HospitalInspections.org

Based on observation, record review, and interview, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. The facility failed to ensure occupancy separation was maintained; failed to ensure an egress was marked with an exit sign; failed to ensure its hazardous area protective enclosures were properly maintained; failed to ensure smoke detectors had been sensitivity tested; failed to ensure portable fire extinguisher was secured and monitored; failed to ensure the subdivision of building spaces separation were properly maintained; failed to ensure fire drills were conducted and documented with transmission time of the alarm signal and failed to ensure annual electrical testing of receptacles was completed (A710).

Based on documentation review, observation during facility tour and staff verification it was determined the facility failed to meet the provisions of the Life Safety Code of the National Fire Prevention Association (NFPA). This had the potential to affect all those utilizing this facility. The facility census was 16 at the beginning of the survey.

Findings include:

K-132 Failed to ensure the integrity of the two hour fire resistive barrier of the occupancy separation

K-293 Failed to ensure proper placement of exit signs

K-321 Failed to ensure the integrity of the one hour fire rating of the hazardous areas

K-345 Failed to perform sensitivity testing of all smoke detectors

K-355 Failed to properly mount portable fire extinguishers and perform monthly checks

K-372 Failed to ensure the integrity of the one hour fire resistive smoke barrier

K-712 Failed to perform fire drills with each shift and ensure the documentation of the transmission of the fire alarm

K-914 Failed to ensure the testing of all receptacles

Please see the Life Safety deficiencies for more details.

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

I. Ensure that the Master Treatment Plan (MTP) of one (1) of eight (8) active sample patients (A8) was revised and based on the patient's presenting needs. This patient demonstrated psychotic symptoms, and either refused or could not participate in the prescribed treatment. The MTP was not revised to include modalities from which this patient could benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients. (See B 118)

II. Develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (A1, A2, A3, A4, A5, A6, A7, and A8) Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs, (See B 121)

III. Develop MTPs that included individualized interventions to address specific treatment needs for eight (8) of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7 and A8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment (See B122)

IV. Provide therapeutic programming to meet the treatment needs for five (5) of eight (8) active sample
Patients (A1, A3, A4, A5, and A8). The content of the groups offered failed to engage the
patients at their cognitive level resulting in the patients' inability to participate when in the
group or refusal to attend the group. The lack of participation was not addressed on any of the
patients'MTPs, nor were any alternative interventions listed. Failure to offer groups focusing on
individual needs limit the patients' ability to recover and can extend the length of hospitalization (See B125)

I. Based on record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) of one (1) of eight (8) active sample patients (A8) was revised, based on the patient's presenting needs. This patient demonstrated psychotic symptoms, and either refused or could not participate in the prescribed treatment. The MTP was not revised to include modalities from which this patient could benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review:

1. Patient A8 was admitted on 3/14/17 with a diagnosis of "Paranoid Schizophrenia with Acute Decompensation" as documented on the psychiatric evaluation, dated 3/15/17. The psychiatric evaluation documented "The patient is decompensating. (S/He) has been refusing to take (his/her) medication, including Haldol Deaconate that is given every month for psychosis. (S/He) is labile. (S/he) has started to yell and curse the staff members, sometimes used profanities. (S/he) is disrupting in the milieu and that is definitely a change from (his/her) usual baseline functioning."

2. Patient A8's Master Treatment Plan, dated 3/17/17, documented one problem: "Pt refuses medications, yells, and paces." The only short term goal listed is "Pt will accept medications when offered." Interventions include "SW will encourage attendance in psychotherapy groups to process needs for medication and reality orientation." "Activity therapy will encourage attendance at groups for pt ..."

3. Patient A8's treatment plan update, dated 3/20/17, stated "Patient refusing all medication due to paranoia 'God told (him/her) (s/ he) didn't need it'; Patient has poor PO [by mouth] intake; Patient refusing labs and Accuchecks; Patient still has periods of agitation; Patient refusing group therapy."

4. Interventions on the treatment plan update, dated 3/20/17, continued "Activity therapy will encourage groups to appropriately express feeling". "Social work will continue to encourage groups and provide 1:1....." There were no new nursing interventions documented on the treatment plan update.



Observations

1. At attendance at treatment planning on 3/20/17 at 10:00 a.m., the treatment team noted patient's lack of progress, medication refusal, refusal of laboratory tests, and paranoid delusions. Conclusion at the meeting was the need for approval of forced medication administrations.

2. Observations on the unit by the surveyor on 3/20/17 revealed patient A8's lack of attendance in groups offered at 10:45 a.m., 11:00 a.m., and 1:10 p.m. During these times patient was observed in his room or in bed.

3. Attempts by the surveyor to interview Patient A8 on 3/20/17 at 1:10 p.m. resulted in the patient stating, "I don't feel like talking right now; I'm in a bad mood." During a second attempt to interview Patient A8 on 3/21/17 at 9:30 a.m., the patient stated, "I am not talking to any more psychiatrists." During both times the patient was observed either in (his/her) room or in bed.

B. Interviews

1 In an interview on 3/21/17 at 2:00 p.m., Social Worker 1 indicated that (s/he) attempts to engage Patient A8 in groups. When not successful (s/he) tries to engage the patient individually, however doesn't always have time to do this or document the encounter with the patient.

2. In an interview on 3/21/17 at 10:30 a.m., the medical director concurred there was a need to engage this patient in active treatment.

3. In an interview on 3/22/17 at 9:15 a.m., Social Worker 3 concurred with findings on Patient A8's Patient Observation Sheet that patient was in (his/her) room from 9:00 a.m. to 12:15 p.m. on 3/20/17 and also on 3/20/17 in the room from 1:00 p.m. to 3:45 p.m. instead of attending any therapeutic activities.

4. In an interview on 3/22/17 at 9:50 a.m., Social Worker 1 concurred that the Treatment Plan Update, dated 3/20/17, did not list essential changes in social services or activity therapy interventions despite the patient's lack of progress and did not list any nursing interventions

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (A1, A2, A3, A4, A5, A6,A7 and A8) Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings Include:

A. Record Review

1. Review of the policy "Multidisciplinary Treatment Planning Policy", Policy Stat ID 2943751 dated 3/2017, described multi-disciplinary long and short term goals as follows: "The goal is expressed in measurable, achievable, time-framed and appropriate terms, given patient's diagnosis, cognitive level of function and condition."

2. Patient A1was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem- "Hitting/aggression toward others, yelling, resistiveness [sic] to cares [sic]. Potential to harm self/others due to unsafe behavior and resistiveness [sic] to cares [sic]" The listed short term goals were "will be compliant with medication; accept care without physical aggression; improved sleep, improved appetite/meal compliance, decreased yelling."

3. Patient A2 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Suicidal ideation with plan." The listed short term goals were "Pt [patient] will eat 50 - 100% of all meals; Pt will verbalize thoughts of self-harm; pt will display a brighter affect/mood."

4. Patient A3 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Paranoid/anxiety, unsafe behaviors; psychosis/flight of ideas; not sleeping." The listed short term goals were "Have decrease in psychosis and engage reality based conversations; Accept and participate in treatment/accept meds (medication) daily."

5. Patient A4 was admitted on 3/16/17. The MTP, dated 3/17/17, identified the problem, "Patient refuses care, hits and yells." The listed short term goals were "Accept care without physical aggression; improve safety awareness."

6. Patient A5 was admitted on 3/5/17. The MTP, dated 3/5/17, identified the problem, "(Patient) struggles with paranoia, delusion r/t (related to) people wanting to kill/harm (him/her) which manifest in pt.'s unwillingness to receive care or comply with medication regimen." The listed short term goals were "Display improvement, as evidenced by objective or subjective report, regarding any of the applicable symptoms associated with mania; pressured speech, reduced need for sleep, appetite disturbance, risk taking behavior, inflated self-esteem, distractibility, flight of ideas, & increase in goal directed activity."

7. Patient A6 was admitted on 3/13/17. The MTP, dated 3/15/17, identified the problem, "Patient is depressed and hopeless with suicide attempt; recent brother's death." The listed short term goals were "Patient will sleep 6 - 8 hours per night; Patient will not talk about self-harm".

8. Patient A7 was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem, "Refusing medications, visual hallucinations, & exit seeking". The listed short term goals were "Accept medications; Report less paranoia; Decreased crying."

9. Patient A8 was admitted on 3/14/17for behavioral decompensation, aggression, and agitation and medication refusal. The MTP, dated 3/14/17, listed the only identified problem as "Pt refuses medication, yells, & paces." The listed short term goal was "Pt will accept medications when offered."

B. Interviews

1. In an interview on 3/21/1917 at 10:00 a.m., Physician 1 concurred that treatment goals were not measurable and observable.

2. In an interview on 3/21/17 at 10:30 a.m., the Medical Director concurred that the current short term goals were not observable or measurable as documented.

3. In an interview on 3/21/17 at 1:00 p.m., Social Worker 2 concurred that short term goals as documented were not observable or measurable.

Based on record review and interview, the facility failed to develop MTPs that included individualized interventions to address specific treatment needs for eight (8) of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7 and A8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment.

Findings Include:

A. Record Review

1. Review of the policy "Multidisciplinary Treatment Planning Policy", Policy Stat ID 2943751 dated 3/2017, described multi-disciplinary interventions as "The interventions shall be highly individualized, reasonable and necessary to improve the condition that necessitated the hospitalization. Such interventions form the basis of "Active Treatment".

2. Patient A1was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem-, "Hitting/aggression toward others, yelling, resistiveness [sic] to cares [sic]. Potential to harm self/others due to unsafe behavior and resistiveness [sic] to cares [sic]". The listed interventions included: "Nursing will monitor for [increased] agitation, yelling; provide [decreased] stimulus and/or diversional acts", "Social Services will provide updates on pts. Status to guardian and facility 2-3 times per week" and "Activity therapy will provide groups daily to provide opportunities for pt (patient) to appropriately express self."

3. Patient A2 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Suicidal ideation with plan." The listed interventions included: "Nursing will monitor intake, encourage self-care, and monitor suicidal thoughts "and "SW (Social Work) will complete MMSE (Mini Mental Status Exam) to determine cognitive level."

4. Patient A3 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Paranoid/anxiety, unsafe behaviors; psychosis/flight of ideas; not sleeping." The listed interventions included: "Nursing will monitor daily medication compliance, s/s (signs/symptoms) of paranoia, for any unsafe behaviors, sleep/wakefulness cycle", "Social Services will provide psychotherapy daily in groups validating current events and reality orientation" and "Activity Therapy will provide groups daily, encouraging appropriate expression of feelings in a reality oriented space."

5. Patient A4 was admitted on 3/16/17. The MTP, dated 3/17/17, identified the problem, "Patient refuses care, hits and yells." The listed interventions included: "Nursing will administer meds and monitor for increased agitation, redirection and encourage activities", "SW will provide update to the pt.'s family 2-3 times per week and assist with finding new placement" and "Activity therapy will provide groups daily, encouraging expression of feelings and modeling appropriate interaction."

6. Patient A5 was admitted on 3/5/17. The MTP, dated 3/5/17, identified the problem, "(Patient) struggles with paranoia, delusion r/t (related to) people wanting to kill/harm (him/her) which manifest in pt.'s unwillingness to receive care or comply with medication regimen." The listed interventions included the nursing intervention, "Nursing will monitor (patient's) compliance with medication and document symptom improvement."

7. Patient A6 was admitted on 3/13/17. The MTP, dated 3/15/17, identified the problem, "Patient is depressed and hopeless with suicide attempt; recent brother's death." The listed interventions included: "Nursing will monitor for SI (Suicidal Ideation), sleep pattern, medication compliance" and "Social services provide supportive psychotherapy."

8. Patient A7 was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem, "Refusing medications, visual hallucinations, & exit seeking". The listed interventions included "nursing will administer medications and assess for signs and symptoms of depression and paranoia" and "SW [social work] will communicate with the pt.'s [patient's] family"

9. Patient A8 was admitted on 3/14/17 for behavioral decompensation, aggression, agitation and medication refusal. The MTP, dated 3/14/17, listed the only identified problem as "Pt refuses medication, yells, & paces." The listed interventions included "nursing will attempt, encourage, & educate pt on the importance of medications" and "SW will encourage attendance in psychotherapy groups to process needs for medication and reality orientation."

B. Interviews

1. In interview on 3/20/17 at 3:00 p.m., Quality Compliance 1 acknowledged that the interventions on the MTP were vague, non- specific and generic discipline functions that would apply to all patients.

2. In interview on 3/21/17 at 8:45 a.m., the Director of Nursing stated that the nursing interventions were generic functions that she would expect the RN to carry out with all patients.

Based on interviews and observations, the facility failed to provide therapeutic programming to meet the treatment needs for five (5) of eight 8) active sample patients (A1, A3, A4, A5 and A8). The content of the groups offered failed to engage the patients at their cognitive level, resulting in the patients' inability to participate when in the group or refusal to attend the group. The lack of participation was not addressed on any of the patients' MTPs nor was any alternative interventions listed. Failure to offer groups focusing on individual needs limits the patients' ability to recover and can extend the length of hospitalization.

Findings include:

A. Observations (All observations were made on the one hospital unit)
1. Observations on 3/20/17 from 10:15-11:00 a.m. (Nutrition Education group for all patients being held 10:00-10:45 a.m.)

Patient A1 was observed sitting in a wheelchair in front of the television. Patient A1 had his/her head down with eyes closed. When called by name he/she looked up and immediately lowered head again and closed eyes.

Patient A3 was observed walking the halls and talking to the nursing staff at the nurses' station.

Patient A4 was observed walking with his/her walker, going in and out of other patients' rooms.

Patient A5 was observed in bed.

Patient A8 was observed in his/her room.

2. Observations on 3/20/17 from 11:00-11:30 a.m. (Occupational Therapy group for all patients being held from 11:00-11:45 a.m.)

Patient A1 was still in front of the television with head down and eyes closed.

Patient A3 was walking the hallway stating, "It's too cold to go to group."

Patient A4 was sitting in the dining room alone.

Patient A5 was in bed.

Patient A8 was in his/her room.

Only five (5) out of the 15 inpatients attended the Occupational Therapy Group. There was not another group or alternate activity offered to the remaining 10 patients.

3. Observations on 3/20/17 from 1:15-1:45 p.m. (A Psychotherapy Group was being held from 1:00-1:45 p.m.)

Patient A1 was in bed.

Patient A3 was walking the hall and demanding that the nurses call the FBI.

Patient A4 was sitting in his/her room.

Patient A5 was in bed.

Patient A8 was in the dining room sitting at an empty table.

According to BHT1 (interview on 3/20/17 at 1:30 p.m.), only five (5) of 15 patients met the criteria to go to the Psychotherapy Group. Only 4 patients attended the group. There was not another group or alternate activity offered to the one (1) patient who failed to attend or to the other remaining 11 patients.

4. Observations on 3/20/17 from 2:00-2:45 p.m. (A Music Group for all patients was being held from 2:00-2:45 p.m.)

Patient A1 was in bed.

Patient A3 was walking in the hall.

Patient A4 entered the group at 2:30 p.m.

Patient A5 was in bed.

Patient A8 was in room.

Only five (5) of the 15 inpatients attended the Music Group. There was not another group or alternate activity offered to the remaining 10 patients.

5. Observations on 3/21/17 from 9:45-10:45 a.m. (A Psychotherapy Group and a Reminiscence Group were being held from 10:00-10:45 a.m.)

Patient A1 was observed in the Reminiscence Group. (S/he) was in a wheelchair, did not respond to questions and did not participate in the activity.

Patient A3 was in his/her room.

Patient A4 was in the dining room sitting at an empty table.

Patient A5 was in the hallway.

Patient A8 was eating in the dining room.

Only 3 patients attended the Psychotherapy Group (1 patient left after 15 minutes). Only 4 patients attended the Reminiscence Group. There was not another group or alternate activity offered to the remaining 10 patients. (Census on 3/21/17 was 17 inpatients)

6. Observations on 3/21/17 from 1:00-1:45 p.m... (A Psychotherapy Group was being held from 1:00-1:45 p.m.)

Patient A1 was observed in his/her wheelchair in front of the television.

Patient A3 was in his/her room.

Patient A4 was observed eating ice cream in the TV room.

Patient A5 was observed in the Psychotherapy Group.

Patient A8 was in bed.

Only seven (7) patients were in the Psychotherapy Group. There was not another group or alternate activity offered to the remaining 10 patients.

B. Interviews

1. In interview on 3/20/17 at 9:50 a.m., RN1 stated that getting patients to go to groups was one of her biggest challenges.

2. In interview on 3/20/17 at 11:00 a.m., BHT2 (Behavioral Health Technician) stated that patient A4 often walked in the hallways and did not go to group.

3. In interview on 3/21/17 at 10:45 a.m., AT1 (Activity Therapist) described the following patients:

a. Patient A1 is "confused. It is hard for (him/her) to go to group if there is any discussion."

b. Patient A3 is "manic and doesn't go to groups."

c. Patient A4 is "pretty confused and hard of hearing. (S/he) will pop into a group but will not stay."

Based on record review and interview, the medical director failed to:

I. Ensure that the Master Treatment Plan (MTP) of one (1) of eight (8) active sample patients (A8) was revised, based on the patient's presenting needs. This patient demonstrated psychotic symptoms, and either refused or could not participate in the prescribed treatment. The MTP was not revised to include modalities from which this patient could benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients. (See B 118)

II. Develop Master Treatment Plans (MTPs) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (A1, A2, A3, A4, A5, A6, A7, and A8) Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs, (See B 121)

III. Develop MTPs that included individualized interventions to address specific treatment needs for eight (8) of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7 and A8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment (See B122)

IV. Provide therapeutic programming to meet the treatment needs for five (5) of eight (8) active sample
(A1, A3, A4, A5 and A8) patients. The content of the groups offered failed to engage the patients
at their cognitive level ,resulting in the patients' inability to participate when in the group or refusal to attend group.
The lack of participation was not addressed on any of the patients' MTPs, nor were any
alternative interventions listed. Failure to offer groups focusing on individual needs limits the
patients' ability to recover and can extend the length of hospitalization. (See B125)

V. Interviews:

1. In an interview on 3/21/17 at 10:00 a.m. Physician I concurred with the findings regarding active treatment provision and treatment planning documentation.

2. In an interview on 3/21/17 at 10:30 a.m. the medical director concurred with findings regarding active treatment provision and treatment planning documentation.

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

l. Ensure that nursing interventions on the Master Treatment Plans were patient specific and addressed individual nursing needs for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) Listed interventions were stated in vague terms and were routine generic nursing discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to nursing staff in providing individualized, coordinated nursing care in the least restrictive environment.

Findings Include:

A Record Review

1 Review of the policy "Multidisciplinary Treatment Planning Policy", Policy Stat ID 2943751 dated 3/2017, described multi-disciplinary interventions as "The interventions shall be highly individualized, reasonable and necessary to improve the condition that necessitated the hospitalization. Such interventions form the basis of "Active Treatment".

2. Patient A1was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem, "Hitting/aggression toward others, yelling, resistiveness [sic] to cares [sic]. Potential to harm self/others due to unsafe behavior and resistiveness [sic] to cares [sic]". The nursing intervention listed was, "Nursing will monitor for [increased] agitation, yelling; provide [decreased] stimulus and/or diversional acts."

3. Patient A2 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Suicidal ideation with plan." The nursing intervention listed was, "Nursing will monitor intake, encourage self-care, and monitor suicidal thoughts."

4. Patient A3 was admitted on 3/15/17. The MTP, dated 3/17/17, identified the problem, "Paranoid/anxiety, unsafe behaviors; psychosis/flight of ideas; not sleeping." The nursing intervention listed was, "Nursing will monitor daily medication compliance, s/s (signs/symptoms) of paranoia, for any unsafe behaviors, sleep/wakefulness cycle."

5. Patient A4 was admitted on 3/16/17. The MTP, dated 3/17/17, identified the problem, "Patient refuses care, hits and yells." The nursing intervention listed was, "Nursing will administer meds and monitor for increased agitation, redirection and encourage activities."

6. Patient A5 was admitted on 3/5/17. The MTP, dated 3/5/17 ,identified the problem, "(Patient) struggles with paranoia, delusion r/t (related to) people wanting to kill/harm (him/her) which manifest in pt's unwillingness to receive care or comply with medication regimen." The nursing intervention listed was, "Nursing will monitor (patient's) compliance with medication and document symptom improvement."

7. Patient A6 was admitted on 3/13/17. The MTP, dated 3/15/17, identified the problem, "Patient is depressed and hopeless with suicide attempt; recent brother's death." The nursing intervention listed was, "Nursing will monitor for SI (Suicidal Ideation), sleep pattern, medication compliance."

8. Patient A7 was admitted on 3/14/17. The MTP, dated 3/17/17, identified the problem, "Refusing medications, visual hallucinations, & exit seeking". The nursing intervention listed was, "nursing will administer medications and assess for signs and symptoms of depression and paranoia."
9..Patient A8 was admitted on 3/14/17 for behavioral decompensation, aggression agitation and medication refusal. The MTP, dated 3/14/17, listed the only identified problem as "Pt refuses medication, yells, & paces." The nursing intervention listed was "nursing will attempt, encourage, & educate pt on the importance of medications."

B. Interview

In interview on 3/21/17 at 8:45 a.m., the Director of Nursing stated that the nursing interventions were generic functions that she would expect the RN to carry out with all patients.

ll. Based on interview and observation, the Director of Nursing failed to ensure that 5 of 8 sample patients attended therapeutic programming (A1, A3, A4, A5 and A8). The lack of participation was not addressed on any of the patients' MTPs, nor was any alternative interventions listed. Failure to offer groups focusing on individual needs limits the patients' ability to recover and can extend the length of hospitalization.

Findings include:

A. Observations (All observations were made on the one hospital unit)


1. Observation on 3/20/17 from 10:15-11:00 a.m. (Nutrition Education group for all patients being held 10:00-10:45 a.m.) Patient A1 was observed sitting in a wheelchair in front of the television.

Patient A1 had (his/her) head down with eyes closed. When called by name (S/he) looked up and immediately lowered head again and closed eyes.

Patient A3 was observed walking the halls and talking to the nursing staff at the nurses' station.

Patient A4 was observed walking with (his /him)walker, going in and out of other patients' rooms.

Patient A5 was observed in bed.

Patient A8 was observed in (his/her) room.

2. Observation on 3/20/17 from 11:00-11:30 a.m. (Occupational Therapy group for all patients being held from 11:00-11:45 a.m.)

Patient A1 was still in front of the television with head down and eyes closed.

Patient A3 was walking the hallway stating, "It's too cold to go to group."

Patient A4 was sitting in the dining room alone.

Patient A5 was in bed.

Patient A8 was in (his/her) room.

Only five (5) out of the 15 inpatients attended the Occupational Therapy Group. There was not another group or alternate activity offered to the remaining 10 patients.

3. Observation on 3/20/17 from 1:15-1:45 p.m. (A Psychotherapy Group was being held from 1:00-1:45 p.m. Pt A1 was in bed.

Patient A3 was walking the hall and demanding that the nurses call the FBI.

Patient A4 was sitting in (his/he)r room.

Patient A5 was in bed.

Patient A8 was in the dining room sitting at an empty table.

According to BHT1 (interview on 3/20/17 at 1:30 p.m.), only five (5) of 15 patients met the criteria to go to the Psychotherapy Group. Only four (4) patients attended the group. There was not another group or alternate activity offered to the one patient who failed to attend or to the other remaining 11 patients.

4. Observation on 3/20/17 from 2:00-2:45 p.m. (A Music Group for all patients was being held from 2:00-2:45 P.M.)

Patient A1 was in bed.

Patient A3 was walking in the hall.

Patient A4 entered the group at 2:30 p.m.

Patient A5 was in bed.

Patient A8 was in room.

Only five (5) of the 15 inpatients attended the Music Group. There was not another group or alternate activity offered to the remaining 10 patients.

5. Observation on 3/21/17 from 9:45-10:45 a.m., (A Psychotherapy Group and a Reminiscence Group were being held from 10:00-10:45 a.m.)

Patient A1 was observed in the Reminiscence Group. (S/he) was in a wheelchair, seemed confused and did not participate in the activity.

Patient A3 was in (his/her) room.

Patient A4 was in the dining room sitting at an empty table.

Patient A5 was in the hallway.

Patient A8 was eating in the dining room.

Only 3 patients attended the Psychotherapy Group (1 patient left after 15 minutes). Only four (4) patients attended the Reminiscence Group. There was not another group or alternate activity offered to the remaining 10 patients. (Census on 3/21/17 was 17 inpatients)

6. Observation on 3/21/17 from 1:00-1:45 p.m. (A Psychotherapy Group was being held from 1:00-1:45 p.m.)

Patient A1 was observed in (his/her) wheelchair in front of the television.

Patient A3 was in(his/her) room.

Patient A4 was observed eating ice cream in the TV room.

Patient A5 was observed in the Psychotherapy Group.

Patient A8 was in bed.

Only seven (7) patients were in the Psychotherapy Group. There was not another group or alternate activity offered to the remaining 10 patients.

B. Interviews

1. In interview on 3/20/17 at 9:50 a.m.RN1 stated that getting patients to group was one of her biggest challenges.

2. In interview on 3/20/17 at 11:00 a.m., BHT2 (Behavioral Health Technician) stated that patient A4 often walked in the hallways and did not go to group.

3. In interview on 3/21/17 at 10:45 a.m., AT1 (Activity Therapist) described the following patients:

a. Patient A1 is "confused. It is hard for (him/her) to go to group if there is any discussion."

b. Patient A3 is "manic and doesn't go to groups."

c. Patient A4 is "pretty confused and hard of hearing. (S/he) will pop into a group but will not stay."