HospitalInspections.org

Based on interview, record review and policy review,the facility failed to follow the process for prompt resolution of patient grievances in 2 of 10 charts reviewed (patient's #22 and #24). Findings include:

On 01/10/12 at approximately 0945 during review of the documents noted for the grievance process patient #22 was admitted on 12/20/11 and discharged on 12/30/11. He voiced a situation that happened to him while hospitalized, to his mother. The patient's mother called the facility the same day (01/03/12). As of 01/10 /12 there was no documentation that showed that the facility was following their policy for a prompt resolution to the grievance.

On 01/10/12 at approximately 1015 during review of the documents noted for the grievance process for patient #24. The patient entered the grievance process on 10/24/11. The patient did not receive any type of communication until 11/23/11.

On 01/11/12 at approximately 0945 the patient's Recipient Rights Representative confirmed these findings.

Based on medical record review and interview the facility failed to ensure all orders are authenticated by physicians for 8 of 16 medical records reviewed (#1, #2, #3, #4, #6, #38 #42, #45) resulting in the potential for medical errors. Findings include:

"Medical Staff Rules and Regulations," under "General Conduct of Care" state:
"Telephone orders for medication shall comply with all of the following requirements:"
(iv.) Countersigned, including date and time, by a member of the Medical staff within 48 hours.
Facility Policy Nsg-V-031 states:
(1) Physician orders will be:
(c) 'given verbally or by telephone to a Registered Nurse or Pharmacist and be signed by the physician within 48 hours.
The above policies were reviewed 1/9/12-1/10/12.

On 1/9/11 from 1055-1120 hours, record review revealed that verbal orders for current adult Partial Program patients were not counter-signed within 48 hours for:
1) patient #38, Physician Initial Orders, taken on 12/27/11, were not counter-signed by the physician until 1/9/12.
2) patient #42, Physician Initial Orders, taken on 1/5/12, were not counter-signed by the physician.
3) patient #45, taken on 12/12/11, for Wellbutrin XL, was not counter-signed.

The above findings were confirmed on 1/9/12 from 1055-1120 hours by the Admitting and Utilization Review Director.


15195

Medial record review on Unit 2B, on 1/9/12 at approximately 1030 to 1200, revealed verbal orders on multiple patients that had not been authenticated by the physician within 48 hours. This was verified by the 2B Unit Secretary and 2B Unit Manager during that time.

Patient #1 had verbal orders for Klonopin 0.5 mg i po bid and Seroquel 300 i po hs dated 1/1/12 that had not been authenticated as of 1/9/12.

Patient #2 had a verbal order to increase Klonopin to 1 mg po bid dated 1/6/12 that had not been authenticated.

Patient #3 had verbal orders written on 1/5/12 for Acetaminophen 650 mg q 6 hours prn pain, Maalox plus 30 mg 4 times a day for gastric distress, Benadryl 50 mg po or IM for extrapyramidal symptoms, that had not been authenticated.

Patient #4 had a verbal order dated 1/5/12 for Methadone 10 mg po q 8 hours prn pain that had not been authenticated within 48 hours, and remained unauthenticated as of 1/9/12.

It was noted that verbal orders were flagged in the medical record and that some orders were signed and others were not. Further interview with the 2B Unit Manager, on 1/9/12 at approximately 1130, revealed that no one takes the flags off the orders on the Unit once the physician signs the orders.


30562

Medical record review on Unit 2 B, on 01/09/12 at approximately 1030 to 1130, revealed that 3 of 6 orders in patient #6's chart had not been countersigned by a physician. This included an order taken at 8 pm on 01/01/12 for " 2:1 Direct Obs R/T Severe Agitation danger to Staff and Peers", and a order dated 01/06/12 at 2330 for Ativan 1 mg po q 6 hours PRN for severe anxiety. An order for Trazadone 100 mg q HS PRN insomnia dated 01/07/12 1920 along with the previous orders were still not signed upon recheck at 0900 01/11/12.

These findings were verified with the 2 B Unit Manager at the time of review on 01/09/12 and on 01/11/12 at approximately 0900.

Based on record review and interview, the facility failed to perform a history and physical (H&P) within 24 hours of admission for 1 (#1) of 12 patients reviewed for H&P. Findings include:

Review of patient #1's medical record on 1/9/12 at approximately 1030 on unit 2B revealed that the patient was admitted on 12/27/11. The H&P was not documented any where in the medical record. Interview with the 2B Unit Manager and Director of Social Work, on 1/9/12 at 1100, verified that the H& P had not been done. Review of the progress notes did not indicate any reason why the H&P had not been done. Review of the facility policy titled "Physical Examination", revision date 8/03, documented that "all patients admitted to the hospital will have a physical examination (H&P) within 24 hours after admission. This patient had been in the facility for 13 days without the H&P performed. Neither the Unit Manager of 2B, nor the Director of Social Work could determine why the H& P had not been done.

Based on staff interview, and document review, the facility failed to ensure that all discharged inpatient's clinical records were complete within 30 days following discharge. Findings include:

During an interview with staff V on 01/11/2012 at 0900 , it was determined that 97 incomplete inpatient clinical records, that had exceeded 30 days following the patient's discharge from the hospital were awaiting signatures from two physicians.

This was verified by Staff V upon completion of the document review.

Based on observation, interview and record review the facility failed to provide pharmaceutical services according to their policies and professional standards of practice resulting in patients receiving medications that were not supervised or distributed by a registered pharmacist.

Failures in the following Standards were noted:

-A0491- Failure to follow accepted standards of practice for storage of sample medications

-A-0500- Failure to control and distribute drugs in accordance with standards of practice consistent with Federal and State law.

-A-0501- Failure to dispense drugs under the supervision of a pharmacist

-A-0505- Failure to avoid exposing Partial Hospitalization Program patients to a supply of outdated drugs

Based on observation, interview and record review, the facility failed to follow facility policy and accepted standards of practice for storage of sample medications for 1 of 1 Partial Hospitalization patients (#37) resulting in the facility's inability to notify the patient should a recall occur. Findings include:

Facility Policy: Nsg-IV-07/Pharmacy #61, states:
D. (1) Keys to the medication cupboards and medication room are to be carried by only licensed nursing personnel."

On 1/9/12 at 1120 hours an Adult Partial Program nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received the medication from staff U, who maintains the sample supply.

On 1/9/12 at 1130 hours the sample medication storage area was observed with Staff U and the Director of Admitting and Utilization Review. Staff U had a key to a closet where sample medications were stored. Staff U verified that she was not a licensed practitioner in any field. Staff U stated that the sample medications were utilized in the private practice of the Adult Services Medical Director (Dr. #1). A tracking sheet for dispensed medications was reviewed.

On 1/9/12 at1410 hours, a Nurse on the Children's Partial Program unit (staff S) identified a discharged patient who had received a sample of the medication Intuniv. Nurse S stated that she received the medications directly from Staff U for patient #37 who was under the care of Dr. #2. Review of the tracking sheet for dispensed medications maintained by Staff U revealed no record of this medication being dispensed to patient #37. An inventory of all medications received was not available.

On 1/9/12 from 1430-1700 hours, review of patient #37's clinical record revealed a progress note by Nurse S stating: "Mom notified of ...addition of Intuniv...Notification form and sample of Intuniv sent home."

The above findings were verified by the Director of Admitting and Utilization Review on 1/11/12 at approximately 1100 hours.


29774

On 1/09/12 at approximately 1150 during a tour of the adult unit C-1's medication room, found in the medication cart a single medication storage box in a top drawer with multiple patients' multidose medication containers stored in a single storage box. Patients' medication included topical creams, eye drops, nose drops and ear drops. The medication cart had individual boxes marked with the patient's room and bed number available for use. When interviewing staff A regarding why multiple patients' medication was stored together and not stored in the patient's designated drawer she replied "I don't know". A review of facility policy titled "Medication Administration" dated 9/08 revealed "...2. Keep medication for external use in a separate cupboard from medication for internal use...". The policy fails to specify that each patient's medication should be segregated from other's medication.

Based on observation and interview, the facility failed to control and distribute drugs in accordance with facility policy and standards of practice consistent with Federal and State law. Findings include:

Facility Policy: Nsg-IV-07/Pharmacy #61, states:
D. (1) Keys to the medication cupboards and medication room are to be carried by only licensed nursing personnel."

On 1/9/12 at approximately 1130 hours, Staff U, an unlicensed staff member, was identified by the Director of Risk Management, as the sole holder of the key to a supply of psychotropic medications. Staff U verified that she holds the key to the sample medication closet and does not know of another sample supply in the facility. The contents of the closet were observed with Staff U and the Director of Admitting and Utilization Review.

Expired medications included: Zyprexa, 3 boxes expired 8/1/08, Lamictal 100 mg., 5 boxes expired 3/10, Stavzor 500 mg. 1 bottled expired 11/10, Cymbalta, 8 boxes expired 3/11, and Geodon 20 mg., 1 box expired 5/11. Staff U was not able to identify the last time these medications were inspected for expiration dates. These findings were verified by Staff U and the Director of Admitting and Utilization Review.

On 1/10/12 at 1500 hours, during an interview, the Director of Pharmacy stated that she is not aware of sample medications being stored and dispensed to Partial Program patients.

Based on observation and interview, the facility failed to dispense drugs under the supervision of a pharmacist placing patients at increased risk of unreported ill effects of medications. Findings include:

On 1/9/12 at 1120 hours an Adult Partial Hospitalization Program Nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received sample medications from staff U, who maintains the sample medication supply utilized by the Children's Adult Partial Hospitalization Program, located across the hall from both programs.

On 1/9/12 at approximately 1130 hours, Staff U, an unlicensed staff member, was identified by the Director of Risk Management, as the sole holder of the key to a supply of psychotropic medications. Staff U verified that she held the key to the sample medication closet and did not know of another sample supply in the facility. The contents of the closet were observed with Staff U and the Director of Admitting and Utilization Review.

On 1/10/12 at 1500 hours, during an interview, the Director of Pharmacy stated that she is not aware of sample medications being stored and dispensed to Partial Program patients.

Based on observation and interview, the facility failed to avoid exposing Partial Hospitalization Program patients to a supply of outdated drugs resulting in the possibility of patients receiving expired, ineffective medications. Findings include:

On 1/9/12 at 1120 hours an Adult Partial Hospitalization Program Nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received sample medications from staff U, who maintains the sample medication supply utilized by the Children's Adult Partial Hospitalization Program.
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On 1/9/12 at 1130 hours the sample medication storage area was observed with Staff U and the Director of Admitting and Utilization Review. The following expired medications were found: Zyprexa, 3 boxes expired 8/1/08, Lamictal 100 mg., 5 boxes expired 3/10, Stavzor 500 mg. 1 bottled expired 11/10, Cymbalta, 8 boxes expired 3/11, and Geodon 20 mg., 1 box expired 5/11. Staff U was not able to identify the last time these medications were inspected for expiration dates. These findings were verified by Staff U and the Director of Admitting and Utilization Review.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon observation and staff interview, the facility failed to properly maintain the physical environment to ensure the safety of patients, visitors and staff.

Findings include:
On 1/10/12 at approximately 9:55 AM, based on observation, the chemical dispensing system in the environmental room was discovered to be connected to the water supply downstream from the built in Atmospheric Vacuum Breaker (AVB) subjecting the device to constant pressure. During tours of patient units, chemical dispensing systems in janitors closets throughout were observed to have the same cross-connection.
On 1/10/12 at approximately 10:05 AM based upon observation, during tour of the rooftop, exhaust fan 11 was discovered to be vibrating loudly. Two Rooftop Units (RTUs) located above the A Unit were also observed to have birdscreen torn and missing at the air intakes. Interview with the Director of Facility and Plant Operations revealed that the HVAC preventative maintenance is performed by a contracted company on a quarterly basis.
On 1/10/12 at approximately 10:45 AM based upon observation during tour of the kitchen it was discovered that the drain line from the ice machine terminates inside of a PVC pipe mounted to the wall. This PVC pipe then discharges into the floor sink located beneath the ice machine, without a clear unobstructed air gap.
On 1/10/12 at approximately 10:15 AM based upon observation, drywall damage was discovered in the A Unit supply room; and at approximately 12:00 PM drywall damage was discovered in the C2 Unit Med Room where a cabinet had been removed.
On 1/10/12 at approximately 12:40 PM during tour of the dietary storage area located in the basement, the following was discovered: a large crack in the quarry tile flooring running the entire length of the walk in cooler and the flooring of the cooler is buckling and is peaked in the middle; cove base is missing to the left of the exterior of the walk in freezer; old or unused equipment stored in an unorganized manner hindering cleaning of the space.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated January 12, 2012 for Life Safety Code.

Based upon observation and staff interview the facility failed to provide a sanitary environment to prevent transmission of infections and communicable diseases in areas throughout the patient units and support spaces.

Findings include:
On 1/10/12 at approximately 10:15 AM, spray bottles with labels reading chart cleaner spray and dry erase board cleaner were discovered stored on shelving above coffee, coffee filters, sugar and creamer; and at approximately 12:15, a spray bottle labeled chart cleaner was observed stored adjacent to crackers, creamers and lids to cups in the pantry of C Unit.
On 1/10/12 at approximately 10:20 AM on the A Unit, a room labeled "clean linen room" was observed to contain clean linen and supplies, as well as contain a clinical sink and a broom and dust pan. At approximately 11:35 AM the clean supply room on the B Unit was observed to also contain a clinical sink.
on 1/10/12 at approximately 11:40 Am, based on observation, the shelving of the patient belonging storage area on B Unit was discovered to be constructed of bare unsealed wood and plywood.
On 1/10/12 at approximately 12:45 based upon observation it was discovered that there are two dumpsters outside of the facility for refuse disposal. These dumpsters were observed to be overflowing, and the lids could no longer be closed. Interview with the Director of Facility and Plant Operations revealed that the waste disposal company comes to empty the containers every other day and that they are regularly filled beyond capacity and the lids cannot be closed.
On 1/10/12 between the hours of 9:45 AM and 12:30 PM, the following conditions were observed: dust and debris accumulation beneath shelving in the A Unit supply room (10:15 AM); dust accumulation on the top of the refrigerator in the A Unit clean linen room (10:20 AM); dust and grease accumulation on wire shelving and tops of coolers in the kitchen (10:45 AM); debris and dropped supplies accumulation beneath shelving in the B Unit supply room (11:30 AM); debris and dust accumulation beneath the medication dispensing unit in the B Unit medication room (11:35 AM); dust and debris accumulation beneath the medication dispensing unit in the C Unit medication room (11:50 AM)); dust accumulation on sloped tops of cabinets in C Unit medication room (11:50 AM); dust accumulation on sloped tops of cabinets in C Unit day room (12:10 PM); dust accumulation on sloped tops of cabinets in C Unit pantry (12:15 PM); dust accumulation on tops of cabinets and refrigerators in the Pharmacy (12:30 PM); 2 tabletop fans with dirt accumulation on the fan blades in the Pharmacy (12:30 PM).
On 1/10/12 at approximately 12:40 PM, the following conditions were observed in the Dietary storage room located in the basement: housekeeping mop and bucket with dirty water in it stored behind a wheeled cart containing single service items; paper napkins stored adjacent to a soiled extension cord and pieces of cove base; feather duster stored adjacent to service equipment; mops and brooms stored on top of boxes of Styrofoam containers; staff coats stored on top of packages of clean linen.
On 1/10/12 at approximately 12:35 PM, 12 boxes of Boost nutritional supplement were observed stored directly on the floor in the corridor outside of the Pharmacy.
On 1/10/12 at approximately 12:15 PM, containers of Styrofoam cups were observed stored directly on the floor in the C Unit pantry.

Based on observation interview and document review the facility failed to monitor for a sanitary environment and ensure that new policies for mitigation of bedbug outbreaks are followed resulting in the potential for transmission of infectious agents among patients being treated by the facility staff and visitors. Findings include:

On 1/9/12 starting at approximately 1015 during facility tour found
a). the bottom of the day room refrigerator on the C 1 side was soiled and had a used plastic bag stuck between the bottom of the refrigerator and the crisper drawer
b). the laundry room had floor storage of a dusty backpack, a white sock and a wash basin surrounded by large amounts of accumulated dust
c). personal items in the double occupied semi private room, 235 were stored around the bathroom sink where there was no available storage space
d). storage units 1, 2, and 4, where patients personal belonging for C 2 are stored had accumulated dust on the floor and in corners of the closets, personal items not bagged or marked with patient names, and facility storage of pillows in the same storage units.
e). personal items in a double occupied semi private room , 232 were stored around the bathroom sink in addition to a large bar soap found in the soap holder in the shower
f). in a double occupied semi private room, 230 a toothbrush and opened toothpaste were stored around the bathroom sink
g). in the medication rooms for C 1 and C 2 , dust has accumulated underneath carts and in corners of the room
h). the storage room for the C 1 men's patient's belongs has accumulated storage of personal clothing and suitcases and various tote bags that are not stored in bags designating patient by name, are stored (piled) on the floor, where there is accumulated dust
i). in the room marked "Phlebotomy" in a room formerly used for seclusion there was floor storage of patient clothing, patient care items and much clutter. Patient belongings are not marked with a name nor stored in a bag. Bags that are in use are ripped open with content spilling over onto the floor
j). the food refrigerator in the C 1 medication room is soiled and had accumulated ice in the freezer section

The above observations were confirmed by staff B.
According to staff W, she conducts quarterly rounds inspecting for cleanliness. A review of the facility "Infection Control Plan 2011 Strategies include to provide a clean, safe hospital environment for personnel, patients, and visitors...". A review of facility documents on 1/11/12 at approximately 1030 reveals completed documents titled infection control rounds in which they find "100% compliance".

On 1/9/11 at approximately 1330 during record review found that Patient #26 was admitted on 12/29/11 with what appeared to be a bedbug who was full with a bloodmeal. Interview with staff J confirms that "we gave him a shower, washed his belongings and treated the room...". Interview with staff W regarding problems with bedbug infestation confirms that they had a problem starting in January 2011 with bedbugs coming in from the community. Reoccurrence occurred throughout 2011. Staff W indicated that after research, a new policy was developed and approved by the Infection Control Committee on 1/2011. A review of the checklist for implementation of the protocol on 12/29/11 reveals blanks in the areas requesting "date and time of contact", and "staff name who located". Additionally the check list that requests "all personal items located room should be inspected and bagged", "all furniture in room should be treated once bed bugs have been verified" and "environmental services will clean room including vacuuming furniture, carpeting and interiors of dresser/wardrobes..." had a "N/A" written on the checklist. Interview with staff W regarding monitoring of implementation for this new policy reveals that she was not aware that this was how the checklist had been completed. Additionally, staff W indicated that she was not aware of the status of the storage of patient personal belongings on the C unit that may contribute to transmission of bedbug infestation.

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

I. Provide Master Treatment Plans (MTP) for 3 of 12 active sample patients (B26, B35 and C26) that were based on the patients' identified needs and were revised when the patients were unwilling to participate in scheduled treatment. These patients demonstrated severe impairment, but the only psychiatric treatments noted on the treatment plans other than medication adjustments were group sessions from which the patients were incapable of benefiting. The treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Provide active treatment measures or purposeful alternative interventions for 4 of 12 active sample patients (B26, B35, C17 and C26). These patients did not routinely attend the scheduled groups and unit activities, and there was no evidence that they received alternative treatment. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them potentially delays their improvement. (Refer to B125-I)

III. Ensure that the severe medical problems of 2 of 3 discharged patients (D6 and D8) reviewed for medical care were evaluated and treated. While hospitalized, Patient D6 developed symptoms of an acute abdomen; patient D8 developed left-sided weakness suggestive of a cerebrovascular accident. Neither patient received immediate medical attention for these problems. Failure to immediately address the serious medical problems compromised the patients' medical status, requiring transfer to a medical hospital. Failure to address serious medical problems in a timely way is a risk to patients' health, and it prevents patients from achieving an optimal level of functioning. (Refer to B125-II)

IV. Ensure that the risk for suicide was evaluated by a psychiatrist prior to discharge for 2 of 2 discharged patients (D9 and D10) reviewed for the occurrence of their death following discharge. Failure to assess the potential for suicide prevents a safe decision about the readiness of patients for discharge and is a risk to the health and life of patients being discharged into the community. (Refer to B125-III)

V. Adequately follow restraint procedures, including needed documentation, for the use of physical holds for 1 of 1 active non-sample patient (C4) reviewed for the use of restraints. Patient C4 was placed in a physical hold (restraint) without a physician order for restraint or documentation of appropriate assessments or monitoring. This deficient practice exposes patients to potential harm from unnecessary restraint and is a violation of patient rights to be free from restraint without documented justification. (Refer to B125-IV)

Based on medical record review and interview, the facility failed to ensure that the Discharge Planning Section of the Psychosocial Assessment for 12 of 12 active sample patients (A8, A14, A17, A43, B11, B17, B35, B44, C9, C17 and C26) included an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; recommendations concerning anticipated necessary steps to be taken for discharge to occur; and anticipated Social Work roles in treatment and discharge planning. These deficiencies result in the treatment team not having the necessary social work information to develop effective and meaningful treatment plans for patients.

Findings include:

A. Record Review

1. Patient A8. According to the Psychosocial Assessment, the patient was admitted to Unit A on 1/5/12 due to assaultive behavior towards a sister, non-compliance with meds, and auditory and visual hallucinations. The "Preliminary Discharge Needs/Plans" section of the Psychosocial Assessment, completed by the unit social worker on 1/5/11, only stated "D/C (discharge) pt (patient) to parents and refer to Easter Seals."

2. Patient A14. According to the Psychosocial Assessment, the patient was admitted to Unit A on 1/5/12 due to threatening suicide at school, mood swings and depression. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 1/6/12, only stated " Pt. [patient] will return home... Pt. (patient) follow up with..."

3. Patient A17. According to the Psychosocial Assessment, the patient was admitted to Unit A on 12/29/11 due to hearing voices saying to leave home, depression, and non-compliance with meds. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment completed by the unit social worker on 12/29/11 only stated "Stabilize and return home to mother -f/u [follow up] with current Tx (Treatment) team."

4. Patient A43. According to the Psychosocial Assessment, the patient was admitted to Unit A on 1/5/12 due to an overdose of medication, suicidal intent, and insomnia and depression. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 1/7/12, only stated "Pt (patient) needs referral for out-patient services."

5. Patient B11. According to the Psychosocial Assessment, the patient was admitted to Unit B on 12/29/11 due to aggressive behavior towards his/her mother, hearing voices, and having frequent mood swings and racing thoughts. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 12/30/11, only provided addresses for home and outpatient therapy.

6. Patient B17. According to the Psychosocial Assessment, the patient was admitted to Unit B on 12/22/11 due to aggressive behavior with staff at the crisis house where s/he was living, and insomnia, and auditory and visual hallucinations. The "Preliminary Discharge/Needs Plan" section of the Psychosocial Assessment, completed by the unit social worker on 12/23/11, only provided addresses for home and out-patient therapy.

7. Patient B26. According to the Psychosocial Assessment, the patient was admitted to Unit B on 12/30/11 due to acute psychosis with assaultive behavior towards his/her mother, poor personal hygiene, and alcohol abuse. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 12/ 31/11, only provided addresses for home and out-patient therapy.

8. Patient B35. According to the Psychosocial Assessment, the patient was admitted to Unit B on 12/28/11 due to verbal and physical aggression towards his/her father, depression, and insomnia. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 12/28/11, only provided addresses for home and out-patient therapy.

9. Patient B44. According to the Psychosocial Assessment, the patient was admitted to Unit B on 12/28/11 due to family concerns about the side effects of medication, and the patient's auditory hallucinations and insomnia. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 12/30/11, only provided addresses for home and out-patient therapy.

10. Patient C9. According to the Psychosocial Assessment, the patient was admitted to Unit C on 1/2/12 due to confusion, delusions and grandiose thinking, and poor personal hygiene. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 1/3/12, only provided addresses for home and out-patient therapy.

11. Patient C17. According to the Psychosocial Assessment, the patient C17 admitted to Unit C on 11/28/11 due to sexually inappropriate behaviors in public, auditory hallucinations, and non-compliance with medications. The "Preliminary Discharge Needs/Plan" section of the Psychosocial Assessment, completed by the unit social worker on 11/29/11, stated "Pt (patient) is currently homeless and further exploration needed for housing." The only other information was an address for out-patient therapy.

12. Patient C26. According to the Psychosocial Assessment, the patient was admitted to Unit C on 12/22/11 due to aggressive behavior in the group home where s/he was living, poor hygiene, and non-compliance with medications. The "Preliminary Discharge Needs/Plan" of the Psychosocial Assessment, completed by the unit social worker on 12/24/11, only provided addresses for home and outpatient therapy.

B. Staff Interviews

1. In an interview on 1/9/12 at 1:20 p.m., SW1 confirmed that the discharge planning information for Patient B35 was not adequately documented in the Psychosocial Assessment.

2. In an interview on 1/9/12 at 1:45 p.m., SW2 confirmed that the discharge planning information for Patient B11 was not adequately documented in the Psychosocial Assessment.

3. In an interview on 1/10/12 at 2:45 p.m., the Director of Social Work confirmed that the Preliminary Discharge Needs/Plan of the Psychosocial Assessments did not provide clear recommendations for appropriate patient discharge planning.

4. In an interview on 1/10/12 at 3:45 p.m., the Director of Social Work confirmed that the Preliminary Discharge Needs/Plan section of the Psychosocial Assessments failed to include an evaluation of high risk patient and/or family psychosocial issues, recommendations concerning anticipated steps to be taken for discharge, and anticipated social work roles in treatment and discharge planning

Based on record review and interview, the facility failed to provide psychiatric evaluations (PEs) for 5 of 12 active sample patients (A8, A14, A17, A43 and C9) that contained sufficient information to justify the diagnoses and treatment. The PEs contained limited information on the patients' diagnoses and mental health status; there also was inadequate documentation of the patient's current illness, past history of illness, social history, or family history. This failure results in a lack of information for the treatment team to formulate appropriate Master Treatment Plans for patients.

Findings include:

A. Record Review

1. Review of the sample patients' psychiatric evaluations (PEs) revealed that for 4 sample patients (A8, A14, A17 and A43), the PEs consisted of a "Physician's Initial Assessment Form" on which much of the information was presented in a check box format. Small areas were provided for elaboration on some items. Half of page two, and pages three and four listed "Mental Status" items which consisted of categories with descriptive words (to be checked if present), and with short lines available for some areas to elaborate on the findings. The PE for an additional sample patient (C9) only contained a short narrative summary with incomplete information.

2. Specific Patient Findings

a. Patient A8. The "Physician's Initial Assessment Form," dated 1/5/12, stated the diagnoses as "Mood NOS (not otherwise specified)/Bipolar Mixed by hx (history)/ ODD (oppositional defiant disorder)." The only mood assessment was "Mood" checked as "ok." No oppositional/defiant behaviors were described. The PE had no account of the patient's current illness, past history of illness, social history, or family history other than "lives [with] family. Fights [with] family. Aggressive. FH (family history) of schizophrenia."

b. Patient A14. The "Physician's Initial Assessment Form," dated 1/6/12, stated the diagnosis as "Bipolar I Depressed." The only mood assessment was "Mood" checked as "Depression - mild to moderate feeling of worthlessness, hopelessness." The PE did not contain an account of the patient's current illness, past history of illness, social history, or family history. The "Present Illness" section read, "Pt (patient) reports depression, anxiety, mood swings [and] panic attacks." The "Past Psychiatric History" was "op (outpatient) - [physician's name]." The only social or family history was "pt. adopted."

c. Patient A17. The "Physician's Initial Assessment Form," dated 12/29/12, stated the diagnoses as "Psychosis NOS/Depression NOS R/O (rule/out) schizophrenia do (disorder) vs MDD (major depressive disorder), severe [with] psychosis." The only assessment for psychosis was the item "Hallucinations" checked as "Clearly described." An assessment of current delusional thinking was not documented. The only mood assessment was "Mood" checked as "Depression - severe - unable to function, classic signs of depression." For "Present Illness" the PE stated "[age] [race/sex] admitted due to paranoid delusions and A.H. (auditory hallucinations). 'Voice tell [sic] me to leave the house.' Mood lability and depression. Hx of noncompliance [with] meds (medications)." The only "Past Psychiatric History" was "outpt (outpatient) tx (treatment) at [facility name]." The only social or family history was "Lives [with] Mo (mother) & sib (sibling). Parents not together. Limited contact [with] fa (father). Denies F.H. (family history) of mental illness."

d. Patient A43. The "Physician's Initial Assessment Form," dated 1/6/12, stated that diagnoses as "Bipolar I Depressed, ODD (oppositional defiant disorder)." The only mood assessment was "Mood" checked as "Depression - Hypomania, euphoria," and "Depression- severe-unable to function, classic signs of depression." The "Present Illness" stated "Pt (patient) reports mood swings, sadness, sleep problems for over a year and a half." The "Past Psychiatric History" stated "none." The only social or family history was "family hx (history) of SA (substance abuse)/Bipolar/Suicidality."

e. Patient C9. The psychiatric evaluation, dated 1/3/12, was a single page dictated PE. The PE did not contain any account of the patient's current illness, past history of illness, social history, or family history other than "has prior hospitalizations" and "possibly not taking medicines, noncompliant."

C. Staff Interview

In an interview on 1/10/12 at 1:10 p.m., the Medical Director stated that the psychiatric evaluations were "less than adequate."

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 5 of 12 active sample patients (A8, A14, A17, A43 and C9) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient.

Findings include:

A. Record Review

For the following Psychiatric Evaluations (dates in parentheses), no assets were identified for the patients: Patient A8 (1/5/12), Patient A14 (1/6/12), Patient A17 (12/29/11), Patient A43 (1/6/12) and Patient C9 (1/3/12).

B. Staff Interview

In an interview on 1/10/12 at 1:10 p.m., the Medical Director stated that the psychiatric evaluations were "less than adequate."

Based on interview and record review, the facility failed to ensure that the Master Treatment Plans (MTP) for 3 of 12 active sample patients (B26, B35, and C26) were based on the patients' treatment needs and were revised when the patients were unwilling to participate in the scheduled treatment program. These patients demonstrated severe impairment, but the only psychiatric treatment noted on the treatment plans, other than medication adjustments, were group sessions, from which the patients were incapable of benefiting. The treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

There was a routine schedule posted for all patients to attend the following daily structured treatment groups: "Community Meeting" "RT" (recreational therapy) and "Group Therapy (no specific focus is listed)."

A. Patient B26

1. As documented in the psychiatric evaluation dated 12/31/11, Patient B26 was admitted on 12/30/2011 with diagnoses of "Schizoaffective Disorder."

2. A review of the Master Treatment Plan dated 12/31/11 revealed that Patient B26 did not have individualized treatment scheduled: the listed interventions, which were the same for any patient with the same listed problem, included: "(RT) Staff will provide activities and groups 5-7 times weekly for 30-60 minutes to assist patient with developing appropriate coping mechanisms and improve communication/interaction skills;" "(RT) Staff will provide structured reality-oriented activity therapy groups 5-7 days a week (as tolerated) to assist patient with identifying what is real, while developing appropriate social skills and way to manage psychotic symptoms;" "(Social Work) Staff will educate patient regarding appropriate community resources to access support from upon discharge as needed;" "(Social Work)Staff will provide group therapy daily to assist patient to identify factors that trigger aggressive feelings and develop coping skills to manage those feelings."

3. Review of "Recreational Therapy Progress Notes" from 1/2/12 through 1/9/12 revealed that Patient B26 attended 0 of 20 RT group sessions during this time period. The notes stated, "sleeping," "declined," or " in bed." There was no documentation of other alternative treatment interventions being offered to the patient.

4. A review of the medical record revealed that as of 1/10/12, there was a failure to address Patient B26's lack of attendance at group therapy or programming activities such as Goal Setting, Coping Skills, Physical Fitness, Team Building, Self Esteem, Social Skills, Anger Management, Creative Expression and Leisure Education. No revisions were made in the treatment plan.

B. Patient B35

1. As documented in the psychiatric evaluation dated 12/29/11, Patient B35 was admitted on 12/28/11 with diagnoses of "Bipolar manic with psychotic features, severe marijuana abuse."

2. A review of the Master Treatment Plan dated 12/30/11 revealed that Patient B35 did not have individualized treatment scheduled; the listed interventions, which were the same for any patient with the same listed problem, included: "(RT)Staff will provide activities and groups 5-7 times weekly for 30-60 minutes to assist patient with developing appropriate coping mechanisms and improve communication/interaction skills;" "(RT) Staff will provide structured reality-oriented activity therapy groups 5-7 days a week (as tolerated) to assist patient with identifying what is real, while developing appropriate social skills and way to manage psychotic symptoms;" "(Social Work) Staff will educate patient regarding appropriate community resources to access support from upon discharge as needed;" " (Social Work) Staff will provide daily group therapy to assist patient to focus on accepting responsibility for self and his/her own choices and develop alternative coping mechanisms to manage urges to use and feelings associated;" "(RT) Staff will provide structured activities 5-7 days/week teaching positive leisure choices to pursue post discharge."

3. Review of the "Recreational Therapy Progress Notes" from 12/29/11 through 1/9/12 revealed that Patient B35 attended 5 of 27 RT group sessions during this time period. The notes stated, "declined," "no participation," "visible on unit," and "sleeping." No other treatment interventions were added to the MTP.

3. A review of the medical record revealed that as of 1/10/12, there was a failure to address Patient B35's lack of attendance at group therapy or programming activities and no revisions were made in the treatment plan.

C. Patient C26

1. As documented in the psychiatric evaluation dated 12/22/11, Patient C26 was admitted on 12/22/11 with diagnoses of "Schizophrenia, paranoid, chronic with acute exacerbation" and "rule out schizoaffective disorder."

2. A review of the Master Treatment Plan dated 12/24/11 revealed that Patient C26 did not have individualized treatment scheduled: the listed interventions, which were the same for any patient with the same listed problem, included: "(RT) Staff will provide activities and groups 5-7 times weekly for 30-60 minutes to assist patient with developing appropriate coping mechanisms and improve communication/interaction skills;" "(RT) Staff will provide structured reality-oriented activity therapy groups 5-7 days a week (as tolerated) to assist patient with identifying what is real, while developing appropriate social skills and way to manage psychotic symptoms;" "(RT) Staff will provide success-oriented activities and groups 5-7 days weekly for 30-60 minutes to increase the patient's self esteem and develop positive ways to cope with depressive feelings;" "(Social Work) Staff will educate patient regarding appropriate community resources to access support from upon discharge as needed;" " (Social Work) Staff will provide daily group therapy to assist patient to focus on accepting responsibility for self and his/her own choices and develop alternative coping mechanisms to manage urges to use and feelings associated;" "(Social Work) Staff will provide group therapy daily to assist patient to identify factors that trigger aggressive feelings and develop coping skills to manage those feelings;" "(Social Work) Staff will provide activities and groups daily for 60-90 min to assist patient with identifying precipitants to depression and developing coping skills to manage related feelings."

3. Review of the "Recreational Therapy group log" for 1/2/12 through 1/9/12 revealed that Patient C26 attended only 11 of 25 Recreational Therapy group sessions during this time period. There was no documentation that other alternative treatment interventions were offered to the patient.

4. A review of the medical record revealed that as of 1/10/12, there was a failure to address Patient C26's lack of attendance at group sessions such as Goal Setting, Coping Skills, Physical Fitness, Team Building, Self Esteem, Social Skills, Anger Management, Creative Expression and Leisure Education. No revisions were made in the treatment plan.

B. Interview

In an interview on 1/9/2012 at 2:30 P.M., RN2 acknowledged the MTPs did not include alternative treatment for patients who did not attend scheduled programming. RN2 stated, "It's not very often that treatment plans are updated; you will not find any difference in the treatment plans."

Based on interview and record review, the facility failed to provide Master Treatment Plans that identified patient-specific short-term (ST) goals stated in observable, measurable, behavioral terms for 12 of 12 sampled patients (A8, A14, A17, A43, B11, B17, B35, B44, C9, C17 and C26). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review

The Master Treatment Plans were generated from a computer software program that included lists of "patient goals" for identified problems such as "Danger to Self ", "Aggression", "Depression", "Psychosis", "Substance Abuse." The short term goals for the identified problems were the same for all patients. The goals also were non-measurable and/or were stated as staff goals for patient participation instead of patient outcome behaviors. Examples of the patient goals for each identified problem are noted below.

a. Eleven of the 12 sample patients (A8, A14, A43, B11, B17, B26, B35, B44, C9, C17 and C26) had the identified problem "Danger to Self." One of the stated goals for this problem (for all patients) was "Patient will participate in all program activities, daily." This is a staff goal for patient participation in treatment, not a measurable patient outcome behavior. Another stated goal, "Patient will talk about feelings of self-harm with staff and contract for safety" is not measurable as stated; the staff cannot know whether the patient has feelings of self-harm.

b. Eleven of the 12 sample patients (A8, A17, A43, B11, B17, B26, B35, B44, C9, C17 and C26) had the listed problem "Psychosis." One of the goals for this problem was stated as: "Patient will get out of bed daily to participate in ADLs." This was a staff goal for patient participation in treatment, not a patient outcome. Another goal, "Patient will get out of bed daily to participate in groups and activities as tolerated" was also a staff goal. The goal, "Patient will be able to appropriately interact with peers/staff each day" is not measurable; the appropriate behaviors were not documented. The goal, "Patient will be able to approach staff when experience auditory and or visual hallucinations and discuss content and identify ways to manage them," is not measurable.

c. Seven of the 12 sample patients (A8, A14, A17, A43, B11, B17 and C26) had the listed problem, "Depression." Examples of stated goals for this problem were "Patient will identify positive attributes each day" (positive attributed unspecified); "Patient will express feelings of depression with staff daily" and "Patient will follow medication regime and report response towards symptoms improvement daily to the nurse or doctor." These goals were not measurable as stated.

d. Eight of the 12 sample patients (A8, A14, A43, B17, B26, B44, C17 and C26) had the listed problem "Aggression." The stated goals for this problem were "Patient will identify triggers daily" and "Patient will be able to express feelings of anger in an appropriate manner daily." These goals were not measurable as stated.

B. Interview:

1. In an interview on 1/10/12 at 3:30 p.m., the Director of Nursing acknowledged the goals on the treatment plans were not measurable or individualized for patients.

2. In an interview on 1/10/11 at 11:15 a.m., RN 5 reviewed the treatment plans and acknowledged that the stated goals were not measurable.

Based on interview and record review, the facility failed to develop Master Treatment Plans that identified physician, nursing, social work and rehabilitation staff interventions to address the specific treatment needs of 12 of 12 active sample patients (A8, A14, A17, A43, B11, B17, B35, B44, C9, C17 and C26). The treatment plans were generated from a computer program that included pre-selected lists of interventions for identified problems. Many of the interventions were the same for all patients with the same problem(s), and they were stated as routine, generic discipline functions that lacked any focus for individualized treatment. In addition, the MTPs failed to list any interventions for the physician (psychiatrist). These failures result in treatment plans that fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

The following 12 sample patient's Master Treatment Plans were reviewed: A8 (1/5/12); A14 (1/7/12); A17 (1/3/12); A43 (1/7/12); B11 (12/31/11); B17 (12/23/11); B26 (12/23/11); B35 (12/30/11); B44 (12/30/11); C9 (1/3/12); Patient C17 (11/29/11) and C26 (12/24/11). The review showed the following:

1. There were no listed interventions for the psychiatrist on any of the patients ' treatment plans.

2. The listed interventions for the nursing, social work, and rehabilitation staff were selected from computerized lists of generic interventions for identified problems such as "Danger to Self "; "Aggression"; "Depression", "Psychosis"; "ADHD" and "Substance Abuse." Most of the interventions were the same for all patients having each of these identified problems. There was no evidence of attempts to individualize the interventions for patients.

3. Eleven of the 12 sample patients (A8, A14, A43, B11, B17, B26, B35, B44, C9, C17 and C26) had the listed problem, "Danger to Self." Generic interventions for this problem were: RN-- "Staff will monitor for safety per level of precaution." Social Work-- "Staff will educate patient regarding appropriate community resources to access support from upon discharge as needed," Recreational Therapy (RT)-- "Staff will provide activities and groups 5-7 times weekly for 30-60 minutes to assist patient with developing appropriate coping mechanisms and improve communication/interaction skills."

4. Eight of the 12 sample patients (A8, A14, A43, B17, B26, B44, C17 and C26) had the listed problem "Aggression." Generic interventions for this problem were: RN-- "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." Social Work-- "Staff will provide group therapy daily to assist patient to identify factors that trigger aggressive feelings and develop coping skills to manage those feelings."

5. Seven of the 12 sample patients (A8, A14, A17, A43, B11, B17 and C26) had the listed problem "Depression." Generic interventions for this problem were: RN-- "Staff will provide medication to decrease depression, as necessary; medication teaching will be done with patient." Social Work-- "Staff will provide activities and groups daily for 60-90 min to assist patient with identifying precipitants to depression and developing coping skills to manage related feelings," RT-- "Staff will provide success-oriented activities and groups 5-7 days weekly for 30-60 minutes to increase the patient's self esteem and develop positive ways to cope with depressive feelings."

6. Eleven of the 12 sample patients (A8, A17, A43, B11, B17, B26, B35, B44, C9, C17 and C26) had the listed problem "Psychosis." Generic interventions for this problem were: RN-- "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." Social Work-- "Staff will provide activities and groups daily (as tolerated) to assist patient with identifying what is real, verbalizing feelings and developing coping and interaction skills." RT- "Staff will provide structured reality-oriented activity therapy groups 5-7 days a week (as tolerated) to assist patient with identifying what is real, while developing appropriate social skills and way to manage psychotic symptoms."

7. Six of the 12 sample patients (A14, A43, B11, B35, C9 and C17) had the listed problem, "Substance Abuse." Generic interventions for this problem were "RN-- "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily." Social Work-- "Staff will provide daily group therapy to assist patient to focus on accepting responsibility for self and his/her own choices and develop alternative coping mechanisms to manage urges to use and feelings associated." RT-- "Staff will provide structured activities 5-7 days/week teaching positive leisure choices to pursue post discharge. "

B. Staff Interviews

1. In an interview on 1/10/12 at 11:30 a.m., MD1, attending psychiatrist, agreed that the physician interventions on the treatment plan for Patient B26 were absent. MD1 stated "I didn't know they don't chart it down anywhere."

2. In an interview on 1/10/12 at 10:50 a.m., SW1 stated that the treatment interventions for Patient B26 were not individualized but were the same as those for all patients with the same listed problems.

3. In an interview on 1/9/12 at 2:30 p.m., RN2 acknowledged that the interventions for Patients C9 and C12 were generic and lacked specific and individualized focus to meet the patients' care needs. RN2 stated "You will not find any difference in the treatment plans."

4. In an interview on 1/10/12 at 1:00 p.m., the Medical Director and the Medical Director for Adult Services agreed that individualized interventions to be performed by psychiatrists were absent in the Master Treatment Plans.

5. In an interview on 1/10/12 at 3:30 p.m., the Director of Nursing verified that individualized nursing interventions were absent in the Master Treatment Plans for Patients C9 and C17, and that the interventions listed were the same for all patients with the same problem.

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

I. Provide active treatment measures or purposeful alternative interventions for 4 of 12 active sample patients (B26, B35, C17 and C26) to move the patients to a higher level of functioning and a less restrictive environment. These patients did not routinely attend the scheduled groups and unit activities, and there was no evidence that they received alternative treatment. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being provided to them in a timely fashion, potentially delaying their improvement.

II. Ensure that the severe medical problems of 2 of 3 discharged patients (D6 and D8) reviewed for medical care were evaluated and treated. While hospitalized, Patient D6 developed symptoms of an acute abdomen; Patient D8 developed left-sided weakness suggestive of a cerebrovascular accident. Neither patient received immediate medical attention for these problems. Failure to immediately address these problems compromised the patients' medical status, requiring transfer to a medical hospital. Failure to address serious medical problems in a timely way is a risk to patients' health, and it prevents them from achieving an optimal level of functioning.

III. Ensure that the risk for suicide was evaluated by a psychiatrist prior to discharge for 2 of 2 discharged patients (D9 and D10) reviewed for the occurrence of their deaths following discharge. Failure to assess the potential for suicide prevents a safe decision about the readiness of patients for discharge and is a risk to the health and life of patients being discharged into the community.

IV. Adequately follow restraint procedures, including needed documentation, for the use of physical holds for 1 of 1 active non-sample patient (C4) reviewed for the use of restraints. Patient C4 was placed in a physical hold (restraint) without a physician order for restraint or documentation of appropriate assessments or monitoring. This deficient practice exposes patients to potential harm from unnecessary restraint and is a violation of patient rights to be free from restraint without documented justification.

Findings include:


I. Failure to provide active treatment based on patient's assessed needs:

A. Observations

1. During an observation on Unit C2 on 1/10/12 at 10 a.m., 8 patients were seen lying in bed and 12 patients were wandering the halls or sitting at a table in the day room while the scheduled community meeting (which was supposed to be attended by all patients) was in progress. The census on the unit was 42.

2. On 1/10/12 at 1:30 p.m. during an observation of the "Men's Group," Patient C17 left the group after 10 minutes and went to bed. No staff inquired about why s/he left or offered alternative treatment. This patient had acute psychotic symptoms but was expected to stay in treatment group 90 minutes.

3. On 1/10/12 at 1:45 p.m., Patient B35 left the "Men's Group" after 10 minutes and went to bed. No staff inquired about why s/he left or offered alternative treatment.

B. Record Review

According to the "Recreational Therapy Progress" notes, Patient B26 did not participate in the offered sessions 23 of 24 scheduled times. There was no document that alternative treatment was offered to the patient.

C. Interview

1. During an interview on 1/9/12 at 2:30 p.m., RN2 stated, "Group is not mandatory; if patients don't think it's beneficial, they can choose not to participate." When asked what alternative treatment programs are offered to patients who do not attend the scheduled group sessions, RN2 stated the patients can go to their room, read a book, or do a "diversion activity" at the table in the dayroom such as a game or puzzle. RN2 stated that diversionary activities are not supervised or conducted by staff.

2. During an interview on 1/10/12 at 10 a.m., MHT3 stated, "Groups cannot be forced." MHT3 also stated that there were no alternatives when patients do not attend groups.

3. During an interview on 1/10/12 at 10:55 a.m., SW1 stated that Patient C26 could do whatever s/he wants on her/his own if s/he walked out of group. SW1 added, "No alternatives are offered to patients or are led by staff." SW1 also stated that C26 was a patient who could become aggressive, and that the groups are not individualized to meet the needs of this patient.


II. Failure to ensure that severe medical problems were evaluated and treated.

A. Patient D6

1. Record Review

a. Patient D6 was an adolescent admitted 10/4/11 at 2:30 a.m. with the diagnoses of "Mood NOS (mood disorder, not otherwise specified)," "ODD (oppositional defiant disorder)," and "ADHD (attention deficit hyperactivity disorder)." At the time of admission, no physical examination was performed. The "Vital Signs Record" completed at the time of admission stated that vital signs were significant for a temperature of 103 (degrees Fahrenheit) and pulse of 112 (beats per minute).

b. The following RN notes documented the patient's condition during the hospitalization on 10/4/11:

2:35 a.m.: "[elevated] temp (temperature) on admission 103 (degrees Fahrenheit) Med (medication): Tylenol Dose: 650 mg (milligrams) po (orally)" and "420 A (a.m.) Temp (temperature) 99.3 7:30 a.m. 99.1."

8:40 a.m.: "Fever 102.3 Med (medication): Tylenol Dose: 325 mg (milligrams) po (orally)" and "Pt (patient) vomiting repeatedly unable to hold anything down."

12:30 p.m.: "Pt still vomiting, temp remains elevated 104.3, unable to tolerate any foods. c/o (complains of) all over body pain. . . [medical provider] consulted. Pt to be transferred to [a medical facility] c/o abdominal pain."

c. The following MHT notes documented the patient's condition as "throwing up" on 10/4/11: 8:30 a.m., 8:45 a.m., 9:15 a.m., 9:30 a.m., 9:45 a.m., 10:00 a.m., 12:15 a.m., 1:00 p.m., 1:15 p.m., 1:30 p.m., and 1:45 p.m.

d. The MHT note on 10/4/11 at 11:30 a.m. stated, "Pt was obs (observed) to vomit multiple times during shift. Pt temperature was recorded at 102.5 throughout shift."

e. The "History and Physical," dictated on 10/4/12 at 1:16 p.m., stated "Abdomen, there is a lot of guarding . . . there is pain especially in the McBurney point." The diagnosis included " Acute abdomen rule out appendicitis" and the recommendations were "transfer to medical facility."

f. The observation monitoring sheet dated 10/4/11 documented that Patient D6 was transferred to a medical facility at 2 p.m.

g. The medical record for Patient D6 contained no documentation that Patient D6 had been seen and evaluated by a physician from the time of the identification of the fever on admission on 10/4/11 at 2:30 a.m. until 10/4/11 at 1 p.m., despite the patient's fever, multiple episodes of vomiting, and pain.

2. Staff Interviews

a. In an interview on 1/10/12 at 1:10 p.m., the Medical Director stated the medical condition of Patient D6 should have been further assessed at the time of admission rather than waiting several hours to perform an evaluation.

b. In an interview with the Medical Director, Director or Adult Services, DON, and Performance Improvement Director on 1/11/12 at 8:45 a.m., the Medical Director stated that "Given that it is a freestanding hospital, that [the evaluation] was really quick." The Medical Director stated, "If I call him [medical physician] for every vomiting, I would have to have someone [medical provider] full time."

c. In an interview on 1/10/12 at 3:40 p.m., the DON agreed that Patient D6 required direct assessments by a physician earlier in the hospitalization.

B. Patient D8

1. Record Review

a. Patient D8 was a middle aged patient admitted 11/21/11 with the diagnoses of "Major depression, severe" and "seizure disorder, arthritis, atrial fibrillation, gout, and CVA (cerebrovascular accident)." The "History and Physical," dictated 11/22/11, documented the diagnoses of "atrial fibrillation," "seizure disorder," and "history of stroke." The neurological examination was within normal limits.

b. A "24 Hour RN Process Note" dated 12/13/11 at 4:30 a.m. stated, "consult for [right] arm numb (numbness)/tingling."

c. The "Consultation Request and Report" completed by the medical provider and dated 12/13/11 at 9:30 a.m. stated, "h/o (history of) Afib (atrial fibrillation)," "numbness h/o (history of) stroke," "tingling, numbness of extremity - rt (right) sided," "weakness of extremity," and "transfer to [medical facility]."

d. The observation monitoring sheet dated 12/13/11 documented that Patient D8 was transferred from the hospital at 10 a.m.

e. The medical record for Patient D8 contained no documentation that Patient D8 had been seen and evaluated by a physician from the time of the acute onset of right-sided weakness and paresthesia (sensation of numbness or tingling) on 12/13/11 at 4:30 a.m. until 9:30 a.m. that morning.

2. Staff Interviews

a. In an interview on 1/10/12 at 1:10 p.m., the Medical Director stated that a physician should have assessed the medical condition of Patient D8 at the time of the onset of the patient's weakness and paresthesia rather than waiting several hours to perform an evaluation.

b. In an interview on 1/10/12 at 3:40 p.m., the DON agreed that Patient D6 required direct assessments by a physician at the time of the onset of the patient's weakness and paresthesia.

c. In an interview with the DON, Medical Director, Director or Adult Services, and Performance Improvement Director on 1/11/12 at 8:45 a.m., the DON stated that the documentation in the medical record showed that the nurse on duty had completed a written "Consultation Request and Report" as a request for a medical consultation when the physician was available, but had not immediately contacted a physician.

III. Failure to ensure the completion of a suicide risk assessment prior to discharge

B. Patient D9

1. Record Review

a. Patient D9 was a young adult admitted on 4/15/11 with a diagnosis of "Bipolar Disorder mixed with psychotic features."

b. The "Psychiatric Evaluation," dated 4/16/11, stated that Patient D9 reported "hearing voices telling [him/her] to kill [him/her] self."

c. The "Multidisciplinary Assessment" completed by an RN stated that Patient D9 "called police stating [he/she] was suicidal - told police [he/she] was in the matrix [and] was thinking about taking pills."

d. The "Physician Initial Order Sheet" dated 4/15/11 at 5:55 p.m. documented that "General Suicide Precautions" were ordered for Patient D9. Patient D9 remained on these precautions at the time of discharge on 4/21/11.

e. The Master Treatment Plan (MTP) dated 4/18/11 stated that Patient D9 had the problem of "Danger to Self " with a "Potential for self-directed harm AEB (as evidenced by) disorganized thoughts, paranoid, guarded, AH (auditory hallucinations), SI (suicidal ideation)."

f. A MHT note on 4/20/11 at 1 p.m. stated that Patient D9 was "very suspicious" with a flat, blunted affect . . .still hearing voices every day." The note quoted Patient D9 as saying " 'I don't notice the meds working yet.' "

g. A psychiatrist note on 4/20/11 at 2:30 p.m. stated that Patient D9 was "hyperactive. Pressure of speech."

h. An RN note on 4/20/11 at 4:55 p.m. stated that Patient D9 was "hearing voices . . . paranoid . . . isolative to room, suspicious."

i. A psychiatrist note on 4/21/11 at 10:20 a.m. stated that Patient D9 was "coherent, alert, intelligent and not psychotic . . . appears to be safe." No other assessment of suicide risk or potential was documented by a psychiatrist at the time of discharge on 4/21/11 at 12:30 p.m.

j. The medical record for Patient D9 contained no documentation that Patient D9 received any assessment of suicidal risk by a physician during the hospitalization other than the general observations noted in the above psychiatrist notes.

2. Document Review

The "Autopsy Protocol" completed by the Deputy Chief Medical Examiner and dated 6/17/11 stated that the death of Patient D9 occurred on 4/23/11 as a result of "drug overdose." The death was classified as a "suicide."

3. Staff Interviews

In an interview on 1/11/12 at 8:20 a.m., the Medical Director, Medical Director of Adult Services, DON, and Performance Improvement Director acknowledged that no physician's evaluation of Patient D9's suicide risk was documented in the medical record at the time of discharge.

A. Patient D10

1. Record Review

a. Patient D10 was a young adult admitted on 5/22/11 with a diagnosis of "Bipolar Disorder, Type I."

b. The psychiatric evaluation "Physician's Initial Assessment Form" stated that the "Justification for admission" was "suicidal threats. Hx Bipolar Disorder. Mood swings." The assessment documented "Suicide" "yes," " ideas." No other specific information regarding the suicide risk for Patient D10 was documented on the assessment form.

c, The "Physician Initial Order Sheet" dated 5/22/11 at 2:30 p.m. documented that "General Suicide Precautions" were ordered for Patient D10. Patient D10 remained on these precautions at the time of discharge on 6/1/11.

d. The psychiatrist progress note dated 5/29/11 at 11:24 a.m. stated that Patient D10 was "currently labile. Still hyperverbal . . . Still have [sic] mood changes. Still feels irritable. [He/she] still needs to be monitored closely." The psychiatrist note dated 5/30/11 at 11:01 a.m. stated that patient D10 "is grandiose and still remains at risk and still needs to be monitored." The psychiatrist note on 5/31/11 at 9:53 a.m. stated that Patient D10 was "anxious and irritable. Affect is labile. [He/she] has been isolative. . ."

e. On the day of discharge (6/1/11), the psychiatrist note at 10:32 a.m. stated, "The patient's mood is more stable. Affect is bright. [He/she] denied thoughts of suicide or homicide ...also denied psychotic symptoms." No other assessment of suicide risk, including the abrupt change in the mental status from previous descriptions, an assessment of potential suicide risk factors present for patient D6, or an assessment of factors that led to the hospitalization and treatment for patient D, was documented at the time of discharge.

f. The medical record for Patient D6 contained no documentation that Patient D10 received an adequate assessment of suicidal risk during the hospitalization or at the time of discharge.

2. Document Review

The "Post Mortem Report" completed by the Assistant Medical Examiner and dated 6/6/11 stated that the death of Patient D10 occurred on 6/5/11 as a result of ingesting multiple drugs. The death was classified as an "accident."

3. Staff Interviews

During an interview on 1/11/12 at 8:20 a.m., the Medical Director, Medical Director of Adult Services, DON, and Performance Improvement Director acknowledged that an evaluation of suicidal risk for Patient D10 was not completed by a physician and documented in the medical record at the time of the patient ' s discharge.

IV. Failure to ensure that physical holds are identified as restraint:

A. Observation

During an observation on ward C2 on 1/9/12 at 1:55 p.m., two mental health technicians were observed placing Patient C4 in a physical hold and moving him/her down the ward hallway.

B. Record Review

A review of the medical record for Patient C4 on 1/10/11 at 3:20 p.m. revealed no physician order for restraint or documentation of appropriate assessments or monitoring for the physical hold on 1/9/12 at 1:55 p.m.

B. Staff Interview

In an interview on 1/10/12 at 3:40 p.m., after reviewing a video recording of Patient C4 being restrained by staff on 1/9/12 at 1:55 p.m. in the hallway on Unit C2, the DON acknowledged that Patient C4 was placed in a physical hold (restraint) but that the event was not documented as a restraint. The DON also acknowledged that there was no physician order for the restraint, and no documentation of the required monitoring and assessments.

Based on observation, interview and document review, the facility failed to assure that the Medical Director, the Director of Nursing, and the Director of Social Work monitored active treatment and took needed corrective actions. Specifically,

I. The Medical Director failed to ensure that: a) patients had individualized Master Treatment Plans and that appropriate changes were made to reflect needed changes in patient treatment (Refer to B144-II); b) patients received immediate medical care for serious medical conditions (Refer to B144-VI); c) patients received a suicide risk assessment prior to discharge (Refer to B144-VII) and d) there were physician orders for physical holds (restraint), and that all required assessments were completed for restraint procedures (Refer to B144-VIII).

II. The Director of Nursing failed to ensure that: a) individualized nursing interventions were included in patient's Master Treatment Plans (Refer to B148-I) and b) that nurses obtained a physician order for the use of physical holds (restraint) and completed all required assessments and documentations. (Refer to B148-II).

III. The Director of Social Services failed to ensure that the Psychosocial Assessments of patients included all required components. The Discharge Planning Section of the Psychosocial Assessments failed to include: a) an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; b) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and c) anticipated Social Work roles in treatment and discharge planning. (Refer to B152)

These failures prevent patients from receiving appropriate care and treatment in a safe environment, enabling them to achieve an optimal level of functioning and discharge in a timely manner.

Based on observation, interview and record review, it was determined that the Medical Director failed to:

I. Ensure that 5 of 12 active sample patients (A8, A14, A17, A43 and C9) received a psychiatric evaluation that contained sufficient information to justify the diagnoses and treatment. The PEs contained limited information on the patients' diagnoses and mental health status; there also was inadequate documentation of the patient's current illness, past history of illness, social history, or family history. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to B110)

II. Ensure that the Master Treatment Plans (MTPs) for 3 of 12 active sample patients (B26, B35 and C26) that were based on the patients' identified treatment needs and were revised when the patients were unwilling to participate in the scheduled treatment. These patients demonstrated severe impairment. The only psychiatric treatment noted on the treatment plans other than medication adjustments were group sessions from which the patients were incapable of benefiting. The treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

III. Ensure that the Master Treatment Plans of 12 of 12 active sample patients (A8, A14, A17, A43, B11, B17, B35, B44, C9, C17, and C26) identified patient-related short-term goals stated in observable, measurable, behavioral terms. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs. (Refer to B121)

IV. Ensure that the Master Treatment Plans of 12 out of 12 active sample patients (A8, A14, A17, A43, B11, B17, B35, B44, C9, C17 and C26) included physician, nursing, social work and rehabilitation staff interventions to address the patient's specific treatment needs The treatment plans were generated from a computer program that included pre-selected lists of interventions for identified problems. The MTPs failed to list any interventions for the psychiatrist. The interventions for other staff were routine, generic discipline functions that lacked focus for individualized treatment. These failures result in treatment plans that fail to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

V. Ensure that active treatment measures or purposeful alternative interventions were provided for 4 of 12 active sample patients (B26, B35, C17, and C26) to move the patients to a higher level of functioning and a less restrictive environment. These patients did not routinely attend the scheduled groups and unit activities, and there was no evidence that they received alternative treatment. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided to them. This potentially delays their improvement. (Refer to B125-I)

VI. Ensure that the severe medical problems of 2 of 3 discharged patients (D6 and D8) reviewed for medical care were evaluated and treated. During the hospitalization, Patient D6 developed symptoms of an acute abdomen. Patient D8 developed left-sided weakness suggestive of a cerebrovascular accident. Neither patient received immediate medical attention for these problems. Failure to immediately address these problems compromised the patients' medical status, requiring transfer to a medical hospital. Failure to address serious medical problems in a timely way is a risk to patients' health, and it prevents them from achieving an optimal level of functioning. (Refer to B125-II)

VII. Ensure that adequate risk assessments were completed and documented prior to discharge for 2 of 2 discharged patients (D9 and D10) reviewed for the occurrence of their death following discharge. This failure to assess the potential for suicide prevents a safe decision about the readiness of patients for discharge and is a risk to the health and life of patients being discharged into the community. (Refer to B125-III)

VIII. Ensure that there were physician orders for staff use of physical holds (restraint), and that all required assessments (e.g., face-to-face assessments) and documentations were completed for 1 of 1 active non-sample patient (C4) reviewed for the use of restraints. Patient C4 was placed in a physical hold (restraint) without a physician order or appropriate assessments or monitoring. This deficient practice exposes patients to potential harm and is a violation of patient rights to be free from restraint without documented justification. (Refer to B125- IV)

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

I. Ensure that the Master Treatment Plans of 12 of 12 active sample patients (A8, A14, A17, A43, B11, B17, B26, B35, B44, C9, C17 C26) included nursing interventions to address the patients' individualized treatment needs. The nursing interventions on the MTPs were routine generic nursing functions that lacked an individual focus for treatment. The absence of individualized nursing interventions on patients' treatment plans hampers staff's ability to provide appropriate care to patients.

Findings include:

A. Record Review:

1. The computerized Master Treatment Plans included lists of generic nursing interventions for the listed problems of "Danger to Self ;" "Aggression;" "Depression", "Psychosis;" "ADHD" and "Substance Abuse" and Hypermania." The interventions for each patient having these listed problems were the same for all patients, with no modifications to individualize them. Specific patient findings are noted below.

2. Patient A8

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." "Attention Deficit Hyperactivity Disorder": "Staff will monitor any changes in attention after use of medication, and document and notify the physician of noted changes."

3. Patient A14 (MTP=1/7/12).

The following nursing interventions were listed for the identified problems: "Danger to Self ": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

4. Patient A17 (MTP=1/3/12).

The following nursing interventions were listed for the identified problems: "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming."

5. Patient A43 (MTP date=1/7/12).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." "Attention Deficit Hyperactivity Disorder": "Staff will monitor any changes in attention after use of medication, and document and notify the physician of noted changes." "Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

6. Patient B11 (MTP=12/31/11).

The following nursing interventions were listed for the identified problems: "Danger to Self ": "Staff will monitor for safety per level of precaution." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." "Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

7. Patient B17 (MTP=12/23/11).

The following nursing interventions were listed for the identified problems: "Danger to Self ": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming."

8. Patient B26 (MTP=12/31/11).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming."

9. Patient B35 (MTP=12/30/11).

The following nursing interventions were listed for the identified problems: "Danger to Self ": "Staff will monitor for safety per level of precaution." "Hypermania": "Staff will instruct patient to speak in a moderate tone of voice when he/she is loud." "Psychosis" ": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." " Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking and disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

10. Patient B44 (MTP=12/30/11).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming."

11. Patient C9 (MTP=1/3/12).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

12. Patient C17 (MTP=11/29/11).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Substance Abuse": "Staff will set limits on negative behavior (e.g. medication seeking, disrespectful communication) encourage patient to attend groups and set short-term attainable goals, daily."

13. Patient C26 (MTP=12/24/11).

The following nursing interventions were listed for the identified problems: "Danger to Self": "Staff will monitor for safety per level of precaution." "Aggression": "Staff will monitor any changes in attention after use of medication and document and notify the physician of noted changes." "Depression": "Staff will provide medication to decrease depression, as necessary Medication teaching will be done with patient." "Psychosis": "Staff will encourage patient to get out of bed daily to attend to ADLs, meals and programming."

B. Staff Interview

In an interview on 1/10/12 at 3:30 p.m. which included a review of the Master Treatment Plans for Patients C9 and C17, the Director of Nursing verified that the MTPs did not include individualized nursing interventions. The DON also acknowledged that the interventions were the same for all patients with the same listed problems.

II. Ensure that the nursing staff had physician orders for the use of a physical hold (restraint). One of 1 active non-sample patient (C4), whose record was reviewed for the use of restraint, was placed in a physical hold with no documented physician order. There also was no documentation of appropriate assessments or monitoring. This deficient practice poses a danger for patients and is a violation of patient rights to freedom from restraint without documented justification.

Findings include:

A. Observation

During an observation on ward C2 on 1/9/12 at 1:55 p.m., two mental health technicians were observed placing Patient C4 in a physical hold and moving him/her down the ward hallway.

B. Record Review

A review of the medical record for Patient C4 on 1/10/11 at 3:20 p.m. revealed no physician order for restraint or documentation of appropriate assessments or monitoring for the physical hold on 1/9/12 at 1:55 p.m.

B. Staff Interview

In an interview on 1/10/12 at 3:40 p.m., after reviewing a video recording of Patient C4 being restrained by staff on1/9/12 at 1:55 p.m. in the hallway on Unit C2, the DON acknowledged that Patient C4 was placed in a physical hold (restraint) but that the event was not documented as a restraint. The DON also acknowledged that there was no physician order for the restraint, and no documentation of the required monitoring and assessments.

Based on record review and interview, the Director of Social Services failed assure that the Psychosocial Assessments for 12 of 12 sample patients (A8, A14, A17, A43, B11, B17, B26, B35, B44, C9, C17 and C26) were complete. Specifically the Discharge Planning Section of these patients' Psychosocial Assessments failed to include: a) an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; b) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and c) anticipated Social Work roles in treatment and discharge planning. This failure results in a lack of social work information for treatment planning. (Refer to B108)