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Based on record review, observations and interviews, the facility failed to:

I. Revise the Master Treatment Plan (MTP) after multiple episodes of restraint of 1 of 2 active sample patients (S38) on the Seguin Unit. The MTP was not updated to address less restrictive interventions to be used by staff to assist Patient S38 to achieve treatment objectives regarding controlling episodes of aggressive behavior. In addition, the facility failed to revise the MTP for 1 of 3 active sample patients (L1) on the Casa Amistad Unit. This patient had no MTP to address current psychiatric problems after being transferred back to the Casa Amistad Unit in Laredo following a three month hospitalization on the Arnold Unit in San Antonio. Failure to do needed revisions of treatment plans results in patients being hospitalized without a treatment plan that adequately reflects the patients' treatment needs, potentially delaying improvement and discharge. (Refer to B118-I)

II. Ensure that Master Treatment plans of 9 of 11 active sample patients (A1, A8, L4, L6, N9, N14, S10, S38 and T17) whose treatment plans were reviewed consistently defined short and long term goals as specific, measurable patient behaviors to be achieved. [Note: sample patient L1 had MTP to review]. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans. (Refer to B121)

III. Ensure that the Master Treatment Plans of 11 of 11 active sample patients whose treatment plans were reviewed (A1, A8, L4, L6, N6, N9, N14, T17, T37, S10 and S38) identified individualized interventions to address the patients' presenting problems and treatment goals. [Note: Patient L1 had no MTP to review].The Master Treatment Plans (MTPs) of the 11 sample patients contained generic and routine discipline functions instead of individualized treatment interventions. The frequency of staff contact and/or the modality (individual or group sessions) was not specified: for registered nurses on the MTPs of 5 patients (A1, A8, L6, S10 and S38); for social work on the MTPs of 8 patients (L4, L6, N6, N9, N14, T17, T37 and S10); for rehabilitation staff on the MTPs of 4 patients (A1, A8, L4 and L6); and for psychology on the MTPs of 2 patients (A1 and T17). In addition, there were no physician interventions on any of the 11 patients' MTPs and no rehabilitation staff interventions on the MTPs of 3 patients (N6, N9 and N14). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

IV. Provide active treatment, including alternative interventions, for 9 of 12 active sample patients (L1, L4, L6, N6, N9, N14, S10, S38, and T17). These patients were either not cognitively capable of participating in assigned treatment or were not motivated to attend the assigned groups. Observations of groups provided on the units revealed that the interventions failed to relate to the specific problems and needs of the above patients. These failures result in patients being hospitalized without all interventions for recovery being provided, potentially delaying their improvement. (Refer to B125-I)

V. Ensure that a physician did a face to face evaluation for 1 of 1 active sample patient (N14) and 3 of 7 non-sample patients (SR1, SR2, and SR3) whose records were reviewed for compliance with seclusion/restraints policy and procedures. For patient N14, the physician wrote a progress note on a restraint incident but stated that he did not provide a face to face evaluation. For Patients SR1, SR2, and SR3, the physician, who was located at the main campus 150 miles from the Casa Amistad unit where these patients were located, used a television monitor to view RNs doing the 1 hour assessment instead of visiting the patients in person. This did not meet the requirements for a face to face evaluation as stipulated in the facility's Patient's Rights Policy. In addition, the physician failed to document the results of the face to face evaluation for 2 of the 7 non-sample patients (SR5 and SR6) whose charts were included in the review for seclusion/restraint compliance. Failure to provide face-to-face assessments by a physician or other qualified clinician also can result in a risk to the patient's life and well-being. (Refer to B125-II)

VI. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety or sedating medications for 1 of 7 non-sample patients added for review of seclusion/restraint (SR7). For this patient, physician orders were written on a PRN (as necessary) basis for vague symptoms labeled "anxiety" or "psychosis." Nurses were allowed to choose the administration route for the same dose of medications by "IM" (intramuscular injection) or "p.o." (by mouth). Additionally, Patient SR7 had PRN orders for at least two medications for similar symptom indications, without specific guidance to nursing as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders also can result in serious complications from improperly administered PRN medications. (Refer to B125-III)

Based on record review and interviews, the facility failed to provide social work assessments that included conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for 7 of 12 active sample patients (A8, L4, L6, N9, S10, T17 and T37).This failure results in a lack of focused social work interventions for treatment planning.

Findings include:

A. Record Review

1. Patient A8: In a Social Assessment dated 6/21/11, in the section titled "Needs/Recommends" (interventions), it was noted: "The patient will be started on meds when [A8] is court compelled to stabilize [A8's] condition. [A8] will be involved in Core Programming to provide daily activities and structure. [A8] will be involved in Coping with Depression to improve [A8's] ability to cope with stressors." There were no specific social work interventions noted in the record.

2. Patient L4: In a Social Assessment dated 6/21/11 it was noted in the section titled "Needs/Recommends": "The patient will be offered the most appropriate treatment regimen as well as education on [L4's] mental illness and medications. [L4] will be offered psychosocial programming and occupational therapy to enhance [L4's] functioning in the community." There were no specific social work interventions noted in the record.

3. Patient L6: In a Social Assessment dated 5/24/11, in the section titled "Needs/Recommends," there was no information noted at all.

4. Patient N9: In a Social Assessment dated 2/24/11 it was noted in the section titled "Needs/Recommends": "Obtaining resources that will allow placement in the least restrictive alternative." No specific social work interventions were noted in the record.

5. Patient S10: In a Social Assessment dated 4/8/11 it was noted in the section titled "Needs/Recommends": "Community resource referrals, Medication Education." No specific social work interventions were noted in the record.

6. Patient T17: In a Social Assessment dated 6/28/11 it was noted in the section titled "Needs/Recommends": "Stabilize on medication, nursing supervision, medication monitoring and discharge planning with assigned Social Worker. While here encourage pt. to attend grps on unit which is also part of treatment plan [sic]." No other social work interventions were noted in the record.

7. Patient T37: In a Social Assessment dated 4/22/11 (pt admitted 4/10/08), it was noted in the section titled "Needs/Recommends": "Focus of treatment is to provide acute care treatment to help stabilize presenting symptoms. Treatment team will monitor patient's progress throughout course of hospitalization and encourage participation in programming activities, most especially the Acceptance group, headed by unit psychologist. Social worker will work together with MHA (mental health authority) liaison to coordinate patient's aftercare at time of discharge." No other social work interventions were noted in the record.

B. Interviews

1. In an interview on 7/14/11 at 10AM, the Director of Social Services was shown the findings noted above; he agreed with the findings.

2. In an interview on 7/14/11 at 11:30AM, the Clinical Director was shown the findings noted above; she agreed with the findings.

Based on record review and interview, it was determined that the psychiatric evaluations of 5 of 12 active sample patients (A8, N6, N9, N14 and S38) included no report of memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. Three of these patients (N6, N9 and N19) were admitted to the facility secondary to cognitive decline from dementia. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A8: In a Psychiatric Evaluation dated 6/18/11, under the section titled "Memory," the portions titled "Immediate Memory; Recent Memory; Remote Memory" were noted to be: "Undetermined-pt unable to cooperate." Physician progress notes since 6/18/11 failed to identify any further attempts to complete the evaluation.

2. Patient N6: In a Psychiatric Evaluation dated 5/5/11, which contained a diagnosis of Alzheimer's Dementia, under the section titled "Memory," the portions titled "Immediate Memory; Recent Memory; Remote Memory; Estimated Intellectual Functioning" were noted to be: "Undetermined-pt unable to cooperate." Physician progress notes since 5/5/11 failed to identify any further attempts to complete the evaluation.

3. Patient N9: In a Psychiatric Evaluation dated 2/9/11, which contained a diagnosis of Alzheimer's Dementia, under the section titled "Memory," the portions titled "Immediate Memory; Recent Memory; Remote Memory; Estimated Intellectual Functioning" were noted to be: "Undetermined-pt unable to cooperate." Physician progress notes since 2/9/11 failed to identify any further attempts to complete the evaluation.

4. Patient N14: In a Psychiatric Evaluation dated 10/26/10, which contained a diagnosis of Alzheimer's Dementia, under the section titled "Memory," the portions titled "Immediate Memory; Recent Memory; Remote Memory; Estimated Intellectual Functioning" were noted to be: "Undetermined-pt unable to cooperate." Physician progress notes since 10/26/10 failed to identify any further attempts to complete the evaluation.

5. Patient T17: In a Psychiatric Evaluation dated 6/23/11, under the section titled "Memory," the portions titled "Immediate Memory; Recent Memory; Remote Memory" were noted to be: "Undetermined-pt unable to cooperate." Physician progress notes since 6/23/11 failed to identify any further attempts to complete the evaluation.

B. Interview

In an interview on 7/14/11 at 11:15AM, the Clinical Director was shown the information noted in section A above; she agreed with findings and stated "our doctors should have gone back and completed the evaluation."

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

I. Revise the Master Treatment Plan (MTP) after multiple episodes of restraint of 1 of 2 active sample patients (S38) on the Seguin Unit. The MTP was not updated to address less restrictive interventions to be used by staff to assist Patient S38 to achieve treatment objectives regarding controlling episodes of aggressive behavior. In addition, the facility failed to revise a MTP for 1 of 3 active sample patients (L1) on the Casa Amistad Unit. This patient had no MTP to address current psychiatric treatment needs after transfer back to the Casa Amistad Unit in Laredo following a three month hospitalization on the Arnold Unit in San Antonio. Failure to do needed revisions of treatment plans results in patients being hospitalized without a treatment plan that adequately reflects the patients' treatment needs, potentially delaying improvement and discharge.

Findings include:

A. Patient S38

1. Patient S38 was admitted to Seguin Unit on 4/20/11. The psychiatric evaluation dated 4/21/11 stated, "25 year old male with Schizophrenia DO [disorder] sent on ED [Emergency Detention] from [county name] due to egression [sic]. In jail 2 weeks after assaulting mother. In jail, assaulted jail staff. Has long history of similar behavior."

2. The following observations on the Seguin Unit were made:

On 7/12/11, the patient was in mechanical restraints from 1p.m. to 3:50p.m. After the surveyor's interview of the patient on 7/12/11 at 12:50p.m., Patient (S38) assaulted the staff assigned to provide one to one observation.

On 7/13/11 from 9:35a.m. to 10:45a.m., Patient S38 was in his bedroom in bed. A review of the unit schedule showed that the patient was assigned to "Current Events" at 9:00a.m., Music Activity at 10:00a.m., and Acceptance Group at 10:45a.m.

On 7/14/11 at 10:05a.m., the patient was in bed. Two staff had been assigned to provide simultaneous observations.

3. The "Treatment Plan Review" entered into the electronic medical record on 5/9/11 stated under "Psychiatric Condition Since Last Review": "Is: Improved." The review also stated under "Three of More Restraint/ Seclusion Events Within 30 days": "No." Under "Are resulting changes in treatment plan necessary," the review stated "No." However, a "Dangerousness Risk Assessment" entered in the electronic system 7/1/11 showed that Patient S38 had three episodes of aggression prior to the review on 5/9/11 and a total of 13 episodes of aggression since his admission on 4/20/11. This risk assessment recommended placement in "A more structured setting which is more suited to the treatment of individuals with persistent psychotic aggression."

4.The "SASH [San Antonio State Hospital] Safety Team.../Patient Check Sheet," from 7/6/11 through 7/9/11 and for 7/11/11, showed that the patient spent most of his time in his bedroom asleep or awake. As of 7/13/11, the treatment plan had not been revised to reflect this lack of participation in the assigned program schedule.

5. A review of Patient S38's treatment interventions on the "Acute Care - Seguin Hall - Program Schedule" showed that the patient was assigned to "Current Events, 7 days per week; Music Activity, 3 days per week; Rehab Activities, 7 days per week two times per day, Monday - Friday and 7 times per day on weekends; Medication Education, 2 days per week; Acceptance Group, 1 day per week; and COPSD [Co Occurring Psychiatric and Substance Use Disorders] Chemical Dependence Education, 2 days per week." A review of the notes in the electronic medical record from the patient's admission through 7/13/11 revealed that there were no notes regarding the patient's attendance or non-attendance in his groups on his program schedule.

6. A review of Patient S38's Master Treatment Plan (MTP), updated on 6/8/11, showed the following active treatment interventions listed: "Individual Medication Education; Medication Education Group; Current Events; Adaptive PE [Physical Exercise]; Acceptance Group; Rehab [Rehabilitation] Activities; and Individual Counseling". There was no method identified to address Patient S38's lack of involvement in his assigned active treatment schedule.

7. There was no documentation in the medical record of de-escalating techniques or strategies to be used to address the patient's multiple episodes of aggressive behavior. The following was the only documentation on the MTP regarding the patient's aggressive behavior:

a. The treatment plan dated 6/8/11 stated under "Use of Restraint or Seclusion," "Objective: Patient will express understanding of the relationship between their [sic] behavior and the use of restraints." The only intervention was, "Licensed Nursing Staff will administer prescribed medications, monitor for side-effects, assess effectiveness, instruct patient. (Specify) as ordered and clinically adjusted by unit physician." There were no written interventions regarding how to involve the patient in activities when in the comfort room [A room set with music, a relaxation chair, and an exercise bike.] or on the unit.

b. The treatment plan updated 7/13/11 stated under "Behavior - aggression (related to psychosis)," "Objective: Patient will be free of assaultive or threatening behaviors which appear clearly attributable to non-transitory paranoid ideas, command hallucinations or severe confusion." The only intervention was "Will use restraints when [patient's name] has physically aggressive behavior as deemed necessary." Again, there were no interventions identified under this objective on the MTP to address what the staff was to do therapeutically when the patient was not exhibiting aggressive behaviors.

8. The facility's policy "Section 4. Treatment Planning: MHRS (Mental Health Record System) 4-2" revised May 2001," under "When Recorded:" stated, " At completion of clinical assessments, diagnostic studies, and testing, but no later than...when a change in the patient's condition, either psychiatric or medical, necessitates the reprioritization of treatment issues or a change in diagnoses..." The policy also states, "For treatment plan review: As clinically indicated, but no later than 14 days after the treatment team has met to complete the Multidisciplinary Treatment Plan (MTP)...Reviews occur also upon major changes in the patient's condition and upon permanent programmatic transfer - time and dates are variable."

9. In an interview on 7/14/11 at 10:20a.m. with Psychologist 1, the treatment interventions for Patient S38 were discussed. Psychologist 1 stated that he staff typically does not do a behavioral plan on an acute unit. Psychologist 1 stated that consistency was difficult because of change of shift, staff being pulled, and patient changes. Psychologist 1 stated that if the patient were transferred to [Hospital's name], he would have a more structured environment.

B. Patient L1

1. Patient L1 was admitted to the Casa Amistad in Laredo, Texas on 8/5/10, transferred to the Arnold Unit in San Antonio, Texas on 8/19/10, and transferred back to Casa Amistad on 12/1/10. The psychiatric evaluation dated 8/6/10 stated that the patient was, "Uncooperative, reportedly refused...medications, experienced auditory hallucinations, paranoid delusions, irritability and aggressive behavior."

2. There was no current Master Treatment Plan found in the electronic record after L1's transfer back to the Casa Amistad Unit. Therefore, it was difficult to discern the treatment goals and interventions for psychiatric problems after the patient's transfer back to Casa Amistad The electronic medical record system had five treatment plans. for the patient (all plans out of date).

a. There was an initial plan dated 8/6/10 completed by the registered nurse at the time of the patient's admission. to the Casa Amistad unit in Loredo.

b. There was a Master Treatment Plan dated 8/19/10. This plan was developed at Casa Amistad and recorded on the day Patient L1 was transferred to the hospital in San Antonio. A progress note by a registered nurse dated 8/19/10 stated, ".. patient was transferred to main hospital for further hospitalization today at 09:45am via state vehicle."

c. A treatment plan dated 8/20/10 was developed after the patient was transferred to the Arnold Unit in San Antonio.

d. There was an updated plan dated 12/15/10 recorded after the patient was transferred on 12/1/10 from the Arnold Unit in San Diego to Casa Amistad. The plan stated, "Reason for Update: Anemia." This plan listed the names of staff employed at the hospital located in San Antonio. The psychiatrist, psychologist, and social worker from San Antonio were all documented as participating in the planning. This plan also contained psychiatric interventions assigned to employees working on the Arnold unit in San Antonio.

e. A treatment plan dated 3/16/11, developed at the Casa Amistad unit, was documented as an "initial treatment plan" for the medical problems, "edema to lower extremities" and "cardiac" problems. This plan included no update of the psychiatric problems to be addressed.

3. The facility's policy "Section 4. Treatment Planning" revised May 2001," stated the following under "When Recorded:" "At completion of clinical assessments, diagnostic studies, and testing, but no later than: 7 days following a patient's admission to the hospital, or 10 days after transfer to another treatment program or another treatment program unit, or when a change in the patient's condition, either psychiatric or medical, necessitates the reprioritization of treatment issues or a change in diagnoses..."

4. In an interview on 7/11/11 at 2:10p.m., with SW1, Patient L1's treatment plans were discussed. SW1 confirmed that there was no treatment plan in the electronic medical record to address the patient's needed psychiatric treatment after the patient's transfer back to Casa Amistad on 12/1/10. SW1 stated, "I completed a draft on 4/13/11 but it was not entered in the electronic record." SW1 also acknowledged that the treatment plan drafted on 4/13/11 was not timely since it was four months after the patient's transfer back to the Casa Amistad unit.

II. Ensure that Master Treatment plans of 9 of 11 active sample patients (A1, A8, L4, L6, N9, N14, S10, S38 and T17) whose treatment plans were reviewed consistently defined short and long term goals as specific, measurable patient behaviors to be achieved. [Note: Sample patient L1 had no MTP to review] This practice compromises staff's ability to evaluate patient progress in treatment and make necessary modifications in patients' treatment plans. (Refer to B121)

III. Ensure that the Master Treatment Plans of 11 of 11 active sample patients (A1, A8, L4, L6, N6, N9, N14, T17, T37, S10 and S38) whose treatment plans were reviewed identified individualized treatment interventions to address patients' presenting problems and treatment goals. [Note: Sample patient L1 had no MTP to review]. The Master Treatment Plans (MTPs) of the 11 sample patients contained generic and routine discipline functions, instead of individualized treatment interventions. In addition, the frequency of staff contact with patients and/or the modality (individual or group sessions) was not specified for registered nurses on the MTPs of 5 patients (A1, A8, L6, S10 and S38); for social work on the MTPs of 8 patients (L4, L6, N6, N9, N14, T17, T37 and S10); for rehabilitation staff on the MTPs of 4 patients (A1, A8, L4 and L6); and for psychology on the MTPs of 2 patients (A1 and T17). In addition, there were no physician interventions on the any of the 11 patients' MTPs, and no rehabilitation staff interventions on the MTPs of 3 patients (N6, N9 and N14). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

Based on record review and interview, the facility failed to ensure that Master Treatment plans of 9 of 11 active sample patients (A1, A8, L4, L6, N9, N14, S10, S38 and T17) whose treatment plans were reviewed consistently defined short and long term goals as specific, measurable patient behaviors to be achieved. [Note Sample patient L1 had no treatment plan as noted in B118 above]. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A1's primary problem was listed on the MTP (7/11/11) as "Behavior - self-injurious." The goal (name for "long-term goal" in this facility), was, "will cope with stressful or frustrating emotions without resorting to self-injurious behavior." The objective (name for "short-term goal" in this facility) was "will use more appropriate, constructive alternative strategies for expressing feelings." These goal/objectives were not measurable in behavioral terms.

2. Patient A8's primary problem was listed on the MTP (6/23/11) as "Psychosis NOS [not otherwise specified]." The goal was "Delusional beliefs and hallucinations will interfere minimally with daily life." The objective was "will refrain from further delusional comments after being re-directed toward reality." These goal/objectives were not measurable in behavioral terms.

3. Patient L4's primary problem was listed on the MTP (7/11/11) as "Psychosis/anxiety." The goal was, "Delusional beliefs and hallucinations will interface minimally with daily life." The objective was "will refrain from further delusional comments after being re-directed towards reality." These goal/objectives were not measurable in behavioral terms.

4. Patient L6's primary problem was listed on the MTP (7/11/11) as "Psychosis - delusions/hallucinations." The goal was "will demonstrate reduction in psychotic symptoms." This goal was not measurable in behavioral terms.

5. Patient N9's primary problem was listed on the MTP (3/22/11) as "Cognitive impairment with depressive symptoms." The goal was "[patient] will maintain attention and concentration for brief periods of time and continue with...pleasant mood to include a sense of humor." This goal was not measurable in behavioral terms.

6. Patient N14's primary problem was listed on the MTP (7/12/11) as "Schizophrenia and Huntington disease." The goal was "[patient] will be less psychotic in...thinking/behaviors." The objective was "[patient] will continue to function to the extent possible, experiencing less increase in paranoid thinking, irritability, and experiencing cooperative behaviors." These goal/objectives were not measurable in behavioral terms.

7. Patient S10's primary problem was listed on the MTP (4/14/11) as "Psychosis." The goal was "contact with reality will be maximized. Delusional beliefs will interfere minimally with daily life." This goal was not measurable in behavioral terms.

8. Patient S38's primary problem was listed on the MTP (6/8/11) as "Auditory Hallucinations." The goal was "will function without responding to auditory or visual hallucinations. Contact with reality will be maximized." This goal was not measurable in behavioral terms.

9. Patient T17's primary problem was listed on the MTP (6/28/11) as "Behavior - hostile/defiant." The goal was "will reduce the intensity and frequency of hostile and defiant behavior to adults." This goal was not measurable in behavioral terms.

B. Interviews

In an interview on 7/14/11 at 9a.m., the Director of Nursing (DON) acknowledged that some of the objectives on the Master Treatment Plans were vague, not measurable and were staff oriented objectives rather than statements that reflected outcome behaviors for patients. The DON also acknowledged that the objectives should be clear enough so that staff can easily observe and document the patient's improvement or lack of improvement.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans of 11 of 11 active sample patients (A1, A8, L4, L6, N6, N9, N14, T17, T37, S10 and S38) whose treatment plans were reviewed identified individualized treatment interventions to address patients' presenting problems and treatment goals. [Note: Sample patient L1 did not have an MTP to review].The Master Treatment Plans (MTPs) of these 11 patients contained generic and routine discipline functions, instead of individualized treatment interventions. The frequency of staff contact with patients and/or the modality (individual or group sessions) was not specified for registered nurses on the MTPs of 5 patients (A1, A8, L6, S10 and S38); for social work on the MTPs of 8 patients (L4, L6, N6, N9, N14, T17, T37 and S10); for rehabilitation staff on the MTPs of 4 patients (A1, A8, L4 and L6); and for psychology on the MTPs of 2 patients (A1 and T17). In addition, there were no physician interventions on the MTPs for any of the 11 sample patients, and no rehabilitation staff interventions on the MTPs of 3 patients (N6, N9 and N14). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (7/1/11), A8 (6/23/11), (L4 (7/11/11), L6 (7/11/11), N6 (updated 7/12/11), N9 (updated 3/22/11), N14 (updated 7/12/11), T17 (6/28/11), T37 (updated 5/04/11), S10 (4/14/11 & updated 7/11/11) and S38 (6/8/11).

1. The following patients had generic and routine nursing functions incorrectly listed as treatment interventions for psychiatric problems:

a. Patients A1, A8, L4, L6, N9, N14, T17, T37, S10, and S38 had the following identical or similarly worded statement: "NI-Medication [class of medication]: Licensed nursing staff will administer [class of medication] medication as ordered and clinically adjusted by unit Physician. Nursing staff will monitor for side effects, assess effectiveness..."

b. Patient T17: "Nursing Staff will observe patient in a variety of situations; identify treatment progress and possible emerging problem areas; and report observations with patient and team daily."

2. Six patients had the following identical or similarly worded generic and routine rehabilitation staff functions incorrectly listed as a treatment intervention:

Patients A1, A8, L4, L6, S10 and S38: "Rehab [Rehabilitation] staff will encourage full participation in activities that promote socialization and constructive use of verbal and nonverbal communication."

3. The following patients had nursing interventions with no frequency of contact and/or no specified modality (individual or group).

a. Patients A1, A8, L6, S10 and S38 had the following identical or similarly worded statement: "Licensed personnel will present patient with information regarding medications identification, desired effects, side effects and the importance of medication compliance to control symptoms of mental illness...As needed." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

b. Patients A1, A8, L6, T17, T37, S10 and S38 had the following identical or similarly worded statement: "Patient will discuss topics issues, events, and happenings that occur in the community, state, and country...5x week." This statement failed to include what the staff would be doing and no modality was listed.

c. Patients A1, A8, T37 and S38 had the following identical or similarly worded statement: "Nursing staff will provide a structured physical exercise program that will improve motor functioning...9x [sic] week 1 hour." This statement failed to include the modality that would be used.

d. Patient A1: "Nursing staff will provide assistance to help patient identify precursors to behavioral problems, help generate possible solutions, support patient in resolving problems; and encourage patient to express feelings appropriately...As needed." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

e. Patients A1, A8, L4, L6, T1738 had the following identical or similarly worded statement: "Nursing staff will reinforce medication - food interaction information; need for aftercare program; aspects of social adjustment, self care needs and involve patient and family in plan...Prior to discharge." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

4. The following patients had habilitation staff interventions with no frequency of contact and/or no specified modality (individual or group).

a. Patients A1, A8 and L6 had the following identical or similarly worded statement: "Rehab staff will lead discussion and exploration of effective problem solving, time management, and emotional control...5x week 1 hours." This statement failed to include the modality that would be used.

b. Patient L4: "COPSD [sic]/Chemical Dependency Education: Rehab staff will discuss issues pertaining to the use of alcohol and drugs especially as substance use effects persons with mental illness..." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

5. The following patients had social work interventions with no frequency of contact and/or no specified modality (individual or group).

a. Patient L4: "Individual Disposition Planning: Will discuss concerns, fears, and expected adjustments regarding patient's return to the community...As scheduled." The specific frequency and number of sessions were not included in the intervention statement.

b. Patients L4, L6, T17, T37 and S10 had the following identical or similarly worded statement: "Individual sessions with patient to discuss placement plans, goals and options, to allow patient to express fears and concerns, and to review/reinforce patient patient's progress. Education regarding aftercare, mental illness, and related topics will be provided to the patient and family as needed." The specific frequency of contact or number of sessions was not included in the intervention statement.


c. Patient N6: "The social worker will provide information about available placements, if any. The social worker will continue to inform and assist the patient's family (sister) via matching the patient's specific needs to the appropriate placement, if ever located."

d. Patients N9 and N14 had the following identical or similarly worded statement: "Social Worker will provide information about available placement and will assist the patient and his family in helping fit his specific needs to the appropriate placement...As needed."

6. Two patients had the following identical or similarly worded psychology intervention with no frequency of contact and/or no specified modality (individual or group):

Patients A1 and T17: "COPSD/Chemical Dependency Education: Psychology staff will teach and discuss issues pertaining to the use of alcohol and drugs especially as substance use effects persons with mental illness...As scheduled."

7. Ten patients (A1, A8, L4, L6, N9, N14, T17, T37, S10 and S38) had no physician interventions included on the Master Treatment Plan.

8. Patient N6 (a geriatric patient) had no psychiatric problems listed. Therefore, there were no nursing, rehabilitation, or physician psychiatric interventions included on the Master Treatment Plan.

9. Patients N9 and N14 had no rehabilitation staff interventions included on the Master Treatment Plans.

B. Staff Interviews

1. In an interview on 7/12/11 at 12:25p.m., with RN1, the treatment plan for Patient S38 was discussed. RN1 stated, "The interventions are not appropriate and should be related to the objective."

2. In an interview on 7/14/11 at 9a.m., with the Director of Nursing (DON), the treatment interventions on the Master Treatment Plans were reviewed. The DON confirmed that listed nursing interventions were routine nursing tasks and functions. The DON also acknowledged that the frequency of contact with the patient was missing in the intervention statements. The DON stated, "We have a lot of work to do on the treatment plans."

3. In an interview on 7/14/11 at 11:30AM, the Clinical Director was shown several of the sample patients' treatment plans. After reviewing the plans, she agreed that there were no physician interventions.

Based on record review and interview, the facility failed to ensure that the electronic medical record contained documentation that nursing interventions listed on the Master Treatment Plans (MTPs) were actually delivered by nurses for 5 of 11 active sample patients (A1, A8, L6, S10 and S38) whose Master Treatment Plans were reviewed, and by psychologists for 2 of the 11 active sample patients (S10 and S38). [Note Sample patient L1 had no MTP to review]. Nurses and psychologists failed to document the patients' attendance or non-attendance in assigned treatment interventions, and to document the topic(s) discussed, and the patients' level of response to the treatment interventions. This failure hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (7/1/11), A8 (6/23/11), L4 (7/11/11), L6 (7/11/11), N6 (updated 7/12/11), N9 (updated 3/22/11), N14 (updated 7/12/11), T17 (6/28/11), T37 (updated 5/04/11), S10 (4/14/11 & updated 7/11/11) and S38 (6/8/11).The review of the notes in the electronic medical records revealed no treatment notes for the following interventions listed on the MTPs:

1. Nursing Interventions

Patients A1, A8, L6, S10 and S38: The MTP stated, "Individual Medication Education: Licensed personnel will present patient with information regarding medications identification, desired effects, side effects and the importance of medication compliance to control symptoms of mental illness...As needed." There was no documentation in the electronic medical record of the patients' attendance or non-attendance in medication education sessions. Additionally there were no treatment notes that recorded the information provided, the topic discussed, or the patients' responses, including level of participation and understanding.

2. Psychology Interventions

Patient S10 and S38: The MTP stated, "Acceptance Group: Psychology staff will help patient gain insight into illness, understand and participate in treatment, develop effective coping strategies." There was no documentation in the electronic medical record of the pateints' attendance or non-attendance in the Acceptance Group sessions. Additionally there were no treatment notes that recorded the information provided, the topic discussed, or the patients' responses, including level of participation and understanding.

B. Staff Interview

In an interview on 7/14/11 at 9:25a.m., with the Information Management Director, the documentation of staff delivery of the interventions on the patients' MTPs and the patient program schedules were discussed The Information Management Director acknowledged that there were no notes in the electronic medical record for patients S10 and S38 regarding the Acceptance Group. The Information Management Director highlighted the printed notes from the electronic record when medications were mentioned. However, these notes only were those entered by nurses documenting encouragement of the patients to continue their medication regime. There was no documentation of individual sessions held with patients regarding their specific medications or the patient ' s response to the medication education.

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

I. Provide active treatment, including alternative interventions, for 9 of 12 active sample patients (L1, L4, L6, N6, N9, N14, S10, S38 and T17). These patients were either not cognitively capable of participating in assigned treatment or were not motivated to attend the assigned groups. Observations of groups provided on the units revealed that the interventions failed to relate to the specific problems and needs of the above patients. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided, potentially delaying their improvement.

Findings include:

A. Active Sample Patient L1

1. Patient L1 was admitted on 8/5/10 to the Casa Amistad unit in Laredo, which was located at a facility 150 miles from the other 4 certified units on the main campus in San Antonio. L1 was transferred to the Arnold Unit in San Antonio on 8/19/10 and transferred back to Casa Amistad on 12/1/10. A psychiatric evaluation, dated 8/6/10 stated that the patient was, "Uncooperative, reportedly refused...medications, experienced auditory hallucinations, paranoid delusions, irritability and aggressive behavior."

2. During observations on 7/11/11 from 9:30a.m. to 10:45a.m. in the dayroom of the Casa Amistad Unit. Patient L1 was seen most of the time either sitting starring in space or looking at the television. At 9:30a.m., a "Cognitive Group" was held by RT1 with four non-sample patients participating. Patient L1 was encouraged to attend this group, but the patient refused. At 10:25a.m., Patient L1 was encouraged to participate in a "Craft Group" held in the dayroom with 4 other non-sample patients. Patient L1 entered this group but left at 10:35a.m. and sat in the dayroom looking at television.

3. The "Acute Care - Casa Amistad - Program Schedule" completed for L1 only had "Social Group" circled for the patient, on Wednesday through Saturday at 10:30a.m. This reflected only 4 hours of active treatment scheduled each week.

4. During an observation on 7/11/11 in the dayroom from 1:50p.m. to 2:30p.m., Patient L1 was found sitting at a table and starring in space and talking to self. Patient L1 later moved to the television area and watched the television. A Karaoke session was being held in the group room. Patient L1 was encouraged to attend but refused.

5. There was no current Master Treatment Plan addressing the patient's psychiatric needs found in the electronic record the time following Patient L1's transfer back to the Casa Amistad Unit on 12/1/10. The plans recorded for the patient were the following: 1) an "initial plan" dated 8/6/10 completed by the registered nurse; 2) a plan dated 8/19/10 that was developed at Casa Amistad and recorded on the day Patient L1 was transferred to the San Antonio facility; 3) a plan dated 8/20/10 developed after the patient was transferred to the Arnold Unit in San Antonio; 4) an updated plan dated 12/15/10 developed at the Arnold Unit unit in Laredo to address the medical problem "Anemia." The treatment plan developed in the Arnold Unit in San Antonio only included the names of staff in that facility, with documentation that the psychiatrist, psychologist, and social worker from the San Antonio campus\participating in the planning. This plan contained psychiatric interventions assigned to clinical staff of the Arnold unit in San Antonio. The only treatment plan developed after the patient's transfer back to the Case Amistad Unit was a plan dated 3/16/11 which only addressed the medical issues "edema of extremities" and a "cardiac" problem. This plan did not address the patient's current psychiatric issues.

6. In an interview on 7/11/11 at 10:10a.m. with RT1, Patient L1's lack of participation in group sessions was discussed. RT1 stated that staff try to get everyone involved even if the patients are not assigned to the group being held. When asked why Patient L1 was only assigned to the social group, resulting in only 4 hours of planned treatment per week, RT stated, "[Staff's name] in San Antonio puts patients in groups."

7. In an interview on 7/11/11 at 2:15p.m., SW1was asked about the Master Treatment Plan for Patient L1. SW1 acknowledged that a plan had not been developed when the patient was transferred back to the Casa Amistad unit in Loredo from the Arnold unit in San Antonio. SW1 stated, "I completed a draft [of the treatment plan] on 4/13/11, but it was not entered in the electronic record." SW1 acknowledged that the plan drafted on 4/13/11 was not timely since it was four months after the patient's transfer back to Casa Amistad.

B. Active Sample L4

1. Patient L4 was admitted on 6/14/11 to Casa Amistad unit with a diagnosis of Chronic Undifferentiated Schizophrenia.

2. During observations on 7/11/11 between 10AM and 3:30PM on the Casa Amistad unit, Patient L4 was usually sitting in the day room watching TV or sitting outside on the patio. Patient L4 attended one session of recreation therapy (Karaoke), where s/he sat and watched as other patients participated.

3. In an interview on 7/11/11 at 12:30PM, Patient L4 stated "I just watch TV or just sit all day. There's very little to do here. I take my medications and just wait for them to work. That's all." When asked whether s/he was involved in any individual therapy, Patient L4 stated "no."

4. Review of Patient L4's Master Treatment Plan dated 7/11/11 revealed no assigned activities, groups or therapy sessions as interventions for the problem of psychosis.

C. Active Sample Patient L6

1. In an interview on 7/11/11 at 9:15a.m., Patient L6 stated that s/he did not know why s/he had been admitted to the hospital, but felt s/he did not need to be there. When asked what s/he did all day, s/he stated "I just sit in the Dayroom most of the day." When asked what s/he had done on the unit over the past weekend, Patient L6 stated, "I watched TV." S/he denied attending any groups.

2. In an interview on 7/11/11 at 9:25a.m., LPN1 stated that patient L6 never attended groups.

3. During an interview on 7/11/11 at 12:10p.m., RT1 stated that all patients are encouraged to attend the scheduled groups. She also stated, "[patient L6] has not done anything since [s/he's] been here..According to the unit activity schedule, RT1 conducted all the groups held on the Casa Amistad unit. Thus, she was in a position to know what groups L6 attended or did not attend.

4. During an observation on the Casa Amistad unit on 7/11/11 from 9:30a.m. to 10a.m., patient L6 was taking a shower and doing laundry. A therapy group titled "Cognitive" was in process in the Dayroom during this time.

5. During an observation on 7/11/11 from 1:30p.m. to 2p.m., patient RT1 was sitting alone at a table in the Dayroom. During this time, a rehabilitation group titled "Karaoke" was being held in room 157 on the Casa Amistad unit. During the observation, no staff approached the patient to encourage her/him to attend the Karaoke group or offer alternative treatment.

6. According to the Psychiatric Evaluation, dated 6/22/11, patient L6 was admitted to the hospital on 6/21/11 with a "diagnosis of paranoid schizophrenia and no medications. The evaluation said that [s/he] was "running in mall...naked" and "...cannot remember this event." "No insight, no motivation, no leisure activities."

7. The Master Treatment plan (MTP) for L6 dated 7/11/11 listed the primary problem as "Psychosis - delusion/hallucinations"... "Patient with disorganized behavior..." "The listed interventions were: "SW [social worker] education regarding aftercare, mental illness, and related topics will be provided to the patient and family as needed" and "Rehab staff [rehabilitation staff] will encourage full participation in activities that promote socialization and constructive use of verbal and nonverbal communication." There was no intervention by a psychiatrist on the Master Treatment plan.

8. Despite the fact that the MTP specified that the patient was to have "full participation in activities that promote socialization and constructive use of verbal and nonverbal communication (see #6 above, the program schedule for the patient only had a "Social Group" highlighted for Wednesday, Thursday and Friday at 10:30a.m.

9. In an interview on 7/11/11 at 8:45a.m., the unit supervisor [unit where L6 resided] stated that only the groups that patients must attend are highlighted on their program schedules.

10. There were 2 computerized progress notes by rehab staff -- one dated 6/22/11 at 1:01p.m. and the other on the same day at 1:03 p.m. Both notes referred to patient L6's need to attend scheduled rehab activity groups and said, "sessions may be group activities or 1:1 (one to one)." There were no notes documenting L6's attendance or lack of attendance in groups or 1:1 sessions.

D. Active Sample Patient N6

1. The initial introduction to geriatric patient N6 came in an interview with RN1 on 7/12/11 at 12:05p.m. During this interview, RN1 stated that N6 required total physical care due to advanced stages of Alzheimer's disease, was on tube feedings, spent most of the day in bed, and was no longer able to communicate coherently with staff. When asked what treatment N6 was being provided on the unit (Navarro unit which was a unit for geriatric patients), RN1 stated, "(N6) used to get range of motion of extremities (legs and arms) by PT [physical therapy], but now the nurses on the unit do it. A music therapist does come in once or twice a week to play music..."

2. During an observation on 7/12/11 around 12:10p.m. on the Navarro unit, N6 was seen in bed in room 151 with his/her eyes closed. No staff member was in the room.

3. In an interview on 7/12/11 at 12:15p.m., SW2 was asked why N6 was a patient on the Navarro unit and what the discharge plans were for her/him. SW2 stated that since N6 was not a citizen of the United States and had advanced Alzheimer's disease and no income, s/he could not be placed in a nursing home. SW2 said, "We have no place to transfer her."

4. According to the Psychiatric Evaluation (PE), last updated dated 5/12/11, patient N6 was admitted on 5/21/04 with a diagnosis of "Dementia of the Alzheimer's type" - "-Dysphagia" and- "Muscular Wasting and Disuse atrophy." The PE stated, "She is a total-care patient with advanced Alzheimer's disease. (N6) is NPD [nothing by mouth] and receives nutrition and medications through...PEG [Percutaneous Endoscopic Gastrostomy)] tube. Staff provides all of...ADL's. (N6) is non-verbal and unable to express ...needs. (N6) is non-ambulatory."

5. The Master Treatment Plan for the patient, dated 7/12/11, listed primary problem as "barriers to discharge - dementia, Alzheimer's disease." "The patient no longer meets criteria for inpatient treatment in a psychiatric facility....requires a high level of total nursing care. However... is not a U.S. citizen, and thus...will be unable to secure funding to allow...to be placed in the least restrictive environment, a nursing care home in the community." "[Name of patient] has no language abilities, is unable to walk, toilet, bathe, and staff assist...in all tasks of daily living." There was no physician intervention on the Master Treatment plan.

6. During observations on 7/13/11 at 9:30a.m. and 12:05p.m., Patient N6 was lying quietly in bed with his/her eyes open. No staff was observed in the room during these times.

7. In an interview on 7/12/11 at 12:05p.m., RN1 was asked if any type of activities were being provided for patient N6. The nurse stated that a Music Therapist came one or twice a week to play recorded music for the patient. A review of Music Therapy progress notes for the week ending 6/17/11 documented that N6 was provided music therapy on 6/15/11 and 6/17/11 and on 6/22/11, 6/24/11 and 7/1/11. According to the documentations, the patient did not receive music therapy on 6/29/11, 7/7/11 or 7/8/11.

8. In an interview on 7/13/11 at 12p.m., MD1 acknowledged that patient N6 was in need of nursing home placement, not psychiatric hospitalization. MD1 stated, "Placement is an issue."

E. Active Sample Patient N9

1. In an interview on 7/12/11 at 12:05p.m., RN1 stated that geriatric patient, N9, never attended groups. "[N9] roams the hallway all day in the Geri chair. (N9) will go to socials or parties once in awhile, but not to groups."

2. According to the Psychiatric Evaluation, dated 2/9/11, patient N9 was admitted on 2/13/04 with a diagnosis of "Dementia due to General Medical condition." "(N9) was enroute to San Francisco and got off...airplane thinking s/he was in San Francisco. After taken [sic] a taxi and driving for several hours unable to locate...requested destination and noting (N9's) confused status, the patient was taken to [name of hospital]." "The patient indicated [sic] several compromised cognitive symptoms and was diagnosed with dementia." --- "(N9) continues to be demented and is not able to articulate...needs and does require 24 hours nursing care for all...ADL's [Activity of Daily Living}." "(N9) continues to be a NH [nursing home] placement candidate and there is an ongoing effort by social services to find a source to accommodate...placement."

3. The Master Treatment Plan, dated 3/22/11, listed patient N9's primary problem as "dementia due to General Medical Conditions: cognitive impairment with depressive symptoms." "[patient] experiences significant memory problems, depression, poor judgment, relies on staff for completion of daily living tasks." "Patient has no funding to pay for needed services in a nursing care facility." The listed intervention was "SW placement assistance: Social worker will provide information about available placements and will assist patient and family by helping fit specific needs to the appropriate placement." There were no physician interventions on the treatment plan, nor were there any recommendations for alternative treatment such as 1:1 approaches instead of groups.

4. The patient was observed sitting alone in a walker chair in the hallway on Navarro unit on 7/13/11 around 10a.m. Two of the 12 patients on the unit had gone to an off-unit music group during this time period.

5. In an interview on 7/13/11 at 12p.m. with MD1, the long length of stays of patient N9 was discussed. MD1 stated that the primary problem for placement of N9 was lack of finance. She added, "Nursing homes will not take [these patients]."

F. Active Sample Patient N14

1. In an interview on 7/12/11 at 12:05p.m., RN1 stated that geriatric patient N14 spent most of the time sitting around the unit watching TV." (N14) sometimes goes outside on fresh air breaks; sometimes (N14) participates a little in exercise groups."

2. According to the Psychiatric Evaluation, dated 10/26/10, patient N14 was admitted on 10/26/07 with a diagnosis of "Psychotic disorder due to the previous history of psychotic symptoms...History of MVA [motor vehicle accident] and "Huntington's disease." "In late September...psychiatric condition deteriorated. (N14) became increasing [sic] more paranoid with multiple acts of aggression towards peers."... "[Patient] required multiple emergency medications to address ...aggression. At the same time (N14's) gait became increasingly more unsteady...upper extremity strength weakness and...falls increased significantly."

3. The Master Treatment Plan for Patient N14, dated 7/12/11, listed the primary problems as "Schizophrenia" and "Huntington's disease." "The patient will require a placement in a structural and safe environment with a locked unit and supervised 24 hour care due to...medically compromised status." The listed intervention was "SW - placement assistance: Social worker will provide information about available placement and will assist the patient and...family in helping fit...specific needs to the appropriate placement."

4. Weekly social work progress notes for N14 were reviewed for the weeks of 6/12/11, 6/26/11, and 7/8/11. Each documented social work session lasted between 30 and 45 minutes. In the session on 6/12/11, the social worker helped the patient call his/her mother. The note included no specific mention of placement issues. Two sessions (one on 7/8/11 and the other on 7/10/11) with patient N14 and family focused on the patient's mood and stressors. Placement issues were not documented as a topic in either session.

5. In an interview on 7/13/11 at 12p.m. with MD1, the long length of stay of patientN14 was discussed. MD1 stated that the primary problem to placement for N14 was the patient's aggressive behavior. Nursing homes will not take [these patients].

G. Active Sample Patient S10

1. Patient S10 was admitted to the Seguin Unit on 4/3/11. The psychiatric evaluation dated 4/4/11 stated, "49 year old...with possible Bipolar disorder and Polysubstance abuse, sent on ED [Emergency Detention] from [County name] due to psychosis..."

2. During observations on 7/12/11 on the Seguin Unit from 1:20p.m. to 2:50p.m., Patient S10 was either sitting in the dayroom, pacing back and forth, or in his/her bedroom. A review of the patient's schedule showed that S10 was only assigned to "Rehab Activity" from 1:15p.m. to 4:30p.m. on 7/12/11. At 1:50p.m. on that day, the staff closed the dayroom and directed patients to go to their bedrooms. At 2:00p.m., Patient S10 attended an "OT Basic Skills Group" held in the occupational therapy room with eight non-sample patients. This group was not circled on Patient S10's schedule ["Acute Care - Seguin Hall- Program Schedule"] and was not included on her Master Treatment plan.

3. During an observation on 7/13/11 on the Seguin Unit from 9:30a.m. to 10:45a.m., Patient S10 was in sitting in the dayroom during the entire time period. Patient S10 had "Current Events" circled on her schedule. This activity was not being held.

4. During an observation on the Seguin Unit on 7/14/11 at 10:15a.m., Patient S10 was found sitting in the dayroom watching television. The "Acute Care - Seguin Hall - Program Schedule" showed that S10 was assigned to Music Activity. A Music Activity group was being held on the other side of the dayroom with 4 other non-sample patients. At 10:40a.m., Patient S10 was still sitting in the dayroom watching television.

5. A review of the Master Treatment Plan for Patient S10, dated 4/14/11, showed the following active treatment interventions: "Medication Education Individual; Medication Education Group; Acceptance Group; Current Events; Rehab [Rehabilitation] Activities; and Individual Counseling."

6. A review of the "SASH [San Antonio State Hospital] Safety Team.../Patient Check Sheet" from 7/7/11, 7/8/11, and 7/9/11 7/11/11 showed that Patient S10 spent most of the time in the dayroom. These check sheets revealed the following:

On 7/7/11 from 7a.m. to 3p.m., the patient was checked as in "DR [Day Room]" except when eating and in the comfort room [a room set with music, a relaxation chair, and an exercise bike] for two 15 minute checks at the end of the shift.

On 7/8/11 from 7a.m. to 3p.m., from 7a.m. to 3p.m., the patient was checked as in "DR [Day Room]" except when eating and in the hallway for three 15 minute checks.

On 7/9/11 from 7a.m. to 3p.m., the patient was checked as in "DR [Day Room]" except when eating, in "IBS [In Bed Asleep]" for four 15 minute checks between 9:00a.m. and 10a.m., and in the hallway for seven 15 minute checks.

7. In an interview on 7/13/11at 9:25a.m., RN2 was asked about the "Current Events Group" scheduled from 9:00a.m. to 10a.m. RN2 stated that patients were out for fresh air break and the current events group was no longer being held. However, a copy of the patient's schedule given to the surveyor on 7/12/11 at 12:30p.m. listed the Current Events group.

8. In an interview on 7/13/11 at 9:55a.m., , when asked about the Current Events group and the Medication Education circled on Patient S10's schedule, Rehabilitation Therapist RT2 stated, "I took these off the schedule because they were not being done."

H. Active Sample Patient S38

1. Patient S38 was admitted to Seguin Unit on 4/20/11. A psychiatric evaluation dated 4/21/11 stated, "Schizophrenia DO [disorder] sent on ED [Emergency Detention] from [county name] due to egression [sic]. In jail 2 weeks after assaulting mother. In jail, assaulted jail staff. Has long history of similar behavior."

2. During an observation on 7/13/11 from 9:35a.m. to 10:45a.m., Patient S38 was in his/her bedroom in bed. A review of his/her schedule showed an assignment to the "Current Events" group at 9:00a.m. [This group was not held], Music Activity at 10:00a.m., and Acceptance Group at 10:45a.m.

3. A review of Patient S38's Master Treatment Plan updated on 6/8/11 showed the following active treatment interventions: "Individual Medication Education; Medication Education Group; Current Events; Adaptive PE [Physical Exercise]; Acceptance Group; Rehab [Rehabilitation] Activities; and Individual Counseling." There was no documentation in the medical record regarding the patient's attendance or non attendance for these assigned group sessions.

4. A review of the "SASH [San Antonio State Hospital] Safety Team.../Patient Check Sheet" from 7/6/11 through 7/9/11 and 7/11/11showed that the patient spent most of the time in bed asleep or awake. These check sheets revealed the following:

On 7/6/11 from 7a.m. to 3p.m., the patient was checked "IBS [In Bed Asleep]" or "IBA [In Bed Awake]" except when eating, and one check in the comfort room.

On 7/7/11 from 7a.m. to 3p.m., the patient was checked "IBS [In Bed Asleep]" or "IBA [In Bed Awake]" except when eating and in the comfort room for eight 15 minute checks.

On 7/8/11 from 7a.m. to 3p.m., the patient was checked "IBS [In Bed Asleep]" or "IBA [In Bed Awake]" except when eating and in the comfort room for eleven 15 minute checks.

On 7/9/11 from 7a.m. to 3p.m., the patient was checked in the comfort room for most of the shift.

On 7/11/11 from 7a.m. to 3p.m., the patient was in the comfort room for two 15 minute checks from 7a.m. to 8a.m.; was in mechanical restraints for seven 15 minute checks from 10a.m. to 11a.m.

5. In an interview on 7/13/11 at 10:35a.m., with MD2, Patient S38's progress was discussed. MD2 stated that Patient S38 continued to have a deeply entrenched psychotic condition and several medications had been tried without success. MD2 noted that the patient had hit several staff and patients. When asked about a behavioral plan for consistent approaches to the patient, MD2 stated that "behavioral plans are not done here."

6. In an interview on 7/14/11 at 10:55a.m., Psychiatric Nursing AssistantPNA3 stated that Patient S38 was on "two to one." [Two staff simultaneously assigned to observe the patient]. When asked if the patient had been participating in scheduled activities, PNA3 stated that the staff had been instructed to keep the patient from other patients, and showed the surveyor a document entitled "Specialized & Sleep Observation Checklist." This checklist had a note that stated, "[Patient to] have meals away from peers due to extended hx [history] of aggression."

I. Active Sample Patient T17

1. Patient T17 was admitted to the Travis unit on 6/23/11 with a diagnosis of Schizophrenia, Undifferentiated type and a history of treatment noncompliance.

2. During an observation on 7/12/11 from 10:30AM to 11:20AM, Patient T17 was observed sitting in a chair in the lobby (day room) while patients were watching TV. Staff did not interact with T17 at anytime during this interval. Per T17's Program Schedule, a "Current Events" group was supposed to be in progress during this time frame. In a discussion with RN8 at 11:15AM, RN8 stated that Current Events group occurred daily and "it's where patients watch the news on TV until lunch time."

3. During an observation on 7/12/11 from 1:30PM to 2:15PM, Patient T17 was observed again sitting in the same chair in the lobby or lying on the bed. Review of the Program Schedule showed that T17 was assigned to "Rehab Activities" daily between 12:45PM and 4:30PM. In a discussion on 7/12/11 at 2:00PM, PNA10 stated that "Rehab activities are pretty loose here; patients can do whatever they want to do, most just sleep off their medications. "

4. In an interview on 7/13/11 at 2:15PM, Patient T17 stated "I'm just doing my time here; they have to discharge me sometime. I just watch TV and sleep all day; no one tells me what groups I have to go to." When Patient T17 was asked if s/he had been e involved with individual therapy as part of the treatment in the facility, s/he stated, "I never have had that therapy here."

5. Review of Patient T17' s Master Treatment Plan dated 6/28/11 failed to identify any problems, goals or interventions related to Patient T17' s history of treatment noncompliance.

J. Specific Unit Findings: Seguin Unit

1. During observations on 7/13/11 at 9:25a.m. on the Seguin Unit, "Current Events" was the only activity on the "Acute Care - Seguin Hall - Program Schedule" listed from 9:00a.m. to 10:00a.m. The surveyor made rounds at 9:35a.m. with RN2 and found that 20 patients were in bed and 2 in their bedroom and up; 7 patients were in the dayroom; and 3 patients were located in the hallway. [Six patients were off the unit at an off unit work program.]

2. In a discussion on 7/13/11 at 9:45a.m., when asked about the number of patients found in bed at 9:35a.m., RN2 stated that the doors to patients' rooms were left unlocked because the Patient Advocate said that patients had a right to have access to their rooms. She also stated, "Unfortunately most patients choose to stay in bed."

3. In an interview on 7/13/11 at 3:00p.m., when asked about the number of patients in bed at 9:30a.m., the Director of Nursing (DON) acknowledged that there was not a lot patient participation and activities on the unit. The DON stated, "We are attempting to have a way for patients to have more opportunities to go out on their own to the library and the fenced area."

II. Ensure that a physician did a face to face evaluation for 1 of 1 active sample patient (N14) and 3 of 7 non-sample patients (SR1, SR2, and SR3) whose records were reviewed for compliance with seclusion/restraints policy and procedures. For patient N14, the physician wrote a progress note on a restraint incident but stated that he did not provide a face to face evaluation. For Patients SR1, SR2, and SR3, the physician, who was located at the main campus 150 miles from the Casa Amistad unit where the patients were located, used a television monitor to view RNs doing the 1 hour assessment instead of visiting the patients in person. This did not meet the requirements for a face to face evaluation as stipulated in the facility's Patient's Rights Policy. In addition, the physician failed to document the results of the face to face evaluation for 2 of the 7 non-sample patients (SR5 and SR6) whose charts were reviewed for seclusion/restraint compliance. These failures violate patients' right to be free from unnecessary restraint. Failure to provide face-to-face assessments by a physician or other qualified clinician also can result in a risk to the patient's life and well-being.

Findings include:

A. Record Review

1. Facility policy titled "Seclusion/Restraint, 50P#: 200-21," date September 28, 2009, states "A physician must perform a face-to-face assessment of the patient within one (1) hour of initiation of restraint or seclusion. This face-to-face assessment must be documented by the physician in the medical record."

2. Active sample patient N14 was placed in a personal horizontal restraint (physical hold) "to help pt [patient] refrain from hitting" on 5/22/11 from 3:45p.m.to 3:55p.m. to administer Haldol 5mg 1m [milligrams intra muscular]. According to the "Nursing Intervention Progress Note "the patient had become agitated without provocation." The physician Progress Note, dated 5/22/11 at 4:30p.m., stated, "Face to face for medical decision making: No." (In an interview on 7/13/11 at 10:35a.m., RN4 stated that this phrase tells whether the physician has seen the patient in person.)

3. Non-sample patient SR1 housed on Casa Amistad unit, located 150 miles from the main campus of San Antonio Hospital, was placed in a "personal restraint" on 6/27/11 from 7:10p.m. to 7:11p.m. according to a "Nursing Intervention Note" dated 6/27/11 at 7:19p.m. The note stated, "Patient was sitting on sofa in day area and...was hallucinating." "[Pt.] got up yelling and quickly struck/hit patient [medical record number of patient] on the left upper side of his head --- three times." "The staff held [SR1] for 10 seconds ----." "Immediately called OD Dr. [officer of day doctor]." --- "He ordered Zyprexa 10mg IM and Ativan 2mg im as emergency medications." No progress note by the on-call physician, who was located on the main campus of San Antonio Hospital, could be found in the patient's record.

4. Non-sample patient SR2, housed on Casa Amistad unit, was placed in a "personal restraint vertical", on 4/5/11 from 7:45p.m. to 7:48p.m., according to a "Nursing Intervention note" dated 4/5/11 at 9:24p.m. The note stated, "Precipitating behavior: aggression, pushing staff" --- "emergency medication" --- "Zyprexa 10mg IM" and "Benadryl 50mg IM." The "Physician Progress Note" dated 4/5/11 at 8:30p.m. stated, "Face to face for Medical Decision Making: No." "Pt [patient] refused to be seen thru [sic] tel [television monitor from Case Amistad to San Antonio State Hospital's main campus]. No report of injury."

5. Non-sample patient SR3, housed on Casa Amistad unit, was placed in " personal vertical restraint" on 4/10/11 at 10:50p.m. "Client was refusing to give staff phone with camera capabilities" --- "A basket hold [personal vertical] was done" --- "removed the phone from...hand without incident." The "Physician Progress Note" dated 4/11/11 at 11:30p.m.stated, "face to face for Medical Decision Making: Yes." The "yes" meant that the patient agreed to be interviewed by the physician on the television monitor.

6. Non-sample patient SR5 was placed in a "personal restraint vertical" on 6/29/11 from 7:35p.m. to 7:39p.m., according to a "chart profile" dated 6/29/11. The note said, "Personal restraint vertical due to severe agitation and aggression toward staff [attempted to hit and kick staff] and imminent self-harm behaviors." No physician progress note could be found in the record to verify that a 1 hour face to face evaluation had been performed by a physician.

7. Non-sample patient SR6 was placed in a "personal restraint" to administer emergency medications on 6/29/11 from 10:09p.m. to 10:11p.m. The nursing note said, "Pt in the Dayroom. Psychotic, threatening peers and staff. The OD doctor [doctor on call] ordered Haldol 5mg IM, Ativan 2mg IM, Benadryl 50mg IM, stat [immediately]." No documentation of a face to face evaluation by the physician after the initiation of the restraint could be found in the patient's record.

8. In an interview on 7/11/11 at 11:15a.m., the Attending Psychiatrist at Casa Amistad stated, "I don't do face-to-face evaluations. It's not part of my contract agreement with the hospital."

9. In an interview on 7/14/11 at 10:36a.m., the issues of physicians not doing face to face evaluations following a seclusion or restraint, and not documenting on the result of the evaluation in a patient's medical record, was discussed with the Medical Director. The Medical Director stated that the facility had a problem with on-call physician coverage, especially at the Casa Amistad which is located 150 miles from the main facility. He stated, "It's been extremely difficult to get a doctor to go there [meaning Casa Amistad unit]."

III. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety or sedating medications for 1 of 7 non-sample patients added for review of seclusion/restraint (SR7). For this patient, physician orders were written on a PRN (as necessary) basis for vague symptoms labeled "anxiety" or "psychosis." Nurses could choose the administration route for the same dose of medications by "IM" (intramuscular injection) or "p.o." (by mouth). Interviews also confirmed that the facility's unwritten policy was to have patients choose their own medications. Nursing staff complied with this unwritten policy and gave patients their own choice of mediations from a list of PRN orders written by the attending physician. Additionally, Patient SR7 had PRN orders for at least two medications for similar symptom indications,

Based on record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment, other than medication usage, for 4 of 5 discharged patients whose records were reviewed (DC2, DC3, DC4 and DC5). This failure compromised the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

1. Patient DC2: In a discharge summary dated 5/16/11, the physician dictating the summary noted under the section titled "Course in Hospital" the following: "Patient transferred to [local hospital] following deterioration. Pt. was intubated followed by family's request of DNR (do not resuscitate/Advance Directive), extubated on 5/6/11 remained at [local hospital] MICU (medical intensive care unit), transferred to [local hospice] on 5/11/11, expired on 5/12/11." No other information about the two years of hospitalization was noted in the report.

2. Patient DC3: In a discharge summary dated 6/5/11, the physician dictating the summary noted under the section titled "Course in Hospital" the following: "We will likely need a court order to compel medication. [Patient DC3] will be placed on Risperdal Consta as [DC3] has some success with that in the past [sic]. [Unit physician] continued the patient on Risperdal and Risperdal Consta. [Another physician] took over the service but it is unclear if he continued the Consta as it is not listed in the discharge medication order note." No other information about the hospitalization was noted in the report.

3. Patient DC4: In a discharge summary dated 5/11/11 , the physician dictating the summary noted under the section titled "Course in Hospital" the following: "Pt. needs to continue his medication. However, because he is going to be living with his father in Mexico it is possible that he will not follow his treatment." No other information about the hospitalization was noted in the report.

4. Patient DC5: In a discharge summary dated 5/24/11 , the physician dictating the summary noted under the section titled "Course of Treatment" the following: "Interventions-structured/supportive milieu and treatment with antoipsychotic [sic] and antihypertensive medication." No other information about the hospitalization was noted in the report.

B. Interview

In an interview on 7/14/11 at 11:15AM, the Clinical Director was shown the information noted in Section A above; she agreed with the findings and stated "this has been a long standing problem."

Based on observation, record review and interviews, the facility allowed Registered Nurses to perform physical examinations for patients admitted to the Casa Amistad unit in Laredo including 3 of 3 active sample patients (L1, L4 and L6). A primary care physician at the San Antonio facility (150 miles away from the Casa Amistad unit) used a telemedicine connection to observe the RN perform the physical examination. The facility had no documentation of any recent training for RNs to perform these examinations. The last training was 10 years ago and not for all current nurses performing the evaluations. This failure places patients at unnecessary risk for missed medical illnesses and places nursing staff in a position of practicing outside the scope of nursing practice (Refer to B137)

Based on observation, record review and interviews, the facility failed to provide adequate medical personnel on site at the Laredo satellite in order to provide physical examinations for 3 of 3 active sample patients at that site (L1, L4 and L6). The facility utilized a primary care physician at the San Antonio facility (150 miles away) to observe a registered nurse perform the physical examination by a telemedicine connection. The facility had no documentation of any recent training for RNs to do the examinations. The last training was 10 years ago and not for all current nurses performing the examinations. There was a psychiatrist in the facility four hours per day who did not perform physical examinations. There were no other physicians or physician extenders, e.g., nurse practitioners or physician assistants, in the Laredo facility. These failures place patients at risk for missed diagnoses or misdiagnosis of medical conditions.

Findings include:

A. Observation

During an orientation to the Laredo unit on 7/11/11 at 9:00AM, the unit nurse manager pointed out a small room on the unit that was used for telemedicine conferencing with the San Antonio facility. In this room were instruments that the nurses used to do physical examinations while a physician in San Antonio looked on and listened.

B. Record Review

1. Patient L1: In a physical examination report dated 8/6/10 it was noted that the examination was completed by a physician who was stationed at the San Antonio facility. The physician verified that the physical examination was performed by telemedicine.

2. Patient L4: In a physical examination report dated 6/15/11 it was noted that the examination was completed by a physician who was stationed at the San Antonio facility. The physician verified that the physical examination was performed by telemedicine.

3. Patient L6: Patient L1: In a physical examination report dated 6/22/11 it was noted that the examination was completed by a physician who was stationed at the San Antonio facility. The physician verified that the physical examination was performed by telemedicine.

4. The nursing department produced a list of four registered nurses who were trained by an advanced practice nurse in providing physical examinations by telemedicine. Three of those nurses still work at the Laredo facility; none of them performed the physical examinations for the three active sample patients; all examinations were performed by the unit nurse manager. The unit nurse manager was not one of the RNs on the list of nurses who had been formally trained to do physical examinations. There have been no updates or trainings since the original training in 2001.

C. Interviews

1. In an interview on 7/11/11 at 10:30AM, the Laredo unit nurse manager stated that he does the physical examination with a physician watching him perform various parts of the exam remotely from San Antonio. He stated that this [RNs doing physical exams with physician watching by a telemedicine monitor] has been occurring for at least 7 years and that he has been doing the examinations for the last 4? years. He reported that he did not receive any formal training for performing the examinations and stated, "The previous nurse manager showed me how to do it." He was asked about what he does for the examination and he proceeded to give detailed information about his examination procedure which included fundoscopic examination, neurological examination and abdominal palpation. When asked if he had received advanced training to do physical examinations, he stated "no, I have not." When asked if he had received training from a physician to do physical examinations, he stated "no." He also stated "Doctors haven't done a physical here in a long time, years."

2. In an interview on 7/11/11 at 11:00AM, MD7 (attending physician in Laredo) was asked who performed the physical examinations for the unit. He stated that it was done by "telemedicine from San Antonio and has been done that way for years." When asked if he [MD7] performed physical examinations, he stated "no, it's not part of my contract." When asked if he provided any guidance or education for nursing related to providing physical examinations, he stated that he did not.

3. In an interview on 7/13/11 at 1:00PM with the Director of Nursing, the information about physical examinations in Laredo was shared with her; she agreed with the findings and stated that she did not know if the nurses in Laredo had received any recent training related to performing physical examinations.

4. In an interview on 7/13/11 at 1:15PM, MD6 (physician listed on three Laredo physical examinations) was asked about the procedure related to the performance of physical examinations by telemedicine. MD6 stated that they [medical staff] had been performing examinations this way for the last 4? years. When asked if MD6 had trained the nurses to perform the examinations, MD6 stated " no." When asked if MD6 had ever been to the Laredo facility to perform examinations, MD6 stated "no." When asked if MD6 knew whether or not nurses were formally trained to perform the examinations, MD6 stated "no." When asked if MD6 had ever confirmed the accuracy of the nursing examinations by performing a reexamination for quality assurance, MD6 stated "no."

5. In an interview on 7/14/11 at 11:30AM, the Clinical Director stated, "I'm aware of the problems you found with the physicals in Laredo; I didn't know that the nurses weren't trained to perform the examinations. We can't get doctors to do the exams in Laredo; we can't recruit a psychiatrist to work for us if they had to do a physical."

Based on record review, interviews and observations, the Clinical Director failed to:

I. Ensure that the psychiatric evaluations of 5 of 12 active sample patients (A8, N6, N9, N14 and S38) included a report of memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. Three of these patients (N6, N9 and N19) were admitted to the facility secondary to cognitive decline from dementia. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Ensure that the Master Treatment Plans (MTPs) were revised after multiple episodes of restraint of 1 of 2 active sample patients (S38) on the Seguin Unit. The MTP was not updated to address less restrictive interventions to be used by staff to assist Patient S38 to achieve treatment objectives regarding controlling episodes of aggressive behavior. In addition, the facility failed to revise the MTP for 1 of 3 active sample patients (L1) on the Casa Amistad Unit. This patient had no MTP to address current psychiatric treatment after being transferred back to the Casa Amistad Unit in Laredo following a three month hospitalization on the Arnold Unit in San Antonio. Failure to do needed revisions of treatment plans results in patients being hospitalized without a treatment plan that adequately reflects the patients' treatment needs, potentially delaying improvement and discharge. (Refer to B118-I)

III. Ensure that Master Treatment plans of 9 of 11 active sample patients (A1, A8, L4, L6, N9, N14, S10, S38 and T17) whose treatment plans were reviewed consistently defined short and long term goals as specific, measurable patient behaviors to be achieved. [Note: patient L1 had no MTP to review]. This practice compromises staff ' s ability to evaluate patient progress in treatment and to make necessary modifications in patients ' treatment plans. (Refer to B121)

IV. Ensure that the Master Treatment Plans of 11 of 11 active sample patients whose treatment plans were reviewed (A1, A8, L4, L6, N6, N9, N14, T17, T37, S10 and S38) identified individualized interventions to address the patients' presenting problems and treatment goals. [Note: Patient L1 had no MTP to review].The Master Treatment Plans (MTPs) of these 11 patients contained generic and routine discipline functions, instead of individualized treatment interventions. The frequency of staff contact and/or the modality (individual or group sessions) was not specified: for registered nurses on the MTPs of 5 patients (A1, A8, L6, S10 and S38); for social work on the MTPs of 8 patients (L4, L6, N6, N9, N14, T17, T37 and S10); for rehabilitation staff on the MTPs of 4 (A1, A8, L4 and L6); and for psychology on the MTPs of 2 patients (A1 and T17). In addition, there were no physician interventions on any of the 11 patients' MTPs and no rehabilitation staff interventions on the MTPs of 3 patients (N6, N9 and N14). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

V. Provide active treatment, including alternative interventions, for 9 of 12 active sample patients (L1, L4, L6, N6, N9, N14, S10, S38, and T17). These patients were either not cognitively capable of participating in assigned treatment or were not motivated to attend the assigned groups. Observations of groups provided on the units revealed that the interventions failed to relate to the specific problems and needs of the above patients. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided. potentially delaying their improvement. (Refer to B125-I)

VI. Ensure that a physician did a face to face evaluation for 1 of 1 active sample patient (N14) and 3 of 7 non-sample patients (SR1, SR2, and SR3) whose records were reviewed for compliance with seclusion/restraints policy and procedures. For patient N14, the physician wrote a progress note on the restraint incident but stated that he did not provide a face to face evaluation. For Patients SR1, SR2, and SR3, the physician, who was located at the main campus 150 miles from the Casa Amistad unit where the patients were located, used a television monitor to view an RN doing the evaluations instead of visiting the patients in person. This is not a "face-to-face" evaluation as required in the facility's Patient's Rights Policy. In addition, the physician failed to document the results of a face to face evaluation for 2 of the 7 non-sample patients (SR5 and SR6) whose charts were reviewed for seclusion/restraint compliance. Failure to provide face-to-face assessments by a physician or other qualified clinician also can result in a risk to the patient's life and well-being. (Refer to B125-II)

VII. Ensure that physician orders provided adequate guidance to nursing staff on the administration of antipsychotic, antianxiety or sedating medications for 1 of 7 non-sample patients added for review of seclusion/restraint (SR7). For this patient, physician orders were written on a PRN (as necessary) basis for vague symptoms labeled "anxiety" or "psychosis." Nurses were allowed to choose the administration route for the same dose of medications by "IM" (intramuscular injection) or "p.o." (by mouth). Additionally, Patient SR7 had PRN orders for at least two medications for similar symptom indications, without specific guidance to nursing as to which medication to use. These failures place the nursing staff in a situation that requires them to function beyond the scope of nursing practice. Ambiguous physician orders also can result in serious complications from improperly administered PRN medications. (Refer to B125-III)

VIII. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 4 of 5 discharged patients whose records were reviewed (DC2, DC3, DC4 and DC5). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

IX. Provide adequate medical personnel on site at the Laredo satellite in order to provide physical examinations for 3 of 3 active sample patients at that site (L1, L4 and L6). The facility utilized a primary care physician at the San Antonio facility (150 miles away) to observe a registered nurse perform the physical examination by a telemedicine connection. The facility had no documentation of any recent training for RNs to perform the physical examinations. (The last training was 10 years ago and not for all current nurses performing these evaluations). There was a psychiatrist in the facility four hours per day who does not perform physical examinations. There are no other physicians or physician extenders present in the Laredo facility. These failures place patients at risk for missed diagnoses or misdiagnosis of medical conditions. (Refer to B137)

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

I. Ensure that the Master Treatment Plans (MTPs) of 10 of 11 active sample patients (A1, A8, L4, L6, N9, N14, T17, T37, S10 and S38) identified individualized nursing interventions to address patients' presenting problems and treatment goals. [Note: Patient L1 had no MTP to review]. The MTPs contained generic and routine nursing functions, incorrectly listed as individualized interventions. In addition, the frequency of contact with patients and/or the modality (individual or group sessions) was not specified on the MTPs of 5 of 11 active sample patients (A1, A8, L6, S10 and S38). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (7/1/11), A8 (6/23/11), (L4 (7/11/11), L6 (7/11/11), N6 (updated 7/12/11), N9 (updated 3/22/11), N14 (updated 7/12/11), T17 (6/28/11), T37 (updated 5/04/11), S10 (4/14/11 & updated 7/11/11) and S38 (6/8/11).

1. The following patients had generic and routine nursing functions incorrectly listed as treatment interventions for psychiatric problems:

a. Patients A1, A8, L4, L6, N9, N14, T17, T37, S10, and S38 had the following identical or similarly worded statement: "NI-Medication [class of medication]: Licensed nursing staff will administer [class of medication] medication as ordered and clinically adjusted by unit Physician. Nursing staff will monitor for side effects, assess effectiveness..."

b. Patient T17: "Nursing Staff will observe patient in a variety of situations; identify treatment progress and possible emerging problem areas; and report observations with patient and team daily."

2. The following patients had nursing interventions with no frequency of contact and/or no specified modality (individual or group):

a. Patients A1, A8, L6, S10 and S38 had the following identical or similarly worded statement: "Licensed personnel will present patient with information regarding medications identification, desired effects, side effects and the importance of medication compliance to control symptoms of mental illness...As needed." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

b. Patients A1, A8, L6, T17, T37, S10 and S38 had the following identical or similarly worded statement: "Patient will discuss topics issues, events, and happenings that occur in the community, state, and country...5x week." This statement failed to say what the nursing staff would be doing or specify the modality for the discussions.

c. Patients A1, A8, T37 and S38 had the following identical or similarly worded statement: "Nursing staff will provide a structured physical exercise program that will improve motor functioning...9x [sic] week 1 hour." This statement failed to include the modality that would be used.

d. Patient A1: "Nursing staff will provide assistance to help patient identify precursors to behavioral problems, help generate possible solutions, support patient in resolving problems; and encourage patient to express feelings appropriately...As needed." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

e. Patients A1, A8, L4, L6, T1738 had the following identical or similarly worded statement: "Nursing staff will reinforce medication - food interaction information; need for aftercare program; aspects of social adjustment, self care needs and involve patient and family in plan...Prior to discharge." The specific frequency of contact or number of sessions and modality were not included in the intervention statement.

B. Staff Interviews

In an interview on 7/14/11 at 9:00a.m. with the Director of Nursing (DON), the treatment interventions on the Master Treatment Plans were reviewed. The DON confirmed that the listed interventions were routine nursing tasks and acknowledged that the frequency of contact with the patient and the modality was missing in many of the intervention statements. The DON stated, "We have a lot of work to do on the treatment plans."

II. Ensure that the electronic medical record contained documentation that interventions listed on the Master Treatment Plans (MTPs) were actually delivered by nurses for 5 of 11 active samples patients (A1, A8, L6, S10 and S38). Nurses failed to document these patients' attendance or non-attendance in assigned treatment interventions, the topic(s) discussed, and the patients' responses to the interventions. This failure hampers the treatment team's ability to determine patients' response to nursing interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (7/1/11), A8 (6/23/11), (L4 (7/11/11), L6 (7/11/11), N6 (updated 7/12/11), N9 (updated 3/22/11), N14 (updated 7/12/11), T17 (6/28/11), T37 (updated 5/04/11), S10 (4/14/11 & updated 7/11/11) and S38 (6/8/11).The review of the documentation in the patients' electronic medical records revealed no treatment notes for the following nursing interventions:

Patients A1, A8, L6, S10 and S38: "Individual Medication Education: Licensed personnel will present patient with information regarding medications identification, desired effects, side effects and the importance of medication compliance to control symptoms of mental illness... As needed." There was no documentation in the electronic medical record recording attendance or non-attendance in medication education sessions. Additionally there were no notes regarding the information provided or topic discussed, or the patient's response including level of participation and understanding.

B. Staff Interview

In a discussion on 7/14/11 at 9:00a.m. with the Director of Nursing (DON), the recording of notes about nursing interventions listed on the treatment plan and program schedule was discussed. The DON acknowledged that the electronic record did not have notes stating what the nurse did during medication education or information provided to the patient.

Based on record review and interview, the Director of Social Services failed to ensure that the social work assessments for 7 of 12 active sample patients (A8, L4, L6, N9, S10, T17 and T37) included conclusions and recommendations, describing anticipated social work roles in treatment and discharge planning This failure results in a lack of focused social work interventions for treatment planning.

Findings include:

A. Record Review

1. Patient A8: In a Social Assessment dated 6/21/11, it was noted in the section titled "Needs/Recommends" for interventions: "The patient will be started on meds when [A8] is court compelled to stabilize [A8] condition. [A8] will be involved in Core Programming to provide daily activities and structure. [A8] will be involved in Coping with Depression to improve [A8's] ability to cope with stressors." There were no specific social work interventions noted in the record.

2. Patient L4: In a Social Assessment dated 6/21/11, it was noted in the section titled "Needs/Recommends" for interventions: "The patient will be offered the most appropriate treatment regimen as well as education on [L4's] mental illness and medications. [L4] will be offered psychosocial programming and occupational therapy to enhance [L4's] functioning in the community." There were no specific social work interventions noted in the record.

3. Patient L6: In a Social Assessment dated 5/24/11, in the section titled "Needs/Recommends" for interventions, there was no information at all.

4. Patient N9: In a Social Assessment dated 2/24/11, it was noted in the section titled "Needs/Recommends" for interventions: "Obtaining resources that will allow placement in the least restrictive alternative." No other social work interventions were noted in the record.

5. Patient S10: In a Social Assessment dated 4/8/11, it was noted in the section titled "Needs/Recommends" for interventions: "Community resource referrals, Medication Education." No other social work interventions were noted in the record.

6. Patient T17: In a Social Assessment dated 6/28/11, it was noted in the section titled "Needs/Recommends" for interventions: "Stabilize on medication, nursing supervision, medication monitoring and discharge planning with assigned Social Worker. While here encourage pt. to attend grps on unit which is also part of treatment plan [sic]." No specific social work interventions were noted in the record.

7. Patient T37: In a Social Assessment dated 4/22/11, (pt admitted 4/10/08), it was noted in the section titled "Needs/Recommends" for interventions: "Focus of treatment is to provide acute care treatment to help stabilize presenting symptoms. Treatment team will monitor patient's progress throughout course of hospitalization and encourage participation in programming activities, most especially the Acceptance group, headed by unit psychologist. Social worker will work together with MHA (mental health authority) liaison to coordinate patient's aftercare at time of discharge." No other social work interventions were noted in the record.

B. Interviews

1. In an interview on 7/14/11 at 10:00AM, the Director of Social Services was shown the findings noted above; he agreed with the findings.

2. In an interview on 7/14/11 at 11:30AM, the Clinical Director was shown the findings noted above; she agreed with the findings.

Based on observation, interview and record review, the facility failed to plan and implement structured programming of therapeutic/leisure activities on evenings and weekends for all patients on the Casa Amistad unit, including 3 of 3 active sample patients (L1, L4, and L6). The lack of evening and weekend activities has resulted in long periods of patient inactivity on the unit, potentially delaying patient's movement toward discharge.

Findings include:

A. Observations and interviews

1. During an observation on 7/11/11 at 9:00a.m. on the Casa Amistad unit, there was no group activity even though the program schedule listed a "Current Events" group at 9:00a.m. The patient census was 14 on this 16 bed unit. Patients were either in their rooms, watching TV in the Dayroom or sitting in the enclosed outdoor area off the Dayroom.

2. In an interview on 7/11/11 at 9:15a.m., active sample patient L6 was asked if he planned to attend the 9:00a.m. group when it started. He stated "No." When asked what he did all day, he stated, "I just sit in the Dayroom most of the day." When asked what he did during the past weekend, he stated that he watched TV.

3. During an observation on the Casa Amistad unit on 7/11/11 from 9:30a.m. to 10a.m., RT #1 was holding the "Cognitive Group." Only 4 of the 14 patients on the unit were attending the group. The other 10 patients either sat around the Dayroom or sat outside. Active sample patients L1, L4, and L6 did not attend the group. L1 sat at a table in the Dayroom and read magazines. L6 took a shower and did his laundry during this time period.

3. In an interview on 7/11/11 at 12:10p.m., RT1 stated that she was the only rehabilitation therapist assigned to the Casa Amistad unit. She stated that she worked 4 days per week, and that she was off on Thursday to attend school and did not work weekends. She stated that she was the only person who routinely held groups on the unit. When asked who covered for her when she was not there, she stated "No one. I leave out art and craft supplies for the nursing staff to use with patients."

B. Document Review and Additional Interviews

1. A review of the Casa Amistad unit activity schedule verified what RT1 said in the above interview about her schedule. There were no groups scheduled after 4:40p.m. during the week on the unit except for a substance abuse group on Wednesdays from 7p.m. to 8p.m. The only groups scheduled on Thursday when RT1 was off duty were " Medication education" from 3:30p.m. to 4:30p.m. and a "Spiritual Group" twice a month from 1:30p.m. to 2:30p.m. Leisure groups were listed on the schedule for two Saturdays per month from 8:00a.m. to 12p.m. There were no scheduled activities the other two Saturdays.

2. In an interview on 7/11/11 at 1:30p.m., the Nursing Director stated that the nursing staff on Casa Amistad was not responsible for groups on evenings and weekends.