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Based on record review and interviews, it was determined that the hospital failed to develop treatment interventions based on the patient's individual needs for 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). Instead, the interventions included discipline assessments inappropriately labeled as interventions, and/or routine, generic discipline functions which were not individualized. These deficiencies result in a lack of guidance for staff to provide individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record review:

1. Patient 1 was admitted on 7/23/2011 with a diagnosis of paranoid schizophrenia. The master treatment plan, dated 7/23/2011, listed problems of auditory/visual hallucinations and disorganized thought process.

Social work interventions for both problems were described as "SS (Social Service) [sic] will provide crisis interventions; case management and D/C (Discharge) [sic] planning."

The psychiatrist intervention for the problem of hallucinations was "Psych Eval [sic]." The psychiatrist intervention for the problem of disorganized thought process was "Meds mgmt [sic]" and "MSE (Mental Status Examination)."

Nursing intervention was: "Nursing will monitor mood and behavior."

These interventions were either assessments or generic activities and were not individualized according to the patient's needs.

2. Patient 2 was admitted on 7/19/2011 with a diagnosis of schizoaffective disorder, depressed type. The master treatment plan, dated 7/25/11 listed the problems as depression, confusion, "unable to care for self," and high risk for suicide.

Identical social work interventions were listed for all 4 problems as follows: "SS will provide CM (Case manager), Crisis Intervention, and D/C planning."

No interventions were listed for the psychiatrist.

Nursing intervention was: "Nursing staff will monitor client for signs and symptoms of depression, compliance with medication schedule."

These interventions were generic activities and were not individualized according to the patient's needs.

3. Patient 3 was admitted on 8/10/11 with a diagnosis of schizophrenia, undifferentiated type. The treatment plan, dated 8/10/11, listed problems of hallucinations and illogical thought processes.

Social work interventions for both problems were "...CM (case management), D/C (discharge) planning, and therapeutic intervention."

Psychiatric interventions were "Meds mgmt," "MSE," and "Psych Eval [sic]."

Nursing interventions were: "Nursing staff to monitor for safety. Encourage med compliance. Redirect as needed."

These interventions were either assessments or generic activities in nature and were not individualized according to the patient's needs.

4. Patient 4 was admitted on 7/15/11 with diagnoses of depressive disorder, NOS (not otherwise speicified) and alcohol abuse. The master treatment plan, dated 7/16/11, listed problems as "at risk for suicide," "depression," and "substance abuse."

Social work interventions were "SS will provide D/C planning, CM, and crisis intervention."

Psychiatrist interventions were "Meds mgmt, MSE, and Psych Eval."

These interventions were either assessments or generic activities and were not individualized according to the patient's needs.

5. Patient 5 was admitted on 7/7/11 with diagnoses of schizoaffective disorder, bipolar type and alcohol abuse. The master treatment plan, dated 7/7/11, listed the following interventions:

Social work interventions for these problems were "...case management, crisis intervention, and discharge planning."

Psychiatrist interventions were absent.

Nursing interventions were: "Nursing to redirect inappropriate behavior and encourage participation in group activities, and nursing staff to continue monitoring behavior and intervene with direction as needed."

These interventions were generic activities and were not individualized according to the patient's needs.

6. Patient 6 was admitted on 8/7/11 with diagnoses of major depressive disorder, severe, with psychotic features, alcohol dependence, cannabis dependence, and borderline intellectual func-tioning. The master treatment plan, dated 8/9/11, listed the following problems: "SI, SIB (Self Injurious Behaviors) [sic]," "hallucinations," "depression," and "SA [sic]."

Social work interventions for each problem were identical and consisted of "...CM, D/C planning, and therapeutic intervention."

Psychiatrist interventions were "Psych Eval, Meds mgmt, and MSE."

Nursing interventions were: "Nursing to monitor for suicidal ideation/self-injurious behavior for client safety. Use appropriate protocol as needed. Encourage participation in groups. Redirect as needed."

These interventions were either assessments or generic activities and were not individualized according to the patient's needs.

7. Patient 7 was admitted on 8/4/11 with a diagnosis of schizoaffective disorder, bipolar type. The master treatment plan, dated 8/5/11 listed only one problem, "disruptive bx" [sic].

Social work interventions were "...crisis intervention, CM, and D/C planning."

Psychiatrist interventions were "Meds mgmt" and "MSE."

Nursing interventions were: "Nursing will monitor behavior and triggers, and offer alternative coping skills."

These interventions were generic activities and were not individualized according to the patient's needs.

8. Patient 8 was admitted on 8/12/11 with diagnoses of schizoaffective disorder, depressed type, and cocaine dependence. The treatment plan, dated 8/12/11, listed the following problems: "SI (suicidal ideation)" "SIB," "depression," "SA (substance abuse)," and "auditory/visual hallucinations."

Social work interventions were identical for all problems and were: "Social services will provide crisis intervention, CM, and D/C planning."

Psychiatrist interventions were "Psych Eval," "Med mgmt," and "MSE."

Nursing interventions were: "Nursing to monitor for suicidal ideation for safety of client. Redirect as needed and use protocol."

These interventions were either assessments or generic activities and were not individualized according to the patient's needs.

B. Interviews

1. In an interview on 8/16/11 at 1:15pm, the Director of Nursing stated that the nursing interventions in the treatment plan were not individualized.

2. In an interview on 8/16/11 at 1:30pm, the Director of Social Work stated that the social work interventions in the treatment plan were not individualized.

3. In an interview on 8/16/11 at 2pm, the Medical Director stated that the psychiatrist interventions were not individualized and agreed that psychiatrist interventions were missing for 2 patients.

Based on observation and interview, the facility failed to protect the privacy rights of the 12 patients on the geriatric psychiatry unit, including two patients (Patients 1 and 5) in the active sample by allowing 24 hour closed circuit television monitoring of all patient bedrooms on the geropsychiatry unit. This failure places patients at risk for not receiving safe and acceptable nursing care and does not allow for privacy.

Findings include:

A. Observation:

During an observation on the geropsychiatry unit on 8/15/11 at 9:30am, it was observed that a television monitor in the nurse's station showed views of all six double-occupancy patient bedrooms on that unit. The monitor could be viewed from the day room as well as the nursing station, and allowed for the potential of patients and visitors to view the monitor.

B. Interview:

1. In an interview on 8/17/11 at 9am, the Chief Administrative Officer confirmed that the cameras on the geropsychiatry unit operated 24 hours a day. She went on to explain that patients were not individually informed of this practice, either verbally or in writing; and were not given the option of declining to be monitored.

2. In an interview on 8/15/11at 11am, the Director of Nursing stated that the cameras on the unit were there when the unit opened and that all six double-occupancy bedrooms are monitored.

Based on record review and review of the By-Laws of the Medical Staff, the facility failed to ensure that discharge summaries were dictated, transcribed, and filed within 30 days of discharge in 2 of 5 discharge records reviewed (Patients D1 and D5). This failure prevents a full account of the patients' inpatient treatment being available for continuity of care in the community.

Findings include:

A. Medical Staff By-Laws Review:

Article VIII of the Medical Staff By-Laws, entitled Rules and Regulations of Inpatient Services, section 30, stated the following: "Within fifteen (15) days of inpatient unit discharge, a Discharge Summary (using the Apalachee Dictation Guidelines) must be dictated by the attending physician for EPH [Eastside Psychiatric Hospital] patients."

Section 32 of the same article stated: "The record must be complete (i.e., all forms entered and completed, all required information documented, and signatures entered) within thirty (30) days of discharge."

B. Record Review:

No discharge summaries were present in the records of Patient D1, discharged 7/11/11 or Patient D5, discharged 7/15/11 as of the date of the record review, 8/16/11.

C. Interview:

In an interview on 8/16/11 at 2pm, the Medical Director acknowledged that the required discharge summaries were not present.

Based on observation, interview, and record review, the facility failed to ensure adequate numbers of qualified staff to provide active treatment to the patient population. Specifically, the Director of Nursing failed to secure adequate nursing staff to ensure the safety of patients and provide for the supervision of non-licensed nursing staff. This failure places patients at risk for not receiving safe and acceptable nursing care and does not allow for direct care staff to receive ongoing supervision from a Registered Nurse. (Refer to B150)

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

1. Ensure that master treatment plans for 8 of 8 active sample patients were individualized (Patients 1,2,3,4,5,6,7 and 8). The interventions were non-specific, similar for all master treatment plans, and consisted of routine, required assessments, such as the psychiatric evaluation, or routine, generic interventions, such as medication management. In addition, psychiatrist interventions were absent in 2 of 8 active sample patients (Patients 2 and 5). This failure resulted in a limited array of active treatment interventions offered by psychiatrists. (Refer to B122).

2. Protect the privacy rights of the 12 patients on the geriatric psychiatry unit, including patients 1 and 5 in the active sample, by allowing 24 hour closed circuit television monitoring of all patient bedrooms on the geropsychiatry unit. This failure places patients at risk for not receiving safe and acceptable nursing care and does not allow for privacy. (Refer to B125).

3. Ensure that physicians completed discharge summaries within 30 days of discharge in 2 of 5 discharge records reviewed (Patients D1 and D5). This failure prevents a full account of the patients' inpatient treatment being available for continuity of care in the community. (Refer to B133).

Based on interviews and record review, the facility failed to employ a Director of Nursing with a Master's Degree in Nursing, and/or have sufficient psychiatric nursing experience with documented evidence of ongoing training, or consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing. This failure places patients at risk for not receiving knowledgeable, safe and acceptable nursing care provided by an adequate number of nursing staff as well as not having acceptable psychiatric nursing interventions provided to patients.

Findings include:

A. Interview

In an interview on 8/16/11 at 1:15p.m. with the Director of Nursing she revealed that she does not have a Master's degree in Psychiatric/Mental Health Nursing and could not present documented evidence of ongoing training or consultation with a nurse who possesses a Master's degree in Psychiatric/Mental Health Nursing. During the interview the Director of Nursing stated, "I have a diploma from a Diploma School of Nursing. I can use the Medical Director or one of the two Advanced Practice RNs for consultation as needed. It happens very informally, and only as needed." When asked if there was any documentation, including notes, logs, or other means of reflecting consultation; the Director of Nursing stated, "No." She was asked if she has any documented evidence of ongoing education or training in Psychiatric/Mental Health Nursing or Nursing Management the Director of Nursing stated, "No."
B. Record Review

1. The Curriculum Vitae provided by the facility for the Director of Nursing reflected that she has a diploma from a school of nursing. She has been a registered nurse for 16 years, however only a portion of that time was spent providing specific psychiatric nursing care.

2. A file containing all continuing education records for the Director of Nursing was requested, but the Director of Nursing was unable to provide the file because she has not participated in any continuing education activities. Therefore, a file does not exist.

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

1. Ensure nursing participation in active psychiatric treatment for all active sample patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) on the adult/geriatric unit. This lack of active psychiatric treatment results in affected patients being hospitalized without all interventions for recovery being provided. (Refer to B125).

Findings include:

A. Interview:

In an interview on 8/16/11 at 1:15pm, the Director of Nursing stated that the nursing interventions in the treatment plan were not individualized.

B. Record Review:

1. Nursing assessments were inappropriately labeled as interventions, and/or routine, generic nursing functions which were not individualized for all 8 active sample patients. These deficiencies result in a lack of guidance for staff to provide individualized patient treatment that is purposeful and goal-directed.

2. Protect the privacy rights of the 12 patients on the geriatric psychiatry unit, including patients 1 and 5 in the active sample, by allowing 24 hour closed circuit television monitoring of all patient bedrooms on the geropsychiatry unit. This failure places patients at risk for not receiving safe and acceptable nursing care and does not allow for privacy. (Refer to B125).

3. Ensure that the staffing pattern included the availability of registered nurses 24 hours each day. This failure places patients at risk for not receiving safe and acceptable nursing care as well as not having an RN consistently available to supervise care and work being provided by direct care staff. (Refer to B150).

Based on interviews, observations, and record review, the facility failed to ensure that the staffing pattern included the availability of registered nurses 24 hours each day. This failure places patients at risk for not receiving safe and acceptable nursing care as well as not having an RN consistently available to supervise care and work being provided by direct care staff.

Findings include:

A. Interviews

1. In an interview on 8/16/11 at 1:15p.m. with the Director of Nursing, she revealed that one RN was assigned to both the adult and geriatric programs on all shifts, with a current census of 31 and a bed capacity of 46. She stated that there is a single nurse's station for both the adult unit and the geriatric unit. The RN on the adult unit is physically separated from the geriatric unit by a closed door. The Director of Nursing stated, "I've asked the assigned RN to make rounds at least once an hour on the geriatric unit." The surveyor asked the Director of Nursing about acuity on the units, she stated, "We get admissions on all shifts .The RN does have to complete the nursing assessment on all shifts. We currently have one RN vacancy. When that unit opened I asked that an RN be assigned there."

2. During an interview on 8/16/11 at 9:15a.m., RN 1 stated, "I'm in charge of the adult and geriatric program. There are times when 70% of my time is spent on the adult side and 30% on the geriatric side. I'm the only RN that works my shift when I'm here."

B. Observations

1. During observations it was noted that there was a closed door that separated the nursing station and the registered nurse from the geriatric unit. The single nurse's station for the adult program was opened for direct access and visualization of the adult unit. The nurse's station failed to allow for direct access and visualization of the geriatric unit by the RN.

C. Record Review

1. The facility Policy and Procedures, dated November 2009 and signed by the Director of Nursing and Program Director and entitled Nursing Staffing/Scheduling Plans, states, "It is the purpose of this procedure to ensure appropriate staff coverage for the inpatient and residential programs .Staffing plans shall be reviewed in detail by the Program Director and Director of Nursing on an annual basis in conjunction with the annual budget review process."

2. A review of nursing staffing documents from 7/31-8/6/11 reflected that there are only 3 full time RNs available to provide 24/7 coverage for the 46 patient bed capacity unit. This does not allow for an adequate number of RNs to provide adequate nursing coverage. This failure places patients at risk for not receiving safe, acceptable standards of nursing practice.

3. A review of quality indicators reflect the average length of stay is approximately 5 days, with admissions occurring on all shifts.

Based on record review and interview, the Director of Social Work failed to ensure that the master treatment plans of 8 of 8 active sample patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) contained social work interventions that were individualized for the patients' specific needs. The interventions were non-specific, similar for all treatment plans, and consisted of generic functions such as case management, discharge planning, and crisis intervention. This failure results in a lack of professionally designed and clinically targeted social work services being provided for patients.

Findings include

A. Record review:

1. Patient 1 was admitted on 7/23/2011 with a diagnosis of paranoid schizophrenia. The master treatment plan, dated 7/23/2011, listed problems of auditory/visual hallucinations and disorganized thought process.

Social work interventions for both problems were described as "SS [sic] will provide crisis interventions, case management and D/C [sic] planning."

2. Patient 2 was admitted on 7/19/2011 with a diagnosis of schizoaffective disorder, depressed type. The master treatment plan, dated 7/25/11 listed the problems as depression, confusion, "unable to care for self," and high risk for suicide.

Identical social work interventions were listed for all 4 problems as follows: "SS will provide CM [sic], Crisis Intervention, and D/C planning."

3. Patient 3 was admitted on 8/10/11 with a diagnosis of schizophrenia, undifferentiated type. The treatment plan, dated 8/10/11, listed problems of hallucinations and illogical thought processes.

Social work interventions for both problems were "...CM (case management), D/C (discharge) planning, and therapeutic intervention."

4. Patient 4 was admitted on 7/15/11 with diagnoses of depressive disorder, NOS and alcohol abuse. The master treatment plan, dated 7/16/11, listed problems as "at risk for suicide," "depression," and "substance abuse."

Social work interventions were "SS will provide D/C planning, CM, and crisis intervention."

5. Patient 5 was admitted on 7/7/11 with diagnoses of schizoaffective disorder, bipolar type and alcohol abuse. The master treatment plan, dated 7/7/11, listed the following interventions:

Social work intervention for these problems were "...case management, crisis intervention, and discharge planning."

6. Patient 6 was admitted on 8/7/11 with diagnoses of major depressive disorder, severe, with psychotic features, alcohol dependence, cannabis dependence, and borderline intellectual functioning. The master treatment plan, dated 8/9/11, listed the following problems: "SI, SIB [sic]," "hallucinations," "depression," and "SA [sic]."

Social work interventions for each problem were identical and consisted of "...CM, D/C planning, and therapeutic intervention."

7. Patient 7 was admitted on 8/4/11 with a diagnosis of schizoaffective disorder, bipolar type. The master treatment plan, dated 8/5/11 listed only one problem, "disruptive bx (behavior) [sic]."

Social work interventions were "...crisis intervention, CM, and D/c planning."

8. Patient 8 was admitted on 8/12/11 with diagnoses of schizoaffective disorder, depressed type, and cocaine dependence. The treatment plan, dated 8/12/11, listed the following problems: "SI (suicidal ideation)" "SIB (self-injurious behavior)," "depression," "SA (substance abuse)," and "auditory/visual hallucinations."

Social work interventions were identical for all problems and were: "Social services will provide crisis intervention, CM, and D/C planning."

These interventions were either assessments or generic activities and were not individualized according to the patient's needs.

B. Interview

In an interview on 8/16/11 at 1:30pm, the Director of Social Work stated that the social work interventions in the treatment plan were not individualized.