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Based on observations, record review and interviews, the facility failed to provide active treatment interventions for 3 of 3 active sample patients (S6, S10 and S36) on Seguin Hall and 2 of 2 active sample patients (T14 and T19) on the Travis Unit who were unwilling or not motivated to attend groups offered and/or assigned. In addition, the facility failed to schedule a sufficient number of unit-based activities to accommodate the number of patients hospitalized on Seguin and Travis Halls. This lack of active treatment results in affected patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on observations, record review and interviews, the facility failed to provide active treatment interventions for 3 of 3 active sample patients on Seguin Hall (S6, S10 and S36) and 2 of 2 active sample patients on the Travis Unit (T14 and T19) who were either unwilling or unmotivated to attend groups offered and/or assigned. In addition, the facility failed to schedule a sufficient number of unit-based activities to accommodate the number of patients hospitalized on Seguin and Travis Halls. This lack of active treatment results in affected patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement.

Findings include:

I. Specific Patient Findings

A. Patient S6

1. Patient S6 was a 50 year old admitted to Seguin Hall on 10/31/11. The Psychiatric Evaluation dated 10/31/11 stated, "...with persistent symptoms of depression, and attempted suicide twice this month..."

2. During observations on Seguin Hall on 11/8/11 from 11:00a.m. to 11:30a.m., and from 1:00p.m. to 4:00p.m., Patient S6 was found in bed at 11:20a.m. and also found in bed from 1:00p.m. to 3:00p.m.

3. Patient S6's treatment plan dated 11/4/11 showed that s/he was assigned to "Occupational Therapy Group" three times a week; "Medication Education...on a 1:1 basis....at least once during hospitalization or at every medication change"; and "Health Education...on a weekly basis." [No delivery method was identified].

4. A review of the progress notes from 10/31/11 through 11/8/11 revealed that Patient S6 only attended an OT group on 11/3/11 and 11/4/11, a nutrition class on 11/3/11, and a music group on 11/4/11. There were no notes reflecting attendance for Health Education had been conducted.

5. In an interview on 11/8/11 at 11:40a.m., Patient S6 stated, "There is very little going on here I was very disappointed about the lack of classes here. I spend a lot of time in my room." S6 also stated, "I was told that I will be discharged Monday but I would rather go home Friday because there is nothing to do here on the weekends, just coloring and making plastic necklaces."

B. Patient S10

1. Patient S10 was a 30 year old admitted to Seguin Hall on 10/27/11. The Psychiatric Evaluation dated 10/27/11 stated, "floridly psychotic...Long history of Schizophrenia with auditory hallucinations."

2. During observations on Seguin Hall on 11/8/11 from 11:30a.m. to 12:30p.m., and from 1:00p.m. to 4:00p.m., Patient S10 was found in bed at 12:40p.m. and was checked periodically from 1:30 to 3:30p.m. and was found in bed each time.

3. Patient S10's master treatment plan dated 11/1/11 showed assignments to "Occupational Therapy Group Cognitive Skills" three times a week; "Medication Education...on a 1:1 basis....at least once during hospitalization or at every medication change"; and "Discharge Education...once at discharge." [No delivery method was identified].

4. A review of Patient S10's "Seguin Hall - Program Schedule" dated 11/6/11 revealed that Patient S10 was assigned to "Rehab Activities" seven days a week at 10:45a.m.; at 5:45 p.m. Monday through Friday; and at 9:00a.m., 10:00a.m., 11:00a.m., 1:30a.m.. and 2:15p.m. on Saturday. This group was not included on the patient ' s master treatment plan. Patient S10 was also assigned to "OT [Occupational Therapy] Basic Life Skills" at 2:15p.m. on Tuesday. Patient S10 did not attend the OT group on 11/8/11.

5. In an interview on 11/8/11 at 2:50p.m., OT#1 was asked about Patients S10's attendance in group. OT#1 confirmed that there was no process for getting patients to groups. OT#1 also stated that patients are given a schedule on admission and could choose to attend any group on the schedule. OT#1 stated that another schedule with assigned groups is provided within 10 days of admission. This meant that patients could be hospitalized for 10 days before receiving a schedule based on their needs.

6. A review of the progress notes from 10/27/11 through 11/8/11 revealed that Patient S10 only attended an OT group on 11/3/11 and 11/4/11. The notes mentioned medications on admissions to get a consent signed, on 11/5/1, the notes mentioned a plan to give patient written education in Spanish, and on 11/8/11 mentioned that Patient S10, "...pt [patient] had no questions regarding her [sic] medication regimen and verbalized an understanding of dosage and frequency..." During interview on 11/8/11 at 11:50a.m., Patient S10 was asked about medications. Patient S10 was unable to name medications.

C. Patient S36

1. Patient S36 was a 28 year old admitted to Seguin Hall on 10/26/11. The Psychiatric Evaluation dated 10/26/11 stated, "Bipolar Disorder, MRE Manic Type, Severe with Psychotic Features.

2. During observations on Seguin Hall on 11/8/11 from 11:00a.m. to 12:30p.m., and from 1:00p.m. to 4:00p.m., Patient S36 was found in the comfort room at 11:15a.m. and was checked periodically from 1:30 to 2:50p.m. was found in the hallway or comfort room. Patient S36 was found in bed at 3:30p.m.

3. Patient S36's master treatment plan dated 11/3/11 showed assignments to "Rehab [Rehabilitation] Activities" [No delivery method was identified]; "Acceptance Group" two day per week; "Medication Education...on a 1:1 basis....at least once during hospitalization or at every medication change"; and "COPSD [Co Occurring Psychiatric and Substance Use Disorders]/Chemical Dependency Education...2 days per week" [No delivery method was identified].

4. A review of Patient S36's "Seguin Hall - Program Schedule" dated 11/6/11 revealed that Patient S10 was assigned to "Rehab Activities" seven days a week at 10:45a.m.; at 5:45p.m. Monday through Friday; and at 9:00a.m., 10:00a.m., 11:00a.m., 1:30a.m., and 2:15p.m. on Saturday. Patient S10 was also assigned to "Acceptance Group" at 11:00a.m. on Tuesdays and 1:30p.m. on Thursdays. Patient S36 was assigned to COPSD [Co Occurring Psychiatric and Substance Use Disorders] at 1:30p.m. on Wednesdays and Thursdays. [The Acceptance Group scheduled at 11:00a.m. on 11/8/11 was not held.]

5. In an interview on 11/8/11 at 3:50p.m. Psychologist #1 was asked about S36's participation in the Acceptance Group and why the group was not held at 11:00a.m. as scheduled. Psychologist #1 stated, "The group was cancelled because there was a psychology department meeting at the time of the group." Psychology #1 also stated that the group had been cancelled several times in the past because of the meeting.

6. A review of the progress notes from 10/26/11 through 11/8/11 revealed that Patient S36 only attended COPSD Group on 11/2/11 and 11/3/11. The progress notes written by Rehabilitation Technician for the "week and weekend of 10/24 - 10/30 stated, "Patient did not attend." The notes made no reference to attendance or non-attendance at the Acceptance Group and 1:1 medication education.


D. Patient T14

1. Patient T14 was a 21 year old admitted to Travis Hall on 10/31/11. The Psychiatric Evaluation dated 10/31/11 stated, "symptoms of psychosis and depression due to withdrawal from heroin."

2. During observations on Travis Hall on 11/8/11 from 9:15a.m. to 1:30p.m., Patient T14 was found in bed at 9:30a.m. and was checked periodically and found in bed at 10:00a.m. and 10:30a.m. Patient T14 attended COPSD Group scheduled at 11:00a.m. and left at 11:10a.m. and was found in the comfort room. The surveyor did not observe any staff encouraging T14 to return to the group.

3. In an interview on 11/8/11 at 4:10a.m., Patient T14's schedule of active treatment was discussed. Psychologist #2 stated Patient T14 had been given group assignments before the 10 day period because of his/her need. Psychologist #2 noted that the patient had minimal participation in the unit schedule.

4. Patient T14's treatment plan dated 11/9/11 showed assignments to "Medication Education...on a 1:1 basis....at least once during hospitalization or at every medication change"; "Occupational Therapy Basic Life Skills at 10:00a.m., 5 days a week"; "COPSD [Co-occurring Psychiatric and Substance use Disorder] at 1:30p.m., 2 days a week"; and "SW [Social Work]-Individual Counseling, as schedule [sic]."

4. A review of the progress notes from 10/31/11 through 11/8/11 revealed that Patient T14 only attended one Music Therapy session on 11/3/11.

5. In an interview on 11/8/11 at 3:45p.m., Patient T14 was asked about going to groups on the unit schedule. Patient T14 stated, "Basically, I sit in my room and wait until tomorrow. There is not much to do. It is sad to see other patients sit in their room all day."

E. Patient T19

1. Patient T19 was a 29 year admitted to Travis Hall on 10/28/11. The Psychiatric Evaluation dated stated, "Actively hallucinating and a danger to himself and others."

2. During observations on Travis Hall on 11/9/11 from 9:15a.m. to 1:30p.m., Patient T19 was found in bed at 9:15a.m. and was checked periodically from 9:30 through 1:30p.m., and found in bed or in the hallway.

3. Patient T19's master treatment plan dated 11/4/11 showed assignments to "Medication Education" ...on a 1:1 basis....at least once during hospitalization or at every medication change; "Stress Management" 1 day a week; "Rehab [Rehabilitation] Activities" [No delivery method was identified]; and "SW [Social Work] - Individual Counseling, as schedule [sic]."

4. A review of Patient T14's "Travis Hall - Program Schedule" dated 11/4/11 revealed that the patient was assigned to "Stress Management" at 11:00a.m. on Wednesdays and "OT Basic Life Skills Group" at 1:00p.m. on Wednesdays. A program schedule dated 11/9/11was submitted to the surveyor on 11/9/11 at 1:23p.m. revealed that Patient T14 was assigned to "OT [Occupational Therapy] Basic Life Skills" at 10:00a.m. Monday through Friday; "Stress Management" at 11:00a.m. on Wednesday; and "Occupational Therapy Basic Life Skills" at 1:00p.m. Monday through Friday.

5. In an interview on 11/9/11 at 9:45a.m., OT#2 was asked about Patient T19's attendance in group. OT#2 stated that this patient had not been enrolled in groups because he was so agitated and said, "All [Patient's name] wants to do is sit in the comfort room."

6. A review of the progress notes from 10/28/11 through 11/8/11 revealed that Patient T19 only attended Music Therapy on 11/3/11 and a note by Rehabilitation therapy stated, "[Patient's name] attended 5 hours of activities for the week of Oct 31 - Nov 6, 2011." Rehabilitation Activities were not included on Patient T19's master treatment plan.

II. Specific Unit Findings:

A. Seguin Hall

1. During observations on 11/8/11 from 11:15a.m. to 4:00p.m. on Seguin Hall, a significant number of patients were in bed. According to the "SASH [San Antonio State Hospital] Safety Team (SST) Dorm /Patient Check Sheet" dated 11/8/11, 18 patients out of 36 patients on the unit at the time were in bed at 11:30a.m. with a range of 8 to 18 patients in bed between 9:00a.m. and 12 noon.

2. A review of "Acute Care - Seguin Hall - Program Schedule revealed that with a bed capacity of 42 and a census of 41 on 11/8/11 and 42 on 11/9/11, there was only one unit-based active treatment group scheduled each hour except for one group scheduled at 10:45a.m. and one group scheduled at 11:00a.m., Monday through Friday. A "Day Program" held off unit was scheduled from 8:30a.m. to 11:00a.m. and 1:15p.m. to 4:00p.m. No patients were recorded as attending the Day Program. Six patients were recorded at 9:00a.m. as attending the work program leaving 36 patients remaining on Seguin Hall. Only " Rehab Activities" were scheduled on the weekends each hour from 9:00a.m. through 5:45p.m. with breaks for meals and fresh air.

3. In an interview on 11/9/11 at 1:45p.m. with the Director of Psychology/Program Coordinator, the number patients found in bed and their lack of participation in active treatment was discussed. The Director of Psychology agreed that a lot of patients were in bed instead of participating in their treatment program. The Director of Psychology stated that they started a program to help identify patients needing to engage in the treatment program. However, the Director of Psychology admitted that there was no formal system to accomplish getting patients to groups but stated that MHTs [Mental Health Technicians] were supposed to have been instructed to prompt patients on a regular basis during change of shift meeting and he was not aware if this intervention had occurred.

3. In an interview on 11/10/11 at 10:30a.m., the Director of Nursing confirmed that there was no formal system to get patients out of bed and involved in their treatment program. The Director of Nursing also agreed that MHTs were not consistently prompting patients to participate in the treatment program and said, "This process is in its infancy." The Director of Nursing also stated that they have not had a meeting to talk to MHTs but "we plan to do this" and said, "We plan to give them a list of patients with group assignments but this had not been implemented yet."

B. Travis Hall

1. During observations on 11/9/11 from 9:15a.m. to 1:30p.m. on Travis Hall, a significant number of patients were in bed. According to the "SASH [San Antonio State Hospital] Safety Team (SST) Dorm/Patient Check Sheet" dated 11/9/11, 15 out of 31 patients on the unit at the time were in bed at 9:00a.m. with a range of 7 to 15 patients in bed between 9:00a.m. and 12 noon.

2. A review of "Acute Care - Travis Hall - Program Schedule revealed that with a bed capacity of 42 and a census of 42 on 11/9/11, there was only one unit-based active treatment group scheduled each hour except for one group scheduled at 10:45a.m. and two groups scheduled at 11:00a.m., Monday through Friday. A "Day Program" held off unit was scheduled from 8:30a.m. to 11:00a.m. and 1:15p.m. to 4:00p.m. None of the patients were recorded on the patient check sheet as attending the day program. Eleven patients were recorded at 9:00a.m. as attending the work program leaving 31 patients remaining on Travis Hall. Only "Rehab Activities" were scheduled on the weekends approximately each hour from 9:00a.m. through 5:45p.m. with breaks for meals and fresh air.

3. During observation on 11/9/11 on Travis Hall at 10:45a.m., the surveyor noted that a "Rehab Activities" Group was scheduled from 10:45a.m. to 11:45a.m. This group was not held. In an interview on 11/9/11 at 11:50a.m., RT #2 confirmed that the group was not held and stated, "I played a game with two patients."

4. In an interview on 11/9/11 at 10:00a.m., Psychologist #2 stated they were aware of the number of patients in beds and said, "There is no formal plan to address this."

5. In an interview on 11/10/11 at 9:30a.m., the Unit Director confirmed that there were "a lot of patients in bed during the day" and agreed that there was no system in place to involve patients in treatment. The Unit Director stated, "It is hard because some of the patients are so challenging, but we try."

Based on observation, record review and interview, the Facility failed to ensure that the Medical Director screened out inappropriate admissions, re-evaluated continued stay and/or discharged to a more appropriate placement 1 of 1 active sample patient (N11) who did not have the cognitive reserve to participate in active psychiatric treatment. By observation, Patient N11 was sufficiently cognitively impaired that they could not benefit from the psychiatric treatment provided. N11 required total care for all of activities of daily living. This failure prevents patient N11 from receiving more appropriate care and treatment in a safe environment that meets all physical needs. (Refer to B144)

Based on observation, record review and interview, the Medical Director failed to screen out from appropriate admission, re-evaluate continued stay and/or discharge to a more appropriate placement 1 of 1 active sample patient (N11) who did not have the cognitive reserve to participate in active psychiatric treatment. By observation patient N11 was sufficiently cognitively impaired and could not benefit from the psychiatric treatment provided. N11 required total care for all her activities of daily living. This failure prevents patient N11 from receiving more appropriate care and treatment in a safe environment that meets all of her physical needs.

Findings include:

A. Observations

1. Patient N11 was observed sitting in a HTR (hydraulic tilt recliner) chair by the nurse's station on Navarro II on 11/8/11 at 11:00a.m. Patient N11 was alone. The patient's eyes were closed and there was no movement of the arms and legs. The patient had a PEG (percutaneous endoscopic gastrostomy) tube running. A small radio, on a nearby table, was playing soft music. Nursing staff would pass by every now and then to check on the patient and the status of the tube feeding. N11 was put back in bed around 11:50a.m.

2. On 11/8/11 at 1:40p.m., a music therapist (MT #1) came to the room with a guitar and a small bongo drum. N11 was lying quietly with eyes closed. N11 respirations were even as evidenced by slight up and down chest movements. MT #1 made soft vocal sounds as N11 breathed in and out. MT #1 called N11's name several times before the patient responded by briefly opening their eyes. MT #1 began playing the guitar and singing several songs as she walked around the patient's bed looking for any physical response from the patient. The patient was observed opening their eyes briefly once or twice, but made no verbal response. MT#1 did get a physical response in the form of a short jerk of N11's arms and quick opening of their eyes when the bongo drums was played close to their head. The music therapy session ended at 9:47a.m.

3. Patient N11 was observed sitting in the HTR chair in the same place mentioned above on 11/9/11 at 9:00a.m. The patient's head was bowed and eyes closed with feeding tube running. No staff was near the patient at that time.

B. Record Review

1. Per Psychiatric Evaluation, updated 5/12/11, "[Name of patient] suffers from advanced Alzheimer's disease and is non-ambulatory and no-communicative. [S/he] is a total care patient who receives feedings and meds [medication] through PEG tube [sic]. Every 2 hours [s/he] receives incontinent care and is repositioned in bed to prevent decubitus ulcers. [S/he] receives PT [physical therapy] at least 2x/week [two times per week] for gentle stretching exercise due to significant contracture in [his/her] neck and extremities. [S/he] spends all [his/her] time in bed or in an HTR chair. [S/he] sleeps a lot during the day. [Name of patient] was seen at [his/her] bedside where [s/he] was resting. [His/Her] eyes were open, though [s/he] was not responsive to this writer or to the Italian translator. [S/he] did not make eye contact." "[Name of patient's] care could be managed in a nursing home setting, though [s/he] is not a US citizen and has no source of funding. As a result, [s/he] continues to require inpatient hospitalization for [his/her] safety."

2. Per Social Work Assessment, dated 7/13/11, "The patient is currently diagnosed with dementia of the Alzheimer's type" --- "The patient's disease has advanced to the point which [sic] the symptoms that brought [his/her] to [name of hospital] are no longer issues. [S/he] is not on any psychiatric medications and has not been since prior to [name of physician's] Psychiatric Evaluation dated May 1, 2009."

3. Treatment Plan Report, updated 10/25/11, "The patient is diagnosed with dementia, and [s/he] is at a high level of nursing care (total). [S/he] does not meet criteria for inpatient treatment in a psychiatric facility." "[Name of patient] experiences the late stages of Alzheimer's and [s/he] does not respond to stimulus/withdrawn/from stimulus. Not interacting with the environment. [Name of patient] has limited ability to communicate with caregivers and is non-responsive to verbal direction. Limited grimacing or altering of facial expression in response to stimuli."

4. Social Work Progress Note Report, dated 11/8/11, "Discharge planning effort. Writer has prepared a letter on behalf of the patient. This letter is to be forwarded to administration. Letter requests consideration for assistance for the patient in obtaining alternative funding (if available) for securing a placement in the least restrictive environment. Due to her current citizenship status (Italian national), [s/he] is unable to qualify for Medicaid/Medicare funding at this time."

C. Interviews

1. In an interview on 11/8/11 at 11:45a.m., MD #1 stated that the facility was trying to get funds from the State for a nursing home placement for N11. "[Patient] is no longer a candidate for this hospital."

2. In an interview on 11/9/11 at 11:20a.m., MHT #1 was asked to describe the nursing care provided for patient N11. S/he stated that patient N11 needs total care, including tube feedings. "We bathe her 3 times a week and check her for incontinence every 2 hours. During the day we get her [patient N11] up between 8 and 9[AM] and put her back to bed around 11 or 11:30 [PM]."

3. During an interview on 11/9/11 at 11:40a.m., RN #1 was asked if psychiatric care was being provided to patient N11. S/he stated that the patient "has advanced dementia, not a behavioral problem. [Patient N11]'s not on any psych [psychiatric] meds. They [hospital] are trying to place [N11] in a nursing home."

4. In an interview on 11/9/11 at 1:45a.m., SW#1 stated "[Name of patient] doesn't need to be here. [Patient N11] is total care. I've sent a letter up the chain of command to the Director of Social Work to check into some kind of State funding for [N11] so [N11] can be placed."

5. In an interview on 11/10/11 at 10:30am, with the Clinical Director, the inappropriate admission and continued stay of patient N11 was discussed. The Clinical Director agreed with the findings and admitted there were several other patients who do not benefit from psychiatric treatment because of their cognitive impairment. The Clinical Director stated, "These patients need a nursing home. We have a residential setting but the patients would not meet the criteria."