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Based on record review and interview, the hospital failed to develop treatment interventions specific to each individual patient based on his/her assessed needs for 6 out of 6 sample patients with the identified problem of self-harm (A3, B1, C4, D1, D2, and E1). This deficiency results in generic interventions which fail to provide a basis for purposeful goal directed treatment, and revisions based on individual needs and assessments.

Findings include:

A. Record Review

1. For the identified problem, self- harm, Patient A3's master treatment plan dated 6/7/11 had the following generic interventions: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient education related to self-harm, effects and side effects of medication administered to treat illness. Patient to attend group therapy related to coping skills. Suicide precautions at level ordered by physician to prevent self-harm."

2. For the identified problem, self-harm, Patient B1's master treatment plan dated 5/24/11 had the following generic interventions, identical or similar to those for patient A3: "Physician assessment to assess suicidality, mood, metal status, and effectiveness of medications. RN assessment to determine suicidality, mood. effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self- Harm."

3. For the identified problem, self-harm, Patient C4's master treatment plan dated 6/3/11 had the following generic interventions, identical to those for patient B1: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self- Harm."

4. For the identified problem, self-harm, Patient D1's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patients B1 and C4: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self-Harm."

5. For the identified problem, self-harm, Patient D2's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patient A3: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient education related to self-harm, effects and side effects of medications administered to treat illness. Patient to attend group therapy related to coping skills. Suicide precautions at level ordered by physician to prevent self-harm."

6. For the identified problem, self-harm, Patient E1's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patients B1, C4 and D1: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self-Harm."

B. Interview:

On 6/14/11 at 11:45AM, the Director of Nursing stated "I see what you mean about the interventions being all the same."

Based on record review and interview, the hospital failed to develop treatment interventions specific to each individual patient based on his/her assessed needs for 6 out of 6 sample patients with the identified problem of self-harm (A3, B1, C4, D1, D2, and E1). This deficiency results in generic interventions which fail to provide a basis for purposeful goal directed treatment, and revisions based on individual needs and assessments.

Findings include:

A. Record Review

1. For the identified problem, self- harm, Patient A3's master treatment plan dated 6/7/11 had the following generic interventions: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient education related to self-harm, effects and side effects of medication administered to treat illness. Patient to attend group therapy related to coping skills. Suicide precautions at level ordered by physician to prevent self-harm."

2. For the identified problem, self-harm, Patient B1's master treatment plan dated 5/24/11 had the following generic interventions, identical or similar to those for patient A3: "Physician assessment to assess suicidality, mood, metal status, and effectiveness of medications. RN assessment to determine suicidality, mood. effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self- Harm."

3. For the identified problem, self-harm, Patient C4's master treatment plan dated 6/3/11 had the following generic interventions, identical to those for patient B1: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self- Harm."

4. For the identified problem, self-harm, Patient D1's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patients B1 and C4: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self-Harm."

5. For the identified problem, self-harm, Patient D2's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patient A3: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient education related to self-harm, effects and side effects of medications administered to treat illness. Patient to attend group therapy related to coping skills. Suicide precautions at level ordered by physician to prevent self-harm."

6. For the identified problem, self-harm, Patient E1's master treatment plan dated 6/10/11 had the following generic interventions, identical to those for patients B1, C4 and D1: "Physician assessment to assess suicidality, mood, mental status, and effectiveness of medications. RN assessment to determine suicidality, mood, effectiveness of patient education on self-control measure, and patient perception of effectiveness of medications. Patient to attend group therapy related to Self-Harm."

B. Interview:

On 6/14/11 at 11:45AM, the Director of Nursing stated "I see what you mean about the interventions being all the same."