HospitalInspections.org

Based on staff interview and review of the laboratory service contract, it was determined the governing body failed to ensure the facility had an effective laboratory service agreement signed and dated.

Findings include:

Review of the laboratory service agreement on 08/12/15 at 4:05 PM revealed it was not signed and dated by the hospital representative, or the general manager of the clinical laboratory.

Interview with Staff B on 08/12/15 at 4:05 PM confirmed the corporate laboratory whom the hospital was contracted with had not sent the service agreement with signatures. Staff B revealed he/she has made three attempts to obtain a faxed copy of the service agreement, and each time the person from the corporate office for the clinical laboratory revealed the service agreement was on the way.

This finding was confirmed with Staff B on 08/12/15 at 4:30 PM. Staff B revealed the facility does not have a copy of the signed service agreement for clinical laboratory.

Based on observation, staff interview, admission packet information review, and policy review, the facility failed to provide patients with information for lodging a complaint/grievance with the State agency. This had the potential to affect all patients of the facility. The hospital census was 64.

Findings include:

On 08/13/15 the hospital policy #SS-021 Patient Complaint and Grievance Process, revised on 06/24/14 was reviewed. The policy documented anyone "may file complaints with the facility." "If the grievance is dissatisfied with the hospital administrator's response, the grievance may appeal to the Ohio Department of Mental Health 614-466-2333." The policy lacked information on the State agency's toll free complaint hotline.

A hospital tour conducted on 08/13/15 at 11:00 AM included the main lobby, the dining room area, and the three patient units. The patient rights information posted on the units lacked complaint information including toll free telephone numbers and addresses for the State agencies, Ohio Department of Health and the Ohio Department of Mental Health. The hospital clients rights specialist, Staff G, confirmed the lack of conspicuously posted State agency complaint hotline information.
On 08/13/15 the patient handbook and patient rights were reviewed. The section on filing a complaint documented "you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/HIPPA/complaints/". The complaint section lacked documentation for any State agency.
The patient rights section of the handbook listed the right to utilize the patient grievance/complaints/concerns process. The section documented "you have a right to an appeals decision and will be given contact information for governing bodies to report grievances to as needed".

Based on medical record review, policy review and staff interview, the facility failed to provide patient education as determined on the nursing care plan. This affected ten of ten patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed on the 2000 unit. The total sample size was 35. The current census at the time of the survey was 64.

Findings include:

Facility policy entitled, "Patient Education" last reviewed 5/2015 reveals the RN is to gather information about patient educational needs and treatment objectives at the time of admission. Specific educational needs related to physical disorders are provided on an individual basis.

1) Patient #1 was admitted to the hospital on 7/18/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/18/15 regarding the admission process to the facility. A nursing care plan dated 7/18/15 for Altered Health Maintenance revealed the nurse was to provide the patient education regarding health risks of continued tobacco use and the benefits of smoking cessation. The care plan indicates the education was to be provided throughout the patient's stay until discharge. The Patient Teaching Record did not reveal teaching regarding smoking cessation since 7/18/15 to date.
A nursing care plan dated 7/18/15 for High Cholesterol Treatment Plan revealed the nurse was to provide teaching regarding dietary issues surrounding ongoing control of cholesterol and teach patient about medication use and assess learning. The Patient Teaching Record did not reveal teaching regarding high cholesterol since 7/18/15 to date.

2) Patient #2 was admitted to the hospital on 7/30/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/30/15 regarding the admission process to the facility.
A nursing care plan dated 7/30/15 for Hepatitis C included teaching the patient hand washing technique with a target date of "through to discharge". The Patient Teaching Record did not reveal teaching regarding hand washing since 7/30/15 to date.

3) Patient #3 was admitted to the hospital on 7/31/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/31/15 regarding the admission process to the facility.
A nursing care plan dated 7/31/15 for Hypothyroidism includes educating the patient on the importance of medication compliance. The Patient Teaching Record did not reveal teaching regarding Hypothyroidism since 7/31/15 to date.

4) Patient #4 was admitted to the hospital on 7/11/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/11/15 regarding the admission process to the facility.
A nursing care plan dated 7/11/15 for Hepatitis C includes teaching the patient hand washing technique with a target date of "through to discharge". The Patient Teaching Record did not reveal teaching for hand washing technique since 7/11/15 to discharge on 8/13/15.

5) Patient #5 was admitted to the hospital on 7/21/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/21/15 regarding the admission process to the facility.
A nursing care plan dated 7/21/15 for Sleep Difficulty includes teaching for comfort measures to promote sleep. On 8/04/15 the nurse noted "unmet". The Patient Teaching Record did not reveal teaching for comfort measures to promote sleep since 7/21/15 to 8/04/15.

6) Patient #6 was admitted to the hospital on 7/28/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/28/15 regarding the admission process to the facility.
A nursing care plan dated 7/28/15 for Impaired Circulation includes teaching the importance of diet restrictions and following an anticoagulant regimen. The Patient Teaching Record did not reveal teaching regarding impaired circulation since 7/28/15 to date.

7) Patient #7 was admitted to the hospital on 7/24/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/24/15 regarding the admission process to the facility.
A nursing care plan dated 7/25/15 for Pain includes teaching coping skills to aid in pain reduction. The Patient Teaching Record did not reveal teaching regarding pain since 7/24/15 to date.

8) Patient #8 was admitted to the hospital on 7/12/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/12/15 regarding the admission process to the facility.
A nursing care plan dated 7/12/15 for Hypertension includes teaching the patient diet, medication usage, signs and symptoms of high blood pressure and lifestyle changes. The Patient Teaching Record did not reveal teaching for Hypertension since 7/12/15 to date. Discharge for this patient is scheduled on 8/14/15.

9) Patient #9 was admitted to the hospital on 7/25/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/25/15 regarding the admission process to the facility.
A nursing care plan dated 7/25/15 for Pain includes teaching the patient coping skills and comfort measures for pain. The Patient Teaching Record did not reveal teaching for coping skills and comfort measures for pain since 7/25/15 to date.

10) Patient #10 was admitted to the hospital on 7/29/15. The Patient Teaching Record in the medical record reveals teaching was provided to the patient on 7/29/15 regarding the admission process to the facility.
A nursing care plan dated 7/29/15 for Hypothyroidism includes teaching the patient the importance of medication compliance. The Patient Teaching Record did not reveal teaching for Hypothyroidism since 7/29/15 to date.

Interview with Staff B on 8/12/15 at 4:15 PM confirmed the education provided by the nurse to the patient should be documented on the facility Patient Teaching Record form. Staff B reported, "If it isn't documented there, it probably wasn't done."

Based on the facility medical record statistics, staff interviews, and policy
review, the facility failed to ensure medical records were completed within 30
days of discharge. This affected 1843 medical records reported in June 2015.
The facility's average delinquency rate for the past 12 months was 19 percent
with an average monthly rate of discharges of 637.

Findings include:

On 08/13/15 the facility policy titled "Medical Staff Rules and Regulations" original, 1/11 was reviewed. The policy under incomplete medical records on page (9 of 9) documented the patient's medical record shall be complete at time of discharge, including progress notes, final diagnosis, and discharge summary. Where this is not possible because final laboratory or other essential reports have not been received at the time of discharge, the patient's chart will be available in the Medical Record Department. If the record remains incomplete after all essential reports have been received and placed on the record, the Medical Record Department shall notify the practitioner of incomplete records. The number of delinquent records and delinquency rate will be reported at each medical Executive Committee Meeting. On page (9 of 9) under Completed Medical Record was documented the medical record must be completed within 30 days after the patient's discharge.

On 08/10/15 at 1:00 PM to 1:45 PM, the facility's medical record department
was observed and reviewed including interviews with the Medical Records Department Manager (Staff F).
Staff B provided the facility's medical record statistics for the past 12 months. Staff
B explained the average delinquent medical record count for June was 1843.

On 08/13/15 at 8:40 AM, Staff B confirmed the medical record statistics
including the facility's average monthly discharge rate of 637, the medical
record delinquency timeframe of 30 days, the delinquent medical record totals
for June 2015 of 1843, and the average delinquency rate for the last 12 months was 19 percent.

Review of the Medical Staff By-Laws under criteria for initiation of determination included corrective action against a physician may be initiated by the Administrator or his/her designee, the Board (or appropriate committee thereof), any officer of the Medical Staff and by the Chairman of any standing committee of the Medical Staff.

This finding was confirmed with Staff B on 08/13/15 at 8:40 AM.

Based on policy review, medical record review, and staff interview, the hospital failed to ensure telephone orders were signed by the prescribing provider within 48 hours. This affected nine of 34 medical records reviewed including Patient's #11,#15, #16, #18, #26, #27, #28, #29, and #30. The hospital census was 64.

Findings include:

On 08/11/15 the hospital policy #NUR 6.9, Complete Medication Orders, revised 06/26/15 was reviewed. The policy documented "all telephone orders must be countersigned, dated and timed, after review by the prescriber or covering prescriber, within forty-eight (48) hours".

1. On 08/13/15 the medical records for Patient #26 was reviewed including telephone orders. A telephone order dated 07/26/15 was not countersigned, dated and timed by the prescriber until 08/07/15. A telephone order dated 07/29/15 was not countersigned, dated and timed by the prescriber until 08/07/15. A telephone order dated 08/04/15 was not countersigned, dated and timed by the prescriber until 08/07/15.

2. On 08/13/15 the medical records for Patient #27 was reviewed including telephone orders. A telephone order dated 08/04/15 was not countersigned, dated or timed by the prescriber.

3. On 08/13/15 the medical records for Patient #28 was reviewed including telephone orders. A telephone order dated 07/23/15 was not countersigned, dated and timed by the prescriber until 08/01/15.

4. On 08/13/15 the medical records for Patient #29 was reviewed including telephone orders. A telephone order dated 08/06/15 was not countersigned, dated or timed by the prescriber.

5. On 08/13/15 the medical records for Patient #30 was reviewed including telephone orders. A telephone order dated 07/29/15 was not countersigned, dated and timed by the prescriber until 08/03/15. A telephone order dated 08/04/15 was not countersigned, dated or timed by the prescriber. A telephone order dated 08/05/15 was not countersigned, dated or timed by the prescriber. A telephone order dated 08/07/15 was not countersigned, dated or timed by the prescriber. A telephone order dated 08/09/15 was not countersigned, dated or timed by the prescriber. A telephone order dated 08/10/15 was not countersigned, dated or timed by the prescriber.

On 08/13/15 at 11:00 AM, Staff B confirmed the lack of signed telephone orders per hospital policy for Patient's #26, #27, #28, #29, and #30.



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6. On 08/12/15, the medical record for Patient #11 was reviewed including telephone orders. Telephone orders dated 08/03/15 and 08/05/15 were not countersigned, dated or timed by the prescriber. This finding was confirmed with Staff B on 08/13/15 at 8:40 AM.

7. On 08/12/15, the medical record for Patient #15 was reviewed including telephone orders. A telephone order dated 07/27/15 was not countersigned, dated or timed by the prescriber. A telephone order dated 07/27/15 was not countersigned, dated or timed by the prescriber until 08/17/15. A telephone order dated 07/29/15 was not countersigned, dated or timed by the prescriber until 08/17/15. A telephone order dated 08/04/15 was not countersigned, dated or timed by the prescriber until 08/07/15. A telephone order dated 08/06/15 was not countersigned, dated or timed by the prescriber until 08/09/15. This finding was confirmed with Staff B on 08/13/15 at 8:40 AM.
8. On 08/12/15, the medical record for Patient #16 was reviewed including telephone orders. A telephone order dated 08/06/15 was not countersigned, dated or timed by the prescriber until 08/09/15. This finding was confirmed with Staff B on 08/13/15 at 8:40 AM.
9. On 08/12/15 the medical record for Patient #18 was reviewed including telephone orders. A telephone order dated 07/26/15 was not countersigned, dated or timed by the prescriber until 07/29/15. A telephone order dated 07/23/15 was not countersigned, dated or timed by the prescriber until 07/29/15. This finding was confirmed with Staff B on 08/13/15 at 8:40 AM.

Based on staff interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, specifically, to ensure building type was of permitted construction type, linen storage areas had a one hour fire rated construction, hazardous areas were protected with a one hour construction, exit access corridors were protected with a one hour construction, doors and door frames in the exit access corridor had the proper fire rating, glass panels in the exit access corridor doors had the proper fire rating, furniture and carpets had an appropriate fire rating, the existing building was fully sprinkled in all areas, the exit egress to public way was properly illuminated, egress doors opening in the direction of egress travel, space open to the corridor are protected with an automatic smoke detection system, and a generator remote annunciator set was in a location that complied with NFPA 99.
Findings include:
See A710.

Based on observation, schematic review, staff interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

See K12 for findings related to the facility failing to ensure building type was of permitted construction type.
See K17 for findings related to the facility failing to ensure areas open to the corridor are protected with electronically supervised smoke detection system or located to allow direct staff supervision.
See K21 for findings related to the facility failing to ensure that doors in the 1 hour exit access corridor had self closing devices.
See K29 for findings related to the facility failing to ensure the one hour protection around the electrical room.
See K33 for findings related to the facility failing to ensure the exit access corridors 1 hour protection is maintained.
See K45 for findings related to the facility failing to ensure emergency illumination is maintained throughout path of egress.
See K56 for findings related to the facility failing to ensure all areas of the hospital are sprinkled as identified upon entrance.
See K72 for findings related to the facility failing to ensure doors in the path of egress opened in the direction of egress.
See K74 for findings related to the facility failing to provide documentation of newly introduced upholstered furniture fire testing.
See K75 for findings related to the facility failing to ensure the linen storage areas had a one hour fire rated construction
See K108 for findings related to the facility failing to ensure a generator remote annunciator panel is located in a regular work station that is manned 24 hours a day.

Based on Observations, Record Review and Staff Interview the facility failed to:

1) Provide Psychosocial Assessments that included individualized social work conclusions and recommendations and social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients. (Refer to B108)

2) Document Physical Examinations for three (3) of eight (8) active sample patients. (Refer to B109)

3) Include an inventory of patients strength, assets and disabilities in the Master Treatment Plans (MTPs). (Refer to B119)

4) Ensure that the Master Treatment Plans included patient related Short Term(ST) and Long Term(LT) goals in observable, measurable, behavioral terms. (Refer to B121)

5) To identify patient specific, individualized treatment modality and focus of intervention. (Refer to B122)

6) Ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plan. (Refer to B123)

7) Ensure the Physicians roles and responsibilities were identified in the MTP. (Refer to B125)

8) Ensure that the physicians followed hospital policy and document progress notes in a timely manner for four (4) of eight (8) active sample patients. (Refer to B126)

9) Ensure the discharge summaries are completed in a timely fashion as defined by hospital policy for four (4) of five (5) discharged sample patients. (Refer to B133)

Based on Record Review and Staff interview for eight (8) of eight (8) (A1, A2, A3, A4, A5, A6, A7 and A8) active sample patients the facility failed to provide Psychosocial Assessment that included individualized Social Work conclusion and Recommendations including social work role in treatment and discharge planning. The recommendations were generic social work responsibilities expected to be provided to all patients. This resulted in absence of professional social work treatment services for eight (8) of eight (8) active sample patients.

The findings include:

Record Review:

1) Patient A1 was hospitalized on 07/09/2015. "Bio-psychosocial assessment" was completed on 07/10/15. The treatment recommendations included "treatment goals, individual/group counseling, coordinate after care".

2) Patient A21 was hospitalized on 07/13/2015. "Bio-psychosocial assessment" was completed on 07/14/15. The treatment recommendations included "Follow treatment/care plans and recommendations, participate in group and individual sessions, Participate in discharge/ after care planning and Follow up".

3) Patient A3 was hospitalized on 07/17/2015. "Bio-psychosocial assessment" was completed on 07/18/15. The treatment recommendations included "individual therapy, group therapy, Relapse prevention plan; along with discharge after care plan".

4) Patient A4 was hospitalized on 07/22/2015. "Bio-psychosocial assessment" was completed on 07/23/15. The treatment recommendations included "participate in treatment goals, individual/group counseling, coordinate after care planning".

5) Patient A5 was hospitalized on 08/03/2015. "Bio-psychosocial assessment" was completed on 08/03/15. The treatment recommendations included "1)Investigate/secure post placement housing, 2) Investigate /secure supportive services, 3) Invest.(sic) pt. current legal status".

6) Patient A6 was hospitalized on 08/04/2015. "Bio-psychosocial assessment" was completed on 08/05/15. The treatment recommendations included "Follow treatment/care plans and recommendations, Attend and participate in groups and individual sessions, Participate in after care/discharge planning and follow up".

7) Patient A7 was hospitalized on 08/05/2015. "Bio-psychosocial assessment" was completed on 08/06/15. The treatment recommendations included "Relapse Prevention, alcohol education, med compliance".

8) Patient A8 was hospitalized on 08/05/2015. "Bio-psychosocial assessment" was completed on 08/07/15. The treatment recommendations included "Follow treatment/care plan recommendations. Attend and participate in individual sessions and groups, Participate in after care/discharge planning and follow up".

Staff Interview:

In a meeting with the Director of Social Services on 08/12/15 at 9:00 am, the Director concurred with the above deficiencies and further stated "we obviously have some things to change".

Based on Record review Policy review and Staff interview, the facility failed to perform and document physical examination for three (3) of the eight (8) active (A4, A5 and A8) sample patients per hospital policy. The absence of this patient information can limit the physician's and Treatment Team's ability to accurately diagnose the patient's condition and to accurately provide a measure of baseline functioning, thereby potentially, adversely affecting patient care.

The findings include:

Record review:

1) Patient A4 was hospitalized on 07/22/15. As of 08/11/15 there was no Physical examination record present in the patient's medical records.

2) Patient A5 was hospitalized on 08/03/15. As of 08/11/15 there was no Physical examination record present in the patient's medical records.

3) Patient A8 was hospitalized on 08/05/15. As of 08/11/15 there was no Physical examination record present in the patient's medical records.

Policy review:

The hospital's Policy and Procedures, Titled "Timeframe for paperwork" Subject "Clinical" revised on 04/18/14 indicates, History and Physical Exams are to be completed within 24 hours by a Physician/NP.

Staff Interview:

In a meeting with the Director of Nursing on 08/11/15 at 10:00 a.m., the director confirmed that the History and Physical Exams were not documented in the Medical records of patients A4, A5 and A8 as of 08/11/15.

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included an inventory of the patient's strengths for eight (8) out of eight (8) active sample patients who had been in the hospital long enough to complete a master treatment plan (A1, A2, A3, A4, A5, A6, A7 and A8). This failure impacts identification of how patient strengths will be utilized in treatment and discharge planning.

Findings include:

A. Policy/Document Review

1. Facility Medical Staff Rules and Regulations outline the "Treatment Plan" requirements for the "Individual Comprehensive Treatment Plan (ICTP)", effective 12/11, "Section IV Medical Records, E. Treatment Plans: 1) The attending physician shall be responsible for the care of the patient. As such, the development, interpretation, and implementation of the treatment plan shall be the responsibility of the physician in conjunction with the multidisciplinary treatment team; 2) A plan of treatment shall be initiated upon admission and shall consist of the physicians' admitting orders and the nursing assessment and individualized treatment plan; 3) The comprehensive treatment plan shall be based upon assessment of the patient's physical, emotional, behavioral, social, recreational, and when appropriate, legal, vocational and nutritional needs; and 4) The comprehensive treatment plan shall delineate the care to be provided and shall include the following: a. Referral for needed services not provided by the facility; b. Specific goals and specific objectives. Anticipated time for objective achievement; c. Objectives shall be written in measurable terms; d. Type and frequency of treatment, services, procedures and activities required to meet the patient's needs; e. Specify the staff responsible for planned approaches; f. Specific criteria to be met for termination of treatment as part of the initial treatment plan; g. Specific plan for involvement of Ridgeview Hospital or significant others; h. The patient and/ or family shall participate in the development of the treatment plan when appropriate and same shall be documented on the comprehensive treatment plan form. The treatment plan shall be reviewed and updated to reflect the patient's clinical status; i. The attending physician shall sign, time and date the treatment plan." The facility refers to the MTP as the ICTP which include "nursing medical care plans" related to the identified problems.

B. Record Review

1. Patient A1 (admitted 7/9/15, MTP 7/12/15). There were no assets documented in the patient's ICTP.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15). There were no assets documented in the patient's ICTP.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15). There were no assets documented in the patient's ICTP.

4. Patient A4 (admitted 7/22/15, MTP 7/25/15). There were no assets documented in the patient's ICTP.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15). There were no assets documented in the patient's ICTP.

6. Patient A6 (admitted 8/4/15, MTP 8/7/15). There were no assets documented in the patient's ICTP.

7. Patient A7 (admitted 8/5/15, MTP 8/8/15). There were no assets documented in the patient's ICTP.

8. Patient A8 (admitted 8/5/15, MTP 8/8/15). There were no assets documented in the patient's ICTP.

C. Staff Interviews

1. In an interview on 8/11/15 at 3:30 p.m., after reviewing the treatment plans for sample patients A1-A8, the Medical Director agreed that the MTP did not document patient strengths/ assets in the Individual Comprehensive Treatment Plan. He also acknowledged the physician's responsibility (as leader of the treatment team) for ensuring complete MTP's.

2. In an interview on 8/10/15 at 1:30 p.m., after reviewing the treatment plans for sample patients A1-A8, the Director of Nursing (DON) acknowledged that the plans did not include patient strengths/ assets that had been identified in the assessments.

Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans (MTP) that identified short term (ST) and long term (LT) goals stated in individualized, observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients who had been in the hospital long enough to complete a master treatment plan (A1, A2, A3, A4, A5, A6, A7 and A8). This failure impacts treatment for patients who do not have goals which are individualized, measurable or based on desired patient care outcomes.

Findings include:

A. Policy/Document Review

1. Facility Medical Staff Rules and Regulations, effective date 12/11, Section IV Medical Records, E. Treatment Plans: 1) The attending physician shall be responsible for the care of the patient. As such, the development, interpretation, and implementation of the treatment plan shall be the responsibility of the physician in conjunction with the multidisciplinary treatment team; 2) A plan of treatment shall be initiated upon admission and shall consist of the physicians' admitting orders and the nursing assessment and individualized treatment plan; 3) The comprehensive treatment plan shall be based upon assessment of the patient's physical, emotional, behavioral, social, recreational, and when appropriate, legal, vocational and nutritional needs; and 4) The comprehensive treatment plan shall delineate the care to be provided and shall include the following: a. Referral for needed services not provided by the facility; b. Specific goals and specific objectives. Anticipated time for objective achievement; c. Objectives shall be written in measurable terms; d. Type and frequency of treatment, services, procedures and activities required to meet the patient's needs; e. Specify the staff responsible for planned approaches; f. Specific criteria to be met for termination of treatment as part of the initial treatment plan; g. Specific plan for involvement of Ridgeview Hospital or significant others; h. The patient and/ or family shall participate in the development of the treatment plan when appropriate and same shall be documented on the comprehensive treatment plan form. The treatment plan shall be reviewed and updated to reflect the patient's clinical status; i. The attending physician shall sign, time and date the treatment plan

B. Record Review

1. Patient A1 (admitted 7/9/15, MTP 7/12/15).

Problem 1 "Substance Use; Identified Diagnosis: Substance Use Disorder; Goal: To be drug and alcohol free; Objectives: Identify 3, people places and things that are situations (sic). Learn 4 new activities to help with boredom;" The plan of treatment, "Individual Comprehensive Treatment Plan" does not specify the long term and short term goals. The first objective statement was not clear.

Problem 2 "Nutrition: Below Body Necessity; Related to: 60-100% intake; As evidenced by: Reported inadequate food intake less than recommended daily allowance with or without weight loss and/ or actual or potential metabolic needs in excess of intake; Plan and Outcome (check those that apply); The patient will:" A standardized, pre-printed form was used and no boxes were checked for the Plan and Outcome. The plan of treatment failed to specify the long term and short term goals.

Problem 3 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" did not specify the short term goals.

Problem 4 "Anxiety Disorder: Inability to be still; Identified Diagnosis: Anxiety Disorder; Goal: To be calm; Objectives: Learn 2 positive coping skills for anxiety. Identify 3 anxiety producing situations." The Goal did not specify how this would be measured. The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals.

Problem 5 "Sleep difficulty related to medication, life style disruptions, as evidenced by difficulty falling or remaining asleep: Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 8 hours of uninterrupted sleep at night. Remain awake during the day". The same Plan/ Outcome was identified (filling in either 6-8 hours of sleep) for each sample patient identified as having sleep difficulty. This same Goal and Objective was present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked. The plan of treatment failed to specify the long term and short term goals.

Problem 6 "Hypertension' related to: substance abuse, sedentary lifestyle, As evidenced by: history of high BP; Long Term Goal: Patient will maintain a normal blood pressure of 120/80; Plan and Outcome: Follow dietary regimen to include low intake of salt; follow medication regimen as ordered by physician; report any signs or symptoms (i.e. headache, dizziness, visual disturbance, nausea, etc.)." A standardized, pre-printed form was used and all boxes were checked for the plan and outcome. The plan of treatment did not specify the short term goal.

Problem7 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired physical mobility; R/T (related to): Environmental; Medication; AEB (as evidenced by): Score of 5 on fall assessment. Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment". The plan of treatment failed to specify the long term and short term goals. This same Goal was present for all sample patients identified as having risk for falls. A standardized, pre-printed form was used that contained pre-printed goals.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15).

Problem 1 "Health Maintenance Altered related to insufficient knowledge of effects of tobacco; Long term goal/ discharge criteria: Patient will identify long-term effect(s) of tobacco use. Short Term Goal: Be open to exploring health risks of tobacco use and the benefits of not smoking." This long term goal and short term goal was the same for all sample patients identified as having tobacco dependence (documented as "Long Term Goal/Objectives" in some patient records). A standardized pre-printed form was used adding only a start date and signature of the RN and patient. Identification of long term effects of tobacco use in the plan of treatment, nursing care plan, would not be a relevant discharge criterion.

Problem 2 "Bipolar; Identified Diagnosis: Bipolar; Goal: Stabilize moods and improve coping skills; Objectives: Identify situations that produce stress, anxiety or depression and plan for these; Learn 5 new ways to distract thoughts or maintain mood." The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals.

Problem 3 "Substance Use; Identified Diagnosis: Substance use (opiate, marijuana, cocaine); Goal: Be drug and alcohol free; Objectives: Learn 5 new triggers and coping skills; Complete relapse prevention plan." The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals. The same Goal to be drug free, alcohol free, prevent relapse was present for sample patients having a substance use problem.

Problem 4 "Sleep Difficulty; Related to: Anxiety response; Difficulty falling or remaining asleep; Plan and Outcomes: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 7 hours of uninterrupted sleep at night. Remain awake during the day." The same Plan/Outcome was identified (filling in 6-8 hours of sleep) for each sample patient identified as having sleep difficulty. The plan of treatment failed to specify the long term and short term goals. This same Goal and Objective was present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15).

Problem 1 "Patient's Depression interferes with daily living; Identified Diagnosis: Major Depressive Disorder; Goal: Patient will reduce his depressive symptoms and develop at least three new coping skills to manage his depression; Objectives: Patient will participate in 50% of groups; Patient will participate in individual therapy; Patient will participate in medication management." The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals. Patient Objectives refer to patient participation in scheduled modalities, some of which specify measures for participation, others do not. The objectives were redundant with patient interventions which list the patient group/ modality.

Problem 2 "Patient's Anxiety interferes with daily living; Identified Diagnosis: PTSD (Post Traumatic Stress Disorder); Goal: Patient will reduce his anxiety and develop three (3) new coping skills to deal with his anxiety. Objectives: Participate in groups 50% of the time; Participate in individual therapy; Participate in medication management. The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals. Patient Objectives refer to patient participation in scheduled modalities, some of which specify measures for participation, others do not. The objectives are redundant with patient interventions which list the patient group/ modality.

Problem 3 "Substance abuse causes patient to be irritable and hard to get along with; Identified Diagnosis: Alcohol use disorder, Opioid use disorder; Goal: Stop abusing substances, take prescriptions, med as prescribed; Objectives: Participate in group at least 50% of the time; participate in individual therapy; take medications as prescribed." Patient Objectives refer to patient participation in scheduled modalities, some of which specify measures for participation, others did not. The objectives were redundant with patient interventions which list the patient group/ modality.

Problem 4 "Sleep Difficulty; Related to: Anxiety response; As evidenced by: difficulty falling or remaining asleep; mood alterations; Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (As Evidenced By) 7 hours of uninterrupted sleep at night; Remain awake during the day." The plan of treatment failed to specify the long term and short term goals. The same Plan/ Outcome was identified (filling in 6-8 hours of sleep) for each sample patient identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 5 "Comfort: Chest Pain; Related to: Coronary Artery Disease; Stress Anxiety; As evidenced by: Person reports or demonstrates a discomfort; H/O CAD (history of coronary artery disease), chest pain; Plan and Outcome; Verbalize relief/ control of pain; Verbalize causative factors associated w/ chest pain." The plan of treatment failed to specify the long term and short term goals. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 6 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: Communication of pain description; Rx treatment; Long Term Goal: Patient will report pain is relieved/ controlled as evidenced by a # < 3 on a scale of 0-10 with decrease in score by discharge; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the long term and short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 7 "Hyperlipidemia; Related to: poor diet and alcohol as stated by patient; Goal: patient will follow recommended diet while at RBH (Ridgeview Behavioral Health); Short Term Goal/ Objective (s): Patient will have acceptable cholesterol level". A standardized, pre-printed form listed one short term goal.

Problem 8 "Pain, Chronic; Related to and Evidenced by: back surgery verbalized by patient; Goal: Pain will remain at a manageable level; Short term Goal/ Objective(s): Client will have an acceptable pain level on a scale of 1-10, with a pain level not to exceed 5." A standardized, pre-printed form listed one short term goal.

Problem 9 "Nursing Care Plan: Hypertension- Care and Client Teaching; AEB (as evidenced by): verbalized by patient; Goal: to maintain blood pressure WNL (within normal limits) SBP (systolic blood pressure) <120/ DBP (diastolic blood pressure) <80 or parameters set by physician. Patient will verbalize understanding of the disease and its long term effects on target organs, Patient will describe disease and its effects on the body." A standardized, pre-printed form listed goals, however failed to specify long term goals/short term goals.

Problem 10 "Sleep Difficulty: Related to: back pain; As evidenced by: Difficulty falling or remaining asleep; Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 6-8 hours of uninterrupted sleep at night. Remain awake during the day." The same Plan/ Outcome was identified (filling in either 6 -8 hours of sleep) for each sample patient identified as having sleep difficulty. The plan of treatment failed to specify the long term and short term goals. This same Goal and Objective was present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 11 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired Physical Mobility; Alternate Diagnosis: Injury; R/T (related to): physiological; other: back (lower) surgery; AEB (as evidenced by) use of assistive device at all times; Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment". The plan of treatment failed to specify the long term and short term goals. This same Goal was present for all sample patients identified as having risk for falls. A standardized, pre-printed form was used that contained pre-printed goals.


4. Patient A4 (admitted 7/22/15, MTP 7/25/15).

Problem 1 "Pain; Related to and Evidenced by: leg, back, shoulder, neck tight aching and throbbing related 10 upon assessment; Goal: pain <5 upon assessment; Short Term Goal: Client will have acceptable pain level on scale of 1-10, with a pain level not to exceed 5." A standardized, pre-printed form listed one short term goal that was present for all sample patients identified as having pain. The identified goal and short term goal were comparable, that is, patient self reported pain level not to exceed, or less than 5. No long term goal identified.

Problem 2 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" failed to specify the short term goals.

Problem 3 "Sleep Difficulty: Related to: Anxiety response; As evidenced by: difficulty falling asleep. Demonstrate an optimal balance of rest and activity A.E.B. (As Evidenced By) 7-8 hours of uninterrupted sleep at night; Remain awake during the day." The plan of treatment failed to specify the long term and short term goals. The same Plan/ Outcome was identified (filling in 6-8 hours of sleep) for each sample patient identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 4 "inability to focus, inability to manage moods; Identified Diagnosis: Mood Disorder NOS (not otherwise specified); Goal: Improve overall mood and improve concentration; Objectives: learn 2 ways to manage frustration in a positive way; learn 3 new positive coping skills". The plan of treatment failed to specify the long term goals and short term goals.

Problem 5 "Substance use; Identified Diagnosis: Opioid use disorder; Goal: to be drug free; Objectives: learn 3 triggers and learn positive coping skills to help with them; learn 4 coping skills to help with stress." The plan of treatment failed to specify the long term and short term goals..The same Goal to be drug free, alcohol free, prevent relapse was present for sample patients having a substance use problem.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15).

Problem 1 "Rapid cycling mood instability; Identified Diagnosis: Bipolar I; Goal: Stabilize moods; Objective: stabilize mood; Med somatic tx (sic) (medication somatic treatment)." The plan of treatment, "Individual Comprehensive Treatment Plan" failed to specify the long term and short term goals. The goal and one objective were identical "stabilize mood". The plan was not individualized with measurable goals.

Problem 2 "Alteration in comfort; related to: joint disease, surgery; as evidenced by communication of pain description; Long term goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 0-10 with decrease in score by discharge of 3 points; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the long term and short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked, including "other" however no other objective was documented.

Problem 3 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" failed to specify the short term goals.

Problem 4 "Nursing Care Plan: Hepatitis; Nursing Diagnosis: Knowledge Deficit with disease course and treatment; AEB (as evidenced by): Lab work indicated positive serum Hepatitis and/ or patient states he/she has tested positive for hepatitis; Goal: Patient verbalizes and demonstrates knowledge of and compliance with treatment regimen and infection control " . The plan of treatment, "nursing care plan: hepatitis" failed to specify the long and short term goals. This same Goal and Objective was present for all sample patients identified as having hepatitis. A standardized, pre-printed form was used.

Problem 5 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: communication of pain description; sleep disturbance; Long Term Goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 0-10 with decrease in score by discharge of 3 points; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 6 "Nursing Care Plan: Seizure; Nursing Diagnosis: Knowledge deficit regarding condition, prognosis, treatment regime, and self care; R/T (related to): Neurological brain disorder; AEB (as evidenced by): Patient states he/ she has a Neurological disorder; Goal: Patient will verbalize an understanding of the disorder and the various stimuli that may be increased/ potentiate seizure activity. Adhere to prescribed medical and/ or regimen. Indicate necessary lifestyle/ behavioral changes as indicated." The plan of treatment: nursing care plan: seizure, failed to specify the long and short term goals. A standardized, pre-printed form was used.

Problem 7 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired Physical Mobility; Alternate Diagnosis: Injury; R/T (related to): environmental, medication, physiological; AEB (as evidenced by) fall risk 4; Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment". The plan of treatment failed to specify the long term and short term goals. This same Goal was present for all sample patients identified as having risk for falls. A standardized, pre-printed form was used that contained pre-printed goals.

Problem 8 "Poly substance Abuse; Identified Diagnosis: Poly substance abuse; opioid use, severe; stimulant use, severe; Goal: Achieve/ Retain freedom for drugs (sic); Objectives: Med somatic tx (sic) (medication somatic treatment); Identify trigger; Aftercare plan". The plan of treatment failed to specify long and short term goals. The listed objectives were not individualized/ measureable and reflected care which would be received by all patients, e.g. medication-somatic treatment, aftercare planning.

6. Patient A6 (admitted 8/4/15, MTP 8/7/15).

Problem 1 "Social Anxiety; Identified Diagnosis: Schizophrenia; Goal: Manage anxiety and learn new coping skills; Objectives Identify and plan for top five (5) anxiety provoking situations; learn three (3) new techniques to handle social situations". The plan of treatment failed to specify the long term and short term goals. The "target date" section was blank.

Problem 2 "Substance Use; Identified Diagnosis: Substance Use Disorder; Goal: Be drug use free; Objectives: Identify and plan for 5 triggers; complete relapse prevention plan". The plan of treatment failed to specify the long term and short term goals. The same Goal to be drug free, alcohol free, prevent relapse was present for sample patients having a substance use problem.
The "target date" section was blank.

Problem 3 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" failed to specify the short term goals.

Problem 4 "Risk for altered respiratory function R/T (related to) environmental allergen; Long term goal/ discharge criteria: Patient will have adequate air exchange AEB (as evidenced by) no dyspnea, orthopnea, cyanosis, e.g. adequate tissue perfusion; Short Term Goal: Patient will report shortness of breath and difficulty breathing; patient will comply with vital signs; patient will comply with medications." A standardized, pre-printed form was used that contained pre-printed goals. Adequate air exchange in the plan of treatment, nursing care plan, would not be a relevant discharge criterion.

7. Patient A7 (admitted 8/5/15, MTP 8/8/15).

Problem 1 "Alcohol use prevents medical compliance for bipolar I; Identified Diagnosis: Alcohol use disorder; Goal: Relapse prevention; Objectives: Relapse prevention; Education." The plan of treatment failed to specify the long term and short term goals. The listed objectives were not individualized/ measureable and reflected care which would be received by all patients, e.g. relapse prevention and education. The documented goal is identical to the documented objective.

Problem 2 "Med compliance - 'when I take my meds I am fine'; Identified Diagnosis: Bipolar I disorder; Goal: Med compliance; Objectives: Med compliance." The plan of treatment failed to specify the long term and short term goals. The listed objectives were not individualized/ measureable. The documented goal is identical to the documented objective.

Problem 3 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired Physical Mobility; Alternate Diagnosis: Injury; R/T (related to): medication; AEB (as evidenced by) fall risk score; Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment". The plan of treatment failed to specify the long term and short term goals. This same Goal was present for all sample patients identified as having risk for falls. A standardized, pre-printed form was used that contained pre-printed goals.

Problem 4 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: communication of pain description; Long term goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 0-10 with decrease in score by discharge; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 5 "Alteration in comfort; related to: joint disease, gout; as evidenced by communication of pain description; Long term goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 1-10 with decrease in score by discharge of three (3) points; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the long term and short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 6 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" failed to specify the short term goals.

8. Patient A8 (admitted 8/5/15, MTP 8/8/15).

Problem 1 "Substance Use; Identified Diagnosis: Substance Use Disorder; Goal: Be free of drug and alcohol use; Objectives: Learn three (3) new triggers and how to handle them; complete relapse prevention plan". The plan of treatment failed to specify the long term and short term goals. The same Goal to be drug free, alcohol free, prevent relapse was present for sample patients having a substance use problem. The "target date" section was blank.

Problem 2 "Depression and Anxiety; Identified Diagnosis: Mood disorder; Goal: Learn to manage moods and coping skills; Objectives: Identify and verbalize three (3) situations that caused anxiety and depression; learn three (3) new coping skills." The plan of treatment failed to specify the long term and short term goals. The "target date" section was blank.

Problem 3 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: change in appetite; sleep disturbance; Long term goal: Patient will report pain is relieved/ controlled as evidenced by a # 0 on a scale of 0-10 with decrease in score by discharge; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication." The plan of treatment failed to specify the short term goals. This same Goal and Objective was present for all sample patients identified as having alteration in comfort. A standardized, pre-printed form was used and all objective boxes were checked.

Problem 4 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation". This same Goal and Objective was present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with one standard objective. The plan of treatment, "medical nursing care plan" did not specify the short term goals.

Problem5 "Nursing Care Plan: Hypothyroidism; Nursing Diagnosis: Potential complications related to hypothyroidism; AEB (as evidenced by: Potential complications related to hypothyroidism; Goal: Patient will be compliant with medications and free from complications of hypothyroidism." The plan of treatment failed to specify the long term and short term goals. A standardized, pre-printed form was used.

Problem 6 "Sleep Difficulty: Related to: Anxiety response; As evidenced by: difficulty falling asleep. Demonstrate an optimal balance of rest and activity A.E.B. (As Evidenced By) 7-8 hours of uninterrupted sleep at night; Remain awake during the day." The plan of treatment failed to specify the long term and short term goals. The same Plan/ Outcome was identified (filling in 6-8 hours of sleep) for each sample patient identified as having sleep difficulty. A standardized, pre-printed form was used and all objective boxes were checked.

C. Staff Interviews

1. In an interview on 8/10/15 at 1:30 p.m., after reviewing the treatment plans, specifically, mood disorder, substance abuse and medical nursing care plans, the Nursing Director acknowledged that the Individual Comprehensive Treatment Plan did not include both long term (LT) and short term (ST) goals, that the goals were generic and not measurable.

2. In an interview with the Medical Director on 8/11/15 at 3:30 p.m., the M

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included psychiatrist, physician, therapist, case manager, nursing and recreation therapy interventions for eight (8) of eight (8) active patients who had been in the hospital long enough to complete a master treatment plan. Interventions listed on the "Individual Comprehensive Treatment Plan" did not reflect individualized interventions/care planning rather include a list of staff modalities with frequency of the modality, without identification of specific interventions and do not specify the focus of individual and group treatment modalities. Interventions on the Medical Nursing Care Plans were completed on generic forms and listed interventions that would be expected to be regularly provided for all patients. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning, specifically interventions necessary to provide active treatment.

Findings include:

A. Policy/Document Review

1. Facility Medical Staff Rules and Regulations outline the "Treatment Plan" requirements for the "Individual Comprehensive Treatment Plan (ICTP)", effective 12/11, "Section IV Medical Records, E. Treatment Plans: 1) The attending physician shall be responsible for the care of the patient. As such, the development, interpretation, and implementation of the treatment plan shall be the responsibility of the physician in conjunction with the multidisciplinary treatment team; 2) A plan of treatment shall be initiated upon admission and shall consist of the physicians' admitting orders and the nursing assessment and individualized treatment plan; 3) The comprehensive treatment plan shall be based upon assessment of the patient's physical, emotional, behavioral, social, recreational, and when appropriate, legal, vocational and nutritional needs; and 4) The comprehensive treatment plan shall delineate the care to be provided and shall include the following: a. Referral for needed services not provided by the facility; b. Specific goals and specific objectives. Anticipated time for objective achievement; c. Objectives shall be written in measurable terms; d. Type and frequency of treatment, services, procedures and activities required to meet the patient's needs; e. Specify the staff responsible for planned approaches; f. Specific criteria to be met for termination of treatment as part of the initial treatment plan; g. Specific plan for involvement of Ridgeview Hospital or significant others; h. The patient and/ or family shall participate in the development of the treatment plan when appropriate and same shall be documented on the comprehensive treatment plan form. The treatment plan shall be reviewed and updated to reflect the patient's clinical status; i. The attending physician shall sign, time and date the treatment plan." The facility refers to the MTP as the ICTP which include "nursing medical care plans" related to the identified problems.


B. Record Review

1. Patient A1 (admitted 7/9/15, MTP 7/12/15).

Problem 1 "Substance Use; Identified Diagnosis: Substance Use Disorder; Goal: To be drug and alcohol free; Objectives: Identify 3, people places and things that are situations (sic). Learn four (4) new activities to help with boredom; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 2 "Nutrition: Below Body Necessity; Related to: 60-100% intake; As evidenced by: Reported inadequate food intake less than recommended daily allowance with or without weight loss and/ or actual or potential metabolic needs in excess of intake; Plan and Outcome (check those that apply); The patient will: A standardized, pre-printed form was used and no boxes were checked for the Plan and Outcome; Interventions: Assess and document patient's dietary history, patterns of ingestion, intolerance to foods, knowledge level; Assess patient likes and dislikes. Inform dietary; Teach techniques to maintain adequate nutritional intake and stimulate appetite: Administer/ instruct pt. on good oral hygiene before and after feedings, maintain pleasant environment for patient." The interventions on the Medical Nursing Care Plans were completed on generic forms with check boxes and listed interventions that would be expected to be regularly provided for all patients.

Problem 3 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation; Nursing Interventions: Provide information regarding health risks of continued tobacco use and the benefits of smoking cessation; Obtain order for medical consult for any patient wishing to explore smoking cessation; Initiate tobacco cessation treatment plan for any patient wishing to start smoking cessation." These same interventions were present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with three nursing interventions.

Problem 4 "Anxiety Disorder: Inability to be still; Identified Diagnosis: Anxiety Disorder; Goal: To be calm; Objectives: Learn two (2) positive coping skills for anxiety. Identify three (3) anxiety producing situations; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/frequencies without identifying the focus of the treatment.

Problem 5 "Sleep difficulty related to medication, life style disruptions, as evidenced by difficulty falling or remaining asleep: Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 8 hours of uninterrupted sleep at night. Remain awake during the day; Nursing Interventions: Explore with client potential contributing factors; Ensure client maintains bedtime routine per client preference, likes to go to bed @ (at)10:00 p.m., prefers quiet, darkness, night light, music; takes sleeping pill as ordered by a physician @ (at) 9:00 p.m.; teach client comfort measures to induce sleep: herbal tea-warm milk, Pillows for support, bedtime snack when appropriate, pain medication if needed, Other: _____; Increase daytime exercise activity." These same interventions were present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used with listed nursing interventions.

Problem 6 "Hypertension' related to: substance abuse, sedentary lifestyle, As evidenced by: history of high BP; Long Term Goal: Patient will maintain a normal blood pressure of 120/80; Plan and Outcome: Follow dietary regimen to include low intake of salt; follow medication regimen as ordered by physician; report any signs or symptoms (i.e. headache, dizziness, visual disturbance, nausea, etc.); Nursing Interventions: Assesses blood pressure every 12 hrs. and PRN, monitor compliance with dietary regimen, administer medication as ordered by physician, instruct patient in: diet, medication usage, signs and symptoms of elevated blood pressure, lifestyle changes, etc., Other: ___". These same interventions were present for all sample patients identified as having hypertension. A standardized, pre-printed form was used with listed nursing interventions.

Problem 7 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired physical mobility; R/T (related to): Environmental; Medication; AEB (as evidenced by): Score of five (5) on fall assessment. Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment; Intervention and frequency: Nurse will obtain level of comprehension by interview at time of diagnosis; Nurse will educate patient of environmental risk factors associated with falls; Nurse will place client of fall precautions per physician's orders; Nurse will place client one 1:1 or Q15 minute checks per physician orders; Nurse will give patient assistive devices per physicians' orders: walker, crutches, cane, wheelchair, etc.; Nurse will document and report falls and injuries; Nurse will review and educate patient of prescribes medications that can increase risk for falls (sic).
These same interventions were present for all patients identified at risk for falls. A standardized, pre-printed form was used with listed nursing interventions.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15).

Problem 1 "Health Maintenance Altered related to insufficient knowledge of effects of tobacco; Long term goal/ discharge criteria: Patient will identify long-term effect(s) of tobacco use. Short Term Goal: Be open to exploring health risks of tobacco use and the benefits of not smoking; Staff Intervention: Provide information regarding health risks of continued tobacco use and the benefits of not smoking. A standardized pre-printed form was used adding only a start date and signature of the RN and patient. Identification of long term effects of tobacco use in the plan of treatment, nursing care plan, would not be a relevant discharge criterion.

Problem 2 "Bipolar; Identified Diagnosis: Bipolar; Goal: Stabilize moods and improve coping skills; Objectives: Identify situations that produce stress, anxiety or depression and plan for these; Learn five (5) new ways to distract thoughts or maintain mood; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 3 "Substance Use; Identified Diagnosis: Substance use (opiate, marijuana, cocaine); Goal: Be drug and alcohol free; Objectives: Learn five (5) new triggers and coping skills; Complete relapse prevention plan; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 4 "Sleep Difficulty; Related to: Anxiety response; Difficulty falling or remaining asleep; Plan and Outcomes: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 7 hours of uninterrupted sleep at night. Remain awake during the day; Nursing Interventions: Explore with client potential contributing factors; Ensure client maintains bedtime routine per client preference, likes to go to bed @ (at)11:00 p.m., prefers quiet, darkness, night light, music; takes sleeping pill as ordered by a physician @ (at) 2100; teach client comfort measures to induce sleep: herbal tea-warm milk, Pillows for support, bedtime snack when appropriate, pain medication if needed, Other: _____; Increase daytime exercise activity." These same interventions were present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used with listed nursing interventions.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15).

Problem 1 "Patient's Depression interferes with daily living; Identified Diagnosis: Major Depressive Disorder; Goal: Patient will reduce his depressive symptoms and develop at least three new coping skills to manage his depression; Objectives: Patient will participate in 50% of groups; Patient will participate in individual therapy; Patient will participate in medication management; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/frequencies without identifying the focus of the treatment.

Problem 2 "Patient's Anxiety interferes with daily living; Identified Diagnosis: PTSD (Post Traumatic Stress Disorder); Goal: Patient will reduce his anxiety and develop three (3) new coping skills to deal with his anxiety. Objectives: Participate in groups 50% of the time; Participate in individual therapy; Participate in medication management; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 3 "Substance abuse causes patient to be irritable and hard to get along with; Identified Diagnosis: Alcohol use disorder, Opioid use disorder; Goal: Stop abusing substances, take prescriptions, med as prescribed; Objectives: Participate in group at least 50% of the time; participate in individual therapy; take medications as prescribed; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 4 "Sleep Difficulty; Related to: Anxiety response; As evidenced by: difficulty falling or remaining asleep; mood alterations; Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (As Evidenced By) 7 hours of uninterrupted sleep at night; Remain awake during the day; Nursing Interventions: Explore with client potential contributing factors; Ensure client maintains bedtime routine per client preference, likes to go to bed @ (at)11:00 p.m., prefers quiet, darkness, night light, music; takes sleeping pill as ordered by a physician @ (at) __pm; teach client comfort measures to induce sleep: herbal tea-warm milk, Pillows for support, bedtime snack when appropriate, pain medication if needed, Other: _____; Increase daytime exercise activity." These same interventions were present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used with listed nursing interventions with blank sections to be filled in by the nurse.

Problem 5 "Comfort: Chest Pain; Related to: Coronary Artery Disease; Stress Anxiety; As evidenced by: Person reports or demonstrates a discomfort; H/O CAD (history of coronary artery disease), chest pain; Plan and Outcome; Verbalize relief/ control of pain; Verbalize causative factors associated w/ chest pain; Nursing Interventions: Assess for causative factors: activity, stress, eating, bowel elimination, angina, Other:___; Assess characteristics of chest pain; location, intensity (scale 1-10), duration, quality, radiation, Other___; Review history of previous pain experienced by patient and compare to current experience; Instruct patient to report pain immediately; EKG monitoring; note and record pattern during pain. Obtain STAT 12-lead EKG per policy for acute changes noted on continuous monitor; Provide a quiet, restful environment; As per physician order, administer analgesics in small increments until pain is relieved or maximum dose is achieved. Monitor BP during administration of pain meds. Assess pt. response to pain medication and notify physician as indicated; Administer nitroglycerine as ordered by physician. Monitor as stated above; Administer replacement oxygen as ordered by physician; Assist in eliminating causative factors as identified by patient assessment (eg ADL's); Other: ___." A standardized pre- printed form was used with listed nursing interventions.

Problem 6 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: Communication of pain description; Rx treatment; Long Term Goal: Patient will report pain is relieved/ controlled as evidenced by a # < 3 on a scale of 0-10 with decrease in score by discharge; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication; Nursing Interventions: Assess and re-assess the severity of pain intensity numerical rating scale; Assess the need for medication; Evaluate the effect of medication administered including the patient's perception of the effectiveness of medication; Educate the patient/ significant other regarding medication; Monitor vital signs; Encourage the patient to reduce intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol; Encourage smoking cessation; Obtain dietician consult; Elevate the patients head during sleeping hours; Encourage the patient to avoid food ingestion three (3) hours prior to going to sleep; Encourage the patient to eat slowly and chew food thoroughly; Encourage the patient to avoid restrictive clothing, lifting heavy objects, straining. These same interventions were present for all sample patients identified as having alteration in comfort: related to esophageal reflux. A standardized, pre-printed form was used with listed nursing interventions.

Problem 7 "Hyperlipidemia; Related to: poor diet and alcohol as stated by patient; Goal: patient will follow recommended diet while at RBH (Ridgeview Behavioral Health); Short Term Goal/ Objective (s): Patient will have acceptable cholesterol level; Intervention: Nursing staff will educate patient to good and bad cholesterol; physician will prescribe medication and monitor results (see MAR-medication administration record); Nursing staff will administer medication (see MAR) as ordered by physician orders and lab results; Nursing staff will teach dietary issues surrounding ongoing control of cholesterol; Nursing staff will teach patient about use of medication and asses (sic) patient's learning." A standardized, pre-printed form was used with listed interventions.

Problem 8 "Pain, Chronic; Related to and Evidenced by: back surgery verbalized by patient; Goal: Pain will remain at a manageable level; Short term Goal/ Objective(s): Client will have an acceptable pain level on a scale of 1-10, with a pain level not to exceed five (5); Interventions: Staff will obtain precise level of pain scale; Staff will educate client pain scale (sic); Physician will review and order medication as needed for pain; Staff will offer emotional support and warm or cold packs along with positioning to relieve pain as ordered; Staff will teach and assess coping skill to aid in pain reduction." These same interventions were present for all sample patients identified as having a pain treatment plan. A standardized, pre-printed form was used with listed nursing interventions

Problem 9 "Nursing Care Plan: Hypertension- Care and Client Teaching; AEB (as evidenced by): verbalized by patient; Goal: to maintain blood pressure WNL (within normal limits) SBP (systolic blood pressure) <120/DBP (diastolic blood pressure) <80 or parameters set by physician. Patient will verbalize understanding of the disease and its long term effects on target organs, Patient will describe disease and its effects on the body; Intervention and Frequency: Nurse will take BPQ4H while on detox level of care and then daily or as ordered by physician; Nurse will observe food choices at meal times. Nurse will assess patient to select recommended foods as appropriate/per dietary; Nurse will obtain weight upon admission and then as ordered by physician; Nurse will obtain patient level of comprehension by interview at the time of admission/ diagnosis and ongoing through discharge; Nurse will provide medication to patient as ordered by physician ongoing through discharge." These same interventions were present for all sample patients identified as having hypertension. A standardized, pre-printed form was used with listed nursing interventions.

Problem 10 "Sleep Difficulty: Related to: back pain; As evidenced by: Difficulty falling or remaining asleep; Plan and Outcome: Demonstrate an optimal balance of rest and activity A.E.B. (as evidenced by) 6-8 hours of uninterrupted sleep at night. Remain awake during the day; Nursing Interventions: Explore with client potential contributing factors; Ensure client maintains bedtime routine per client preference, likes to go to bed when tired, prefers quiet, darkness, night light, music; takes sleeping pill as ordered by a physician; teach client comfort measures to induce sleep: herbal tea-warm milk, Pillows for support, bedtime snack when appropriate, pain medication if needed, Other: _____." These same interventions were present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used with listed nursing interventions.


Problem 11 "Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired Physical Mobility; Alternate Diagnosis: Injury; R/T (related to): physiological; other: back (lower) surgery; AEB (as evidenced by) use of assistive device at all times; Goal: Patient will be able to verbalize understanding of potential health hazards, patients will be able to demonstrate injury prevention measure for self and patient will remain free of falls. Nurse will provide and maintain safe environment; Intervention and frequency: Nurse will obtain level of comprehension by interview at time of diagnosis; Nurse will educate patient of environmental risk factors associated with falls; Nurse will place client of fall precautions per physician's orders; Nurse will place client one 1:1 or Q15 minute checks per physician orders; Nurse will give patient assistive devices per physicians' orders: walker, crutches, cane, wheelchair, etc.; Nurse will document and report falls and injuries; Nurse will review and educate patient of prescribes medications that can increase risk for falls (sic). These same interventions were present for all patients identified at risk for falls. A standardized, pre-printed form was used with listed nursing interventions.

4. Patient A4 (admitted 7/12/15, MTP 7/25/15).

Problem 1 "Pain; Related to and Evidenced by: leg, back, shoulder, neck tight aching and throbbing related 10 upon assessment; Goal: pain <5 upon assessment; Short Term Goal: Client will have acceptable pain level on scale of 1-10, with a pain level not to exceed 5; Interventions: Staff will obtain precise level of pain scale; Staff will educate client pain scale (sic); Physician will review and order medication as needed for pain; Staff will offer emotional support and warm or cold packs along with positioning to relieve pain as ordered; Staff will teach and assess coping skill to aid in pain reduction." These same interventions were present for all sample patients identified as having a pain treatment plan. A standardized, pre-printed form was used with listed nursing interventions

Problem 2 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation; Nursing Interventions: Provide information regarding health risks of continued tobacco use and the benefits of smoking cessation; Obtain order for medical consult for any patient wishing to explore smoking cessation; Initiate tobacco cessation treatment plan for any patient wishing to start smoking cessation." These same interventions were present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with three nursing interventions.

Problem 3 "Sleep Difficulty: Related to: Anxiety response; As evidenced by: difficulty falling asleep. Demonstrate an optimal balance of rest and activity A.E.B. (As Evidenced By) 7-8 hours of uninterrupted sleep at night; Remain awake during the day; Nursing Interventions: Explore with client potential contributing factors; Ensure client maintains bedtime routine per client preference, likes to go to bed @ (at)2100, prefers quiet, darkness, night light, music; takes sleeping pill as ordered by a physician @ (at) __pm; teach client comfort measures to induce sleep: herbal tea-warm milk, Pillows for support, bedtime snack when appropriate, pain medication if needed, Other: _____; Increase daytime exercise activity." These same interventions were present for all sample patients identified as having sleep difficulty. A standardized, pre-printed form was used with listed nursing interventions with blank sections to be filled by the nurse.

Problem 4 "inability to focus, inability to manage moods; Identified Diagnosis: Mood Disorder NOS (not otherwise specified); Goal: Improve overall mood and improve concentration; Objectives: learn two (2) ways to manage frustration in a positive way; learn three (3) new positive coping skills; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 5 "Substance use; Identified Diagnosis: Opioid use disorder; Goal: to be drug free; Objectives: learn three (3) triggers and learn positive coping skills to help with them; learn four (4) coping skills to help with stress; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15).

Problem 1 "Rapid cycling mood instability; Identified Diagnosis: Bipolar I; Goal: Stabilize moods; Objective: stabilize mood; Med somatic tx (sic) (medication somatic treatment; Interventions: weekly individual therapy; daily process group; daily life skills group; daily education group; daily recreation group; daily goals group; All therapies will continue for the duration of hospitalization." The interventions listed treatment modalities/ frequencies without identifying the focus of the treatment.

Problem 2 "Alteration in comfort; related to: joint disease, surgery; as evidenced by communication of pain description; Long term goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 0-10 with decrease in score by discharge of three (3) points; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication; Nursing Interventions: Assess and re-assess the severity of pain using a pain intensity numerical rating scale; Identify the location, duration, aggravating/ alleviating factors; assess the need for medication; Evaluate the effect of pain medication administered including the patient's perception of the effectiveness of medication; Educate the patient/ significant other regarding medication; Educate the patient/ significant other regarding medication; Monitor side effects of pain medication; Monitor vital signs; Initiate comfort measures; Utilize alternative methods for management of pain; Other:___." These same interventions were present for all sample patients identified as having pain. A standardized, pre-printed form was used with listed nursing interventions.

Problem 3 "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Long Term Goal: Patient will identify long-term effects of tobacco use; Objectives (check all that apply) the patient will: be open to exploring the health risks associated with tobacco use and the benefits of smoking cessation; Nursing Interventions: Provide information regarding health risks of continued tobacco use and the benefits of smoking cessation; Obtain order for medical consult for any patient wishing to explore smoking cessation; Initiate tobacco cessation treatment plan for any patient wishing to start smoking cessation." These same interventions were present for all sample patients identified as having tobacco dependence. A standardized, pre-printed form was used with three nursing interventions.

Problem 4 "Nursing Care Plan: Hepatitis; Nursing Diagnosis: Knowledge Deficit with disease course and treatment; AEB (as evidenced by): Lab work indicated positive serum Hepatitis and/ or patient states he/she has tested positive for hepatitis; Goal: Patient verbalizes and demonstrates knowledge of and compliance with treatment regimen and infection control; Intervention and frequency: Nurse will teach patient via didactic lecture and 1:1 regarding disease process, disease transmission, complications, treatment, and signs of relapse; Nurse will teach patient infection control precautions and then have patient verbalize procedure such as avoiding sharing razors, toothbrushes, and safe sex; Nurse will have client demonstrate hand washing technique, this is successful in preventing the spread of hepatitis A,B, and C; Nurse will educate patient on the need to refrain from all mood altering chemicals and future donations." A standardized, pre-printed form was used with nursing interventions.

Problem 5 "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux and/ or esophageal inflammation; As evidenced by: communication of pain description; sleep disturbance; Long Term Goal: Patient will report pain is relieved/ controlled as evidenced by a # <3 on a scale of 0-10 with decrease in score by discharge of three (3) points; Objectives: Demonstrate or state pain relief and/ or tolerate level of pain; Report level of pain based on numeric scale of 1-10 on a daily basis; Will report level of pain on a numeric scale after 1 hour of receiving PRN medication; Nursing Interventions: Assess and re-assess the severity of pain intensity numerical rating scale; Assess the need for medication; Evaluate the effect of medication administered including the patient's perception of the effectiveness of medication; Educate the patient/ significant other regarding medication; Monitor vital signs; Encourage the patient to reduce intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol; Encourage smoking cessation; Obtain dietician consult; Elevate the patients head during sleeping hours; Encourage the patient to avoid food ingestion 3 hours prior to going to sleep; Encourage the patient to eat slowly and chew food thoroughly; Encourage the patient to avoid restrictive clothing, lifting heavy objects, straining. These same interventions were present for all sample patients identified as having alteration in comfort: related to esophageal reflux. A standardized, pre-printed form was used with listed nursing interventions.

Problem 6 "Nursing Care Plan: Seizure; Nursing Diagnosis: Knowledge deficit regarding condition, prognosis, treatment regime, and self care; R/T (related to): Neurological brain disorder; AEB (as evidenced by): Patient states he/ she has a Neurological disorder; Goal: Patient will verbalize an understanding of the disorder and the various stimuli that may be increased/ potentiate seizure activity. Adhere to prescribed medical and/ or regimen. Indicate necessary lifestyle/ behavioral changes as indicated; Intervention and frequency: Nurse will obtain a level of comprehension by interview at time of diagnosis; Nurse will educate by didactic and lecture the effects of ET

Based on policy review, record review and interview, the facility failed to identify the name of the psychiatrist, physician, registered nurse, practical nurse, mental health worker, social worker, recreation therapist, case manager, or therapist responsible for carrying out interventions listed on the Master Treatment Plan (MTP). Each plan for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 & A8) had a signature for either the registered nurse or therapist who documented the plan, however did not specify staff responsible for carrying out the interventions. Without this differentiation it was not possible to determine which staff person was responsible for ensuring that the interventions were properly delivered. These failures can result in diffusion of responsibility, lack of accountability, and potentially, failure to deliver all required interventions to meet patients' identified needs.

Findings Include:

A. Policy/Document Review

1. Facility Medical Staff Rules and Regulations outline the "Treatment Plan" requirements for the "Individual Comprehensive Treatment Plan (ICTP)", effective 12/11, "Section IV Medical Records, E. Treatment Plans: 1) The attending physician shall be responsible for the care of the patient. As such, the development, interpretation, and implementation of the treatment plan shall be the responsibility of the physician in conjunction with the multidisciplinary treatment team; 2) A plan of treatment shall be initiated upon admission and shall consist of the physicians' admitting orders and the nursing assessment and individualized treatment plan; 3) The comprehensive treatment plan shall be based upon assessment of the patient's physical, emotional, behavioral, social, recreational, and when appropriate, legal, vocational and nutritional needs; and 4) The comprehensive treatment plan shall delineate the care to be provided and shall include the following: a. Referral for needed services not provided by the facility; b. Specific goals and specific objectives. Anticipated time for objective achievement; c. Objectives shall be written in measurable terms; d. Type and frequency of treatment, services, procedures and activities required to meet the patient's needs; e. Specify the staff responsible for planned approaches; f. Specific criteria to be met for termination of treatment as part of the initial treatment plan; g. Specific plan for involvement of Ridgeview Hospital or significant others; h. The patient and/ or family shall participate in the development of the treatment plan when appropriate and same shall be documented on the comprehensive treatment plan form. The treatment plan shall be reviewed and updated to reflect the patient's clinical status; i. The attending physician shall sign, time and date the treatment plan." The facility refers to the MTP as the ICTP which include "nursing medical care plans" related to the identified problems.

B. Record Review

1. Patient A1 (admitted 7/9/15, MTP 7/12/15). The MTP included problems related to Substance Use; Nutrition Below Body Necessity; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Anxiety Disorder; Sleep Difficulty; Hypertension; and Risk for Falls. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15). The MTP included problems related to Substance Use; Altered Health Maintenance Related to insufficient knowledge of effect of tobacco; Bipolar and Sleep Difficulty. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15). The MTP included problems related to Major Depressive Disorder; PTSD (Post Traumatic Stress Disorder); Sleep Difficulty; Comfort: Chest Pain Related to Coronary Artery Disease; Alteration in Comfort Related to Esophageal reflux; Hyperlipidemia; Pain, Chronic Related to and as evidenced by back surgery; Hypertension; Sleep Difficulty and Risk for Falls. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

4. Patient A4 (admitted 7/12/15, MTP 7/25/15). The MTP included problems related to Pain: Related to and Evidenced by: leg, back, shoulder, neck tight and aching rated 10 on assessment; Altered Health Maintenance Related to insufficient knowledge of tobacco; Sleep Difficulty; Inability to focus, inability to manage moods; and Substance Use. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient ' s specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15). The MTP included problems related to Rapid cycling mood instability, Alteration in comfort related to joint disease; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Hepatitis; Alteration in Comfort Related to Esophageal reflux; Seizure; Risk for Falls and Poly substance Abuse. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

6. Patient A6 (admitted 8/4/15, MTP 8/7/15). The MTP included problems related to Social Anxiety; Substance Use; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; and risk for altered respiratory function R/T (related to) environmental allergen. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient ' s specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

7. Patient A7 (admitted 8/5/15, MTP 8/8/15). The MTP included problems related to Alcohol use prevents medical compliance for bipolar I; Med compliance; Risk for Falls; Alteration in Comfort Related to Esophageal reflux; Alteration in comfort related to joint disease, gout; and Altered Health Maintenance Related to insufficient knowledge of effects of tobacco. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

8. Patient A8 (admitted 8/5/15, MTP 8/8/15). The MTP included problems related to Substance Use; Depression and anxiety; Alteration in Comfort; Related to: Esophageal reflux; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Hypothyroidism; and Sleep Difficulty. The MTP did not include the name of the physicians responsible for the psychiatric and medical care of the patient. The treatment modality (individual and group) was listed in the MTP, however staff names were not included to identify the patient's specific case manager, therapist, recreation therapist. The names of direct care nursing staff assigned responsibility for carrying out the plan and monitoring effectiveness were not documented in nursing care plans. The nursing care plans do not specify which interventions must be carried out by a registered nurse.

C. Staff Interview

1. In an interview on 8/11/15 at 3:30 p.m., after reviewing the treatment plans for sample patients A1-A8, the Medical Director acknowledged that the interventions on the patients' MTPs were not assigned to specific staff. He agreed that the treatment plans are expected to specify the staff responsible for the interventions.

2. In an interview on 8/10/15 at 1:30 p.m., after reviewing the treatment plans for sample patients A1-A8, the Director of Nursing (DON) said that the MTPs/ Nursing Care Plans do not identify the specific staff assigned for the interventions and this will need to be corrected.

Based on record review, policy and interviews, the facility failed to ensure proper documentation of patient records. Review of treatment plans revealed that signature of psychiatrist was absent on the MTP and/or subsequent weekly Multidisciplinary Treatment Plan Reviews for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 & A8). This results in uncertainty regarding the physician involvement/responsibility for the active treatment of the patient.

Findings Include:

A. Policy/Document Review

1. Facility Medical Staff Rules and Regulations outline the "Treatment Plan" requirements for the "Individual Comprehensive Treatment Plan (ICTP)", effective 12/11, "Section IV Medical Records, E. Treatment Plans: 1) The attending physician shall be responsible for the care of the patient. As such, the development, interpretation, and implementation of the treatment plan shall be the responsibility of the physician in conjunction with the multidisciplinary treatment team; 2) A plan of treatment shall be initiated upon admission and shall consist of the physicians' admitting orders and the nursing assessment and individualized treatment plan; 3) The comprehensive treatment plan shall be based upon assessment of the patient's physical, emotional, behavioral, social, recreational, and when appropriate, legal, vocational and nutritional needs; and 4) The comprehensive treatment plan shall delineate the care to be provided and shall include the following: a. Referral for needed services not provided by the facility; b. Specific goals and specific objectives. Anticipated time for objective achievement; c. Objectives shall be written in measurable terms; d. Type and frequency of treatment, services, procedures and activities required to meet the patient's needs; e. Specify the staff responsible for planned approaches; f. Specific criteria to be met for termination of treatment as part of the initial treatment plan; g. Specific plan for involvement of Ridgeview Hospital or significant others; h. The patient and/ or family shall participate in the development of the treatment plan when appropriate and same shall be documented on the comprehensive treatment plan form. The treatment plan shall be reviewed and updated to reflect the patient's clinical status; i. The attending physician shall sign, time and date the treatment plan." The facility refers to the MTP as the ICTP which include "nursing medical care plans" related to the identified problems.

B. Record Review

1. Patient A1 (admitted 7/9/15, MTP 7/12/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form on 7/12/15 during the initial 72 hour meeting to develop the Master Treatment Plan and on the Week 1 Multidisciplinary Treatment Plan Review Form for the treatment team review on 7/16/15. Based on signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form on 7/16/15 during the initial 72 hour meeting to develop the Master Treatment Plan, on the Week 1 Multidisciplinary Treatment Plan Review Form for the treatment team review on 7/20/15 and on Week 2 Multidisciplinary Treatment Review form for the treatment team review on 8/3/15. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form for the Week 2 treatment team review held on 7/31/15 and for the Week 3 Multidisciplinary Treatment Review form for the treatment team review held on 8/7/15. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

4. Patient A4 (admitted 7/12/15, MTP 7/25/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form for the Week 2 treatment team review held on 8/4/15. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form on 8/6/15 during the initial 72 hour meeting to develop the Master Treatment Plan, on the Week 1 Multidisciplinary Treatment Plan Review Form for the treatment team review on 8/9/15. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

6. Patient A6 (admitted 8/4/15, MTP 8/7/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form for the Week 1 treatment team review held on 8/11/15. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

7. Patient A7 (admitted 8/5/15, MTP 8/8/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form on 8/8/15 during the initial 72 hour meeting to develop the Master Treatment Plan. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

8. Patient A8 (admitted 8/5/15, MTP 8/8/15). The psychiatrist failed to sign the Multidisciplinary Treatment Plan Review Form on 8/8/15 during the initial 72 hour meeting to develop the Master Treatment Plan. Based on the signature absence in the medical record documentation, it is not evident that the responsible physician was involved in the treatment planning.

C. Interview

1. In an interview on 8/11/15 at 3:30 p.m., The Medical Director agreed that the psychiatrist was expected to sign the Multidisciplinary Treatment Plan Review Form when participating in development/ review of the MTP, during the treatment planning meetings. He also acknowledged the physician's responsibility (as leader of the treatment team) for ensuring complete MTP's. The Medical Director said that there was a change in medical staff documentation and timeliness of documentation since March 2015 when additional beds were opened at the hospital.

2. In an interview on 8/10/15 at 1:30 p.m., The Director of Nursing agreed that the signature of the participating psychiatrist was expected to be documented on the Multidisciplinary Treatment Plan Review form along with other treatment team member signatures.

Based on Record review, Policy review and Staff interview the hospital failed to ensure that progress notes by the physician were recorded in a timely manner for four (4) of eight (8) active sample patients (A1, A2, A3 & A4). This deficiency results in an absence of assessment and monitoring of patient response to interventions in a timely fashion potentially affecting appropriate timely interventions and/or length of hospital stay.

The findings include:

Record Review

1) Patient A1 was hospitalized on 07/09/2015. The physician progress notes were not recorded between 07/25/15 and 07/30/15 and between 07/30/15 to 8/06/15.

2) Patient A2 was hospitalized on 07/13/2015. The physician progress notes were not recorded between 07/13/15 and 07/19/15, between 07/19/15 to 07/25/15 and between 07/31/15 to 08/06/15.

3) Patient A3 was hospitalized on 07/17/2015. The physician progress notes were not recorded between 0730/15 and 08/06/15.

4) Patient A4 was hospitalized on 07/22/2015. The physician progress notes were not recorded between 07/29/15 and 08/05/15.

Policy Review:

The hospital Medical Staff Rules and Regulations, section IV. Medical Records; under section F. Progress Notes, states "A detailed progress note shall be recorded by the attending physician at least every three days."

Staff Interview:

In a meeting with the Director of medical records at 3:00 p.m. on 08/11/2015, the staff concurred that the physician progress notes were not present in the medical records per hospital policy for the patients A1, A2, A3 & A4 as above.

Based on Record review, Policy review and staff interview the facility failed to ensure that patient discharge summaries were completed in a timely fashion as defined by hospital policy requirements for four (4) of the five (5) discharged sample patients (D2, D3, D4 and D5). This compromises the effective transfer of the patient's care to the next care provider.

Findings include:

Record Review:

1) Patient D2 was discharged on 06/09/2015 and the discharge summary was completed on 07/29/2015.

2) Patient D3 was discharged on 06/14/2015 and the discharge summary was completed on 07/22/2015.

3) Patient D4 was discharged on 06/17/2015 and the discharge summary was completed on 07/21/15.

4) Patient D5 was discharged on 06/22/2015 and the discharge summary was completed on 07/30/2015.

Policy Review:

The hospital Medical Staff Rules and regulations under IV. Medical Records, section G Discharge Summary states "Discharge summaries shall be dictated or written at time of discharge and no later than thirty (30) days after discharge by attending physician or his designee".

Staff Interview:

In a meeting with the Director of medical records on 08/11/2015 at 3:00 p.m., the Director concurred that the discharge summaries of patient's D2, D3, D4 and D5 were not completed within thirty (30) days per hospital policy.

The Medical Director failed to adequately monitor and evaluate the quality the care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

1) The Physical examinations were completed and documented as per hospital policy. (Refer to B109)

2) The treatment plans list inventory of patients assets (B119), Short Term and Long Term goals (B121) , Treatment modalities are specific to patient's identified problems (B122), Specific staff names were listed for carrying out identified treatment modalities (B123), and documented evidence of Physicians involvement in completion of MTP (B125).

3) The Physicians progress notes were documented in a timely fashion as per hospital policy.(Refer to B126)

4) The discharge summaries were completed in a timely manner per hospital policy. (Refer to B133)

In an interview with the Medical Director on 8/11/15 at 3:30 p.m., the Clinical Director concurred with the above deficiencies and further stated "our treatment plans are not specific, no physician role identified in the treatment plan".

Based on record review and interview, it was determined that the Director of Nursing (DON) failed to ensure the quality of nursing input in the development of the Master Treatment Plan (MTP) The MTP's for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This was evident based on deficiency of short term and long term goals, individualized and measurable nursing interventions, and identification of specific assigned nursing personnel to carry out the MTP.

A. Record Review: Lack of Individualized Nursing Interventions on the MTPs

1. Patient A1 (admitted 7/9/15, MTP 7/12/15). Nursing Care Plans included: "Nutrition: Below Body Necessity; Related to: 60-100% intake; As evidenced by: Reported inadequate food intake less than recommended daily allowance with or without weight loss and/ or actual or potential metabolic needs in excess of intake. Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco as evidenced by: patients continued use of tobacco products; Sleep difficulty related to medication, life style disruptions, as evidenced by difficulty falling or remaining asleep; Hypertension' related to: substance abuse, sedentary lifestyle, As evidenced by: history of high BP; Nursing Care Plan: Risk for Falls; Nursing Diagnosis: Impaired physical mobility; R/T (related to): Environmental; Medication; AEB (as evidenced by): Score of 5 on fall assessment." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

2. Patient A2 (admitted 7/13/15, MTP 7/16/15). Nursing Care Plans included: "Health Maintenance Altered related to insufficient knowledge of effects of tobacco and Sleep Difficulty". A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

3. Patient A3 (admitted 7/17/15, MTP 7/20/15). Nursing Care Plans included: "Sleep Difficulty; Comfort: Chest Pain; Related to: Coronary Artery Disease; Medical Problem: Alteration in Comfort; Related to: Esophageal reflux; Hyperlipidemia; Pain, Chronic; Related to and Evidenced by: back surgery; Hypertension; Nursing Care Plan: Risk for Falls." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

4. Patient A4 (admitted 7/12/15, MTP 7/25/15). Nursing Care Plans included: "Pain; Related to and Evidenced by: leg, back, shoulder, neck tight aching and throbbing related 10 upon assessment; Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

5. Patient A5 (admitted 8/3/15, MTP 8/6/15). Nursing Care Plans included: "Alteration in comfort; related to: joint disease, surgery; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Nursing Care Plan: Hepatitis; Medical Problem: Alteration in Comfort; Related to: Esophageal reflux; Nursing Care Plan: Seizure; Nursing Care Plan: Risk for Falls." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

6. Patient A6 (admitted 8/4/15, MTP 8/7/15). Nursing Care Plans included: "Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Risk for altered respiratory function R/T (related to) environmental allergen." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

7. Patient A7 (admitted 8/5/15, MTP 8/8/15). Nursing Care Plans included: "Nursing Care Plan: Risk for Falls; Medical Problem: Alteration in Comfort; Related to: Esophageal reflux; Alteration in comfort; related to: joint disease, gout; Medical Problem: Altered Health Maintenance Related to insufficient knowledge of effects of tobacco." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

8. Patient A8 (admitted 8/5/15, MTP 8/8/15). Nursing Care Plans included: "Medical Problem: Alteration in Comfort; Related to: Esophageal reflux; Altered Health Maintenance Related to insufficient knowledge of effects of tobacco; Nursing Care Plan: Hypothyroidism; Sleep Difficulty." A standardized, pre-printed form was used for Nursing Care Plans. These plans did not always specify the short term goal and the names of staff members designated to carry out the plans were not designated. Nursing care plans were generic for patients having similar problems and did not reflect individual care needs.

B. Interview

1. In an interview on 8/11/15 at 1:00 p.m., after reviewing the treatment plans for patients A1 through A8, the Director of Nursing (DON) acknowledged that the Nursing Care Plans used pre-printed, standardized forms. She agreed that short term and long term goals were not always designated and that the goals and interventions were generic for patients having the same problems. The DON agreed that the name of the registered nurse initiating the Nursing Care Plan was listed, however the plans did not delineate which staff would carry out which interventions, and names for the registered nurses, licensed practical nurses and mental health technicians responsible for implementing the plans.

Based on record review and staff interview the social services director failed to insure that the bio-psychosocial assessments for eight (8) of eight (8) active sample patients included individualized conclusions and recommendations and that the social work role is clearly identified in treatment and discharge planning. (Refer to B108)

In a meeting with the Director of Social Services on 8/12/15 at 9:00 a.m., the director concurred with the above identified deficiencies stating "we obviously have some things to change".