HospitalInspections.org

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

I. Provide comprehensive social work assessments for eight (8) of eight (8) sample patients (patients A1. A2, A4, A5, A6, A7, A8, and A9). A "biopsychosocial assessment," completed in the emergency department by staff who were not social workers, did not identify specific community resources or the social worker's roles related to treatment and discharge planning. As a result, the treatment team did not have necessary social information and evaluation of patients' social functioning level to utilize in developing treatment goals and active treatment interventions. (Refer to B108)

II. Develop and document comprehensive Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). Instead, social services providers, with limited or no input from other clinical disciplines, completed treatment plans. In addition, these MTPs were not developed using a consensus agreement among clinical staff during treatment team meetings. This practice fails to reflect input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118)

III. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:

A. Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms for seven (7) of eight (8) active sample patients. (A2, A4, A5, A6, A7, and A9). (Refer to B119)

B. Individualized, measurable, and observable goals and objectives for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B121)

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B122)

D. The name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B123)

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

IV. Ensure that appropriate physician orders were written for episodes of seclusion and chemical restraints for three (3) of four (4) non-sample patients (C1, C3, and C4) selected to review use of seclusion and restraints. The use of these restrictive procedures without documented justification results in a violation of the patients' right to be free from restraints and treated in the least restrictive environment. (Refer to B125-I)

V. Provide adequate training for registered nurses (RNs) assigned to conduct the required one-hour face-to-face assessments of foour (4) of four (4) non-sample patients (C1, C2, C3, and C4) selected to review episodes of seclusion and restraint. Specifically, for these patients who were placed in seclusion and/or received chemical restraints, there was no documented evidence that RNs received training and were competent to conduct the required one-hour face-to-face assessment in accordance with CMS standards. The lack of an adequate RN training program potentially results in a failure to conduct a comprehensive review of the patient's condition to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's behavior. In addition, inadequate training may potentially lead to a failure to detect a physical injury sustained during the application of restrictive procedures. (Refer to B125-II)

Based on record reviews and interview, the facility failed to provide comprehensive social work assessments that included a social evaluation reflecting conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). A "biopsychosocial assessment," completed in the emergency department by staff who were not social workers, did not identify specific community resources or the social worker's roles related to treatment and discharge planning. As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and active treatment interventions.

Findings include:

A. Record Review

1. Patient A1 was admitted on 5/26/16 for treatment of schizoaffective disorder following a recent suicide attempt by overdose. The biopsychosocial assessment completed on 5/26/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

2. Patient A2 was admitted on 6/3/16 with a diagnosis of dementia after he had threatened to kill his home provider and had wandered away from his group home. The biopsychosocial assessment completed on 6/3/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

3. Patient A4 was admitted on 5/22/16 for treatment of schizoaffective disorder, manifested by hostility, agitation, and apparent auditory hallucinations. The biopsychosocial assessment completed on 5/22/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

4. Patient A5 was admitted on 6/1/16 for treatment of schizophrenia and polysubstance dependence after threats to kill others and himself. The biopsychosocial assessment completed on 6/1/16 did not address the availability community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

5. Patient A6 was admitted on 5/23/16 for treatment of schizoaffective disorder, bipolar type. The biopsychosocial assessment completed on 5/23/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

6. Patient A7 was admitted on 5/28/16 for treatment of schizoaffective disorder, depressed type. The biopsychosocial assessment completed on 5/28/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

7. Patient A8 was admitted on 5/29/16 for treatment of schizophrenia and threats to kill others. The biopsychosocial assessment completed on 5/29/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

8. Patient A9 was admitted on 5/25/16 for treatment of schizophrenia after she was evicted from her apartment and became agitated over the prospect of being homeless. The biopsychosocial assessment completed on 5/25/16 did not address the availability of community resources for care or the role of the social worker in assessment, treatment, or discharge planning.

B. Interviews

1. In an interview on 6/6/16 at 3:30 p.m., the Acute Care Service (ACS) Administrator and the Quality Management Director confirmed that social work assessments had not been performed "for some time."

2. In an interview on 6/7/16 at 2:00 p.m., SW1 and SW2 confirmed that social work assessments were no longer performed.

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

I. Develop and document comprehensive Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). Instead, social services providers, with limited or no input from other clinical disciplines, completed treatment plans. Additionally, these MTPs were not developed using a consensus agreement among clinical staff during treatment team meetings. This practice fails to reflect input by all team members resulting in the potential to compromise patients ' opportunity to receive appropriate treatment measures.

Findings include:

A. Observation

The surveyors attended a meeting of the treatment team on the Acute Care Unit on 6/7/16 at 8:30 a.m. The social service provider, who was reported to be responsible for writing the treatment plan, conducted the meeting. The registered nurse provided a shift report regarding each patient and report on each new patients. The social service provider shared information to the team about existing and new patients, contacts with collateral sources, and discharge planning issues. The psychiatrist, a registered nurse, and social service providers attended this meeting. A member of the activity therapy staff was not in attendance. There was little or no input from the nursing staff and the activity therapy staff.

B. Interviews

1. In an interview on 6/716 at 12:30 p.m. with the Director of Activity Therapy, the treatment planning process. He confirmed that social service staff was responsible for developing the treatment plan and stated that he did not attend the treatment team meeting. He acknowledged information about each patient ' s activity therapy needs was not available to the social services since activity therapy staff was currently not completing activity therapy assessments.

2. In an interview on 6/7/16 at 2:00 p.m., SW #1 stated, " Although you [referring to the surveyors] did not observe this today, the social worker sits in the treatment team meeting to provide and accept information from the other team members and then writes the treatment plan. "

3. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, the treatment planning process was discussed. When asked about the deficient nursing intervention statements, she admitted that registered nurses were not involved in formulating nursing interventions based on nursing assessment data. She noted, " Social workers are in charge of the MTP. "

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components of the MTPs. Specifically, the MTPs were missing the following components:

A. Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms for 7 of 8 active sample patients. (A2, A4, A5, A6, A7, and A9). (Refer to B119).

B. Individualized, measurable, and observable goals and objectives for 8 of 8 active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B121).

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient ' s presenting psychiatric problems for 8 of 8 active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B122).

D. The name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for 8 of 8 active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B123).

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

III. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed in seclusion or restraint. Specifically, for 4 of 4 non-sample patients selected to review episodes of seclusion and restraint (C1, C2, C3, C4, and C5), MTPs were not revised to include the following: problem statements related to the use of seclusion and/or chemical restraint to control aggressive behavior; treatment goals; and interventions outlining healthy alternatives and approaches for patients to use to replace or reduce aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient C1 admitted 1/11/16 had 14 episodes of seclusion and/or chemical restraints during a period from 3/7/16 through 5/30/16. A review of seclusion and restraint episodes in May 2016 revealed that the patient had been secluded 5 times (5/2/16, 5/5/16, 5/6/16, 5/10/16, and 5/21/16) and was chemically restrained on 5/10/16. The revised MTP dated 5/30/16 was not modified to include the following: a problem statement regarding the use of a seclusion and restraint procedure to manage aggressive and violent behavior; treatment goals and objectives; and interventions to reflect alternatives to seclusion and restraint and approaches the patient could use to replace aggressive behavior(s).

2. Patient C2 admitted 4/15/16 received a chemical restraint episode on 4/20/16. The MTP dated 4/26/16 was not modified to include the following: a problem statement regarding the use of a chemical restraint procedure to manage aggressive and violent behavior; treatment goals and objectives; and interventions to reflect alternatives to chemical restraint and approaches the patient could use to replace aggressive behavior(s).

3. Patient C3 admitted in 5/3/16 had an episode of restraint (chemical) and seclusion on 5/6/16. The MTP dated 5/11/16 was not modified to include the following: a problem statement regarding the use of a seclusion and restraint procedure to manage aggressive and violent behavior; treatment goals and objectives; and interventions to reflect alternatives to restraint and approaches the patient could use to replace aggressive behavior(s).

4. Patient C4 admitted 5/5/16 received a chemical restraint on 5/5/16 and 5/6/16 and was secluded on 5/8/16 and 5/19/16. The MTP dated 5/26/16 was not modified to include the following: a problem statement regarding the use of a seclusion and restraint procedure to manage aggressive and violent behavior; treatment goals and objectives; and interventions to reflect alternatives to chemical restraint and seclusion and approaches the patient could use to replace aggressive behavior(s).

B. Policy Review

A review of the facility's policy titled "Special Treatment Procedures Adult" contained no provisions to revise the Master Treatment Plan after an episode of seclusion or restraint in accordance with CMS requirements.

C. Interview

In an interview on 6/8/16 at 10:25 a.m., the Director of Quality Improvement acknowledged that treatment plans were not revised to address the use of restrictive procedures. She also admitted that the policy did not contain provisions regarding modifying the master treatment plan after the use of seclusion and chemical restraint to manage aggressive behaviors.

Based on record review and staff interviews, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs) for seven (7) of eight (8) active sample patients (A2, A4, A5, A6, A7, A8, and A9). Instead, the problems on the treatment plans included generalized statements, diagnostic terms, and/or psychiatric jargon rather than behaviorally descriptive psychiatric problem statements based on clinical assessment data and how presenting symptoms were specifically manifested by each patients. This failure potentially 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

1. Patient A2's MTP dated 6/4/16 had the following psychiatric problem statement: Problem #1 - "Here to visit friend." "Problem As Evidenced By: only oriented to self, [s/he] was baker acted at [his/her] group home fr [sic] reportedly making threats to staff and wandering away." Problem #2 - "Dementia." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 6/3/16 documented the following descriptive information: "...presents to The Centers...after the client reportedly ran away/wandered from [his/her] Group Home Residence after threatening to kill [his/her] Caregiver...The client has shown an inability to keep up with [his/her] ADL's [activities of daily living] as evidenced by the feces located on [his/her] hands and fingers as well as [his/her] body order...only oriented to person as [s/he] was unable to inform this writer of the date, the President, the city, and the State [s/he] currently resided in." Most of this information was not included on the MTP to provide a clear descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 6/4/16 contained a diagnosis of "Major neurocognitive disorder due to possible Alzheimer's disease" and documented, "Paranoid and Gross Memory Deficits [There were no descriptive information included regarding these findings included in the psychiatric evaluation].

2. Patient A4's MTP dated 5/24/16 had the following psychiatric problem statement: Problem #1 - "auditory hallucinations, suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] has become increasingly hostile and exhibiting bizarre behavior over the past two weeks. [Patient's name] has been responding to internal stimuli, curses at other residents and caregivers, and hasn't been sleeping." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 5/22/16 documented the following descriptive information: "...complaints of increasing hostile behavior, insomnia, and hallucination...[S/he] denies any hallucinations however is clearly responding to internal stimuli while in the lobby considering [his/her] full blown conversations with nobody present." There was no descriptive information regarding the patient's suicidal ideations identified in the problem statement, or whether there was a plan. Most of this information was not included on the MTP to provide a clearer descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 4/24/16 contained a diagnosis of "Schizoaffective disorder, Bipolar type" and documented, "The patient's medication was recently changed and [s/he] subsequently became hostile, loud, bizarre...[S/he] has difficulty initiating sleep."

3. Patient A5's MTP dated 6/2/16 had the following psychiatric problem statement: Problem #1 - "suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] was refusing to go to [his/her] o/p [outpatient] appointment today and further threatened to kill [himself/herself] and anyone who got close to him." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 6/3/16 documented the following descriptive information: "...[S/he] denies making any suicidal or homicidal threats and [s/he] states 'she's (mother) just thinking I said that, and if I did say it I wouldn't have meant it because I would never hurt myself. ' [S/he] admits being irritated...admits to ongoing depression...caused by being on probation and house arrest following [his/her] arrest...reports ongoing symptoms of poor sleep...Per mother...client has a tendency to lie about [his/her] symptoms...has been delusional and responding to internal stimuli...claimed the city of Clearwater had been hit by a nuclear bomb...continued to have conversations with people whom aren't there...has been threatening suicide constantly however has never voiced a plan and has never attempted...made threats to hurt others by making bombs however has never hurt anyone." Most of this information was not included on the MTP to provide a clear descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 6/3/16 contained a diagnosis of "Schizophrenia" and documented, "Pt [Patient] kept his thoughts to [himself/herself] and didn't exhibit bizarre ideas. Mom said [s/he]'s been having, and believing, ideas that there's been or will be nuclear explosions, etc. that [Patient's name] hears voices distressing to him, [s/he] can't focus on constructive activities...threw appliances out the window beside the house..."

4. Patient A6's MTP dated 5/24/16 had the following psychiatric problem statement: Problem #1 - "auditory/visual hallucinations, suicidal ideations." "Problem As Evidenced By: [Patient's name] making delusional statements, such as believing that the year was 2005;...spiritually engaged since I was a child...we'll see each other soon..." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 5/23/16 documented the following descriptive information: "...was observed by employees of Publix...lifting her dress and exposing [himself/herself]...contact with [his/her] Mx [mother] and aunt who both advised that [Patient's name] is dx [diagnosed] with a mental condition but does not take [his/her] medications...[S/he] reports...weaned [himself/herself] off of [his/her] medications and does not want to take them... reports being allergic to them." There was no information provided about hallucinations or suicidal ideations identified in the problem statement. Most of this information was not included on the MTP to provide a descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 5/24/16 contained a diagnosis of "Schizoaffective disorder, Bipolar type" and documented, "...Long history of medication non compliance ... [S/he] admits that it has been a long time ago since took medication..."

5. Patient A7's MTP dated 5/28/16 had the following psychiatric problem statement: Problem #1 - "Auditory hallucinations." "Problem As Evidenced By: [Patient's name] presenting voluntarily due to hearing voices for the past four days. [S/he] stated that [they [sic] voices are really bothering [him/her]...does not believe [his/her] medications are working." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 5/28/16 documented the following descriptive information: "...Daughter stated she found a suicide note her [parent] wrote and her [parent] has been hitting [himself/herself]. She reports her [parent] has not been taking [his/her] medication and is a threat to [himself/herself]." There was no information regarding the content of the patient ' s auditory hallucinations. Most of this information was not included on the MTP to provide a clear descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 6/316 contained a diagnosis of "Schizoaffective disorder, Depressive type."

6. Patient A8's MTP dated 5/28/16 had the following psychiatric problem statement: Problem #1: "Homicidal ideations and Psychosis." "Problem As Evidenced By: [Patient's name]...was homicidal. [S/he]...said [his/her] name was 'Hulon the 6th' and appeared to be actively psychotic and responding to some internal stimuli." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 5/28/16 documented the following descriptive information: "...[S/he] was irritable; poor eye contact; and give brief answers, [S/he] said, 'My name is Hulon the 6th; am homicidal - no plan; anger at people, things, bats and heathens, am upset, hostile.'... hx [history] of poor compliance with tx [treatment]." There was no descriptive information regarding the content of the patient's internal stimuli or homicidal ideations. Most of this information was not included on the MTP to provide a clear descriptive picture of the patient's behaviors and level of functioning.

b. The psychiatric evaluation dated 5/30/16 contained a diagnosis of "Unspecified Schizophrenia spectrum..." and documented, "Admitted to HI [homicidal ideation] towards unknown people as well as worsening of command type auditory hallucinations. During evaluation, pt [patient] noted to be in threatening posture. Angry and hostile..." The psychiatric evaluation did not provide information regarding the content of command hallucinations.

7. Patient A9's MTP dated 5/26/16 had the following psychiatric problem statement: Problem #1 - "auditory/visual hallucinations, suicidal/homicidal ideation." "Problem As Evidenced By: [Patient's name] is grossly disorganized, acutely psychotic; [Patient's name] stated 'I was upset today because was kicked out of the house...reports [s/he] is hearing voices as bad as before in Nov." Clinical assessment data revealed the following additional information:

a. The patient's Biopsychosocial dated 5/25/16 documented the following descriptive information: "...repeatedly facing severe psychosocial stressors (pending homelessness)...report hx [history] of talking to [his/her] sister that wasn't there and thinking [s/he] was bieg [sic] framed..." Most of the information in the biopsychosocial and psychiatric evaluation was not included on the MTP to provide a clear descriptive picture of the patient's behaviors and level of functioning.

b. The Psychiatric Evaluation dated 5/28/16 documented the following descriptive information, "[S/he]...refers to voices coming from the wall, people say bad things about [him/her], the TV talking about [him/her]." There was no information provided to substantiate the problem noted regarding suicidal and homicidal ideation.

B. Interviews

1. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute the findings and acknowledged that problem statements were not descriptive of each patient's presenting symptoms.

2. In an interview on 6/8/16 at 10:25 a.m. with the Director of Quality Improvement, MTPs and the treatment planning process were discussed. She stated, "I am not surprised at the findings. We had not had stable leadership for a while and have lost some of the gains we made in the past."

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9) that identified individualized patient-related short-term goals (called objectives by the facility) stated in observable, measurable, and behavioral terms. Objectives did not include what the patient would do to lessen the severity of problems identified on admission. In addition, the objectives did not define patient outcomes or areas of patient improvement and were not specifically related to each' patient's presenting symptom. Several objective statements described staff expectations regarding obtaining information from the patient to collect assessment data. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (5/27/16); A2 (6/4/16); A3 (No Treatment plan); A4 (5/24/16); A5 (6/2/16); A6 (5/24/16); A7 (5/28/16); A8 (5/30/16) and A9 (5/26/16). This review revealed the following deficient objectives for psychiatric problems. Goals and objective statements were not individualized and were identical or similarly worded statements despite each patient's having different problems and presenting symptoms.

1. Patient A1's MTP listed the following goal and objective statements for problem #1: "[Patient's name] states that [s/he] attempted suicide due to [his/her] Latuda...states [s/he's] been feeling suicidal for about 1 month."

Goal: "[Patient's name] will restart [his/her] medication and be discharged. This goal was not behaviorally specific or directly related to the problem statement regarding suicidal behavior. There was no information in the problem statement regarding non-compliance with medications.

Objective 1A - "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] symptoms and behavior." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting positive action behavior(s) that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.
Objective 1E - "[Patient's name] will speak with the nursing staff daily regarding [his/her] safety." This objective was a staff expectation to maintain patient safety, rather than a measurable patient outcome statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

2. Patient A2's MTP listed the following objective statements for psychiatric problems:

a. Problem #1: "Here to visit friend." Problem As Evidenced By: "only oriented to self, [s/he] was baker acted at [his/her] group home fr [sic] reportedly making threats to staff and wandering away."

Goal: "to visit." This goal statement was not a patient outcome statement and was not related to psychiatric reasons the patient was hospitalized.

Objective 1A: "[Patient's name] will talk with psychiatrist each day about [his/her] mood, safety and any current thoughts of hurting [himself/herself] or others." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting measurable and positive action behavior(s) that the patient would take to replace, lessen, and/or eliminate the presenting symptoms such as treats to staff.

Objective 1B: "[Patient's name] and his support systems will participate in [his/her] treatment and discharge planning at least one time by the target date...will identify someone who is supportive in [his/her] life to help with [his/her] discharge." This objective was a staff expectation rather than a patient outcome statement regarding what the patient will do or say to show specific improvement in behaviors to meet his or her needs for discharge needs, specific or potential community resources, and aftercare needs.
Objective 1C: "[Patient's name] will talk with the nurse at least 2 times a day about [his/her] safety and any medical problems [s/he] is having." This objective was a staff expectation to maintain patient safety and to obtain information from the patient, rather than a measurable and behavioral oriented statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or improve symptoms identified in the problem statement. This objective statement was not relevant to the problem statement since there was no information included about medical problems.
Objective 1D: "[Patient's name] will identify one activity that makes him happy." This objective was non-specific, not measurable, or related to the patient ' s problem statement or presenting symptoms.

b. Problem #2 - "Dementia."

Goal: "will remain oriented to person, place, time and situation."

Objective 2A - "will remain oriented to person, place, time, and situation." The goal and objective statements were non-specific since the problem statement was a diagnosis with no descriptions regarding the patient's level of functioning or how the patient was manifesting dementia.

3. Patient A4's MTP listed the following objective statements for Problem #1: "auditory hallucinations, suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] has become increasingly hostile and exhibiting bizarre behavior over the past two weeks. [Patient's name] has been responding to internal stimuli, curses at other residents and caregivers, and hasn't been sleeping."

Goal: "[Patient's name] will restart [his/her] medications and be discharged." This goal was identical to Patient A1's goal statement. This goal was also not behaviorally specific or directly related to the problem statement. There was no information in the problem statement regarding non-compliance with medications.

Objective 1A: "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] symptoms and behavior." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting positive action behavior(s) that the patient would take to lessen, and/or improve the auditory hallucinations and hostile behavior.
Objective 1E: "[Patient's name] will speak with the nursing staff daily regarding [his/her] safety." This objective was a staff expectation to maintain patient safety, rather than a measurable patient outcome statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or eliminate the problems and/or symptoms identified in the problem statement.

4. Patient A5's MTP listed the following objective statements for Problem #1: "suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] was refusing to go to [his/her] o/p [outpatient] appointment today and further threatened to kill [himself/herself] and anyone who got close to him."

Goal: "[Patient's name] will restart [his/her] medication and be discharged." This goal was not behaviorally specific or directly related to the problem statement regarding suicidal behavior. There was no information in the problem statement regarding non-compliance with medications.

Objective 1A - "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] symptoms and behavior." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting positive action behavior(s) that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

Objective 1B: "[Patient's name] will learn least one way in which [s/he] can cope with his mood and thoughts." This objective was not individualized or behaviorally specific reflecting which moods and thoughts the patient needed to manage.
Objective 1E - "[Patient's name] will speak with the nursing staff daily regarding [his/her] safety." This objective was a staff expectation to maintain patient safety, rather than a measurable patient outcome statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

5. Patient A6's MTP listed the following objective statements for Problem #1: "auditory/visual hallucinations, suicidal ideations." "Problem As Evidenced By: [Patient's name] making delusional statements, such as believing that the year was 2005;...spiritually engaged since I was a child...we ' ll see each other soon..."

Goal: "[Patient's name] will restart [his/her] medication and be discharged. This goal was not behaviorally specific or directly related to the problem statement regarding suicidal behavior. There was no information in the problem statement regarding non-compliance with medications.

Objective 1A - "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] symptoms and behavior." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting t positive action behavior(s) that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

Objective 1B: "[Patient's name] will learn least one way in which [s/he] can cope with his mood and thoughts." This objective was not individualized or behaviorally specific reflecting which moods and thoughts the patient needed to manage.
Objective 1E - "[Patient's name] will speak with the nursing staff daily regarding [his/her] safety." This objective was a staff expectation to maintain patient safety, rather than a measurable patient outcome statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

6. Patient A7's MTP listed the following objective statements for problem #1: "Auditory hallucinations." "Problem As Evidenced By: [Patient's name] presenting voluntarily due to hearing voices for the past four days. [S/he] stated that [they [sic] voices are really bothering [him/her]...does not believe [his/her] medications are working."

Goal: "Medication changes." This goal was a clinical task performed by physicians not a patient outcome statement directly related to the patient's presenting symptoms or problems.

Objective 1A - "[Patient's name] wants to meet with psychiatrist once daily to discuss hearing voices and changing and/adjusting [his/her] medications." This objective did not include behavioral and measurable outcome statements regarding what the patient would do or say to show improvement related to hearing voices, ways s/he could manage the voices and medications once discharged.
Objective 1D - "[Patient's name] wants to talk to the daily to discuss [his/her] thoughts and feelings of safety." This objective was related to maintaining the patient's safety, however, it was not a measurable patient outcome related positive action behaviors the patient can take to manage thoughts and feeling associated with hearing voices.

7. Patient A8's MTP listed the following objective statements for Problem #1: "Homicidal ideations and Psychosis." "Problem As Evidenced By: [Patient's name]...was homicidal. [S/he]...said [his/her] name was 'Hulon the 6th' and appeared to be actively psychotic and responding to some internal stimuli."

Goal: "[Patient's name] would like to be discharged." This goal was not behaviorally specific or directly related to the patient's presenting problem related to being homicidal and responding to internal stimuli.

Objective 1A - "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] his homicidal ideations and psychosis." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting positive action behavior(s) that the patient would take to replace, lessen, and/or eliminate the homicidal ideations and psychosis.

Objective 1B: "[Patient's name] wants to identify one positive way to help [him/her] cope with thoughts of hurting others and psychosis. This objective was very broad, not specific, or written in behavioral terms.
Objective 1C - "[Patient's name] wants to talk with the nurse staff daily to discuss [his/her] thinking and feelings of safety." This objective was related to maintaining the patient's safety, however it was not a measurable and behavioral patient outcome regarding what the patient would say and/or do to show improvement in presenting symptoms.

None of the objective mentioned above were individualized patient outcome statements, since the problem statement was not behavioral descriptive of how the patient specifically manifested homicidal ideations and psychosis. This made it difficult to formulate objectives that would assist staff to know what to observe to determine the patient's improvement.

8. Patient A9's MTP listed the following objective statements for Problem #1: "auditory/visual hallucinations, suicidal/homicidal ideation." "Problem As Evidenced By: [Patient's name] is grossly disorganized, acutely psychotic; [Patient's name] stated 'I was upset today because I was kicked out of the house...reports [s/he] is hearing voices as bad as before in Nov."

Goal: "[Patient's name] will restart [his/her] medication and be discharged. This goal was not behaviorally specific or directly related to the identified problem statement. There was no information in the problem statement regarding non-compliance with medications.

Objective 1A - "[Patient's name] and/or guardian is willing to speak with psychiatrist once a day to talk regarding [his/her] symptoms and behavior." This objective was a staff expectation to obtain information from the patient rather than an objective reflecting positive action behavior(s) that the patient would take to replace, lessen, and/or improve problems and/or symptoms identified in the problem statement.

Objective 1B: "[Patient's name] will learn least one way in which [s/he] can cope with his mood and thoughts." This objective was not individualized or behaviorally specific reflecting which moods and thoughts the patient needed to manage.

Objective 1C: [Patient's name] and/or guardian is able to identify one person who [s/he] feels is supportive to be a part of [his/her] treatment." This objective was not a individualized patient outcome written in measurable and behavioral terms.
Objective 1E - "[Patient's name] will speak with the nursing staff daily regarding [his/her] safety." This objective was a staff expectation to maintain patient safety, rather than a measurable patient outcome statement reflecting positive action behaviors that the patient would take to replace, lessen, and/or improve the problems and/or symptoms identified in the problem statement.

B. Interviews

1. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute the findings and agreed that goal and objective statements were not individualized.

2. In an interview on 6/8/16 at 10:25 a.m. with the Director of Quality Improvement, the MTPs and treatment plan process were discussed. She stated, "I am not surprised at the findings. We had not had stable leadership for a while and have lost some of the gains we made in the past."

3. In an interview on 6/8/16 at 11:30 a.m. with the Medical Director, MTPs were reviewed. He did not dispute the findings regarding goals and objectives.

C. Policy Review

A review of the facility's policy titled "Special Treatment Procedures Adult" revealed the following stipulation: "The objectives of the plan meets the following criteria: They included identified steps to achieve the goals. They are sufficiently specific to assess the progress. They are expressed in terms that provide indices of progress. The facility failed to comply with these policy requirements for objectives included on master treatment plans.

Based on observation, record review, document review, and interview, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. In addition, MTPs did not include a nurse led group listed on the unit's daily schedule and attended by six (6) of eight (8) active sample patients (A1, A2, A4, A5, A8, and A9). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

I. Failure to include individualized treatment intervention

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/27/16); A2 (6/4/16); A4 (5/24/16); A5 (6/2/16); A6 (5/24/16); A7 (5/28/16); A8 (5/30/16) and A9 (5/26/16). This review revealed that the MTPs included but not limited to the following deficient intervention statements. None of the intervention statements were individualized and were identical or similarly worded statements.
1. Patient A1's MTP listed the following interventions statements for problem #1: "[Patient's name] states that [s/he] attempted suicide due to [his/her] Latuda...states [s/he's] been feeling suicidal for about 1 month."

Psychiatrist Interventions: "[Patient's name] and/or guardian will speak with the psychiatrist to discuss [his/her] symptoms which lead to admission in order to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements with [Patient's name] mood."

Social Work Intervention: "[Patient's name] will speak with social services staff during group sessions or one on one sessions about options [s/he] can use when [s/he] feels upset. [Patient's name] will receive handouts on mental illness, how to function with mental illness, and good coping skills."

Nursing Intervention: "[Patient's name] will meet with the nursing staff in a one to one meeting or group session to discuss [his/her] depression to ensure [s/he] is able to remain safe on the unit. Nursing staff will monitor for safety to ensure [Patient's name] remains safe on the unit and does not have thoughts of harm."

Rehabilitation (Activity Therapy): "[Patient name] will attend recreation therapy group once a day to learn activities that will help [him/her] stay calm and refocus [his/her] depression."

These intervention statements were not individualized and focused what the patient will be doing rather than what clinical staff would be doing to assist the patient to improve presenting symptoms such as providing information regarding medications, assisting the patient to learn new skills to manage symptoms of depression, etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to the patient's presenting symptoms and would be provided regardless of the patient's presenting symptoms.

2. Patient A2's MTP listed the following interventions statements:

a. Problem #1: "auditory hallucinations, suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] has become increasingly hostile and exhibiting bizarre behavior over the past two weeks. [Patient's name] has been responding to internal stimuli, curses at other residents and caregivers, and hasn't been sleeping."

Psychiatrist Interventions: "The psychiatrist will meet with [Patient's name] to talk about [his/her] feelings, mood, and thoughts of suicide/homicide to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements."

Social Work Intervention: "Social Services will talk with [Patient's name] support system and/or guardian in person or over the phone to discuss what occurred which led to the Baker Act, what previous psychiatric treatment, concerns of safety, and plans for discharge and follow up care services available."

Nursing Intervention: "Nursing staff will monitor for safety, and dispense medications as prescribed..." The nurse will talk with [Patient's name] about [his/her] mood and any thoughts of suicide/ homicide to sure that [s/he] remains safe. The nurse will assess for lethality and provide support as needed to help [him/her] calm down and remain safe."

Rehabilitation (Activity Therapy): "Recreational activities will be offered once a day to provide [Patient name] the opportunity to relax and learn new ways to help cope with stress once discharged."

These intervention statements were not individualized to reflect would be doing to assist the patient to improve his or her presenting symptoms and maintaining the highest level of functioning. Interventions identified for the psychiatrist, social work, and nursing staff regarding evaluating, monitoring and assessing the patient's behavior, calling the patient's guardian, and dispensing medications were routine discipline functions and were not specific active treatment interventions. These discipline functions were understood aspects of on-going assessment and standards of practice provided for all patients.

b. Problem #2 - "Dementia."

Staff Intervention: "Will meet with staff 1:1 or in group to discuss ways to remain oriented x4, i.e. written info [information], calendar, name and date, etc." "Will meet with staff 1:1 or in group to learn and demonstrate techniques of self care."

Since the problem statement was not descriptive of this patient's level of functioning, skills, and abilities, the interventions were very broad and possibly unrealistic given the patient's diagnosis of "Major neurocognitive disorder due to possible Alzheimer's disease" and the "2-10 days" length of stay noted on the MTP. These interventions did not identify a specific level of functioning to be maintained, focus of orientation, and self-care that would beneficial to this patient's return to the community. Additionally, the intervention statements did not include a frequency of contact and name(s) of clinical staff accountable to implement interventions.

3. Patient A4's MTP listed the following interventions statements for Problem #1: "auditory hallucinations, suicidal/homicidal ideations." "Problem As Evidenced By: [Patient ' s name] has become increasingly hostile and exhibiting bizarre behavior over the past two weeks. [Patient's name] has been responding to internal stimuli, curses at other residents and caregivers, and hasn't been sleeping."

Psychiatrist Interventions: "[Patient's name] and/or guardian will speak with the psychiatrist to discuss [his/her] symptoms which lead to admission in order to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements with [Patient's name] mood."

Social Work Intervention: "[Patient's name] will speak with social services staff during group sessions or one on one sessions about options [s/he] can use when [s/he] feels upset. [Patient's name] will receive handouts on mental illness, how to function with mental illness, and good coping skills." "[Patient name] and/or guardian will meet a social services staff to identify someone who is supportive to be a part of [his/her] treatment and discharge planning. Social Services will contact support system in order to gather collateral and plan for discharge."

Nursing Intervention: "[Patient's name] will meet with the nursing staff in a one to one meeting or group session to discuss [his/her] depression to ensure [s/he] is able to remain safe on the unit. Nursing staff will monitor for safety to ensure [Patient's name] remains safe on the unit and does not have thoughts of harm."

Rehabilitation (Activity Therapy): "[Patient name] will attend recreation therapy group once a day to learn activities that will help [him/her] stay calm and refocus [his/her] aggression."

These intervention statements were not individualized and focused what the patient will be doing rather than what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as providing information regarding medications (benefits, side effect), assisting the patient to learn new skills to manage symptoms of depression, etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to this patient's presenting symptoms and/or problem. These interventions would be provided to all patients regardless of their identified problem. In addition, social services interventions identifying supportive persons and contacting support systems were social work functions that were understood aspects of assessment and standards of practice for all patients.

4. Patient A5's MTP listed the following interventions statements for Problem #1: "suicidal/homicidal ideations." "Problem As Evidenced By: [Patient's name] was refusing to go to [his/her] o/p [outpatient] appointment today and further threatened to kill [himself/herself] and anyone who got close to him."

Psychiatrist Interventions: "[Patient's name] and/or guardian will speak with the psychiatrist to discuss [his/her] symptoms which lead to admission in order to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements with [Patient's name] mood."

Social Work Intervention: "[Patient's name] will speak with social services staff during group sessions or one on one sessions about options [s/he] can use when [s/he] feels upset. [Patient's name] will receive handouts on mental illness, how to function with mental illness, and good coping skills." "[Patient name] and/or guardian will meet a social services staff to identify someone who is supportive to be a part of [his/her] treatment and discharge planning."

Nursing Intervention: "[Patient's name] will speak with nursing staff daily regarding [his/her] safety."

Rehabilitation (Activity Therapy): " [Patient name] will attend recreation therapy group once a day to learn activities that will help [him/her] stay calm and refocus [his/her] mood and thoughts. "

These intervention statements were not individualized and focused what the patient will be doing rather than what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as providing information regarding medications (benefits, side effects), assisting the patient to learn new skills to manage symptoms or problems identified in the problem statement, etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to the patient's presenting symptoms and/or problem. These interventions would be provided to all patients regardless of their identified problem(s). In addition, social services interventions identifying supportive persons and contacting support systems were social work functions that were understood aspects of assessment and standards of practice for all patients.

5. Patient A6's MTP listed the following interventions statements for Problem #1: "auditory/visual hallucinations, suicidal ideations." "Problem As Evidenced By: [Patient's name] making delusional statements, such as believing that the year was 2005; ...spiritually engaged since I was a child...we ' ll see each other soon..."

Psychiatrist Interventions: "[Patient's name] and/or guardian will speak with the psychiatrist to discuss [his/her] symptoms which lead to admission in order to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements with [Patient's name] mood."

Social Work Intervention: "[Patient's name] will speak with social services staff during group sessions or one on one sessions about options [s/he] can use when [s/he] feels upset. [Patient's name] will receive handouts on mental illness, how to function with mental illness, and good coping skills." "[Patient name] and/or guardian will meet a social services staff to identify someone who is supportive to be a part of [his/her] treatment and discharge planning. Social Services will contact support system in order to gather collateral and plan for discharge."

Nursing Intervention: "[Patient's name] will meet with the nursing staff in a one to one meeting or group session to discuss [his/her] depression to ensure [s/he] is able to remain safe on the unit. Nursing staff will monitor for safety to ensure [Patient's name] remains safe on the unit and does not have thoughts of harm."

Rehabilitation (Activity Therapy): "[Patient name] will attend recreation therapy group once a day to learn activities that will help [him/her] stay calm and refocus [his/her] aggression."

These intervention statements were not individualized and focused what the patient will be doing rather than what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as providing information regarding medications, assisting the patient to learn new skills to manage symptoms and/or problems identified etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's
behavior were routine discipline functions and were not specific to the patient's presenting symptoms and/or problem. These interventions would be provided to all patients regardless of their identified problem. In addition, social services interventions identifying supportive persons and contacting support systems were social work functions that were understood aspects of assessment and standards of practice for all patients.

6. Patient A7's MTP listed the following interventions statements for Problem #1: "Auditory hallucinations." "Problem As Evidenced By: [Patient's name] presenting voluntarily due to hearing voices for the past four days. [S/he] stated that [they [sic] voices are really bothering [him/her]...does not believe [his/her] medications are working."

Psychiatrist Interventions: "The Psychiatrist/Licensed Practitioner will meet with [Patient's name] face to face to discuss [his/her] thoughts and feelings. The Psychiatrist/Licensed Practitioner will perform a full evaluation to determine [his/her] treatment needs. Staff will monitor [his/her] behaviors on the unit and assess [him/her] for the need of inpatient psychiatric treatment."

Treatment Staff Intervention: "Treatment staff will meet with [Patient's name] in a group setting to talk to [sic] ways to cope with [his/her] stressors and will also encourage participation in group activities." This intervention statement did not include a frequency of contact and name of clinical staff accountable to implement the intervention.

Nursing Intervention: "Nursing staff will meet with [Patient's name] daily and encourage [him/her] to discuss [his/her] thoughts and how the medications, if indicated, are affecting [him/her] as well as [his/her] feelings of safety."

Social Work Intervention: "Social Services will contact [Patient's name] support system in order to gather additional information, to discuss safety concerns, and discharge planning."

These intervention statements were not individualized and did not specify what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as helping the patient to understand benefits and signs and symptoms of medications as well as how to manage medications, assisting the patient to learn new skills to manage symptoms related to hearing voices etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to the patient's presenting symptoms and/or problem(s). These interventions would be provided to all patients regardless of their identified. In addition, social services intervention regarding identifying supportive persons was a social work function that was understood aspects of assessment and standards of practice for all patients.

7. Patient A8's MTP listed the following interventions statements for Problem #1: "Homicidal ideations and Psychosis." "Problem As Evidenced By: [Patient's name]...was homicidal. [S/he]...said [his/her] name was 'Hulon the 6th' and appeared to be actively psychotic and responding to some internal stimuli."

Psychiatrist Interventions: "The Psychiatrist/Licensed Practitioner will meet with [Patient's name] face to face to discuss [his/her] thoughts and feelings. The Psychiatrist/Licensed Practitioner will perform a full evaluation to determine [his/her] treatment needs. Staff will monitor [his/her] behaviors on the unit and assess [him/her] for the need of inpatient psychiatric treatment."

Treatment Staff Intervention: "Treatment staff will meet with [Patient's name] in a group setting to talk to [sic] ways to cope with [his/her] stressors and will also encourage participation in group activities." This intervention statement did not include a frequency of contact and name of clinical staff accountable to implement the intervention.

Nursing Intervention: "Staff will meet with [Patient's name] daily and will encourage [him/her] to discuss [his/her] thoughts and how the medications, if indicated, are affecting [him/her] as well as [his/feelings of safety."

Social Work Intervention: "Social Services will contact [Patient's name] support system in order to gather additional information, to discuss safety concerns, and discharge planning."

These intervention statements were not individualized and did not specify what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as helping him or her understand how to manage medications, assisting the patient to learn new skills to manage symptoms and/or problem(s) identified, etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. In addition, social services intervention regarding identifying supportive persons was a social work function that was understood aspects of assessment and standards of practice for all patients.

8. Patient A9's MTP listed the following interventions statements for Problem #1: "auditory/visual hallucinations, suicidal/homicidal ideation." "Problem As Evidenced By: [Patient's name] is grossly disorganized, acutely psychotic; [Patient's name] stated 'I was upset today because was kicked out of the house...reports [s/he] is hearing voices as bad as before in Nov."

Psychiatrist Interventions: "[Patient's name] and/or guardian will speak with the psychiatrist to discuss [his/her] symptoms which lead to admission in order to determine the best course of treatment including adjusting [his/her] medications. The psychiatrist will meet daily to evaluate for any problem or improvements with [Patient's name] mood and thoughts."

Social Work Intervention: "[Patient's name] will speak with social services staff during group sessions or one on one sessions about options [s/he] can use when [s/he] feels upset. [Patient's name] will receive handouts on mental illness, how to function with mental illness, and good coping skills." "[Patient name] and/or guardian will meet a social services staff to identify someone who is supportive to be a part of [his/her] treatment and discharge planning. Social Services will contact support system in order to gather collateral and plan for discharge."

Nursing Intervention: "[Patient's name] will meet with the nursing staff in a one to one meeting or group session to discuss [his/her] depression to ensure [s/he] is able to remain safe on the unit. Nursing staff will monitor for safety to ensure [Patient's name] remains safe on the unit and does not have thoughts of harm."

Rehabilitation (Activity Therapy): "[Patient name] will attend recreation therapy group once a day to learn activities that will help [him/her] stay calm and refocus [his/her] hallucinations."

These intervention statements were not individualized and focused what the patient will be doing rather than what clinical staff would be doing to assist the patient to improve his or her presenting symptoms such as helping the patient to understand and manage his or her medications, assisting the patient to learn new skills to manage symptoms related to hearing voices, etc. Interventions identified for the psychiatrist and nursing staff regarding evaluating and monitoring the patient's behavior were routine discipline functions and were not specific to the patient's presenting symptoms and/or problem. These interventions would be provided to all patients regardless of their identified problem. In addition, social services interventions identifying supportive persons and contacting support systems were social work functions that were understood aspects of assessment and standards of practice for all patients.

B. Interviews

1. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute the findings that intervention statements were not individualized and were routine nursing tasks instead of active treatment interventions to assist patients to make improvements in their presenting symptoms.

2. In an interview on 6/8/16 at 10:25 a.m. with the Director of Quality Improvement, the MTPs and treatment plan process were discussed. She did not dispute the findings that most interventions on MTPs were identical or similarly worded and were not individualized.

3. In an interview on 6/8/16 at 11:30 a.m. with the Medical Director, MTPs were reviewed. He did not dispute the findings regarding intervention statements. He acknowledged that the interventions did not show the psychiatrist's involvement with patients to provide information and assist them to manage their presenting symptoms.

II. Failure to include nurse led group on MTPs

A. Observation

During an observation on 6/7/16 at 10:10 a.m. in the dining room, Patients A1, A2, A4, A5, A8, and A9 attended a group titled, "Medication/Health Group" on the "ACS [Acute Care Services] Daily Schedule" to be held two times per day at 10:00 a.m. and 4:00 p.m. LPN #1 conducted the group and presented information on hypertension and discussed factors that affect blood pressure level and medications used to control hypertension.

A. A review of Master Treatment Plans for Patients A1, A2, A4, A5, A8, and A9 revealed that the "Medication/Health Group" was not included as active treatment interventions. There was no intervention statement that outlined the focus of treatment for each patient and a frequency of contact.

B. Interviews

1. In an interview on 6/7/16 at 10:40 a.m. with LPN #1, the Medication/Health Group was discussed. She reported that she or the RN conducted this group each day. She stated, "I am not involved with the treatment plan. I only document a group note for patients attending the group."

2. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, the Medication/Health Group was discussed. She did not dispute the findings that this group was not included on MTPs of patients attending the group.

Based on record review and interview, the facility failed to identify the name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). MTPs contained the discipline responsible for implementing the intervention but not the name of the person accountable to ensure that the patient received the assigned intervention. This practice results in the facility's inability to clearly monitor staff accountability for seeing that specific interventions are carried out.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (updated 11/25/14), A2 (12/1/14), A3 (11/25/14), A4 (updated 11/24/14), and A5 (11/26/14). This review revealed that none of the MTPs included both the name and discipline of clinical staff responsible for implementing interventions outlined on the MTPs. Since intervention statements only included the discipline, it was not clear what staff was accountable to ensure that interventions identified on MTPs were carried out especially for interventions to be implemented by social work, activity therapy and nursing staff.

B. Interviews

1. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute the findings and agreed that both the staff's name and discipline should be included on plans.

2. In an interview on 6/8/16 at 10:25 a.m. with the Director of Quality Improvement, MTPs were discussed. She did not dispute the findings.

Based on record and interview, the facility failed to appropriately document seclusion and chemical restraints used to control patients' violence toward self and others. Specifically, the facility failed to:

I. Ensure that appropriate physician orders were written for episodes of seclusion and chemical restraints for three (3) of four (4) non-sample patients (C1, C3, and C4) selected to review use of seclusion and restraints. The use of these restrictive procedures without documented justification results in a violation of the patients' right to be free from restraints and treated in the least restrictive environment.

II. Provide adequate training for registered nurses (RNs) assigned to conduct the required one-hour face-to-face assessments of four (4) of four (4) non-sample patients (C1, C2, C3, and C4) selected to review episodes of seclusion and restraint. Specifically, for these patients who were placed in seclusion and/or received chemical restraints, there was no documented evidence that RNs received training and were competent to conduct the required one-hour face-to-face assessment in accordance with CMS standards. Additionally, the RN who initiated the restrictive procedure also performed the one-hour face-to-face assessment preventing a creditable evaluation of the procedure used. The lack of an adequate RN training program potentially results in a failure to conduct a comprehensive review of the patient's condition to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's behavior. In addition, inadequate training may potentially lead to a failure to detect a physical injury sustained during the application of restrictive procedures.

Findings include:

I. Failure to write appropriate orders for episodes of seclusion and chemical restraints

A. Record Review

1. Patient C1 admitted 1/11/16 had 14 episodes of seclusion and/or chemical restraints during a period from 3/7/16 through 5/30/16. A review of seclusion and restraint episodes in May 2016 revealed the patient was secluded 5 times (5/2/16, 5/5/16, 5/6/16, 5/10/16, and 5/21/16) and chemically restrained on 5/10/16. There were no physician's orders for located in the facility's electronic records for the episodes of seclusion for this patient that occurred in May 2016, except for the seclusion that occurred on 5/2/16. This physician's order stated, "Seclusion." This order failed to include a time limit, a reason for the seclusion, or release criteria so that staff observing the patient could ensure that the seclusion was discontinued at the earliest possible time.

2. Patient C3 admitted in 5/3/16 had a restraint episode (chemical) and seclusion on 5/6/16. There was no physician order located in the electronic record for the seclusion on 5/6/16. This order failed to include a time limit, a reason for the seclusion, or release criteria so that staff observing the patient could ensure that the seclusion was discontinued at the earliest possible time.

3. Patient C4 admitted 5/5/16 had a restraint episode (chemical) on 5/5/16 and 5/6/16 and was secluded on 5/8/16 and 5/19/16. There was no physician order for the seclusion on 5/8/16 found on the electronic printout but there was an order for 5/9/16 stating, "Seclusion due to pt [patient] stripping and voiding on the floor." This order failed to include a time limit and did not comply with the facility's policy that stipulated the order must be "written within one (1) hour of initiation of the procedure or the client must be immediately released." The form titled, "Seclusion Flow Sheet" documented that the patient was placed in seclusion on 5/8/16 at 7:30 a.m. for "stripping and voiding." For the seclusion on 5/19/16, the physician's order dated 5/19/16 stated, "30 minutes seclusion." This order failed to include a reason for the seclusion or release criteria so that staff observing the patient could ensure that the seclusion was discontinued at the earliest possible time.

B. Interview

In an interview on 6/8/16 at 11:30 a.m. with the Medical Director, physician's orders for episodes of seclusion and chemical restraint were discussed. He did not dispute the findings and stated, "There should be an order for seclusion. You can't put the patient in seclusion without an order." He also noted that, "The RN is required to call the MD to release the patient from seclusion."

C. Policy Review

A review of the facility's policy titled "Special Treatment Procedures Adult" contained the following requirements:

1. "In an emergency, any registered...who is trained in the use of seclusion may initiate the procedure...If imposed without a prior order, an order must be obtained from a physician or physician assistance and written within one hour of initiation of the procedure or the client must be immediately released. For Patients C1 and C4, the facility failed to follow its policy regarding having a written order within one hour of the procedure.

2. "Orders for seclusion must define specific time limits." The orders for Patients C1 on 5/2/16 and C4 on 5/9/16 did not include a time limit.

3. "Clients are to immediately informed of the behavior that caused their seclusion and the behavior and conditions necessary for release. Staff may use criteria to guide early release from seclusion." The facility policy did not spell out who had the authority to institute early release nor factors that were to be used to determine early release of the patient from seclusion.

II. Failure to provided trained RNs to conduct face-to-face assessments after restrictive procedures

A. Medical Record Review

1. For the following patients who had episodes of seclusion and restraint (chemical), the face-to-face assessment documentation contained no information regarding the effectiveness of the intervention, the need to continue or terminate the seclusion, the cause of the incident, whether the restrictive procedure was appropriate to address the aggressive behavior(s) or pertinent observations that might be helpful in case a similar intervention was needed in the future. In addition, other than contacting the physician to obtain the order for episodes of seclusion and chemical restraint, the form used to document the one-hour face-to-face assessment did not include documentation showing the RN consulted with the attending physician to review the face-to-face assessment information collected including the patient's physical condition and psychological status. The forms titled, "Seclusion Flow Sheet" documented to the following episodes of seclusion and chemical restraint.

a. Patient C1 had 14 episodes of seclusion and/or chemical restraints during a period from 3/7/16 through 5/30/16. A review of seclusion and restraint episodes in May 2016 revealed the patient was secluded 5 times (5/2/16, 5/5/16, 5/6/16, 5/10/16, and 5/21/16) and chemically restrained on 5/10/16.

b. 2. Patient C2 admitted 4/15/16 received a restraint episode (chemical) on 4/20/16.

c. Patient C3 admitted in 5/3/16 had a restraint episode (chemical) on and seclusion on 5/6/16.

d. Patient C4 2 admitted 5/5/16 had a restraint episode (chemical) on 5/5/16 and 5/6/16 and was secluded on 5/8/16 and 5/19/16.

2. The RN who completed the one-hour face-to-face assessments for the patients mentioned above also initiated the restrictive procedure. This potentially prevented a creditable evaluation of the appropriateness of the restrictive procedure used.

B. Document Review

A review of the training and competency files for the RNs who completed the one-hour face-to-face assessments for non-sample Patients C1, C2, C3, and C4 did not contained documented evidence that each of the RNs had completed comprehensive training and return demonstrations to show competency to conduct a physical assessment including a review of systems, conduct a behavioral assessment, assess medications, review recent labs, and evaluate the appropriateness of the restraint or seclusion procedure. Additionally, the training files contained no evidence that these RNs received annual basic training and completed competency assessments regarding use of seclusion and restraint. that showed documented competencies.

C. Policy Review

A review of the facility's policy titled "Special Treatment Procedures Adult" revealed that the facility policy did not outline training requirements for RNs who completed the one-hour face-to-face assessment after episodes of seclusion and/or restraint in accordance with CMS requirements. The policy only listed training... "The Center's rules/regulations/policies/procedures/philosophy re the use of seclusion." There was no other information or content regarding training requirements included in this policy.

D. Interviews

1. In an interview on 6/7/16 at 2:30 p.m., with the Interim Director of Nursing, training and competency folders of RNs completing the face-to-face assessments were reviewed. After review by the DON and research of other sources to find documented evidence of these RNs competency, she admitted that there was no such evidence of RN competency to complete the face-to-face assessment. She stated, she was aware of CMS requirements.

2. In an interview on 6/8/16 at 10:25 a.m. with the Director of Quality Improvement, the facility policy regarding seclusion and restraint was discussed. She admitted that the policy did not have requirements regarding release criteria or training for RN who complete the one-hour face-to-face assessment.

3. In an interview on 6/8/16 at 11:30 a.m., the Medical Director, after understanding requirements, did not dispute the findings regarding the failure of the facility to have trained RNs to complete the face-to-face assessment.

Based on record review and interviews, the facility failed to provide adequate social work staff to complete comprehensive psychosocial assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, A8 and A9). These failures potentially hinder adequate planning appropriate active treatment intervention being provided for patients based on their presenting problems and needs. These assessments were not reviewed by a trained or licensed social worker to ensure quality and appropriateness of psychosocial information contained in the Biopsychosocial assessment.

Findings include:

A. Record Review

A review of records revealed that the facility failed to provide qualified social workers to complete psychosocial assessments. A Biopsychosocial assessment completed in the admission area was used to include information related to the psychosocial assessment. Staff other than a trained or licensed social worker completed these assessments for eight (8) of eight (8) active sample patients for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9).

B. Interview

In an interview on 6/7/16 at 2:00 p.m. SW #1 and SW #2 confirmed that staff other than a trained or licensed social worker performed the biopsychosocial assessments and the information required for the psychosocial assessment. They said that there was no Director of Social Services or a master's level social worker provided oversight of these duties in the absence of a Director.

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

I. Document and provide a credible mortality review process for two (2) of two (2) patients who dead shortly after discharge (M1 and M2). The absence of such a process results in a failure to identify practices that could have contributed to adverse outcomes, educate peers about these failures, and reduce the risk of recurrence of similar adverse events.

Findings include:

A. Record review

1. Patient M1 was admitted on 11/2/15 and discharged on 11/5/15. The patient was admitted following a suicide attempt. Diagnoses were Adjustment disorder with mixed disturbance of conduct and emotions, Disruptive mood regulation disorder, Opioid use disorder, moderate, and Alcohol use disorder, mild. The patient committed suicide by hanging on 11/15/15. Autopsy was completed on 11/16/15, and the report was received by the hospital on 6/8/16 after a second request was submitted during the survey. No mortality review was completed by the hospital.

2. Patient M2 was admitted on 1/12/16 and discharged on 1/15/16. The reason for admission was a report from the family member who accompanied the patient to the hospital that the patient had threatened suicide. Identified stressors were the deaths of his wife and his mother and the foreclosure of his home. The patient committed suicide by hanging on the day of discharge from the hospital. Autopsy was completed on that date but was not received by the hospital until 6/7/16 after a second request was submitted during the survey. No mortality review was completed by the hospital.

B. Interviews

1. In an interview on6/6/16 at 12:30 p.m., the Risk Manager stated that medical staff "do not do mortality reviews."

2. In an interview on 6/8/16 at 11:30 am, the Medical Director stated, "I agree that the treatment plans should be modified." Regarding the patient deaths s/he said, "Mortality reviews should always be done."

3. In an interview on 6/6/16 at 3:00 p.m., the Quality Management Director said, "We do not have a policy on death reviews."

II. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed in seclusion or restraint. Specifically, for four (4) of four (4) non-sample patients selected to review episodes of seclusion and restraint (C1, C2, C3, C4, and C5), MTPs were not revised to include the following: problem statements related to the use of seclusion and chemical restraint to control aggressive behavior; treatment goals; and interventions outlining healthy alternatives and approaches for patients to use to replace or reduce aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118-III)

III. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide active treatment for seven (7) of eight (8) active sample patients (A12, A15, B10, C4, C5, D6, and D13). Specifically, the MTPs were missing the following components:

A. Clearly defined problem statements written in behavioral and descriptive term for six (6) of eight (8) active sample patients (A2, A4, A5, A6, A7, and A9). (Refer to B119)

B. Individualized goals and objectives for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B121)

C. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B122)

D. The name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9). (Refer to B123)

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

III. Ensure that appropriate physician orders were written for episodes of seclusion and chemical restraints for three (3) of four (4) non-sample patients (C1, C3, and C4) selected to review use of seclusion and restraints. The use of these restrictive procedures without documented justification resulted in a violation of the patients' right to be free from restraints and treated in the least restrictive environment. (Refer to B125-I)

Based on document review and staff interview, the Interim Director of Nursing (DON) did not have a Master's Degree in Psychiatric Mental Health nursing, or ongoing training related to psychiatric mental health nursing plus psychiatric experience, and/or documented evidence of consultation from a nurse with a Master's in Psychiatric Mental/Health Nurse. This results in no designated expertise in psychiatric nursing care to provide oversight and monitor the quality of nursing care provided by nursing personnel.

Findings include:

A. Document Review

A review of the DON's resume' revealed that she held a Masters in Nursing Administration with approximately six years experience in psychiatric/mental nursing. The DON was not able produce documented evidence of ongoing training in psychiatric and mental health nursing.

B. Interview

In an interview on 6/7/16 at 2:30 p.m., the DON acknowledged that she did not have documented evidence of ongoing training in psychiatric nursing and did not have access to a registered nurse with a Master ' s Degree in Psychiatric Nursing to provide consultation. She stated, "I am aware of the CMS requirements."

Based on observation, record review, and interview, the Interim Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON did not monitor to:

I. Provide Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. In addition, MTPs did not include a nurse led group listed on the unit's daily schedule and attended by six (6) of eight (8) active sample patients (A1, A2, A4, A5, A8, and A9). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

I. Failure to include individualized treatment intervention

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/27/16); A2 (6/4/16); A3 (No Treatment plan); A4 (5/24/16); A5 (6/2/16); A6 (5/24/16); A7 (5/28/16); A8 (5/30/16) and A9 (5/26/16). This review revealed that the MTPs included but not limited to the following deficient intervention statements. None of the intervention statements were individualized and were identical or similarly worded statements.

II. Provide adequate training for registered nurses (RNs) assigned to conduct the required one-hour face-to-face assessments of four (4) of four (4) non-sample patients (C1, C2, C3, and C4) selected to review episodes of seclusion and restraint. Specifically, for these patients who were placed in seclusion and/or received chemical restraints, there was no documented evidence that RNs received training and were competent to conduct the required one-hour face-to-face assessment in accordance with CMS standards. Additionally, the RN who initiated the restrictive procedure also performed the one-hour face-to-face assessment preventing a creditable evaluation of the procedure used. The lack of an adequate RN training program potentially results in a failure to conduct a comprehensive review of the patient's condition to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's behavior. In addition, inadequate training may potentially lead to a failure to detect a physical injury sustained during the application of restrictive procedures. (Refer to B125-II)

III. Ensure that continuity of nursing care was maintained on the distinct part unit. Specifically, there was no dedicated registered (RN) staff assigned to the unit. Staff was floated from non-distinct part units to provide RN coverage. During the survey, there was an agency nurse assigned on 6/6/16 and a per diem RN assigned on 6/7/16. Failure to provide consistent staff resulted in active treatment groups not being conducted and documented.

Finding include:

A. Observation

During observations on 6/6/16 and 6/7/16 from 4:00 p.m. to 4:30 p.m., the Medication/Health Group scheduled for 4:00 p.m. was not held as scheduled.

C. Interviews

1. In an interview on 6/6/16 at 4:10 p.m., RN #1 stated that she was not aware of the group scheduled at 4:00 p.m.

2. In an interview on 6/7/16 at 10:40 a.m. LPN #1 stated, "I usually conducts the group at 10:00 a.m." She was not sure if the RN was responsible for the afternoon group.

3. In an interview on 6/7/16 at 4:15 p.m., RN #2 stated, "No, I was not aware of the Medication Group scheduled for 4:00 p.m." She noted, "I have never conducted this group. I am responsible for attending the treatment team meetings, processing new admissions and discharges."

4. In an interview on 6/7/16 at 2:30 p.m., the DON stated, "I am not surprised that it is not held. A lot has fallen by the wayside with changes in staff." She acknowledged that there was not a lot of continuity of psychiatric nursing care on the unit and "glue to hold the place together."

Based on interviews, the hospital failed to provide a Director of Social Work who had overall responsibility for evaluating the quality and appropriateness of social services furnished by the hospital. Specifically the facility failed to designate a social worker to provide adequate oversight to:

I. Ensure adequate clinical leadership in social work to monitor the quality of social work practice and provide supervision of social work staff. At the time of the survey, there was no Director of Social Work employed by the facility. Without monitoring, there is potential for major gaps in social service provision in these areas.

Findings include:

Interviews

1. In an interview on 6/6/16 at 3:30 p.m., the ACS Administrator and the Quality Management Director said that there was currently no Director of Social Work.

2. In an interview on 6/7/16 SW1 and SW 2 at 2:00 p.m. confirmed the absence of a Director.

II. Ensure that comprehensive social work assessments were completed for eight (8) of eight (8) sample patients (patients A1. A2, A4, A5, A6, A7, A8, and A9). A "biopsychosocial assessment," completed in the emergency department by staff who were not social workers, did not identify social work roles related to treatment and discharge planning. (Refer to B108)

III. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed in seclusion or restraint. Specifically, for four (4) of four (4) non-sample patients selected to review episodes of seclusion and restraint (C1, C2, C3, C4, and C5), MTPs were not revised to include the following: problem statements related to the use of seclusion and chemical restraint to control aggressive behavior; treatment goals; and interventions outlining healthy alternatives and approaches for patients to use to replace or reduce aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118-III) [Note: At this facility, social work staff were responsible for formulating the master treatment plan]

IV. Provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7, A8, and A9) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment. (Refer to B122-I)