Findings:

1. On 04-29-13 at 1:35 pm, in the presence of employee #A4, it was observed in a refrigerator located behind the adult serving line area, there were 3 covered food containers with salad lettuce, 3-bean salad and Kool Aid, respectively. The containers were not the original container. Each container lacked a label indicating the food by its common name and date.

2. Review of a hospital policy entitled OCCUPATIONAL THERAPY/NUTRITION AND DIETETICS DEPARTMENT, section II. Procedure, Food Preparation and Storage, effective March, 2013, indicated food, whether raw or prepared, if removed from the original container or package, shall be stored in a clean, covered container with a label identifying the food by its common name and the date.

Based on Life Safety Code (LSC) survey, Larue D. Carter Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies.

This five story facility with a basement was determined to be of Type II (222) construction and was partially sprinklered. The hospital was constructed primarily in the 1930's as several separate buildings and has been modified into one building. The most recent addition occurred in the mid 1990's. The building description is as follows:
Building 1 is a five story building. The first floor is business/educational occupancy, the second, third and fourth floors are health care occupancy and the fifth floor is business occupancy. There is smoke detection located at cross corridor smoke barrier doors, elevator lobbies, machine rooms, waiting rooms open to the corridor; in corridors of the first, second, third, fourth and fifth floors and duct detectors in the penthouses.
Building 2 is a three story building. The first floor is industrial/storage space and the second and third floors are business occupancy. There is smoke detection located at the smoke and fire barrier doors, elevator lobbies and machine rooms.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 4 doors serving a kitchen, a hazardous area, was held open only by a device arranged to automatically close the door upon activation of the fire alarm system (see K 021), failed to ensure openings through 1 of 5 ceiling smoke barriers were protected to maintain the smoke resistance of each smoke barrier (see K 025), failed to ensure 1 of 5 hazardous areas such as the kitchen was separated from other spaces by smoke resisting partitions and doors and failed to ensure 1 of 4 doors serving hazardous areas such as the kitchen were self closing and would latch into the door frame and failed to ensure that 1 of 2 corridor doors to hazardous areas on the first floor of Building 2 such as a combustible storage room over 50 square feet in size was provided with a self closing device which would cause the door to automatically close and latch into the door frame and failed to ensure the 1 of 1 corridor doors to hazardous areas on the first floor of Building 2 such as a trash collection room was provided with a self closing device which would cause the door to automatically close and latch into the door frame (see K 029), failed to ensure 1 of over 100 corridor doors did not require more than one releasing operation to open it (see K 038), failed to document testing of emergency lighting for 2 of 2 battery operated emergency lights (see K 046), failed to include the use of kitchen fire extinguishers in 1 of 1 written fire safety plan for the facility in the event of an emergency (see K 048), failed to install 1 of over 200 smoke detectors where airflow would not prevent operation of the detector (see K 052), facility failed to ensure 8 of over 200 sprinkler heads were maintained (see K 062), failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area and failed to ensure 1 of over 40 portable fire extinguishers was readily accessible (see K 064), failed to ensure 1 of 102 fire dampers was provided necessary maintenance at least every six years (see K 067), failed to ensure 2 of 2 kitchen hood self contained chemical extinguishing systems was compliant with standard UL 300 and failed to ensure 2 of 2 kitchen exhaust systems was cleaned semiannually (see K 069), failed to ensure 1 of 1 space heaters was equipped with heating elements not exceeding 212 degrees Fahrenheit (see K 070), failed to ensure 2 of 2 emergency generators were equipped with a remote manual stop (see K 144), failed to provide a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period (see K 154) and failed to provide a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period (see K 155).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, record review and interview, the facility failed to ensure 1 of 4 doors serving a kitchen, a hazardous area, was held open only by a device arranged to automatically close the door upon activation of the fire alarm system, failed to ensure openings through 1 of 5 ceiling smoke barriers were protected to maintain the smoke resistance of each smoke barrier, failed to ensure 1 of 5 hazardous areas such as the kitchen was separated from other spaces by smoke resisting partitions and doors and failed to ensure 1 of 4 doors serving hazardous areas such as the kitchen were self closing and would latch into the door frame and failed to ensure that 1 of 2 corridor doors to hazardous areas on the first floor of Building 2 such as a combustible storage room over 50 square feet in size was provided with a self closing device which would cause the door to automatically close and latch into the door frame and failed to ensure the 1 of 1 corridor doors to hazardous areas on the first floor of Building 2 such as a trash collection room was provided with a self closing device which would cause the door to automatically close and latch into the door frame, failed to ensure 1 of over 100 corridor doors did not require more than one releasing operation to open it, failed to document testing of emergency lighting for 2 of 2 battery operated emergency lights, failed to include the use of kitchen fire extinguishers in 1 of 1 written fire safety plan for the facility in the event of an emergency, failed to install 1 of over 200 smoke detectors where airflow would not prevent operation of the detector, facility failed to ensure 8 of over 200 sprinkler heads were maintained, failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area and failed to ensure 1 of over 40 portable fire extinguishers was readily accessible, failed to ensure 1 of 102 fire dampers was provided necessary maintenance at least every six years, failed to ensure 2 of 2 kitchen hood self contained chemical extinguishing systems was compliant with standard UL 300 and failed to ensure 2 of 2 kitchen exhaust systems was cleaned semiannually, failed to ensure 1 of 1 space heaters was equipped with heating elements not exceeding 212 degrees Fahrenheit, failed to ensure 2 of 2 emergency generators were equipped with a remote manual stop, failed to provide a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period and failed to provide a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

Findings:

1. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the main kitchen was not separated from the Youth Dining Room and the entrance door to the Youth Dining Room was self closing but was held open by a door stop which would not allow the door to close automatically upon activation of the fire alarm system.

2. In interview at the time of observation, P1 stated the main kitchen is open to the Youth Dining Room and acknowledged the entrance door to the Youth Dining Room was held open by a door stop.

3. Observation with P1, M1 and S1 during tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13 indicated the attic access door in the ceiling in Building 1, Room 1-4029 was observed in the open position.

4. In interview at the time of observation, P1 stated no one was working in the attic and acknowledged an open access door in the ceiling above Room 1-4029 did not maintain the smoke resistance of the smoke barrier.

5. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the main kitchen was open to the Youth Dining Room

6. In interview at the time of observation, P1 acknowledged the main kitchen is open to the Youth Dining Room because there are two passageways into the kitchen directly behind the serving line which were each not equipped with a smoke resistant partition or door.

7. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the entry door to the Youth Dining Room from the kitchen corridor was not provided with a self closing device.

8. In interview at the time of observation, P1 acknowledged the entry door to the Youth Dining Room from the kitchen corridor is not provided with a self closing device.

9. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m. indicated the corridor door to Room 2-1003 in Building 2 was not provided with a self closing device. Room 2-1003 measured 252 square feet and was being utilized as a storage room for gloves, paper towels, trash bags and supplies in combustible boxes.

10. In interview at the time of observation, P1 acknowledged Room 2-1003 measured greater than fifty square feet, was used to store combustible supplies in boxes and the corridor door was not provided with a self closing device.

11. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m. indicated the corridor door to Room 1-1042 in Building 1 was not provided with a self closing device. Room 1-1042 was being utilized as a storage room for ten red bag biohazard waste bins each providing 28 gallons of storage capacity.

12. In interview at the time of observation, P1 acknowledged Room 1-1042 was utilized to store trash and the corridor door was not provided with a self closing device.

13. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the corridor door to the Med Room identified as Room 8-2074 in Building 8 had two locks on the door and a key was needed to unlock each lock on the door.

14. In interview at the time of observation, the P1 acknowledged the corridor door to the Med Room identified as Room 8-2074 in Building 8 has two locks on the door and a key was needed to unlock each lock on the door.

15. Review of "Emergency Lighting Inspection Form" documentation with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated monthly functional testing and annual testing for two battery operated emergency lights in the facility were not itemized for tests conducted during the twelve month period from 05/22/12 through 04/10/13. The aforementioned documentation stated the "Type of Inspection" as monthly or annual, the "Type of Equipment" tested as "Emergency Lighting" and the "Location of Equipment" as "buildings # 18-10-3-2-1-27-11-8" tested but did not itemize the devices tested. As a result, the total number of battery operated emergency lights in the facility which were tested and the individual device location could not be determined from the aforementioned documentation.

16. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated one battery operated emergency light was observed at the emergency generator location in Building 27 and one at the second emergency generator location in the powerhouse water softener room in Building 1.

17. In interview at the time of record review, the P1 acknowledged monthly functional testing and annual testing documentation for two battery operated emergency lights in the facility was not itemized for the aforementioned tests.

18. Review of "Fire Response Plan" documentation with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated the fire disaster plan did not address the use of the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system.

19. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a K-class fire extinguisher was located in the kitchen.

20. In interview at the time of record review, P1 acknowledged the written fire safety plan for the facility did not include kitchen staff training to activate the overhead hood extinguishing system to suppress a fire before using the K-class fire extinguisher.

21. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the smoke detector on the ceiling in the second floor lobby outside Unit 2C by the elevators was located one foot from a return air vent.

22. In interview at the time of observation, P1 acknowledged the aforementioned smoke detector location was installed on the ceiling less than three feet from a return air vent.

23. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated the following sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling:
a) in Building 1 in the corridor outside Rooms 1-5010, 1-3075, and 1-3004.
b) in Building 1 in Rooms 1-4056, 1-4021 and in the closet identified as Room 1-2052.
c) in Building 8 in the corridor outside Room 8-3025 and Room 8-3074.

24. In interview at the time of the observations, P1 acknowledged the aforementioned sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling.

25. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

26. In interview at the time of observation, P1 acknowledged a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

27. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a portable fire extinguisher in the first floor basketball gym was in a locked glass cabinet mounted in the wall. The cabinet door could not be unlocked after five repeated attempts because the cabinet door was bent.

28. In interview at the time of observation, S1 acknowledged they could not access the portable fire extinguisher located in the first floor basketball gym.

29. Review of "Smoke & Fire Damper Inspection Report" documentation dated 08/10/10 with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated the inspection report for the fire damper identified as B1-M4S-4 had stated "springs are broke won't close" in the comments section for "Damper function." In addition, the aforementioned fire damper inspection report stated "needs work."

30. In interview at the time of record review, P1 stated no additional documentation of fire damper testing was available for review and acknowledged documentation for the repair or replacement of the aforementioned fire damper was not available for review.

31. Review of "Restaurant Systems Work Order" documentation dated 08/22/12 and 02/26/13 with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated "No" was listed as the response to "Is System UL 300?" on each of the aforementioned work order documents for two kitchen hood extinguishing systems in the facility. In addition, the "Comments" section of the aforementioned documentation stated "recommend upgrading system."

32. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a total of two kitchen hood extinguishing systems were observed in the main kitchen for the facility.

33. In interview at the time of record review, P1 stated each of the two kitchen hood extinguishing systems have not been upgraded to UL 300 and acknowledged restaurant systems work order documentation identified the kitchen hood extinguishing systems as not compliant with UL 300.

34. Review of "Invoice" documentation dated 02/21/12 and 08/15/12 with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated semiannual kitchen range hood cleaning documentation after 08/15/12 was not available for review.

35. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a semiannual maintenance cleaning sticker dated 08/15/12 affixed to the kitchen range hoods.

36. In interview at the time of record review and observation, P1 acknowledged it had been more than six months since the most recent range hood cleanings.

37. Observation with P1, M1 and S1 during tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13 indicated one operable portable space heater in operation in the Director's Office (Room 1-5007) on the fifth floor.

38. In interview at the time of observation, E1 stated documentation of the heating element operating temperature was not available for review and acknowledged a space heater was being utilized in the Director's Office (Room 1-5007) on the fifth floor.

39. Observation with P1, M1 and S1 during tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 indicated a remote shut off device was not found for the 200 kW diesel fired emergency generator (Generator #1) or the 295 kW diesel fired emergency generator (Generator # 2). Generator # 1 is located in the softener room for the Powerhouse in Building 1 and Generator # 2 is located in Building 27, which only houses the generator. Each of the aforementioned emergency generators had a manual stop button at the engine location but did not have a remote manual stop outside of the room where the emergency generator was located.

40. In interview at the time of the observations, P1 stated each emergency generator was installed prior to 2003 and acknowledged there is no remote emergency shut off device for each of the two aforementioned emergency generators.

41. Review of "Fire Response Plan" documentation with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

42. In interview at the time of record review, P1 acknowledged a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

43. Review of "Fire Response Plan" documentation with P1, M1 and S1 from 9:45 a.m. to 12:10 p.m. on 04/29/13 indicated a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

44. In interview at the time of record review, P1 acknowledged a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

Based on observation and document review, the hospital failed to follow its policy for proper storage of outside trash.

Findings:

1. On 04-29-13 at 11:10 am in the presence of employee #A4, it was observed all around the outside trash compactor, there was a great deal of trash, including but not limited to, milk cartons, dietary supplies, and general paper rubbish.

2. Review of a hospital policy entitled NUTRITION AND DIETETICS DEPARTMENT, section ISDH REGULATION-Section 19-Garbage and Refuse, approved March, 2013, indicated outside storage areas or enclosures shall be large enough to store garbage and refuse containers that accumulate and shall be kept clean. Garbage and refuse containers, dumpsters, and compactor systems located outside shall ... [be] kept clean.

Based on observation and interview, the hospital failed to have regular periodical preventive maintenance (PM) of 1 piece of equipment.

Findings:

1. In interview, on 04-29-13 at 11:45 am, employee #A4 was requested to provide documentation of PM on a Body Solid Universal Weight machine located in the Physical Therapy area.

2. In interview, on 05-02-13 at 9:40 am, employee #A4 indicated there was no documentation on the above piece of equipment and no further documentation was provided prior to exit.

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

1. Ensure that the Master Treatment Plans (MTPs) for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1) were comprehensive, integrated, and included all necessary elements. Treatment plans in this Facility were called "Client Treatment Plan Reports." Physicians (psychiatrists) entered very few interventions on the MTPs. Instead they developed separate "Medical Care Plans" and "Medical Care Plan Updates" for all active sample patients. These "plans" were summaries of the medical and psychiatric services provided, usually over the preceding month. The content recapitulated the patient's multi-axial diagnoses, allergies, current and discontinued medications, and a general summary of progress. Specific psychiatrist and internal medicine/family practice interventions were not described, and the plan bore no relationship to the "Client Treatment Plan Reports" or "Client Treatment Plan Report Updates" developed by some of the psychiatrists and by non-medical members of the treatment team. These "Medical Care Updates" functioned more as monthly summaries of psychiatric care and other medical services than updated treatment plans.

MTPs were missing components such as (1) the inclusion of active medical problems and how they were being addressed by physicians and nurses (See B126 and B127); (2) the delineation of specific treatment modalities that would be brought to bear by the individual members (i.e. physicians, nurses, social workers, substance abuse counselors, rehabilitation therapists) of the interdisciplinary team in addressing the identified patient problems (See B122); and (3) the identification of the individual team members responsible for carrying out the treatment modalities (See B123). The absence of an integrated, comprehensive written treatment plan results in a lack of coordinated and organized treatment, hampers the staffs' ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems, and presumes that the oral communication of treatment focus will be sufficient for the provision of comprehensive and integrated treatment. (Refer to B118.)

2. Ensure that the treatment plans of 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions inappropriately written as treatment interventions, or listed groups/activities to be provided for the patients as the intervention. The listed "interventions" failed to include the specific focus of treatment. In addition, some of the treatment plans failed to include interventions by key staff, such as a physician and/ or social worker. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment. (Refer to B122.)

3. Ensure that the responsible staff listed next to the interventions on the Master Treatment Plans included each person's name and discipline for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). Many of the Master Treatment Plans listed multiple persons, by name or discipline only, as being responsible for the same intervention. In addition, the responsible persons were not updated on 2 of 10 Master Treatment Plans (A7, A8) when the patients moved from one unit to another. These practices result in the facility's inability to monitor staff accountability for specific treatment interventions. (Refer to B123.)

4. Ensure that the progress notes of 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1)) provided by the physicians responsible for the care of patients related to the goals of the treatment plan and provided precise statements on progress related to an identified problem (psychiatric, behavioral, or medical). The inability to link the assessment of patient progress, as carried out by the designated responsible physicians, to specific patient problems, goals, and objectives, compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs. (Refer to B126.)

5. Ensure that nurses regularly recorded treatment notes of patients in achieving their active treatment goals for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). This failure results in a lack of evidence that nurses are actually involved in the care of patients. (Refer to B127.)

6. Ensure that the social work members of the treatment team provided written progress notes that presented precise statements on progress related to identified problem(s), goal(s), and objective(s) for which social work interventions were provided for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1). The inability to link the assessment of patient progress, as carried out by the designated responsible social work staff, to identified patient problems, goals, and objectives compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs, and to adequately plan for the patient's successful return to the community. (Refer to B128.)

Based on record review and interview, the facility failed to ensure that the findings of physical and neurological examinations performed were adequately documented in 4 of 10 active sample patients (A9, and A24, B2 and C1). The absence of this patient information limits the clinician's ability to accurately diagnose the patient's condition, to provide a measure of baseline functioning, and also potentially to provide necessary medical treatment.

Findings include:

A. Record Review

1. Active sample patient A9: the general physical examination, dated 1/15/13, was incomplete, with check marks in the sections for the major organ systems but no documentation of the specific tests performed; the neurological examination section on cranial nerves, gait, sensory, motor, cerebellum, and reflexes was not completed.

2. Active sample patient A24: in the physical examination, dated 4/11/13, the cranial nerve section of the neurological examination was noted as "intact" without an indication that the function of specific nerves was examined; a test of reflexes was not performed.

3. Active sample patient C1: results of the neurological examination of cranial nerves III through XII were missing from the physical examination, dated 8/3/12.

4. Active sample patient B2: entire physical examination, dated 1/8/13, was incomplete, with check marks in the sections for the major organ systems but no documentation of the specific tests performed; the neurological examination section on cranial nerves, gait, sensory, motor, cerebellum, and reflexes was not completed.

B. Interview

In an interview on 4/30/13 at 4:15 PM, the Medical Director agreed that the physical examinations in active sample patients A9, and A24, B2 and C1 were incomplete, with incomplete documentation of the cranial nerve examination in active sample patient C1; incomplete documentation of the general physical examination in active sample patients A9 and B2; and incomplete documentation of the cranial nerve examination in active sample patient A24.

Based on record review and interview, the Facility failed to ensure that the Master Treatment Plans (MTPs) for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1) were comprehensive, integrated, and included all necessary elements. Treatment plans in this Facility were called "Client Treatment Plan Reports." Physicians (psychiatrists) entered very few interventions on the MTPs. Instead they developed separate "Medical Care Plans" and "Medical Care Plan Updates" for all active sample patients. These plans were usually summaries of the medical and psychiatric services provided over the preceding month. The content recapitulated the patient's multi-axial diagnoses, allergies, current and discontinued medications, and a general summary of progress. Specific psychiatrist and internal medicine/family practice interventions were not described, and the plan bore no relationship to the "Client Treatment Plan Reports" or "Client Treatment Plan Report Updates" developed by some of the psychiatrists and non-medical members of the treatment team. These "Medical Care Updates" functioned more as monthly summaries of psychiatric care and other medical services than updated treatment plans.

MTPs were missing components such as (1) the inclusion of active medical problems and how they were being addressed by physicians and nurse (See B26 and B27); (2) the delineation of specific treatment modalities that would be brought to bear by the individual members (i.e. physicians, nurses, social workers, substance abuse counselors, rehabilitation therapists) of the interdisciplinary team in addressing the identified patient problems (See B122); (3) the frequency and duration of the modalities (See B122); and (4) the identification of the individual team members responsible for carrying out the treatment modalities (See B123). The absence of an integrated, comprehensive written treatment plan results in a lack of coordinated and organized treatment, hampers the staffs' ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems, and presumes that the oral communication of treatment focus will be sufficient for the provision of comprehensive and integrated treatment.

Findings include:

A. Record Reviews

1. In section VI. "Procedures and Responsibilities" of the facility's policy: "Treatment Planning Policy" (H-2400.22.1, signed by the Superintendent on March 19, 2013), item D. states, "The treatment plan begins with identified problems and a goal, objective(s), and intervention(s) are then linked;" item E. states, "The Master Treatment Plan will be updated as scheduled...." The policy does not provide definitions for the component parts of a treatment plan that would guide staff in its development. In section V. "Statement of Policy," the policy makes reference to the creation of a "medical plan of care" that "will be completed within 24 hours by the attending physician to guide the initial treatment of the patient." However, the existence of a separate "Medical Care Plan/Updates," is not described, nor is there a description of how such separate medical plans would be integrated into the problems, goals, objectives, and interventions in the patient's Master treatment Plan.

2. Active sample patient A1, admitted on 7/17/12, Client Treatment Plan Report (Scheduled Update), dated 3/27/13:

a. Interventions for the problem "relapse proneness" listed as the intervention: "assign [A1] to keep a daily record of anxiety, including each situation that caused anxious feelings, the negative thoughts precipitating anxiety, and a ranking of the severity of the anxiety from 1 to 10." This is not a treatment modality (i.e. intervention).

b. A second intervention for the same problem stated: "provide [A1] with individual and group SA [substance abuse] therapy sessions in order to assist [A1] in listing reasons why [A1] should stay in chemical dependence treatment." Neither the frequency nor the duration of the proposed treatment modalities was stated. No nursing interventions were listed.

c. Interventions for the problem "recreation and leisure" stated: "[A1] and the Recreational Therapist (RT) will develop a schedule of activities that [A1] can participate in each day to broaden [his/her] knowledge and experience of that activity." This intervention was a generic function of RT and lacked the specificity of a designed set of recreational or rehabilitative treatment modalities based on patient need and progress, for a patient who had been admitted to the facility on 7/17/12, some 8 months earlier.

d. Interventions for the problem "anger management" stated: "educate [A1] about the tendency to engage in addictive behavior as a means of relieving uncomfortable feelings. Develop a list of several instances of occurrence." This is not an intervention; no frequency or duration was noted, and the approach was not related to addressing the designated problem of "anger management."

3. Active sample patient A2, admitted on 10/30/12, Client Treatment Plan Report (Scheduled Update), dated 4/24/13:

a. Interventions for the problem "psychosis" stated "reinforce the client for initiating appropriate social interaction with others daily. Encourage patient to attend 100% of all group activities." These are not treatment modalities with a declared duration and frequency. In addition, no specific psychiatric or nursing interventions are listed for the treatment of "psychosis."

b. Interventions for the problem "independent activities of daily living (IADL)" stated "aid the client in developing a specific schedule for completing IADLs (e.g. morning self-care/hygiene, medication, clean room and make bed prior to morning meeting Monday through Friday, etc. [sic]" These are generic nursing care tasks and are not specific treatment modalities. In addition, no specific social work or therapeutic recreation modalities were listed for this patient, who had been in the facility for 6 months.

4. Patient A7 was admitted 11/7/12. A7's Master Treatment Plan (MTP), last updated 4/3/13, listed a problem as- "The patient has a history of psychotic thinking, physical aggression, paranoia, and treatment non-compliance." Interventions - "Staff will continue to ask [name of patient] about [her/his] current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication education and treatment compliance." This intervention listed generic functions, and groups without specific focus, frequency or duration to meet the patient's needs. In addition, at the end of this intervention, the following was included - "Additional staff responsible: RT and nursing staff and needed [sic]." The rehabilitation staff, and nursing staff associated with this intervention were not listed by name, and the unit social worker was not included.

5. Patient A8 who was hearing impaired was admitted 8/13/07. A8's Master Treatment Plan (MTP), last updated 4/25/13, listed the problem - "Expressive and receptive language deficits." Objective - "[Name of patient] will be encouraged daily to persist in attempts to communicate using words, gestures, and ASL [American Sign Language] to get [his/her] needs met and participate in formal assessments." This "objective" is really a generic staff intervention. Other interventions were: "3C staff will encourage and reinforce attempts to use verbal or manual [ASL] communication"; "Goal setting 1x [1 time]/ weekly, gym 1x weekly, and Journey Through Life 2x/ weekly." All of these interventions failed to include a specific focus related to the stated problem.

6. Patient A9 was admitted 1/5/12. A9's MTP, last updated 4/23/13, listed the problem as "Schizoaffective Disorder." "[Name of patient] is diagnosed with Schizoaffective Disorder, per past assessments. [Her/his] thinking is poor and is easily distracted. [S/he] denies hallucinations but can be observed responding to internal stimuli." Interventions included: "Identified staff will monitor [name of patient] medication compliance and effectiveness on at least a daily basis. When behavior is appropriate, [name of patient] will participate in unit groups/programming for education and treatment." This is a generic intervention without a specific focus, frequency or duration. A physician was not assigned an intervention. RN/LPN was identified as "Additional Staff Responsible." Rehabilitation staff was also not assigned interventions, even though (non-specific) RT groups were referred to in the intervention.

7. Patient A23 was admitted 4/17/13. The MTP, dated 4/25/13, listed a problem of "psychosis": "Patient responds to verbal stimuli, hears voices of enlightenment [sic]."
The following interventions listed were really goals: "Patient will take medication as prescribed by physician to decrease psychotic symptoms....Patient will attend morning meeting at least 4x/ week. Patient will participate in all assigned groups and activities." All the groups listed lacked specific focus or duration. With exception of the morning meeting, none of the groups listed included a frequency of occurrence. Social worker and Rehabilitation staff were not assigned interventions.

8. Patient A24 was admitted 4/11/13. The MTP, dated 4/17/13, listed the problem as "Treatment Non-Compliance": "[Name of patient] has a history of not taking [his/her] psychiatric medication; especially when out in the community." The objective was: "[Name of patient] will take all medication as prescribed on a daily basis." The intervention was: "Staff will remind [ patient] to take all medication as prescribed on a daily basis. Staff will encourage [patient] to attend the medication management groups as well as other psychosocial groups in order to gain more insight into the importance of taking medication daily." There was no specific duration for the groups mentioned. There was also no delineation of responsibility for each assigned staff. Social Work and rehabilitation staff were not assigned interventions.

9. Active sample patient B1, admitted on 6/11/12, Client Treatment Plan Report (Scheduled Update), dated 4/18/13:

a. Interventions for the problem "anger management" listed generic treatment modalities, and did not document the duration or frequency with which they would be offered: "through individual and group therapy, [B1] will learn alternative ways of handling conflictual situations....; [B1] will take all medications as prescribed." No psychiatric interventions or nursing interventions were listed.

b. Interventions for the problem "conduct disorder" stated "[B1] will be offered individual therapy, group therapy; rehabilitation therapy; daily programming on the unit; academic; and medical services." These are not specifically delineated treatment modalities, and do not have a declared duration and frequency. In addition, some of the offerings had no bearing on the identified problem (i.e. "academic instruction" and "medical services").

c. Interventions for the problem "parental conflicts" stated "[B1] and [B1's] father will identify healthy alternatives to negative/assaultive behaviors through individual and family therapy." Neither the frequency nor the duration of the proposed therapeutic modalities was provided.

10. Active sample patient B2, admitted on 1/7/13, Client Treatment Plan Report (Scheduled Update), dated 4/9/13: Interventions for the problem "oppositional defiant" listed one intervention as "[B2] will meet with [his/her] therapist to develop coping skills to deal with stress. [S/he] will learn to follow rules and cooperate on the unit and at home," without any indication of either the duration or frequency of the intervention; a second intervention for the same problem stated "[B2] will learn coping skills with [his/her] therapist. [S/he] will participate in the behavior level program on the unit," a repetition of the previous intervention; a third intervention stated "Recreation/Rehab staff will offer other healthy activities for [B2] to participate in daily," without any delineation of what these activities would be or how often and for how long they would be provided. No psychiatric interventions or nursing interventions were listed.

11. Active sample patient C1, admitted on 8/2/12, Client Treatment Plan Report (Scheduled Update), dated 4/10/13:

a. Interventions for the problem "anger management" stated "[C1] will meet weekly with [his/her] individual therapist to work on effective communication and assertiveness skills to help [C1] express [his/her] anger in a controlled fashion." This is a generic intervention; in addition, the duration of the therapy sessions was not stated.

b. Intervention for the problem "attention deficit/hyperactivity disorder" stated "[C1] will participate in recreational activities and community outings to help [him/her] learn new coping skills to manage symptoms and to increase social skills, emotion regulation, and communication skills." The interventions lacked specificity, and did not note duration or frequency of the proposed interventions. No psychiatric interventions or nursing interventions were listed.

c. Interventions for the problem "oppositional defiant" stated "an individual behavioral reward system focusing on daily point levels will be designed and implemented by [name of patient's] individual therapist, and reviewed with [him/her] multiple times per week by the individual therapist." This is not a treatment modality. In addition, clearly stated specific treatment interventions to address a persisting problem with "oppositional defiant" behaviors should be component of an updated treatment plan some 8 months into the hospital course (admission date).

B. Interview

In an interview on 4/30/13 at 4:15 p.m, the Medical Director agreed that none of the "Client Treatment Plan Reports" described specific treatment modalities (interventions) with a clear delineation of duration and frequency. She also agreed that the psychiatric and medical interventions were not included in the "Client Treatment Plan Reports" but stated that a synopsis of psychiatric and medical treatments for the previous month was written in a separate "Medical Care Plan/Update." She concurred that the "Medical Care Plan/Updates" for the active sample patients did not delineate specific psychiatric or medical treatment interventions, but, instead, summarized the care provided by medical staff and any outside consultants during the interval month.

Based on record review and interview, the facility failed to ensure that the treatment plans for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions inappropriately written as treatment interventions or listed general groups/activities to be provided for all the patients as the intervention. The listed groups/activities, by title only, failed to include the specific focus or duration of treatment. In addition, some of the treatment plans failed to include interventions by key staff, such as a physician and social worker. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy, titled "Medical Record Documentation," Policy Number H-2520.2.3, no date, stated under "Person Centered Treatment Plan" that "A Person Centered Treatment Plan describes the partnership between the hospital team, the client, community supporters, and treatment providers by establishing meaningful individualized recovery goals, therapeutic relationships that are collaborative, consultative and mentoring, and specific interventions that facilitate discharge."

2. Active sample patient A1, admitted on 7/17/12, Client Treatment Plan Report (Scheduled Update), dated 3/27/13: Interventions for the problem "relapse proneness" listed as the intervention "assign [A1] to keep a daily record of anxiety, including each situation that caused anxious feelings, the negative thoughts precipitating anxiety, and a ranking of the severity of the anxiety from 1 to 10." This is not a treatment modality (i.e. intervention). A second intervention for the same problem stated "provide [A1] with individual and group SA [substance abuse] therapy sessions in order to assist [A1] in listing reasons why [A1] should stay in chemical dependence treatment." Neither the frequency nor the duration of the proposed treatment modalities was stated. No nursing interventions were listed.
Interventions for the problem "recreation and leisure" stated "[A1] and the recreational therapist will develop a schedule of activities that [A1] can participate in each day to broaden her knowledge and experience of that activity." This intervention was a generic function of RT and lacked the specificity of a designed set of recreational or rehabilitative treatment modalities based on patient need and progress for a patient who had been admitted to the facility on 7/17/12, some 8 months earlier. No nursing interventions were noted.
Interventions for the problem "anger management" stated "educate [A1] about the tendency to engage in addictive behavior as a means of relieving uncomfortable feelings. Develop a list of several instances of occurrence." This is not an intervention, no frequency or duration is noted, and the approach is not related to addressing the designated problem of "anger management."

3. Active sample patient A2, admitted on 10/30/12, Client Treatment Plan Report (Scheduled Update), dated 4/24/13: Interventions for the problem "psychosis" stated "reinforce the client for initiating appropriate social interaction with others daily. Encourage patient to attend 100% of all group activities." These are not treatment modalities with a declared duration and frequency. In addition, no specific psychiatric or nursing interventions are listed for the treatment of "psychosis."

Interventions for the problem "independent activities of daily living (IADL)" stated "aid the client in developing a specific schedule for completing IADLs (e.g. morning self-care/hygiene, medication, clean room and make bed prior to morning meeting Monday (sic) through Friday (sic), etc." These are generic nursing care tasks and are not specific treatment modalities. In addition, no specific social work or therapeutic recreation modalities were listed for this patient, who has been in the facility for 6 months.

4. Patient A7 was admitted 11/7/12. A7's Master Treatment Plan (MTP), last updated , 4/3/13, listed a problem as- "The patient has a history of psychotic thinking, physical aggression, paranoia, and treatment non-compliance." Objective - "[Name of patient] will be able to continue to report a decrease in psychotic symptoms through the consistent use of psychotropic medications." Interventions - "Staff will continue to ask [name of patient] about [her/his] current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication education and treatment compliance." This intervention listed generic functions and groups without a specific focus, frequency or duration to help meet the patient's needs. The unit social worker, rehabilitation staff, and nursing staff associated with this intervention were not listed by name. At the end of this intervention, the following was included - "Additional Staff Responsible: RT and nursing staff and needed [sic]."

5. Patient A8 who was hearing impaired was admitted 8/13/07. A8's Master Treatment Plan (MTP) was last updated 4/25/13, listed the problem - "Expressive and receptive language deficits." Objective - "[Name of patient] will be encouraged daily to persist in attempts to communicate using words, gestures, and ASL [American Sign Language] to get [his/her] needs met and participate in formal assessments." This "objective" is really a staff intervention. Other interventions were: "3C staff will encourage and reinforce attempts to use verbal or manual [ASL] communication", "Goal setting 1x [1 time]/ weekly, gym 1x weekly, and Journey Through Life 2x/ weekly." All of these interventions failed to include a specific focus for treatment.

6. Patient A9 was admitted 1/5/12. A9's MTP, last updated 4/23/13, listed the problem as "Schizoaffective Disorder". "[Name of patient] is diagnosed with Schizoaffective Disorder, per past assessments. [Her/his] thinking is poor and is easily distracted. S/he denies hallucinations but can be observed responding to internal stimuli."
Objective - "[Name of patient] will demonstrate a decrease in psychotic symptoms through the use of psychotropic medications as prescribed and compliance with therapeutic treatment as scheduled." The objective is not measurable as written.
Interventions include: "Identified staff will monitor [name of patient] medication compliance and effectiveness on at least a daily basis. When behavior is appropriate, [name of patient] will participate in unit groups/programming for education and treatment." (This is a generic intervention without a specific focus, frequency or duration.) A physician was not assigned interventions. RN/LPN were identified as "Additional Staff Responsible." Rehabilitation staff were also not assigned interventions even though non-specific RT groups were referred to in the intervention.

7. Patient A23 was admitted 4/17/13. The MTP, dated 4/25/13, listed a problem of "psychosis". "Patient responds to verbal stimuli, hears voices of enlightenment."
Objective - "Patient will socialize/interact with staff and peers appropriately." This objective is vague and difficult to measure. The following interventions listed were really goals: "Patient will take medication as prescribed by physician to decrease psychotic symptoms. Patient will attend morning meeting at least 4x/ week. Patient will participate in all assigned groups and activities." All the groups listed had no specific focus or duration. With exception of the morning meeting, none of the groups included a frequency of occurrence. Social worker and rehabilitation staff were not assigned interventions.

8. Patient A24 was admitted 4/11/13. The MTP, dated 4/17/13, listed the problem as "Treatment Non-Compliance." "[Name of patient] has a history of not taking her psychiatric medication; especially when out in the community." The objective was "[name of patient] will take all medication as prescribed on a daily basis." The intervention was "Staff will remind [name of patient] to take all medication as prescribed on a daily basis. Staff will encourage [name of patient] to attend the medication management groups as well as other psychosocial groups in order to gain more insight into the importance of taking medication daily." There was no duration for the groups mentioned . There was also no delineation of responsibility for each assigned staff. Neither Social Work nor Rehabilitation staff was assigned interventions.

9. Active sample patient B1, admitted on 6/11/12, Client Treatment Plan Report (Scheduled Update), dated 4/18/13: Interventions for the problem "anger management" listed generic treatment modalities, but did not document the duration or frequency with which they would be offered: "through individual and group therapy, [B1] will learn alternative ways of handling conflictual situations....; and "[B1] will take all medications as prescribed." No psychiatric interventions or nursing interventions were listed.
Interventions for the problem "conduct disorder" stated "[B1] will be offered individual therapy, group therapy; rehabilitation therapy; daily programming on the unit; academic; and medical services." These are not specifically delineated treatment modalities with a declared duration and frequency. In addition, some of the offerings had no bearing on the identified problem (i.e. "academic instruction" or "medical services").
Interventions for the problem "parental conflicts" stated "[B1] and [B1's] father will identify healthy alternatives to negative/assaultive behaviors through individual and family therapy. Neither the frequency nor the duration of the proposed therapeutic modalities was provided.

10. Active sample patient B2, admitted on 1/7/13, Client Treatment Plan Report (Scheduled Update) dated 4/9/13: Interventions for the problem "oppositional defiant" listed one intervention as "[B2] will meet with [his/her] therapist to develop coping skills to deal with stress. [S/he] will learn to follow rules and cooperate on the unit and at home," without any indication of either the duration or frequency of the intervention; a second intervention for the same problem stated [B2] will learn coping skills with [his/her] therapist. "[S/he] will participate in the behavior level program on the unit," a seeming repetition of the previous intervention; a third intervention stated "Recreation/Rehab staff will offer other healthy activities for [B2] to participate in daily," without any delineation of what these activities would be or how often and for how long they would be provided. No psychiatric interventions or nursing interventions were listed.

11. Active sample patient C1, admitted on 8/2/12. Client Treatment Plan Report (Scheduled Update) dated 4/10/13: interventions for the problem "anger management" stated "[C1)] will meet weekly with [his/her] individual therapist to work on effective communication and assertiveness skills to help [C1] express [his/her] anger in a controlled fashion. The duration of the therapy sessions was not stated. Intervention for the problem "attention deficit/hyperactivity disorder" stated "[C1] will participate in recreational activities and community outings to help [him/her] learn new coping skills to manage symptoms and to increase social skills, emotion regulation, and communication skills." The description lacked specific treatments aimed at addressing the attention deficit problem. The interventions lacked specificity, and did not note duration or frequency of the proposed interventions. No psychiatric interventions or nursing interventions were listed. Interventions for the problem "oppositional defiant " stated "an individual behavioral reward system focusing on daily point levels will be designed and implemented by [name of patient's] individual therapist, and reviewed with [him/her] multiple times per week by the individual therapist." This is not a specific treatment modality. In addition, clearly stated specific treatment interventions to address a persisting problem with "oppositional defiant" behaviors should be a component of an updated treatment plan 8 months into the hospital course (8/2/12 admission date).

B. Interviews

1. In an interview on 4/29/13 at 1:50 pm with the Unit 4C staff, MD1, RN4, and SW1 agreed that active sample patient B1's "Client Treatment Plan Report (Scheduled Update)" dated 4/18/13 did not include a description of specific treatment modalities for each identified problem. MD1 acknowledged that she composed a separate "Medical Care Plan/Update" covering the previous month ending 4/18/13 in which she summarized psychopharmacologic medication changes made and medical services provided during that interval. She agreed that there was no mention of specific nursing interventions on her "Medical Care Plan" or on the "Client Treatment Plan Report (Scheduled Update)." MD1 and SW1 agreed that no specific group therapies or recreation/rehabilitative groups/activities were mentioned in the most recent "Client Treatment Plan Report (Scheduled Update)."

2. In an interview on 4/30/13 at 11:50 a.m., the generic MTP of active sample patient A23 was discussed with RN #7. She did not dispute the findings. RN #7 stated the Avatar computer system limited choices for goals/interventions and thereby prevented staff from being more individualized and specific.

3. In an interview on 4/30/13 at 4:15 PM, the Medical Director agreed that none of the "Client Treatment Plan Reports" described specific treatment modalities (interventions) with a clear delineation of duration and frequency. She also agreed that the psychiatric and medical interventions were not included in the "Client Treatment Plan Reports" but stated that a synopsis of psychiatric and medical treatments for the previous month was written in a separate "Medical Care Plan/Update." She concurred that the "Medical Care Plan/Updates" for the active sample patients did not delineate specific psychiatric or medical treatment interventions during the interval month.

4. In an interview on 4/30/13 at 4:20 p.m., the problem of generic discipline treatment plans was discussed with RN #6. RN #6 stated that the Avatar system does not allow staff to be creative and called the present system, used for three years, antiquated.

Based on record review and interview, the facility failed to ensure that the responsible staff listed next to the interventions on the Master Treatment Plans included each person's discipline for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). Many of the Master Treatment Plans listed multiple persons, by name or discipline only, as being responsible for the same intervention; or when the "intervention" was broad in scope and actually covered multiple modalities, the plans did not clearly delineate the staff member responsible for each particular treatment modality. In addition, the responsible persons were not updated on 2 of 10 Master Treatment Plans (A7, A8) when the patient moved from one unit to another and the staff changed. These practices result in the facility's inability to monitor staff accountability for specific treatment interventions.

Findings include:

A. Record Review

1. The facility policy "Treatment Planning Policy" (H-2400.22.1, signed by the Superintendent on March 19, 2013), makes reference to participation by "chaplaincy; nursing; nutrition; psychiatry; psychology; rehabilitation; social work; dietary; substance abuse" in the assessment and treatment planning processes (Section IV. "Definitions," item 1 "Clinical Disciplines;" Section VI. "Procedures and Responsibilities" subsections A and B). It does not provide direction on how those staff members on the treatment team should document their involvement by name and credential on the plan.

2. Patient Records

Failure to list one responsible person by name and discipline for each intervention on the Master Treatment Plan:

a) Active sample patient A1 (admitted on 7/17/12) "Client Treatment Plan Report (Scheduled Update)" dated 3/27/13: for the first intervention, "relapse proneness," 4 different staff members were listed as "responsible staff" with no delineation of how each staff member would be responsible for the same specific treatment modality. For the second intervention, consisting of "individual therapy and group SA [substance abuse] therapy sessions," again, 4 different staff members were assigned as "responsible staff" without any indication of what each staff member's role or function would be for this intervention. Credentials were not associated with the staff members' names.
For the intervention associated with the problem "recreation and leisure," the credential of the assigned staff member was not included.
For the intervention associated with the problem "anger management," 4 different staff members were assigned to "educate [A1] about the tendency to engage in addictive behavior..." without any delineation of the specific modality each staff member would utilize to "educate" the patient.. Credentials were not associated with the staff members' names.

b) Active sample patient A2 (admitted on 10/30/12) Client Treatment Plan Report (Scheduled Update) dated 4/24/13: The interventions for the problem "psychosis" were "reinforce the client for initiating appropriate social interaction with others daily. Encourage patient to attend 100% of all group activities." Four staff members were listed as "responsible staff" (a social worker, 2 nurses, and a psychiatrist) without any clear delineation of what treatment modality each would be utilizing. No credentials were associated with the staff members' names.
For the intervention ("aid the client in developing a specific schedule for completing IADLs.... ") which was associated with the problem "independent activities of daily living (IADL)," 4 different staff members (across 4 different disciplines, social work, nursing, psychiatry, and rehabilitation therapy) were assigned to carry out the same task without any delineation of how each would be responsible for the same specific treatment modality. No credentials were associated with the staff members' names.

c) Patient A7 was admitted on 11/7/12. The Master Treatment Plan (MTP), updated 4/3/13, listed the problem as "The patient has a history of psychotic thinking, physical aggression, paranoia, and treatment non-compliance."
Intervention - "Staff will continue to ask [name of patient] about [her/his] current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication education and treatment compliance." At the end of this intervention, the following was included - "Additional Staff Responsible: RT and nursing staff and [sic] needed." Four responsible staff from the patient's previous unit were listed by name. The staff listed were no longer treating the patient. There was also no specific function or delineation of responsibility spelled out for each assigned staff.

d) Patient A8 was admitted 8/13/07. A8's MTP, last updated 4/25/13, listed the problem as- "Expressive and receptive language deficits."
Interventions included: "3C staff will encourage and reinforce attempts to use verbal or manual communication, Unit meeting 4x/weekly, Intervention 1x /weekly, and Journey Through Life 2x /weekly."
One responsible staff was listed by name only with no specific discipline listed.

e) Patient A9 was admitted 1/5/12. A9's MTP, last updated 4/23/13, listed the problem as "Schizoaffective Disorder".
Interventions included: "Identified staff will monitor [name of patient] on at least a daily basis. When behavior is appropriate, [name of patient] will participate in unit groups/programming for education and treatment." One responsible staff was listed by name, but no discipline. "Additional Staff Responsible: RN/LPN" was also added, with no assignment of responsibility.

f) Patient A23 was admitted on 4/17/13. The MTP, dated 4/25/13, listed a problem of "psychosis". Interventions: "Patient will take medication as prescribed by physician to decrease psychotic symptoms. Patient will attend morning meeting at least 4x /week." Both of these interventions had 2 persons assigned as "Responsible Person" with no delineation of responsibility. The names were present, but no identified disciplines. "Patient will participate in all assigned groups and activities." One identified staff without a designated discipline was assigned as the "Responsible Person."

g) Patient A24 was admitted on 4/11/13. The MTP, last updated 4/17/13, listed
The problem as "Treatment Non-Compliance." Intervention: "Staff will remind [name of patient] to take all medication as prescribed on a daily basis. Staff will encourage [name of patient] to attend the medication management group, as well as other psychosocial groups, in order to gain more insight into the importance of taking medication daily." 2 responsible staff were listed by name, but no discipline, followed by "Additional Staff Responsible: BHRA's and nursing staff." There was no delineation of responsibility for any of the staff assigned.

h) Active sample patient B1 (admitted on 6/11/12) "Client Treatment Plan Report (Scheduled Update)" dated 4/18/13: For the problem "anger management," the intervention "[B1] will take all medication as prescribed" was assigned to two psychiatrists not identified by their credentials on the plan, neither of whom signed the plan, and for a plan which indicated on its signature page that only one of the psychiatrists was actually involved in the patient's treatment. One other staff member whose credential was not provided and who did not sign the plan also was listed as a "responsible party" for the intervention. For the problem "conduct disorder," 4 different staff members were listed as "staff responsible" without any clarity on which staff were assigned to any specific treatment modality. Credentials were not associated with the staff members' names. For the problem "child/parent conflicts," 2 different staff members, as well as a social work intern, were assigned to the same "intervention" (defined as both "individual" and "family" therapies) without clearly stating which staff member was assigned to which of the two modalities being offered. In addition, an intern in a training program would not be considered a "responsible party" for the delivery of a treatment intervention; only a fully-credentialed staff member of the facility can be assigned responsibility.

i) Active sample patient B2 (admitted on 1/7/13) "Client Treatment Plan Report (Scheduled Update)" dated 4/9/13: Although single responsible parties were listed for interventions to address the problem "anger management," each staff member's credential was not included after the name.
For the problem "oppositional defiant," two interventions were listed; however, the designated "staff responsible" for the second intervention "...learning coping skills..." did not sign the treatment plan. No credentials were associated with either of the staff members' names.

j) Active sample patient C1 (admitted on 8/2/12) "Client Treatment Plan Report (Scheduled Update)" dated 4/10/13: for the problem "attention deficit/hyperactivity disorder," the interventions, consisting of recreational activities and community outings, were assigned to B1's classroom teacher, and not to designated nursing or recreation staff.

Failure to update the names of responsible staff on the MTP after a patient is transferred to a new unit:

a) On 4/30/13 at 12:15 p.m., RN #3 stated in an interview that patient A7 was transferred to unit 2C from 3A "over a month ago." When RN #3 was asked to identify some staff on A7's MTP, dated 4/3/13, RN #3 stated that the staff listed on the MTP for the problem of "psychosis" were staff from 3A, not the patient's present unit (2C) staff.

b) Patient A8's MTP was last updated 4/25/13. For the problem - "legal concern - incompetent to stand trial," the name of the responsible staff for the intervention "forensic assessment and legal education as scheduled" was a physician on 3A. The patient's present unit was 3C. For the intervention "Restoration/Education ICST Group" - the social worker listed as responsible staff was assigned to 2C and 4B. She was not the social worker assigned to unit 3C, per RN#8, in an interview on 4/30/13 at 11:30 a.m.

B. Interviews

1. In an interview on 4/30/12 at 12:25 pm, Substance Abuse counselor (SA1), who had just completed running a substance abuse education group, was asked to review active sample C1's "Client Treatment Plan Report (Scheduled Update) dated 4/10/13. Although her name and signature appeared on the plan's signature page, she agreed that her group did not appear as an intervention addressing a named problem and that her name did not appear as a "responsible party" associated with any treatment modality on C1's plan.

2. In an interview on 4/30/13 at 3:30 pm, the Director of Social Work agreed that the social work staff listed as "responsible parties" on MTPs did not include the social worker's credential. She further agreed that the specific modality being carried out by a particular social worker often was not clearly specified on the MTP.

Based on record review, Policy review and interview, the facility failed to ensure that the progress notes of 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1) provided by the physicians responsible for the care of patients related to the goals of the treatment plan and provided statements on progress related to an identified problem (psychiatric, behavioral, or medical). The inability to link the assessment of patient progress, as carried out by the designated responsible physicians, to specific patient problems, goals, and objectives compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs.

Findings include:

A. Record Review

1. The facility's policy H-2520.2.3 "Medical Record Documentation" states on page 5 that notes should document "the client's progress and current status in meeting the goals and objectives of his/her treatment plan."
Psychiatrists only make hand-written chart entries in the progress note section of the medical record when there is an acute issue/occurrence to document. Instead, the attending psychiatrists provide a typewritten monthly note (Medical Care Plan/Update), timed with the treatment planning meeting, that summarizes the psychiatric medication changes and other medical interventions provided during the preceding month. Although summary reports for 9 of 10 active patients (A1, A2, A7, A8, A23, A24, B1, B2 and C1) were present in the medical record, they were not linked to identified problems, goals, or objectives in the patient's master treatment plan (Client Treatment Plan Report). Patient A9, admitted 1/5/12, did not have any physician progress notes since 3/25/13. The interventions to be performed by the attending psychiatrist were not described under an identified problem with associated goal and objective in the treatment plan; nor were medical problems that had been identified in the physical examination or the psychiatrist's Medical Care Plan/Update incorporated into the master treatment plan under identified medical or preventive health problems.

2. Active sample patient A1 (admitted on 7/17/12): Medical Care Plan Update, dated 3/27/13, for the period 1/29/13 to 3/27/13 documented the current DSM (Diagnostic and Statistical Manual) diagnoses, allergies, current psychiatric medications and prn [as needed] medications, discontinued medications, a summary of patient progress to-date including laboratory studies obtained and general health issues. However, the clinical data did not relate to any psychiatric or behavioral problems noted on A1's Client Treatment Plan Report (3/27/13) for the same time period.

3. Active sample patient A2 (admitted on 10/30/12): Medical Care Plan Update dated 4/24/13 for the period 12/4/12 to 1/29/13 (crossed out, but correct interval not added) documented the current DSM diagnoses, provided a summary of psychiatric symptomatology and psychopharmacologic management, and provided a general physical update. However, the clinical data did not relate to any psychiatric or behavioral problems noted on A2's Client Treatment Plan Report (4/24/13) for the same time period.

4. Patient A7 was admitted on 11/7/12. The most recent Master Treatment Plan (MTP) was dated 4/3/13. The one intervention on the plan associated with the physician, plus 4 other staff members, was: "Staff will continue to ask [name of patient] about his current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication and treatment compliance." The only recent Physician Progress Note, dated 3/19/13 at 3:30p.m. and labeled "Late entry, included some of the following information:" "[Name of patient] was seen 3/15/13 after transfer to 2C Transitional Unit. [S/he] notes in the interview that [s/he] has a degree in Psychology but that [s/he] first came ill [sic] at age 25 years old. [S/he] reported doing well enough on Haldol"---"[S/he] had been living at the Independent Living Facility but [s/he] noted [s/he] ended up at the police station not completely dressed in this period of time." The physician's note went on to say that "the patient states [s/he's] ready for discharge if an appropriate setting can be found" - "Continue same medication & [and] plan to discharge when arrangements + [plus] follow up are in place." There was no mention of groups listed in intervention above. There was also nothing about the role and focus the physician would play in treatment.

5. Patient A8 was admitted 8/13/07. The most recent MTP was dated 4/25/13. The Attending physician, along with a psychologist, had one intervention listed. It was "Forensic Assessment and legal education as scheduled." There was a separate "Medical Treatment Plan/update," dated 4/25/13 at 8:00 a.m., which did document information on current DSM diagnoses, medications, medical issues. The "Psychiatric Symptomology Data" section stated: "Pt. has continued to use mixture of gestures and ASL [American Sign Language], though not fluent during this period. Pt. has been performing well and is participating in therapy sessions. Pt. has not shown aggression during this period, though has been involved in confrontation with another pt. that appears to have taken offence to this pt." This note in the "Medical Treatment Plan" did not address any specific focus on the therapy sessions being provided.

6. Patient A9 was admitted on 1/5/12. The most recent MTP, dated 4/23/13, did not contain any physician interventions. There were no Physician Progress Notes since 3/25/13.

7. Patient A23 was admitted on 4/17/13. The most recent MTP, dated 4/25/13, did not contain any physician interventions. There was a patient "Medical Care Plan", dated 4/25/13, with the section called "Psychotic Medical Management - Data" left blank. There were no progress note summaries by the attending noted since 3/25/13.

8. Patient A24 was admitted on 4/11/13. The MTP, dated 4/12/13, had 2 interventions which were for a physician [and an RN]. The interventions read as follow- "Staff will remind [name of patient] to take all medications as prescribed on a daily basis. Staff will encourage [name of patient] to attend the medication management group, as well as other psychosocial group, in order to gain more insight into the importance of these medications daily." There was no weekly progress note by the Attending during the month of April 2013. There was a weekly progress note by a Resident, not signed by the Attending, dated 4/18/13 at 9:00 a.m. The note stated: "Pt. is doing well. [S/he] says [s/he] needs to take [his/her] meds every day instead of every 3 days like [s/he] was before [s/he] arrived. [S/he] is excited about [his/her] treatment here. [S/he] was not interested to go [sic] to groups about substance abuse, but says [s/he] will go if [s/he] has to. No complaints"---"Pt. is level 1 & [and] staff reports no problems." There was no mention of any specific groups/activities. Nor was there any information related to any medication issues from the treatment plan.

9. Active sample patient B1 (admitted on 6/11/12): Medical Care Plan Update dated 4/18/13 for the period 3/21/13 to 4/18/13 documented the current DSM diagnoses, allergies, currently psychiatric and other medications, prescribed medications, prn medications, medical history and current general health issues, but did not provide a description of B1's clinical progress to-date; the summary was not problem-oriented and specific treatment interventions by the psychiatrist were not recounted. There was no correlation to the Client Treatment Plan Report (4/18/13) covering the same time interval.

10. Active sample patient B2 (admitted on 1/7/13): Medical Plan Update dated 4/9/13 for the period 3/12/13 to 4/9/13 documented the current DSM diagnoses, allergies, current list of prescribed medications, prn medications, discontinued medications, and provided a clinical summary of B2's progress during the period as well as general health issues addressed during the interval. However, the clinical data did not relate to any psychiatric or behavioral problems noted on B2's Client Treatment Plan Report (4/9/13) for the same time period.

11. Active sample patient C1(admitted on 8/2/12): Medical Care Plan Update dated 4/10/13 for the period 3/12/13 to 4/10/13 documented the current DSM diagnoses on all 5 axes, allergies, current scheduled medications and prns [as needed], discontinued medications, information on current behavior and general health, but the clinical data were not linked to any specific problem (psychiatric or behavioral) listed on the Client Treatment Plan Report (4/10/13) covering the same time frame.

B. Interview

1. In an interview on 4/30/13 at 11:00 a.m., MD #2 indicated that she thought her treatment interventions were ordering medications, labs, and coordinating medical care for her patients. She indicated that she did not write progress notes in the medical record, but, instead, summarized "what I'm doing" in the Medical Care Update. She agreed that the documentation in the Medical Care Update was not problem-focused and did not indicate how often the psychiatrist actually met with the patient.

2.. In an interview on 4/30/13 at 4:15 p.m., the Medical Director agreed that none of the "Client Treatment Plan Reports" described specific treatment modalities (interventions) with a clear delineation of duration and frequency. She also agreed that the psychiatric and medical interventions were not included in the "Client Treatment Plan Reports" but stated that a synopsis of psychiatric and medical treatments for the previous month was written in a separate "Medical Care Plan/Update." She concurred that the "Medical Care Plan/Updates" for the active sample patients did not delineate specific psychiatric or medical treatment interventions, nor did they relate to problems, goals, and objectives delineated in the "Client Treatment Plan Report, She stated that they summarized the psychopharmacologic management provided by the attending psychiatrist and any care provided by the facility's medical staff and any outside consultants during the interval month as coordinated by the attending psychiatrist.

Based on record review and interview, the facility failed to ensure that nurses regularly recorded the progress of patients in achieving their active treatment goals for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). Nursing progress notes were not related to the problems, goals and objectives described in the treatment plans. Instead, nurse's notes usually related to special occurrences on the unit. This failure results in a lack of evidence that nurses are actually involved in the care of patients.

Findings include:

A. Record Review

1. Facility policy, titled "Medical Record Documentation", Number H-2520.2.3, no date, states: "Interdisciplinary Progress Notes" should be "completed by members of the treatment team on a weekly basis for the first [2] months." Then "updated every[30] days thereafter; more often if needed. The primary nursing care provider for a client[patient] writes at least one progress note per shift depending upon the condition of the client. A registered Nurse or Licensed Practical Nurse is to write a monthly summary progress note on all clients....Notes should be used as the basis for requiring treatment plans and should include the following items:-Documentation of implementation of the treatment plan,...Documentation of the client's progress and current status in meeting the goals and objectives of his/her treatment plan, Documentation of all treatment rendered to the client and results of treatment."

2. Active sample patient A1 admitted on 7/17/12:
Nursing progress note, dated 4/1/13 at 1:10 p.m., stated: - "Pt. [patient] remains on SIB (self-injurious behavior)/assault perk (precautions) Q15 (every 15 minute) checks unit restricted. Pt. ate very little for bkfast/supplement shake given. Pt. continues to c/o general malaise. Medication compliant. Attended some groups on unit....Redirected at x5 [five times] when inappropriately touching peers. Cont. [sic] to monitor."
Progress note on 4/24/13 at 3:15 p.m. stated - "Pt. has attended groups and had meals did hygiene no behavior problems ok all day." There was no reference to specific groups, or the focus and progress of this patient in meeting identified goals from the Master Treatment Plan (MTP).

3. Active sample patient A2 admitted on 10/30/12: Monthly progress note summary on 4/13/13 at 10:00 a.m. stated: "Problem: Psychosis - Pt. remains guarded and paranoid. Pt. continues to have disorganized thoughts. Pt. continues to respond to internal stimuli at xs (times). Pt. continues to deny hallucinations and very little insight to illness. Continues to exhibit negative symptoms of isolation and poor self-care. Pt. prompted/cued to attend therapeutic groups...." Remainder of the note documents medications provided over the month.
Progress note on 4/19/13 3:15 p.m.: "Pt. (with) level 3 Attending groups and meals (without) difficulty. Pt. guarded but able to respond appropriately during conversation. Compliant (with) meds [medications]. Continue to monitor."

Progress note on 4/26/13 2:10 p.m.: "Pt. level 3 Calm pleasant, cooperative. Pt. initiates conversation (with) peers/staff. Makes appropriate eye contact. Pt. affect congruent (with) verbal expression. Compliant (with) meds. Well groomed. Attended groups/meals. Continue to monitor."

None of these notes addressed the patient's focus and/or progress in assigned groups.

4. Patient A7 was admitted on 11/7/12.
The most recent Nursing Summary, dated 4/8/13 at 11:00 p.m., included the following: "Patient remains on level 4 and follows unit rules. Cooperative with staff and compliant with staff giving meds [medications]. Attends groups and unit activities. Uses pass and comes up for meds [medications]. Quiet and stays in [his/her] room a lot. Talks of grandiose things [s/he] will do after leaving LCH [Larue Carter Hospital]. Good ADL's [activities of daily living], pleasant, and no medical problems." The progress note did not address any of the patient's progress toward meeting the goals and objectives listed in the MTP. Nor did it document any specific treatment rendered to the patient and/or the results of such treatment. This pt. was very psychotic; his/her physician filed for commitment and pt arrived at hearing in his/her underwear, saying s/he was there to take care of his/her father's business; this degree of continuing illness was not addressed in the notes.

5. Patient A8 was admitted on 8/12/07. The most recent Nursing Summary in the progress notes, dated 4/24/13 at 10:30 a.m., included the following: "Pt. [patient] remains ICST [Incompetent To Stand Trial]. Level 2 for group activity [needs to be escorted]. PT had no behavior problem in this review period. [S/he] attends groups as scheduled and is compliant with medications. ASL [American Sign Language] interpreter always present on the unit to convey pt.'s need [sic] effectively to the nursing staff "---" Pt. has not had any family visit but speaks to family on video phone. Pt. is on a 2000 [sic] controlled diet with double vegetables." The progress note continued on about current medical issues. The notes did not address any information on the patient's progress toward any goals and objectives listed in the MTP. Nor did the note document any specific nursing treatment rendered to the patient and/or the results of such treatment.

6. Patient A9 was admitted on 1/5/12. The most recent Nursing Progress Notes, dated 4/19/13 (no time), included the following: "Pt. remains a fall risk on 1:1 [one to one] obs [observation] for assault + [plus] safety. Pt. has had several medications changes over the past month." The progress went on to discuss the medication changes and other medical issues related to the patient's diabetes. "Pt. has been attending groups and participating in unit activities. Pt. also still does have episodes of being combative and aggressive. PRN's [as needed] are sometimes effective. Pt. has started going to the business office [with] staff to withdraw money out of her acct [account]." The progress note failed to address any of the patient's progress towards meeting the specific goals and objectives listed on the MTP. Nor did it address any specific interventions and focus, and how the patient was progressing or not progressing toward goal achievement.

7. Patient A23 was admitted on 4/17/13.
The Nursing Weekly Summary, dated 4/21/13 at 9:00 a.m., included the following: "Patient admitted on 4/11/13, diagnosed [with] bipolar disorder. [S/he] has adjusted well to [his/her] move here. Interacted well [with] follow peers and staff. [S/he] has an hx [history] of non-medication compliance. This has not been an issue since coming to LCH [Larue Carter Hospital]. [His/her] bx [behavior] has been appropriate. [S/he] has begun to work up the level system. Is currently a level 1? [S/he] keeps [his/her] self well groomed." This progress note failed to address any of the patient's progress toward meeting the specific goals and objectives listed on the MTP. The notes also did not address any specific nursing treatment interventions and how the patient was responding or progressing toward goal achievement.

8. Patient A24 was admitting on 4/11/13. There was no nursing note listed as a weekly summary. The day shift nursing note of 4/24/13 at 1:30 p.m. stated: "Pt. continues to walk the halls [and] talk to self @ [at] times. [S/he] has been cooperative [with] unit routines. [S/he] continues on 15 min. [minute] checks for escape/assault precautions. Will cont. [continue] to monitor pt. Dad is currently visiting." The progress note did not address any information about specific goals/objective on the patient's MTP or how the patient was responding to them. Specific groups and activities assigned to the patient were also omitted, making it difficult to ascertain how the patient was progressing toward goal achievement.

9. Active sample patient B1 admitted on 6/11/12:
Monthly summary, dated 4/17/13 at 2:30 a.m., stated: "pt. remains alert & oriented x 3. pt. has not had any incidents of seclusion or restraints this review period. Pt. has not been placed on any precautions this past month. Pts. levels this month include Level I x 0 days, Level II x 0 days, Level III x 10 days, Level IV x 27 days....pt remains medication compliant and attends scheduled group therapies. Will continue to monitor as ordered." The remainder of the note details the prn medications received, the medication changes made, the medical appointments obtained, visits which occurred during the preceding month. The progress note did not address specific groups the patient was attending or how the patient was responding to them.

10. Active sample patient B2 admitted on 1/7/13:
On 4/9/13 11:05 p.m., the nursing progress stated: "Pt. went to outer rec [recreational activity off the unit] did ok. Pt. had some minor redirects (without) aggression No other behavioral issues to report at this time. Pt. asleep at this time."
Progress note on 4/17/13 1:20 p.m.Stated: "Pt. attended podiatry follow up (sic) appt. Pt. had ingrown toenail removed on (right) great toe. Upon return to the unit pt. reported discomfort. Pt. given 600 mg ibuprofen po for pain. Pt. able to ambulate, but not without some discomfort. Pt. attended PM school. Will continue to monitor patient. Follow-up (sic) scheduled for 5/1/13 @ 1000."
The progress notes did not address specific groups the patient was attending or how the patient was responding to them.

11. Active sample patient C1admitted on 8/2/12:
Progress Note, dated 4/4/13 at 9:31 p.m., stated "patient participated in group, took shower, and went to dinner. Patient participated in Music Group, ate snack, and cooperated with medication. Patient had a phone call but was asleep. Patient had a good evening. "Progress note, dated 4/9/14 at 11:30 p.m., stated: - "patient had a great evening...Patient took shower, ate dinner, minimal redirects, patient had a group with jada [sic] and attended therapy with social worker, ate snack, went to bed."
Progress note, dated 4/23/13 at 9:29 p.m., stated: "patient participated in goals group, took shower and went to dinner. Patient participated in Social Worker's hygiene group, ate snack and cooperated with medication. Patient went with Social Worker for therapy and then went to bed well. Patient had a good evening."
Progress note, dated 4/26/13 at 3:45 p.m., stated: "patient attend (sic) AM school without any problems attend (sic) talent show @ this time. Also on home visit." Although shift notes mentioned patient participation in some group activities, there were not modality-specific problem-referenced treatment notes that provided information on the focus of the group and the patient's response to the group therapy.

B. Interview

In an interview on 4/30/13 around 10:15 a.m., it was noted to RN#2 that the Nursing Summaries mentioned general groups patients were attending, but did not include information on specific problem goals, objective and how patients were progressing toward discharge readiness. RN #2 did not dispute the findings.

Based on record review and interview, the facility failed to ensure that the social work members of the treatment team for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1) provided written progress notes that presented statements on progress related to identified problem(s), goal(s), objective(s) for which social work interventions were provided. The inability to link the assessment of patient progress, as carried out by the designated responsible social work staff, to identified patient problems, goals, and objectives compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs, and to adequately plan for the patient's successful return to the community.

Findings include:

A. Record Review

1. The facility's policy H-2520.2.3 "Medical Record Documentation" states on page 5 that notes should document "the client's progress and current status in meeting the goals and objectives of his/her treatment plan."

2. Active sample patient A1 admitted on 7/17/12:
A social work progress note dated 3/31/13 at 5:25 p.m. and labeled "Psychoeducation/Discharge Planning" described A1's recent physical violence directed toward staff, and indicated that A1 "is no longer a candidate for discharge at this time. Pt. will have to maintain a level four status and not engage in violent, aggressive behaviors for at least 60 days before referral for discharge will be discussed." Although "frequent contact with patient throughout the month" was noted, neither the duration nor regular frequency of any specific therapeutic modality is described. The social worker's contact with A1 was not associated with any identified problem, goal, or objective on A1's treatment plan.
A social work progress note dated 4/22/13 and labeled "Psychoeducation/Discharge Planning" described A1's current level on the unit and also describes what the social worker discussed with A1 during the session. However, information on the specific treatment modality and on the duration of the session were not provided, nor was the session associated with any identified problem, goal, or objective on A1's treatment plan. The clinician writing the progress note indicated that the session would be the last one held with the patient, but did not provide any information on who would replace her on A1's treatment team, providing social work treatment interventions.

3. Active sample patient A2 admitted on 10/30/12:
A social work progress note written on 4/25/13 at 12:38 p.m.and labeled "Psychoedu/Discharge [sic]" documented "continual contact is made w/ patient's mother regarding outpatient status and treatment. Mother is also contacted regarding med management, education of meds, nature of illness, treatment, and resources available to the family." Reference was also made to contact with A2 - "Pt. has been encouraged to increase independence and socialization skills" - as well as to A2's overall progress. However, the progress note was not linked to an identified problem, goal, or objective on A2's treatment plan, nor does the note describe the actual treatment modality being provided, its duration, or its frequency.

4. Patient A7 was admitted on 11/7/12. The most recent MTP, dated 4/3/13, did not list a role by the social worker, nor were there any summaries of treatment mentioned by this staff from March 19, 2013 on to end of April/2013..

5. Patient A8 was admitted on 8/13/07. The most recent MTP, dated 4/25/13, did not contain any interventions by a social worker. The monthly social work progress note, dated 4/23/13 at 1:30 p.m., stated: "Pt. remains level 1 for routine privileges, but level 2 for groups. Pt. is ICST [Incompetent to Stand Trial] and continues to have little to no progress [sic]. There are currently no plans for discharge due to pt.'s unresolved legal issues." The progress note did not describe any actual treatment being provided by the social worker.

6. Patient A9 was admitted on 1/5/12. The monthly social work summary, dated 3/27/13 at 1:45 p.m., stated: "Pt. remains of [sic] fall risk, 1:1 [one to one] observation for assault and safety. Pt. thought process is loose in conversation. Pt. has mood changes constantly throughout the month both pleasant and irritable [sic]/agitated. Pt. participated in groups weekly and compliant with [his/her] medication. Pt.'s sister/guardian request for medication updates regularly which SW [social work] provided. Dr added a new diagnosis to pt. which is dementia. SW notified pt.'s guardian of update to pt.'s diagnosis. SW will refer pt. [agency] for possible nursing home placement." There was no information on what specific groups the patient was assigned or attending, or the focus, frequency or duration. The note contained just general information.

7. Patient A23 was admitted on 4/17/13. The most recent MTP, dated 4/25/13, did not contain any social work interventions. The weekly social work progress note, dated 4/24/13 at 12:15 p.m., stated: "Pt. remains 15 min VS [15 minute vital signs], but is able to go to the gym with staff escort. [S/he] has been exhibiting bizarre bx [behavior]---For example, [s/he] has been observed writing on the window sill, on the [illegible words], etc. Observed @ [at] times laughing inappropriately &[and] responding to "internal stimuli. Gatekeeper [person who triages patient's process through system] visited this A.M [morning] for initial visit. Pt. was cooperative with the interviewer but presented with a flat affect. Gatekeeper explained that pt. needs to consistently attend groups, be compliant with meds [medications], & earn level 4 [highest level] before discharge." This progress note did not address any of the social worker's role, objectives and focus of treatment for patient A23.

8. Patient A24 was admitted on 4/11/13. The MTP, dated 4/17/13, did not contain any social work interventions. The weekly note by a social worker, dated 4/16/13 at 2:45 p.m., stated: "Pt. remains UR [meaning unknown- not found in facility's policy CH - 2520.2.3 for medical record documentation on abbreviations]. Sleeps @ night & has had [no] bx [behavior] problems. Attends the groups that [s/he] can, compliant with meds, [no] family contact this week. Discharge plan is for pt. to return to semi-independent living program [cluster apt]."---"Will continue to work with pt. & family in meeting discharge criteria." There were no specifics on information on how often social worker will meet with family and/or progress on any specific placement site.

9. Active sample patient B1 admitted 6/11/12:
A social work progress note, dated 4/4/13 at 4:30 p.m., provided information on "family sessions via phone, with both father and grandmother." However, the note was not linked to a specific problem, goal, or objective in B1's treatment plan, nor were the frequency or duration of the sessions provided during the interval described in the progress note.
A social work progress note, dated 4/5/13 at 3:50 p.m., provided documentation of an individual therapy session with B1. However, this note was not linked to a specific problem, goal, or objective in B1's treatment plan, nor was the duration of the session provided in the progress note. In addition, the note was written by a social work student and was not countersigned by the supervising social worker.
A social work progress note dated 4/19/13 provided documentation of an individual therapy session. However, the note was not linked to a specific problem, goal, or objective in B1's treatment plan, nor was the duration of the session provided in the progress note. In addition, the note was written by a social work student and was not countersigned by the supervising social worker.

10. Active sample patient B2 admitted 1/7/13:
A social work progress note, dated 4/9/13 at 12:50 p.m., provided documentation of a recent treatment plan update during which B2's grandparents participated by phone. The note indicated that the social worker planned to meet in person with the grandparents on their upcoming visit to the hospital. However, the note was not linked to a specific problem, goal, or objective in B1's treatment plan, nor did it indicate if family therapy would become a regular treatment intervention provided by social work, and, if so, what the frequency and duration of the sessions would be.

11. Active sample patient C1 admitted 8/2/12: For the month of April, there were no documented social work progress notes for C1 despite the fact that the Client Treatment Plan Report dated 4/10/13 indicated that family therapy was being provided on a weekly basis.

B. Interview

In an interview on 4/30/13 at 3:30 p.m. with the Director of Social Work, the Director acknowledged that her social work staff members were not writing "problem-oriented, modality specific" progress notes. When asked about the quality of documentation related to discharge planning documentation; she stated "we need to capture this better...."

Based on record review and interview, the facility failed to ensure that rehabilitation therapy staff documented in the progress notes responses to treatment rendered for 10 of 10 active patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). This failure results in an absence of information upon which to assess patient responses to interventions thus allowing necessary modifications to current treatment.

Findings include:

A. Record Review

1. Active sample patient A1 admitted 7/17/12:
RT Monthly Note dated 4/21/13 provided documentation on A1's group attendance - "pt. continues to attend (greater than) 75% of scheduled groups." The note also itemized the groups A1 was currently scheduled to attend - "Basic social skills, Health & safety, Alternatives, Building Health relationships, Art/Music on the unit, 217 unit activity, Wellness." The note summarized A1's behavior and attitude across the groups. However, the monthly note did not link the patient's progress to specifically recommended group recreation therapy interventions based on the problems, goals, and objectives described in the treatment plan.

2. Active sample patient A2 admitted 10/3012:
RT Monthly Note dated 4/21/13 provided documentation on A2's group attendance - "Pt. continues to attend (greater than) 75% of scheduled problems (sic); and described the patient's behavior and participation over the interval - "Pt. has slept through x2 (two) groups since last note." The note also itemized the groups A2 was currently scheduled to attend -" Pt. currently scheduled I following groups: basic Social Skills, Workplace fund., Healthy Lifestyles, Cognitive Therapy, Concentration, Art/Music on the unit, Volleyball, Wellness, and unit activities." The note summarized A2's degree of concentration, participation, social behavior across the groups. However, the monthly note did not link the patient's progress to specifically recommended group recreation therapy interventions based on the problems, goals, and objectives described in the treatment plan.

3. Patient A7 was admitted on 1/7/12. The RT Progress Note, dated 4/30/13 at 8:00 p.m. stated, "Pt. has attempted 60 - 70% of [his/her] programs. Trend [sic] of spending more time in [his/her] room - less in programs. Some delusional thought about transporting to a different place by thinking. Pleasant - cooperative." The RT Progress Note did not address specific activity groups or focus for this patient.

4. Patient A8 was admitted on 8/13/07. The Monthly RT Progress Note, dated 4/30/13 at 4:45 p.m., stated: "Pt. remaining on [his/her] level 3 and attends all [his/her] scheduled groups and activities. Pt. has had some issue getting participation pts. [points] as [s/he] stated [s/he] doesn't understand writer and staff will continue to encourage pt. to participate as much as [s/he] can with a [+] [positive] attitude." The note did not address any specific groups or focus for the patient. It just mentioned that A8 was having some difficulty understanding. [A8 has a hearing impairment.]

5. Patient A9 was admitted on 1/5/12. The RT Progress Note, dated 4/8/13 at 1:10 p.m. stated: "[Name of patient] has [his/her] ups and down days. In a good day [s/he] speaks sometimes in the groups and sometimes [s/he] participates in some groups." There was no mention was or the patient's responses to the groups.

6. Patient A23 was admitted on 4/17/13. The RT Weekly Progress Note, dated 4/30/13 at 4:15 p.m., stated: "Pt. continues to do well and has moved to level 2. Pt. participates in all gym activities and it appears to calm [him/her] down. Writer will continue to encourage [+] behaviors.. Gym was considered a leisure activity open to all patients who wanted and could attend based on their levels. It was not an assigned group for A23. There was no mention of specific groups the patient was assigned to from his/her individual activity schedule."

7. Patient A24 was admitted on 4/11/13. The patient's MTP, dated 4/17/13, had no RT interventions listed. The RT Progress Note, dated 4/17/13 at 11:40 a.m., stated: "Initial Assessment computed and placed in chart at this time. Pt. participated appropriately in the assessment. Pt. is adjusting well to the unit. Pt. is attending and participating in groups on the unit such as "Medication Management", "Healthy Lifestyle", and "Using Our Strengths....Pt is wanting to be cooperative with treatment and get out of the hospital [sic]." A review of the patient's individual schedule, dated April 29 - May 3, listed several RT groups assigned, such as "Music Group" on Mondays at 2:00 p.m. and "Ceramics/Art" on Friday at 1:00 p.m. None of these groups contained specific focus for the patient. There was an absence in the progress notes of the patient attending any of these assigned groups.

8. Active sample patient B1admitted 6/11/12: No monthly recreation therapy progress note for the treatment period ending 4/18/13 could be found in the medical record.

9. Active sample patient B2 admitted 1/7/13: No monthly recreation therapy progress note for the treatment period ending 4/9/13 could be found in the medical record.

10. Active sample patient C1 admitted 8/2/12:
The recreation therapy progress note dated 4/10/13 stated "Pt. attended thirty-three RT activities this review. [C1] attended 89% of scheduled gym groups. [C1] participated fully in activities but continued to struggle with getting along with peers. Pt. has a difficult time coping with stress and anger as well as can have a negative attitude....often requires several redirections when annoyed with his peers during an activity....At times [s/he] can be bossy and demanding of [his/her] peers. [S/he] attended eleven other in hospital activities and eight level outings with no reported incidents." Although the progress note describes C1's participation and peer relationships, the note is not problem-oriented, does not relate to patient goals and objectives on the treatment plan and does not indicate what specific recreation therapy treatment modalities were recommended on the treatment plan.

B. Interview

In an interview on 4/30 at 2:00 p.m. with the Rehabilitation Director, the absence of specific group with a focus on the MTP was mentioned. He did not dispute the findings.

Based on record review and interview, the facility failed to ensure that the Discharge Summaries for 3 of 5 discharged patients (D1, D3 and D5) included a summary of all the treatment received in the hospital and the patients' response to treatment other than medications. This failure compromised the effective transfer of the patients' care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for each individual patient.

Findings include:

A. Record Review

1. Facility policy, titled "Medication Record Documentation", Number H-2520.2.3, no date, stated under the section for Discharge Summary: "Hospital course - summarize course and progress of client, [including]: clinical problem, clinical course of client treatment - psychotropic medications, psychotherapy, ECT [Electric Convulsive Therapy], medical treatment, consultations...Rehabilitation and milieu therapies."

2. Patient D1, admitted 7/12/12 and discharged 3/1/13, had a Discharge Summary [called "Separation Summary" at this facility], dated 2/28/13, that included a "Hospital Course" which only addressed medication treatment for mental and physical problems. There was no mention of psychosocial treatment interventions in the "Hospital Course" section.

3. Patient D3, admitted 1/14/13 and discharged 3/25/13, had a Discharge Summary, dated 4/1/13, that addressed only the medication treatment in the "Hospital Course" section.

4. Patient D4, "Separation Summary," dated 4/1/13, with a discharge date of 3/27/13, summarized the various psychotropic medications that were prescribed over the patient's course. No summary of the psychosocial, psychotherapeutic, or rehabilitative/leisure activities provided to the patient were described.

4. Patient D5, "Separation Summary," dated 3/27/13, with a discharge date of 3/27/13, summarized the patient's absence of adverse behavioral issues and the patient's mental status, but did not summarize the therapeutic modalities offered the patient during the hospitalization.

B. Interview

In an interview on 5/1/13 at 11:45 AM, the Medical Director agreed that the descriptions provided in the "hospital course" section of the "Separation Summary" for the noted samples did not adequately describe the treatments provided to the patient during the hospitalization or provide information on the patient's response to the treatment provided.

Based on record review and interview, the facility failed to ensure that the arrangements for continuing care after discharge were described for 1 of 5 sample discharge patients (D4), with specific appointment dates, and names and addresses of the service providers, as well as documentation of the patient's living arrangement after discharge. This failure results in a lack of clarification that the patient will receive the necessary care and services in a timely fashion in the context of a safe living environment consistent with the patient's needs.

A. Record Review

Patient D4's "Separation Summary," dated 4/1/13, with a discharge date of 3/27/13, did not contain information on the services and treatment that the patient would be receiving after discharge. Where the patient would be residing was not documented. Associated discharge documents, "Discharge Instructions for Continuity of Care," and "Discharge/Leave Instructions," did not contain this information.

B. Interview

In an interview on 5/1/13 at 11:45 a.m., the Medical Director agreed that none of the discharge-related documents ("Separation Summary," "Discharge Instructions for Continuity of Care," and "Discharge/Leave Instructions,") for discharge sample D4 documented the arrangements for the patient's services and supports after discharge from the facility.

Based on record review and interview, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to ensure that:

1. The findings of physical and neurological examinations performed were completely documented in 4 of 10 active sample patients (A9, A24, B2, and C1). The absence of this patient information limits the clinician's ability to accurately diagnose the patient's condition, to provide a measure of baseline functioning, and also potentially to provide necessary medical treatment. (Refer to B109.)

2. The Master Treatment Plans (MTPs) for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1) were comprehensive, integrated, and included all necessary elements. Treatment plans in this Facility were called "Client Treatment Plan Reports." Physicians [psychiatrists) entered very few interventions on the MTPs. Instead they developed separate "Medical Care Plans" and "Medical Care Plan Updates for all active sample patients. These plans were summaries of the medical and psychiatric services provided over the preceding month. The content recapitulated the patient's multi-axial diagnoses, allergies, current and discontinued medications, a general summary of progress, and any physical medicine interventions provided. Specific psychiatrist and internal medicine/family practice interventions were not described, and the plan bore no relationship to the "Client Treatment Plan Report" or "Client Treatment Plan Report (Scheduled Update)" developed by some psychiatrists and other non-medical members of the treatment team. These "Medical Care Updates" functioned more as monthly summaries of psychiatric care and other medical services than updated treatment plans.
MTPs were missing components such as (1) the inclusion of active medical problems and how they were being addressed by physicians and nurses (See B126 and B127); (2) the delineation of specific treatment modalities that would be brought to bear by the individual members (i.e. physicians, nurses, social workers, substance abuse counselors, rehabilitation therapists) of the interdisciplinary team in addressing the identified patient problems and (3) the identification of the individual team members responsible for carrying out the treatment modalities. The absence of an integrated, comprehensive written treatment plan results in a lack of coordinated and organized treatment, hampers the staffs' ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems, and presumes that the oral communication of treatment focus will be sufficient for the provision of comprehensive and integrated treatment. (Refer to B118.)

3. The treatment plans of 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1) identified active treatment measures that addressed the individual patient specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions inappropriately written as treatment interventions or listed groups/activities to be provided for the patients as the intervention. The listed "interventions" failed to include the specific focus of treatment. In addition, some of the treatment plans failed to include interventions by key staff, such as a physician, nurse and/or social worker. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific interventions needed and the purpose for each. These failures potentially result in inconsistent and/or ineffective treatment. (Refer to B122.)

4. The responsible staff listed next to the interventions on the Master Treatment Plans included each person's discipline for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). Many of the Master Treatment Plans listed multiple persons, by name or discipline only, as being responsible for the same intervention. There was no delineation of functions from one discipline to another. In addition, the responsible persons were not updated on 2 of 10 Master Treatment Plans (A7, A8) when the patient moved from one unit to another. These practices result in the facility's inability to monitor staff accountability for specific treatment interventions. (Refer to B123.)

5. The progress notes of 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1) provided by the physicians responsible for the care of patients related to the goals of the treatment plans, and provided statements on progress related to an identified problem (psychiatric, behavioral, or medical). The inability to link the assessment of patient progress, as carried out by the designated responsible physicians, to specific patient problems, goals, and objectives compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs. (Refer to B126.)

6. Nurses regularly recorded the progress of patients in achieving their active treatment goals for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1). This failure results in a lack of evidence that nurses are actually involved in the care of patients. (Refer to B127.)

7. The social work members of the treatment team for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2, and C1) provided written progress notes that presented statements on progress related to identified problem(s), goal(s), objective(s) for which social work interventions were provided. The inability to link the assessment of patient progress, as carried out by the designated responsible social work staff, to identified patient problems, goals, and objectives compromises the treatment team's ability to ensure that comprehensive and integrated treatment is being provided to meet all the identified patient needs, and to adequately plan for the patient's successful return to the community. (Refer to B128.)

8. Rehabilitation therapy staff documented in the progress notes responses to treatment rendered for 10 of 10 active patients (A1, A2, (A7, A8, A9, A23, 24, B1, B2 and C1). This failure results in an absence of information upon which to assess patient responses to interventions thus allowing necessary modifications to current treatment. (Refer to B129.)

9. The Discharge Summaries for 3 of 5 discharged patients (D1, D3 and D5) included a summary of all the treatment received in the hospital and the patients' response to treatment other than medication. This failure compromised the effective transfer of the patients' care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for each individual patient. (Refer to B133.)

10. The arrangements for continuing care after discharge were described for 1 of 5 discharged sample patients (D4), with specific appointment dates, and names and addresses of the service providers, as well as documentation of the patient's living arrangement after discharge. This failure results in lack of clarification that the patient will receive the necessary care and services in a timely fashion in the context of a safe living environment consistent with the patient's needs. (Refer to B134.)



Interviews

1. In an interview on 4/30/13 at 4:15 p.m., the Medical Director agreed that physical examination reports and neurological examinations in 4 of 10 active sample patients(A9, A24, B2 and C1) were incomplete. In a discussion of the Master Treatment Plans (MTPs), the Medical Director concurred that, for 10 of 10 active sample patients (A1, A2, A7, A8, A9, A23, A24, B1, B2 and C1), the MTPs lacked identified active treatment measures that addressed specific patient problems; that listed "interventions" failed to include the specific focus of treatment; that some of the treatment plans failed to include interventions by key staff, such as a physician, nurse and/or social worker; and that many MTPs listed multiple persons as being responsible for the same intervention. In a discussion of chart documentation, the Medical Director agreed that the progress notes written by staff across the various disciplines providing care (e.g. psychiatry, medicine, nursing, social work, psychology and rehabilitation therapy) did not link the assessment of patient progress, as carried out by the designated responsible staff member, to specific patient problems, goals and objectives.

2. In an interview on 5/1/13 at 11:45 a.m., the Medical Director agreed that the Discharge summaries of 3 of 5 discharged patients (D1, D3 and D5) failed to provide a summary of all treatment received during the hospital course; and that arrangements for continuing care after discharge was not documented in the Discharge Summary of 1 of 5 discharged sample patients (D4).

Based on record review and interview, the facility failed to: monitor the quality and appropriateness of nursing care. Specifically, the Nursing Director failed to:

1. Ensure that the Master Treatment Plans (MTPs, called "Client Treatment Plan Reports" in this facility) for 6 of 10 active sample patients (A2, A7, A8, A9, A2 and, A24) had specific nursing interventions that included a focus, frequency and duration. The nursing interventions were generic functions of the discipline. Some of the objectives for the interventions were staff related, not patient related (what the staff wanted the patient to do.) 4 of 10 MTPs did not have patient interventions by nursing staff (A1, B1, B2 and C1).
The absence of specific nursing interventions hampers the staffs' ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems, and presumes that the oral communication of treatment focus will be sufficient for the provision of comprehensive treatment.

Findings include:

A. Lack of specific Nursing Interventions in the Master Treatment Plans.

1. Active sample patient A2, admitted 7/17/12, "Client Treatment Plan Report (Scheduled Update)", dated 4/24/13: Interventions for the problem "independent activities of daily living (IADL) stated "aid the client in developing a specific schedule for completing IADLs (e.g. morning self-care/hygiene, medication, clean room and make bed prior to morning meeting Monday (sic) through Friday (sic), etc." These are generic nursing care tasks and are not specific treatment modalities.

2. Patient A7 was admitted 11/7/12. A7's Master Treatment Plan (MTP), last updated 11/3/12, listed a problem as- "The patient has a history of psychotic thinking, physical aggression, paranoia, and treatment non-compliance."
Interventions - "Staff will continue to ask [name of patient] about [her/his] current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication education and treatment compliance." At the end of this intervention, the following was included - "Additional staff responsible: RT and nursing staff and needed [sic]."
This intervention listed generic functions, and groups without a specific focus, frequency or duration to help meet the patient's needs. The nursing staff associated with this intervention were not listed by name.

3. Patient A8 who is hearing impaired was admitted 8/13/07. A8's Master Treatment Plan (MTP), last updated 4/25/13, listed the problem - "Expressive and receptive language deficits."
Objective - "[Name of patient] will be encouraged daily to persist in attempts to communicate using words, gestures, and ASL [American Sign Language] to get his needs met and participate in formal assessments." I nurse and 3 Behavioral Health Recovery Associates were listed as responsible persons. This "objective" is really a staff intervention.

4. Patient A9 was admitted 1/5/12. A9's MTP, last updated 4/23/13, listed the problem as "Schizoaffective Disorder." "[Name of patient] is diagnosed with Schizoaffective Disorder, per past assessments. [Her/his] thinking is poor and is easily distracted. [S/he] denies hallucinations but can be observed responding to internal stimuli."
Interventions included: "Identified staff will monitor [name of patient] medication compliance and effectiveness on at least a daily basis. When behavior is appropriate, [name of patient] will participate in unit groups/programming for education and treatment." This is a generic intervention without a specific focus, frequency or duration. RN/LPN were identified as "Additional Staff Responsible."

5. Patient A23 was admitted 4/17/13. The MTP, dated 4/25/13, listed a problem of "psychosis." "Patient responds to verbal stimuli, hears voices of enlightenments."
The following nursing intervention listed was: "Patient will take medication as prescribed by physician to decrease psychotic symptoms." A nurse was included as a responsible person; the nurse's function was not spelled out..

6. Patient A24 was admitted 4/11/13. The MTP, last updated 4/17/13, listed the problem as "Treatment Non-Compliance." "[Name of patient] has a history of not taking [his/her] psychiatric medication; especially when out in the community." The objective was: "[name of patient] will take all medication as prescribed on a daily basis." The intervention was: "Staff will remind [name of patient] to take all medication as prescribed on a daily basis. Staff will encourage [name of patient] to attend the medication management groups as well as other psychosocial groups in order to gain more insight into the importance of taking medication daily." The responsible staff included a nurse. There was no specific focus, frequency or duration of the intervention, and the function of the nurse was not spelled out.

B. Master Treatment Plans that did not have Nursing interventions by a professional nurse.
The following active sample patients (date of most recent MTP in parentheses), did not list any RN interventions: A1 (3/27/13), B1 (MTP dated 4/18/13), B2 (MTP dated 4/9/13) and C1 (MTP dated 4/10/13).

II. Ensure that nursing staff were identified on the Master Treatment plan Interventions by name and discipline for 6 of 10 active sample patients (A2, A7, A8, A9, A23 and A24).

Findings include:

A. Record review

1. Active sample patient A2, admitted on 10/30/12, "Client Treatment Plan Report (Scheduled Update)" dated 4/24/13: The intervention for the problem "psychosis" ("reinforce the client for initiating appropriate social interaction with others daily. Encourage patient to attend 100% of all group activities.") listed 4 staff members by name as "responsible staff " without any clear delineation of what treatment modality each would be utilizing. No credentials were associated with the staff member's names.
For the intervention associated with the problem "independent activities of daily living (IADL)," 4 different staff members were assigned by name without any delineation of which staff member was responsible for any specific treatment modality. No credentials were associated with the staff members' names, one of whom was a nurse, per interview with RN#1 on 4/29/13 at 11:30 a.m.

2. Patient A7 was admitted on 11/7/12. The Master Treatment Plan (MTP), updated 4/3/13, listed the problem as- "The patient has a history of psychiatric thinking, physical aggression, paranoia, and treatment non-compliance."
An intervention was - "Staff will continue to ask [name of patient] about [her/his] current psychotic symptoms, monitor medication, and assign programming to address reality orientation, symptom management, diagnosis education, medication education and treatment compliance." Four responsible staff from the patient's previous unit were listed by name, but not by discipline, and with no delineation of responsibility. At the end of this intervention, the following was included - "Additional Staff Responsible: RT and nursing staff and [sic] needed."

3. Patient A8 was admitted 8/13/07. A8's MTP, last updated 4/25/13,
listed the problem as- "Expressive and receptive language deficits."
Nursing interventions included: "3C staff will encourage and reinforce attempts to verbal or manual communication, Unit meeting 4x/weekly, Intervention 1x/weekly, and Journey Through Life 2x/weekly."
One responsible staff was listed by name only, without discipline identified,. In an interview on 3/29/13 at 11:30 a.m., RN#1 identified the responsible person as a nurse.

4. Patient A9 was admitted 1/5/12. A9's MTP, last updated 4/23/13, listed the problem as "Schizoaffective Disorder".
Interventions included: "Identified staff will monitor [name of patient's] on at least a daily basis. When behavior is appropriate, [name of patient] will participate in unit groups/programming for education and treatment." One responsible staff was listed by name, but not by discipline. At the end of the intervention was the statement: "Additional Staff Responsible: RN/LPN." There was no delineation of responsibilities for each of the staff assigned to carry out this intervention.

5. Patient A23 was admitted on 4/17/13. The MTP, dated 4/25/13, listed a problem of "psychosis".
Interventions:

a. "Patient will take medication as prescribed by physician to decrease psychotic symptoms. Patient will attend morning meeting at least 4x /week." Both of these interventions had 2 persons assigned as "Responsible Person" with no delineation of responsibility. The names were present, but no identified disciplines.

b. "Patient will participate in all assigned groups and activities." One identified staff without a designated discipline was assigned as the "Responsible Person." The staff was identified by RN#1 as a nurse.

6. Patient A24 was admitted on 4/11/13. The MTP, last updated 4/17/13, listed the problem as "Treatment Non-Compliance." Intervention: "Staff will remind [name of patient] to take all medication as prescribed on a daily basis. Staff will encourage [name of patient] to attend the medication management group , as well as other psychosocial groups, in order to gain more insight into the importance of taking medication daily." 2 responsible staff were listed by name, but no discipline, followed by "Additional Staff Responsible: BHRA's and nursing staff." There was no delineation of responsibility for each of the staff assigned to carry out this intervention..

III. That there was adequate numbers of registered nurses (RNs) on many hours of duty to provide direct patient care and to supervise non-professional nursing personnel (LPNs - licensed practical nurses, and BHRAs - Behavioral Health Recovery Associates (also known as Mental Health Technicians). The Nursing Director listed "zero" RNs for 15 of 21 shifts reviewed for the period of 4/19-21/13 and 4/26-29/13 (3 shifts/day x 7 days of staff analysis on 7 locked units and 1 unlocked unit). In addition, there were 3 instances over a 3 day period where a nurse was covering two units on a shift, with no LPN back-up on one of the units, resulting in no licensed nursing staff present on a unit during the times the RN was on the second unit providing patient care and staff supervision. These two situations result in a lack of consistent professional nursing presence to provide on-going patient assessments, and direction and supervision of non-professional nursing personnel. The lack of RN staff also creates a potential safety issue for the patients. Refer to B149.

Interview

In an interview on 4/30/13 at 4:20 p.m. with the Nursing Director, the concern over number of "zero" RN staff found on the nurse staff analysis dated 4/19/13 - 4/20/13 and 4/26/13 4/29/13 was discussed. The Nursing Director did not agree with the findings: he felt the number of "zero" RNs was not that high. The Nursing Director stated, "I work hard to get nursing coverage. I even approve ahead of time a lot of agency nurses and overtime for staff nurses. I do the best I can."
The "nursing staffing minimum" sheet (used by the Facility to determine number of staff needed for each unit) was also discussed with the Nursing Director. It was pointed out to the Nursing Director that the "minimum staff" just says how many staff, i.e. "5 staff, 3 staff", and fails to identify the type and number of nursing staff for each shift, i.e. 1 RN, 1 LPN, 3 BHRAs. The Nursing Director did not try to clarify that.

Based on record review and interview, the Nursing Director has failed to provide adequate numbers of registered nurses (RNs) on many hours of duty to provide direct patient care and to supervise non-professional nursing personnel (LPNs - licensed practical nurses, and BHRAs - Behavioral Health Recovery Associates (also known as Mental Health Technicians). The Nursing Director provided "zero" RNs for 15 of 21 shifts reviewed (3 shifts/day x 7 days of staff analysis on 7 locked units and 1 unlocked unit). In addition, there were 3 instances over a 3 day period where a nurse was covering two units on a shift with no LPN back-up on one of the units, causing no licensed nursing staff present on a unit during the times the RN was on the second unit providing patient care and staff supervision or off the unit for reasons such as lunch.. These two situations result in a lack of consistent professional nurses to provide on-going patient assessments, and direction and supervision of non-professional nursing personnel. The lack of RN staff also creates a potential safety issue for the patients.

Findings include:

A. Record Review

The facility is currently operating 8 patient units on 3 different floors (number of unit co-insides with its floor location in the building). There are 5 adult units (2A, 2C, 3A, 3C and 3E), 1 Children's unit (4C), and 2 Adolescent units (4C girls and 4E boys). All the patient units were locked except one (2C), which is an Adult Transitional program for preparing identified patients for discharge. 7 days of nurse staffing was provided by the Director of Nursing for the period of 4/19/13 to 4/21/13 (3 days) and 4/26/13 to 4/29/13 (4 days). An analysis of the data revealed the following: 15 of 21 shifts during this period of time had "zero" RNs:

1. Locked Adult unit 2A- On 4/21/13 on the 3-11 shift, census 18, there was "zero" RN staff. The patients were diagnosed primarily as Attention Deficit Hyperactive Disorder (ADHD) and Oppositional Defiant Disorder (ODD). The licensed nurse on the unit was an LPN. The nursing needs assessments sheet for this unit, dated 4/29/13, listed 9 potentially assaultive patients; 2 patients with high potential for self-injury (requiring close observation); 9 patients who were experiencing active hallucinations/delusions and were in potential jeopardy (health safety) due to their symptoms, thus requiring close monitoring by nursing staff; 6 patients on medication; 4 patients constantly demanding staff time (i.e. requests, interruptions); and 3 patients who were on special monitoring due to eating disorders.

2. Unlocked Adult Unit 2C had "zero" RN on 4/19/13 on 11-7 shift (current census 8); "zero" RNS on 4/22/13 and 4/29/13 on 3-11 shifts (current census 7 each day). All 3 shifts had a LPN as the licensed nurse on the unit. The nursing needs assessment sheet dated 4/29/13 listed: 4 patients as being potential assaultive; 1 low risk suicidal patient; and 4 patients experiencing hallucinations/delusions.

3. Locked Adult Unit 3E - had "zero" RN on 3-11 shift (current patient census 14). The patients were medically compromised. The licensed nurse on the shift was an LPN. The nursing needs assessment sheet dated 4/29/13 listed: 1 total physical patient care; 6 requiring partial assistance; 2 patients requiring partial assistance with mobility and 1 requiring total assistance with mobility; 3 diabetic checks; 2 assaultive/violent patients; 1 actively assaultive (had evidenced physically/verbally within 48 hours); 6 patients experiencing hallucinations/delusions; 2 on medication; 1 patient receiving ECT (Electric Convulsive Therapy); 7 constantly demanding staff time; 2 patients on 1:1 supervision; and 1 patient on constant line of sight supervision.

4. Locked Adult Patient Unit 3C had "zero" RN on 4/25/13 on 11-7 shift (current census 23 clinically ill patients). The licensed nurse on the unit was an LPN. The nursing needs assessment sheet, dated 4/24/13 listed: 1 diabetic check; 3 patients requiring partial physical assistance from staff; 1 patient requiring partial assistance with mobility; 1 patient on seizure precaution; 5 potentially assaultive patients; 5 patients with hallucinations/delusions; 5 patients on medication; 1 patient receiving ECT; and 4 patients demanding staff time.

5. Locked Children's Unit 4B had "zero" RN on 4/21/13 7-3 shift (census 11). The unit was covered by a LPN. The nursing needs assessment sheet, dated 4/29/13 listed: 11 patients requiring partial assistance from staff with physical care; 5 patients potentially assaultive; 3 actively assaultive; 11 requiring medication; 3 patients on assault precautions; 1 on full precautions; 11 constantly demanding staff time; 2 on 1:1 (one to one) supervision; and 11 who were on special monitoring due to eating disorder.

6. Locked Female Adolescent Unit 4C had "zero" RN on 4/19/13 (census10) and 4/27/13 (census 9) for 3-11 shifts. 4C also had "zero" RN on 4/19/13 (census10) and 4/28/13 (census 11) for 11-7 shifts. All 4 shifts had an agency LPN on duty during these shifts. The nursing needs assessment sheet, dated 4/28/13 listed: 8 patients requiring partial staff assistance with physical care; 1 patient needing a dressing change; 7 requiring skin care; 2 actively assaultive; 1 intermediate risk for suicide; 1 patient with acute risk for suicide; 2 on medications; 6 patients hallucinating/delusional; 2 on assault precautions; 1 on elopement precautions; all patients demanding staff time; 2 on 1:1 supervision; and 4 on line of sight supervision.

7. Locked Male Adolescent Unit 4E had "zero" RN on 4/20/13 7-3 and 11-7 shifts (census 10), 4/21/13 3-11 shift (census 10), and 4/8/13 3-11 shift (census 11). All 4 shifts listed had an agency LPN as the licensed nursing staff on duty. The nursing needs assessment sheet, dated 4/29/13 listed: 1 patient requiring dressing changes; 1 on seizure 6. Locked Female Adolescent Unit 4C had "zero" RN on 4/19/13 (census10) and 4/27/13 (census 9) for 3-11 shifts. 4C also had "zero" RN on 4/19/13 (census10) and 4/28/13 (census 11) for 11-7 shifts. All 4 shifts had an agency LPN on duty during these shifts. The nursing needs assessment sheet, dated 4/28/13 listed: 8 patients requiring partial staff assistance with physical care; 1 patient needing a dressing change; 7 requiring skin care; 2 actively assaultive; 1 intermediate risk for suicide; 1 patient with acute risk for suicide; 2 on medications; 6 patients hallucinating/delusional; 2 on assault precautions; 1 on elopement precautions; all patients demanding staff time; 2 on 1:1 supervision; and 4 on line of sight supervision.

Incidents on staffing analysis for same period as above where 1 RN had to cover 2 different patient units, resulting in less than 1 full time equivalent registered nurse for a unit.

1. On 4/27/13 on 7-3 shift 1 RN covered Unit 2C (an open Adult Unit) on the second floor and 3C (a locked Adult Unit) one floor above 2C on the third floor. Census on 2C was 8 and on 3C was 11. 3C housed non-English speaking, clinically ill and hearing impaired patients. The number of RN staff listed on staffing analysis sheet (4/19/13 - 4/21/13 and 4/26/13 - 4/29/13) was 0.25 RN and "zero" LPN on 2C on 7-3 shift on 4/27/13 and 4/28/13. The same RN spent 0.75 time on unit 3C on 4/27/13 7-3 shift. There was1 LPN on the shift.

2. On 4/28/13 on 7-3 shift 1 RN covered unit 2C and 3C. Census on 2C was 7 and on 3C was 23. The RN staff for this shift was listed as 0.25 RN ( "zero" LPN) on 2C and 0.25 RN and 1 agency LPN.

3. On 4/26/13 one RN covered 4B (locked Children's Unit) and 4E (locked Adolescent
Male Unit) on 11-7 shift. Census on 4B and 4E were 11patients each. The one RN's time was divided as 0.5 RN on 4B and 0.5 RN on 4E. Neither unit had an LPN assigned to serve as backup when the RN was on the other unit - a potentially dangerous situation of patients' safety, with the absence of an RN's presence at all times to monitor both patients and non-professional staff.

B. Staff Interview

1. In an interview on 4/29/13 at 11:45 a.m., RN #2 was asked what s/he felt about RN staffing coverage in the facility. RN #2 stated, "There is definitely a shortage. I'm the only nurse on and I need help with medications and an admission." When asked if s/he had requested additional help, RN #2 stated, "Yes, but, you see, so far I am still the only one (RN) here."

2. In an interview on 4/29/13 at 12:15 p.m. about RN staff coverage, RN #1 was asked who covers the RN during lunch period when there is only 1 RN scheduled on a shift. RN #1 stated, "We leave the keys with a nurse on another unit while we are at lunch." When asked what nursing staff remained on the unit during the nurse's absence, RN #1 stated, "The BHRAs (Behavioral Healthcare Associates/Mental Health Technicians)."

3. In an interview on 4/30/13 at 4:20 p.m. with the Nursing Director, the concern over number of "zero" RN staff found on the nurse staff analysis dated 4/19/13 - 4/20/13 and 4/26/13 - 4/29/13 was discussed. The Nursing Director did not agree with the findings: he felt the number of "zero" RNs was not that high. The Nursing Director stated, "I work hard to get nursing coverage. I even approve ahead of time a lot of agency nurses and overtime for staff nurses. I do the best I can." The "nursing staffing minimum" sheet (used by the Facility to determine the number of nurses needed for each unit) was also discussed with the Nursing Director. It was pointed out to the Nursing Director that the "minimum staff" just says how many staff, i.e. "5 staff, 3 staff", and fails to identify the type and number of nursing staff for each shift, i.e. 1 RN, 1 LPN, 3 BHRAs. The Nursing Director did not try to clarify that.

Based on record review and interview, the Rehabilitation Therapy staff failed to plan and implement programming of therapeutic/leisure activities on the evening and weekend shifts for 6 of 8 inpatient units (2A, 3A, 3C, 3E, 4C and 4E). Per evening and weekend schedules and staff interviews, only patients on level 2 or above may participate in these activities, which are primarily held off unit in such places as the gym, library or outdoors. There were currently 25 patients who were on level one and could not go off the unit to these activities. In addition, the weekend activities were optional for those patients who could go off the unit. This deficiency results in an absence of therapeutic activities on evenings and weekends for the level one patients who have to remain on the unit(s).

Findings include:

A. Record Review

1. A review of the individual schedule for active sample patient A24 on Unit 3A revealed that activity groups were scheduled Monday through Friday during the 7-3 shift. An Adult Evening schedule dated April 29 - May 5, 2013, hanging on the bulletin board near the nurse's station, listed three to 6 groups from 4:00 - 7:00, but all of the groups were in off unit areas. A weekend activities list dated for Saturday May 4 and Sunday May 5 listed 8 activities between 9:00 a.m. and 3:00 p.m. on Saturday and 6 activities on Sunday between the hours 9:00 a.m. and 8:00 p.m. Both schedules had a "Reminder" at the bottom of each page stating "A level 2 or above is required for all evening and weekend activities."

2. Unit charge nurses or unit directors (who are also registered nurses) were asked on 5/1/13 to provide the number of patients on level 1 on each of their units, to ascertain how many people could not benefit from the evening and weekend off unit activities. Unit 2C, a transitional unit (patients being prepared to return to the community), and 4B (a Children's Unit) were both omitted. (Unit 2C was an unlocked unit and patients could come and go unattended. The Children's Unit had a special program separate from the Adolescent and Adult patients.) The total number of level one patients was 25 out of a possible 123 (minus 12 beds on unit 2C and 11 beds on 4B) as follows: unit 2A had 2 level ones, 3A - 8, 3C - 8, 3E - 5, 4C - 7 and 4E - 2.

B. Interviews

1. In an interview on 4/29 at 11:00 a.m., RN #3 was asked why many of the patient schedules only showed or listed activities Monday through Friday and did not include evening and weekend activities. RN #3 stated that most evening and weekend activities were leisure. RN#3 said, "Patients can choose to go or not. It's their call."

2. In an interview on 4/29/13 at 3:30 p.m., active sample patient A24 was asked about the weekend activities schedule and what s/he thought about it. S/he stated, "We have an option, we either choose to attend or sleep."

3. In an interview on 4/29/13 at 3:00 p.m. with MHT #2 (called Behavioral Health Recovery Associate, or BHRA, at this facility), s/he was asked to describe the patient's weekday versus weekend activities at this facility. MHA #2 stated, "The weekend activities are leisure and the Monday through Friday ones are more formal." MHT #2 went on to say that the patients must go to weekday groups or risk losing their privileges (levels), but are free to do whatever they want on the weekend.

4. In an interview on 4/30/13 at 2:00 p.m. with the Rehabilitation Director, he confirmed that the evening and weekend activities, which were leisure in nature and provided by his staff, were primarily held off the patient units for patients who had off unit privileges.