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Based on medical record review and staff interview it was determined that for 12 of 12 active sample patients the Psychiatric Evaluations failed to include an inventory of patient assets which could be used in planning treatment (Patients A3, A20, A41, A53, B5, B13, B25, B31, C5, C7, C18 and C34). Failure to identify these patient assets impairs the treatment team's ability to develop interventions utilizing the individual strengths of each patient.

The findings include:

A. Record Review

1. Patient A3: The Psychiatric Evaluation dated 2/23/12 had the sole asset "healthy" listed.

2. Patient A20: The Psychiatric Evaluation dated 2/24/12 had the sole asset "Healthy" identified.

3. Patient A41: The psychiatric Evaluation dated 2/22/12 had "Supportive family" as the sole asset described.

4. Patient A53: The Psychiatric Evaluation dated 2/23/12 had "Healthy" as the sole asset identified.

5. Patient B5: The Psychiatric Evaluation dated 2/23/12 had "Supportive family" as the sole asset described.

6. Patient B13: The Psychiatric Evaluation dated 2/24/12 had "Intelligent" as the sole asset identified.

7. Patient B25: The Psychiatric Evaluation dated 2/29/12 had "Leading fighter for goodness" as the sole asset described.

8. Patient B31: The Psychiatric Evaluation dated 2/28/12 had no assets described.

9. Patient C5: The Psychiatric Evaluation dated 3/01/12 had "Cooperative and average intelligence" as the identified assets.

10. Patient C7: The Psychiatric Evaluation dated 2/29/12 had "Supportive family" as the sole asset identified.

11. Patient C18: The Psychiatric Evaluation dated 2/25/12 for patient assets stated "unknown."

12. Patient C34: The Psychiatric Evaluation dated 2/25/12 had "Supportive family" as the sole asset identified.

B. Staff Interview

On 3/05/2012 at 2:00PM the clinical director was interviewed. He was shown examples of the findings cited in Section I above. He agreed that these were not descriptive of assets of the patient that might be utilized to establish individualized therapeutic interventions.




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Based on record review and interview the facility failed to provide Master Treatment Plans (MTP) for 12 of 12 active sample patients (A3, A20, A41, A53, B5, B13, B25, B31, C5, C7, C18, & C34) that identified patient-related treatment goals in observable, measurable, and behavioral terms. The MTPs failed to provide "short-term objectives" which stated what the patient would do to lessen the severity of the identified problem (s), and that were patient specific rather than generalized statements of behavior(s). In addition, many of the "short-term objective" statements were stated as staff expectations for patient's participation instead of patient outcome behaviors. Failure to identify individualized and measurable "short-term objectives" for patients hampers the team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings include:

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). The findings were as follows:

1. Nine patients (A3, A53, B5, B13, B25, B31, C5, C18, and C34), with "Danger to Self" listed as a problem, had the same preprinted "short-term objective" checked on the Master Treatment Plan. Patients A3, B13, B25, B31, C5, C18, and C34 all had the following preprinted short-term objectives checked: "Patient will refrain from gestures/attempts to harm self, during hospital stay. Patient will talk about what triggers his/her impulse to self-harm," with the wording "prior to D/C [discharge]" hand written on the treatment plans for Patients A53, B5, B31, C5, and C34. Patients A53 and B5 had one of the two preprinted short-term objectives checked. These objectives were not measurable or patient specific.
Patient B25's Master Treatment Plan included the following hand written short-term objective for the problem of Danger to Self: "Pt [patient] will be able to engage in reality oriented therapy for 15-20 mins [minutes] daily to [decrease] delusional & confused thoughts prior to D/C [discharge]." This was a staff objective for the patient's participation in treatment instead of a behavioral patient outcome.

2. Eight patients (A3, A20, A41, A53, B13, B25, B31, and C34) with "Aggression" listed as a problem all had the following identical two preprinted "short-term objectives" checked on the Master Treatment Plan: "Patient will be able to express feelings of anger in an appropriate manner daily. Patient will ask to remove self from milieu when patient recognizes aggressive feelings." These objectives were not measurable and/or stated in behavioral terms.
Patient A20's Master Treatment Plan included the following hand written short-term objectives for the problem of Aggression: "Will provide pt [patient] [with] quiet environment and give 1:1 time [with] staff when feeling aggressive. Will help pt [patient] to identify cues & triggers prior to acting aggressive prior to D/C [discharge]." These were staff objectives instead of patient outcome behaviors to lessen the severity of the problem.

3. Six patients (A3, A53, B31, C5, C7, and C34) had "Depression" listed as a problem. Patients A3, B31, C5, and C34 all had the following preprinted short-term objectives checked: "Patient will get out of bed daily to participate in ADL's. Patient will get out of bed daily to participate in groups and activities as tolerated. Patient will follow medication regime and report response toward symptom improvement daily to the nurse or MD." These objectives were staff expectations for the patient's participation instead of patient outcome behaviors.

Patient A53 had two of the four preprinted short -term objectives checked and Patient C7 had three of the four preprinted short-term objectives checked. Patient C34's Master Treatment Plan included the following hand written short-term objective for the problem of Depression: "Pt [patient] will participate in 1 RT group daily displaying moderate motivation, prior to D/C [discharge]." This was a staff expectation for the patient's participation in treatment instead of a specific patient outcome behavior.

4. Five patients (A41, B13, B25, B31 and C18), with "Psychosis" listed as a problem all had the following identical four preprinted "short-term objectives" checked on the Master Treatment Plan: "Patient will be able to comply with the medication regime daily. Patient will be able to approach staff when experiencing auditory and/or visual hallucination and discuss content and identify ways to manage them. Patient will begin to verbalize hope and plan for the future free of suicidal ideation. [Note: None of these patients presented with suicidal ideation on admission.] Patient will demonstrate a decrease in hallucinations/delusions AEB [as evidenced by] (left blank)." These objectives were not measurable or stated in behavioral terms and one was a staff expectation regarding the patient's complying with medication regime instead of the patient's specific behavior outcome.

Patients A3 had three of the four preprinted objectives and had the following hand written short-term objectives for the problem listed as Psychosis: "Pt [patient] will actively participate in activities milieu [sic]. Patient will actively participate in RT daily [without] signs of responding to internal stimuli prior to D/C [discharge]." These statements were staff expectations for the patient's participation in activities instead of statements of the patient's outcome behavior(s). Patient B5 had the following hand written short-term objective for the problem listed as Psychosis: "Pt [patient] will be able to engage in RT reality oriented therapy 15-20 mins [minutes] [without] signs of paranoid or delusional thoughts prior to D/C." This was a staff expectation for the patient's participation in treatment instead of a specific patient outcome behavior.

B. Staff Interviews

1. During an interview on 3/6/12 at 11:45a.m. with RN1, the Master Treatment Plan for C18 was discussed. RN1 stated that the registered nurse initiated the treatment plan on admission of the patients and identified problems and objectives. RN1 agreed the treatment plan contained short term objectives that were not measurable and admitted that some objectives were staff objectives.

2. During an interview on 3/7/12 at 9:00a.m. with the Director of Nursing, the Master Treatment Plans for B31, C5, C7 and C34 were discussed. The Director of Nursing agreed that some short-term objectives on the treatment plans were not measurable and some were stated as staff expectations for participating in programming.




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Based on record review and interviews, the facility failed to develop individualized Master Treatment Plans (MTP) that clearly delineated interventions to address specific patient problems and treatment objectives. Specifically, treatment plans failed to include:

I. Specific and individualized treatment interventions. Instead treatment interventions, when included, were discipline functions incorrectly listed as treatment interventions: for 9 of 12 active sample patients (A3, A20, A41, B5, B31, C5, C7, C18, & C34) by the psychiatrist; for 9 of 12 active sample patients (A3, A20, A41, A53, B31, C5, C7, C18, and C34) by nursing staff; for 6 of 12 active sample patients (A20, A41, B5, B13, B25, and B31) by social workers; and for 5 of 12 active sample patients (A20, B25, B31, C18, and C34)by the recreational therapist.

II. How treatment interventions, when included, would be delivered (individual and/or group sessions); the frequency of contact between clinician and patient; and the focus of treatment for 12 of 12 active sample patients (A3, A20, A41, A53, B5, B13, B25, B31, C5, C7, C18, & C34). This included treatment interventions by physicians for 9 of 12 active sample patients (A3, A20, A41, B5, B31, C5, C7, C18, & C34); by nursing staff for 7 of 12 active sample patients (A3, B5, B13, B25, B31, C7 and C34) and by social workers and recreational therapists for 12 of 12 active sample patients listed above.

III. Treatment interventions to be implemented by all clinical staff. The MTPs failed to include physicians for all listed psychiatric problems for 8 of 12 active sample patients (A3, A53, B5, B13, B25, B31, C7 and C18) and nursing interventions for all listed problems for 5 of 12 active sample patients (A3, B5, B13, B25, B31, C7 and C34).

IV. Medication Groups conducted by nurses, listed on the "Unit Program Schedule" and attended by 2 of 4 active sample patients on Unit B (B5 and B31).

These failures potentially result in lack of direction for clinicians regarding the specific treatment approaches and focus of treatment for each individual patient, and potentially results in inconsistent and/or ineffective treatment.

Findings include:

I. Routine and Generic Discipline Functions

A. Review of Records

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). The review revealed the following generic and routine discipline functions written as treatment interventions:

1. Patient A3:
Problem: "Danger to Self..." - "Physician will prescribe mood stabilizer to improve symptom reduction."
Problem: "Depression" - "Physician will prescribe antidepressant to improve symptom reduction."
Problem: "Aggression..." - "Physician will prescribe mood stabilizer to improve symptom reduction. Nursing Staff will encourage Pt [patient] to attend & participate in grp [group] activities x2 daily."
Problem: "Psychosis" - "Nursing Staff will assist patient to maintain a normal cycle of sleep." Problem: "Post Traumatic Stress Disorder..." - "Nursing will monitor & assess for sleep q [every] day."

2. Patient A20:
Problem: "Aggression..." - "Physician will prescribe medication to improve symptom reduction. Nursing will set limits on aggressive behavior via: providing pt [patient] with unit schedule and appropriate behavioral expectations."
Problem: "Oppositional Defiance..." - "Physician will prescribe medication to improve symptom reduction. Nursing staff will allow patient to take time out, reduce stimuli, encourage relaxation...Nursing staff will set firm consistent limits and stick to unit schedule. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will set clear expectations at start of session."
Problem: "Attention Deficit Hyperactivity Disorder..." - "Physician will prescribe ADHD meds to improve symptom reduction."
Problem: "Autism and Developmental Disorders..." - "Physician will prescribe ind tx (i.e. individual treatment) 7x week. Social Worker will recommend evaluation to [Doctor's name] per mom's request to confirm Asberger's [sic] Dx [diagnosis]."

3. Patient A41:
Problem: "Psychosis..." - "Psychiatrist will prescribe antipsychotic to improve symptom reduction. Nursing staff will offer 1:1 time during hospital stay as needed when patient has [increased] tension rt [related to] perseveration to assist relaxation [sic]."
Problem: "Aggression..." - "Psychiatrist will prescribe medications to improve symptom reduction. Nursing staff will set limits on aggressive behavior via: [positive] coping skills. Social Worker will offer redirection for aggressive behavior."

4. Patient A53:
Problem: "Danger to Self..." - "Nursing staff will offer 1:1 time with pt [patient] when pt [patient] notifies staff of feelings of self harm during hospital stay."
Problem: "Aggression..." - "Nursing staff will set limit on aggressive behavior via: allowing pt [patient] to remove self from milieu when aggressive feelings are recognized."

5. Patient B5:
Problem: "Danger to Self..." - "Physician will prescribe antipsychotic to improve symptom reduction. Social Worker will complete social work assessment and discharge safety plan. Social Wrk [work] will encourage pt [patient] to allow family contact to coordinate appropriate discharge plan."
Problem: "Psychosis..." - "Physician will prescribe antipsychotic to improve symptom reduction. Social Worker will encourage pt to participate in daily social work groups for 60 - 70 minutes [sic] reality orient. Social wrk [work] will coordinate aftercare with [agency initials]." Problem: "Family Conflict..." - "SW [Social Worker] will [sic] family members to [sic] conflict. SW [Social Worker] will recommend outpt [outpatient] family therapy."

6. Patient B13: Problem: "Danger to Self..." - "Social Worker to develop crisis safety plan for pt [patient] to access/utilize post discharge."

7. Patient B25:
Problem: "Psychosis..." - "Social Worker will speak with family and case manager re baseline." Problem: "Aggression..." - "Social Worker will contact pt's mother and case manager re: baseline and confirm pt's living arrangements. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will allow breaks & pt to leave as needed to cool down."

8. Patient B31:
Problem: "Danger to Self..." - "Physician will prescribe medication to improve symptom reduction."
Problem: "Depression..." - "Physician will prescribe medications to improve symptom reduction. Nursing Staff will provide medication to decrease depression as necessary."
Problem: "Aggression..." - "Social work will contact pt's [patient's] AFC home to determine if pt [patient] can return. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will allow pt to leave & take breaks as needed to cool down."
Problem: "Psychosis..." - "Physician will prescribe medication to improve symptom reduction. Nursing Staff will encourage the patient to discuss real people and events, while participating in a structured environment with [left blank]. Social Worker will obtain pt's most recent medication from [agency's initials] to provide to [MD's name]. Social work will coordinate aftercare with [agency's initials]."

9. Patient C5:
Problem: " Danger to Self..." - "Physician will prescribe antidepressant to improve symptom reduction. Nursing Staff will assess SI [suicide ideation] BID [two times per day] & PRN [as needed]."
Problem: "Depression..." - "Physician will prescribe antidepressant to improve symptom reduction. Nursing Staff will assess depression BID [twice a day] & PRN [as necessary]."

10. Patient C7:
Problem: "Danger to Self..." - "Physician will prescribe antidepressants to improve symptom reduction."
Problem: "Depression..." - "Physician will prescribe antidepressant to improve symptom reduction & mood stabilizers. Nursing Staff will monitor pt [patient] for s/s [signs/symptoms] of Depression and side effects of medications. Social Worker will encourage pt [patient] to increase his activities of daily living to provide opportunities to build more social support."

11. Patient C18:
Problem: "Danger to Self..." - "Physician will prescribe antipsychotic to improve symptom reduction." Problem: "Impaired Intellectual Functioning...Nursing staff will assist patient with ADLs, meals and toileting as needed. Staff [Recreational Therapist] adapt and provide structured, success-oriented activities and groups 5-7 weekly as tolerated."
Problem: "Psychosis ..." - "Physician will prescribe antipsychotic to improve symptom reduction. Nursing Staff will encourage the patient to discuss real people and events, while participating in a structured environment with peers and staff. Recreational Therapist will prompt pt to engage in reality oriented task when responding to internal stimuli."
Problem: "Attention Deficit Hyperactivity Disorder..." - Staff [Nursing] will monitor any changes in attention after use of medications and document and notify the physician of noted changes."

12. Patient C34:
Problem: "Danger to Self..." - "Physician will prescribe anxiolytic & antianxiety med to improve symptom reduction. Nursing Staff will monitor pt [patient] for efficacy of antidepressant Tx [treatment] and side effects of medications. Recreational Therapist will provide services 5-7 days/week and will offer pt alternative activities when needed."
Problem: "Depression..." - "Physician will prescribe antidepressant med to improve symptom reduction. Nursing Staff will provide medication to decrease depression, as necessary..." Problem: "Aggression..." - "Physician will prescribe anxiolytic & antianxiety med [medication] to improve symptom reduction. Nursing Staff will set limits on aggressive behavior via: encouraging pt [patient] to discuss healthy coping skills."

B. Staff Interviews

1. During an interview on 3/6/12 at 11:45a.m. with RN1, the treatment plan for C18 was discussed. RN1 agreed the treatment plan contained interventions that were routine and generic nursing functions.


2. During an interview on 3/7/12 at 9:00a.m. with the Director of Nursing, the treatment plans for B31, C5, C7 and C34 were discussed. The Director of Nursing agreed that the interventions were nursing tasks and stated that the form needed to be changed.

II. Interventions that failed to include delivery method, frequency and focus of treatment

A. Review of Records

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). [Note: All plans reviewed used the revised treatment plan form mentioned in the facility's POC (Plan of Correction).] The review revealed the following treatment interventions that failed to include delivery method (individual or group sessions), the frequency of contact with the patient, and/or focus of treatment.

1. Nine of twelve active sample patients' records (A3, A20, A41, B5, B31, C5, C7, C18, & C34) had the same generic physician statement, with no details as to type of contact, frequency of contact or focus of contact for all problems where physician involvement was noted: "Physician will prescribe [class of drug named] to improve symptom reduction." Refer to Section I above for each record ' s specific findings.

2. Patient A3: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff and social worker, and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Social Worker will encourage pt [patient] to better express feelings through writing letters or journal. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will provide opportunities to learn [positive] coping skills to [decrease] thoughts of harm."
Problem #2: "Depression..." - "Nursing staff will encourage pt [patient] to attend & participate in grp [group] activities x's 2 daily. Social Worker will encourage pt to identify triggers of anger toward sister. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide activities to increase socialization [with] peers and ¿depression."
The treatment interventions for problem #3: "Aggression..." and problem #4: "Psychosis..." were statements with no delivery method and frequency of contact with the patient to be implemented by the nursing staff and social worker and no delivery method be implemented by recreational therapists.

3. Patient A20: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff and social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Aggression..." - "Social Worker will complete safety crisis plan [with] pt and parent to identify triggers/stressors and set [positive goals] for [positive] behavior. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will allow pt to take breaks to cool down and help pt learn alternative reactions to situations."
Problem #2: "Oppositional Defiance..." - "Social Worker will explore [with] pt, mother and school triggers/stressors and devise D/C plan to address pt [negative] behavior and outline reasonable expectations. Recreational Therapist will provide services 5-7 days/week and will set clear expectations at start of session."
The treatment interventions for problem #3: "Attention Deficit Hyperactivity Disorder..." and problem #4: Autism and Developmental Disorders..." were statements with no delivery method and frequency of contact with the patient to be implemented by the nursing staff ["Nsg [Nursing] staff will assist pt. [patient] to [decrease] [his/her] agitated feelings y assisting [him/her] to learn to verbalize [his/her] anger vs [versus] acting out"], and social worker; and no delivery method to be implemented by recreational therapists.

4. Patient A41: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Psychosis..." - "Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will assist pt in identifying [negative] bx [behavior] and learning alternative reactions to situations."
Problem #2: "Aggression..." - "Social Worker will assist pt in reality orientation. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide verbal prompts to remain in session and recognize [negative] bx [behavior]. "

5. Patient A53: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff and social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Nursing staff will encourage patient to express feelings and identify positive coping skills. [No focus present. The frequency of "daily" was hand written.] Social Worker will work with pt in regards to coping skills. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will assist pt in identifying triggers and alternative coping skills to assist [with] triggers for self harming [sic]."
Problem #2: "Depression..." - "Social Worker will help pt [sic] with depression by deep breathing. Recreational Therapist will provide services 5-7 days/week for 30 to 60 minutes and will provide [sic] programming for pt participation in leisure activities and help pt identify [positive] leisure activities to ¿mood."
The treatment interventions for problem #3: "Aggression..." and Problem #4: "Family Conflict..." were statements with no delivery method and frequency of contact with the patient to be implemented by the nursing staff and social worker and no delivery method to be implemented by recreational therapists.

6. Patient B5: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will offer opportunities to learn [positive] outlets to [sic] emotions. Assist pt in identifying [negative] bx [behavior] and learning alternative reactions to situations."
Problem #2: "Psychosis..." - "Recreational Therapist will provide services 5-7 days/week for 30-60 minutes daily and will provide reality oriented activities to help assist [with] delusional thoughts."

7. Patient B13: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Social Worker will provide reality testing and orientation regarding patient's paranoid delusions... Will educate patient regarding appropriate coping skills to utilize when angry or anxious. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will provide an opportunity to learn [positive] coping skills."
Problem #2: "Psychosis..." - "Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide verbal prompts to remain in session and recognize [negative] bx [behavior]."
Problem #3: "Aggression..." - "Social Worker will educate patient re consequences of aggressive and destructive behavior...Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide physical exercise to ¿ aggressive bx] behavior."

8. Patient B25: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Psychosis..." - "SW [Social Worker] will engage [patient] in reality oriented conversations. [No delivery method and frequency of contact with patient included]. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes daily and will provide alternative activities for pt [patient] when experiencing delusional thoughts."
Problem #2: "Danger to Self..." - "Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide opportunities for reality oriented socialization ¿ delusional & confused thoughts."
Problem #3: "Aggression..." - "Social Worker will encourage patient to attend groups to identify triggers and alternative coping skills.

9. Patient B31: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff and social work staff, and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills. Social Worker will complete discharge safety plan with pt [patient] and pt's [patient's] case manager to determine an appropriate discharge plan. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will provide a [positive] physical outlet to help ¿ thoughts of self harm or harming others."
Problem #2: "Depression..." - "Nursing Staff will assist patient in learning healthy coping skills for depression. ... Medication teaching will be done with patient."
Problem #3: "Aggression..." and -problem #4: "Psychosis..." were discipline tasks written as intervention statements.

10. Patient C5: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff and social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills. Social Worker will work with patient to develop a safety crisis plan and review upon D/C [discharge]. SW [Social Worker] will educate importance of staying on medication. Recreational Therapist will provide services 5-7 days/week for 30 to 60 minutes and will provide opportunities to learn [positive] coping skills to ¿ thoughts of self harm." Problem #2: "Depression..." - "Social Worker will encourage pt to attend group to discuss triggers to [sic] and healthy ways [sic] [with] Depression. Recreational Therapist will provide services 5-7 days/week for 30 -60 minutes and will provide activities to ¿ socialization [with] peers."

11. Patient C7: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Social Worker will create a safety crisis plan with pt [patient] due to danger to self and multiple attempts overdosing. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will provide self esteem programming to [increase] sense of self worth."
Problem #2: "Depression..." - [Note: All interventions were routine discipline tasks. See B122, Part I.]

12. Patient C18: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by nursing staff and the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self..." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills. Deep breathing, talking with staff [sic]. Social Worker will review [with] pt d/c [discharge] safety plan. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes and will provide [positive] outlets to express emotions related to running away from group home."
Problem #2: "Impaired Intellectual Functioning..." - "Staff [Social Worker] will educate patient regarding appropriate community resources to access support upon discharge, as needed..."
The treatment interventions for problem #3: "Psychosis..." and Problem #4: "Attention Deficit Hyperactivity Disorder..." were statements with no delivery method and frequency of contact with the patient to be implemented by the nursing staff and social worker and no delivery method be implemented by recreational therapists.

13. Patient C34: The Master Treatment Plan included the following problems with treatment interventions that had no delivery method and frequency of contact with the patient included for interventions to be implemented by nursing staff and the social worker and no delivery method included for interventions to be implemented by recreational therapists.
Problem #1: "Danger to Self ... " - " Social Worker will assist the pt [patient] in completing a safety crisis plan upon D/C [discharge]. Recreational Therapist will provide 5-7 days/week for 30 to 60 minutes daily and will provide [positive] outlets to express emotions."
Problem #2: "Depression..." - "Nursing Staff ... Medication teaching will be done with patient. Social Worker will address positive activities which increase self esteem and mood."
Problem #3: "Aggression..." - "Social Worker will educate pt on coping skills to assist in managing anger. Recreational Therapist will provide services 5-7 days/week for 30-60 minutes and will provide [positive] outlets and coping skills to assist [with] [decrease] Aggressive Bx [behavior]."

B. Staff Interviews

1. During an interview on 3/6/12 at 11:45a.m. with RN1, the treatment plan for C18 was discussed. RN1 agreed that the interventions statements on the treatment plan did not specify method of delivery, frequency or focus of treatment.

2. During an interview on 3/6/12 at 2:30 with the Director of Performance Improvement and Director of Nursing, the treatment plans for B31, C5, C7 and C34 were discussed. The Directors agreed that the intervention statements on the treatment plans did not specify method delivery, frequency of contact or focus of treatment.

III. Failure of MTPs to include treatment modalities/interventions for all disciplines

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). The MTPs did not contain treatment modalities/interventions to be implemented by psychiatrists for Patients (A3, A53, B5, B13, B25, B31, C7, and C18) and by nursing staff for Patient B5, B13, B25, B31 and C7.

1. Patient A3: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist for problem #5: "Post Traumatic Stress Disorder."

2. Patient A53: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist for problem #2 - "Depression" and problem #3 - "Aggression."

3. Patient B5: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist and by nursing staff for problem #1: "Danger to Self " and problem #2: "Psychosis."

4. Patient B13: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist and nursing staff for problem #1: " Danger to Self, " problem #2: "Psychosis" and problem #3 "Aggression."

5. Patient B25: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist and nursing staff for problem #1: "Psychosis," problem #2: "Danger to Self" and problem #3: "Aggression."].

6. Patient B31: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist for problem #1: "Danger to Self," problem #2: "Depression" and for problem 3: "Aggression." There was no nursing intervention checked or hand written in for problem #3.

7. Patient C7: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist and nursing staff for problem #1: "Danger to Self." There was also no intervention to be implemented by the psychiatrist for problem #2: "Depression."

8. Patient C18: There were no interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist for problem #4: "Attention Deficit Hyperactivity Disorder" and problem #5: "Seizure Disorder related to per history."

B. Staff Interviews:

1. On 3/05/2012 at 2:00PM the clinical director was interviewed. He confirmed that some problem statements had no treatment interventions checked from the preprinted list or hand written in to be implemented by the psychiatrist.

2. During an interview on 3/6/12 at 2:30, the Director of Nursing acknowledged that the treatment plans for B5, B14, and B31 did not contain nursing interventions checked or hand written in to be implemented by nursing staff.

IV. Failure of MTPs to include nursing groups attended by patients

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): B13 (2/23/12) and B31 (2/27/12).

During discussion at 1:25p.m. on 3/6/12, RN2 confirmed that the Medication Group listed on the Adult Unit B Schedule was assigned to and conducted by nurses.
During observation on 3/6/12 at 1:30p.m. in the Group Room, Patient B13 and B31attended a group listed as "Medication Group" on the Adult Unit B's Schedule. The nurse discussed general information about medications and gave each patient a folder with written information about taking medications.
Review of the treatment plans for these two patients revealed that this group was not included on these patients' treatment plans.

C. Staff Interviews

1. During an interview on 3/6/12 at 1:50p.m., when asked about the MTPs for Patients B13 and B31, LPN1 acknowledged that the Medication Group that she conducted was not included on patients' treatment plans.

2. During an interview on 3/6/12 at 2:30, the Director of Nursing acknowledged that the Medication Group listed on the Unit's B schedule was not included on the treatment plans for patients B13 and B31.




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Based on medical record review and staff interview it was determined that the clinical director failed to ensure that, for 12 of 12 active sample patients, their Psychiatric Evaluations described individualized assets and that their Treatment Plans contained patient specific goals and described the treatment modalities that would be utilized to accomplish them. These failures result in a lack of awareness of specific patient strengths to guide treatment team staff and fail to describe the goals for patient achievement or the modalities that have been selected to help them reach their goals. (Patients A3, A20, A41, A53, B5, B13, B25, B31, C5, C7, C18 and C34)

Findings include:

1. Failure to ensure that Psychiatric Evaluations contained patient assets to be used in treatment: See B117 for details.

2. Failure to set measurable patient treatment goals: See B121 for details.

3. Failure to adequately describe therapeutic modalities by all disciplines, and in particular assure physician interventions were present and adequately described for all patient problems identified: See B122 for details.




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Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Ensure that Master Treatment Plans contained specific and individualized nursing interventions. Instead nursing interventions were generic nursing functions incorrectly listed as treatment interventions for 9 of 12 active sample patients (A3, A20, A41, A53, B31, C5, C7, C18, & C34).

II. Ensure that Master Treatment Plans reflected how nursing interventions would be delivered (individual and/or group sessions), the frequency of contact, and the focus of treatment for 8 of 12 active sample patients (A3, A20, A41, A53, B31, C5, C18, & C34).

III. Ensure that nursing interventions were included on the treatment Master Treatment Plans for five of 12 active sample patients (B5, B13, B25, B31 and C7).

IV. Ensure that Medication Group conducted assigned to nurses, and isted on the "Unit Schedule" was included on the MTPs of 2 of 4 active sample patients on Unit B (B13 and B31). (Refer to B122-IV).

These failures potentially result in lack of direction for clinicians regarding the specific treatment approaches and focus of treatment for each individual patient, and potentially results in inconsistent and/or ineffective treatment.

Findings include:

I. Routine and Generic Nursing Functions

A. Review of Records

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). The review revealed the following generic and routine discipline functions written as treatment interventions:

1. Patient A3: Problem: "Aggression..." - "Nursing Staff will encourage Pt [patient] to attend & participate in grp [group] activities x2 daily." Problem: "Psychosis" - "Nursing Staff will assist patient to maintain a normal cycle of sleep." Problem: "Post Traumatic Stress Disorder..." - "Nursing will monitor & assess for sleep q [every] day."

2. Patient A20: Problem: "Aggression..." - "Nursing will set limits on aggressive behavior via: providing pt [patient] with unit schedule and appropriate behavioral expectations." Problem: "Oppositional Defiance..." - "Nursing staff will allow patient to take time out, reduce stimuli, encourage relaxation...Nursing staff will set firm consistent limits and stick to unit schedule."

3. Patient A41: Problem: "Psychosis..." - "Nursing staff will offer 1:1 time during hospital stay as needed when patient has ¿tension rt [related to] perseveration to assist relaxation." Problem: "Aggression..." - "Nursing staff will set limits on aggressive behavior via: [positive] coping skills."

4. Patient A53: Problem: "Danger to Self..." - Nursing staff will offer 1:1time with pt [patient] when pt [patient] notifies staff of feelings of self harm during hospital stay" Problem: "Aggression..." - " Nursing staff will set limit on aggressive behavior via: allowing pt [patient] to remove self from milieu when aggressive feelings are recognized."

5. Patient B31: Problem: "Depression..." - "Nursing Staff will provide medication to decrease depression as necessary. Problem: "Psychosis..." - "Nursing Staff will encourage the patient to discuss real people and events, while participating in a structured environment with [left blank].

6. Patient C5: Problem: "Danger to Self..." - "Nursing Staff will assess SI [suicide ideation] BID [two times per day] & PRN [as needed]." Problem: "Depression..." - "Nursing Staff will assess depression BID & PRN."

7. Patient C7: Problem: "Depression..." - "Nursing Staff will monitor pt [patient] for s/s [signs/symptoms] of Depression and side effects of medications.

8. Patient C18: Problem: "Impaired Intellectual Functioning..." - Nursing staff will assist patient with ADLs, meals and toileting as needed. Problem: "Psychosis..." - "Nursing Staff will encourage the patient to discuss real people and events, while participating in a structured environment with peers and staff." Problem: "Attention Deficit Hyperactivity Disorder..." - "Staff [Nursing] will monitor any changes in attention after use of medications and document and notify the physician of noted changes."

9. Patient C34: Problem: "Danger to Self..." - "Nursing Staff will monitor pt [patient] for efficacy of antidepressant Tx [treatment] and side effects of medications." Problem: "Depression..." - "Nursing Staff will provide medication to decrease depression, as necessary..." Problem: "Aggression..." - "Nursing Staff will set limits on aggressive behavior via: encouraging pt [patient] to discuss healthy coping skills."

B. Staff Interviews

During an interview on 3/7/12 at 9:00a.m. with the Director of Nursing, the treatment plans for B31, C5, C7 and C34 were discussed. The Director of Nursing agreed that the interventions were routine nursing tasks and stated that the form needed to be changed.

II. Interventions that failed to include delivery method, frequency and focus of treatment

A. Review of Records

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12).).] The review revealed the following nursing treatment interventions that failed to include delivery method (individual or group sessions), the frequency of contact with the patient, and/or focus of treatment.

1. Patient A3: The Master Treatment Plan included the following nursing treatment intervention with no delivery method and frequency of contact. Problem #3: "Aggression..." - "Nursing Staff will provide alternative means for pt to deal [with] [his/her] anger..."

2. Patient A20: The Master Treatment Plan included the following nursing treatment interventions with no delivery method and frequency of contact. Problem #3: "Attention Deficit Hyperactivity Disorder..." - "Nursing Staff will provide [positive] outlets; drawing and redirect pt to appropriate behavior." Problem #4: "Autism and Developmental Disorders..." - "Nursing staff will assist pt to ¿ [his/her] agitated feelings by assisting [him/her] to learn to verbalize [his/her] anger vs [versus] acting out."

3. Patient A53: The Master Treatment Plan included the following nursing treatment intervention with no delivery method and frequency of contact with the patient included for interventions to be implemented by the nursing staff. Problem #4: "Family Conflict..." - "Nursing staff will assist patient in developing improved communication skills and problem solving skills with family members."

4. The Master Treatment Plan included the following nursing treatment interventions with no delivery method and frequency of contact with the patient. Problem #1: "Danger to Self..." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills." Problem #2: "Depression..." - "Nursing Staff will assist patient in learning healthy coping skills for depression. Nursing Staff will...Medication teaching will be done with patient. [No focus of treatment identified.] Problem #3: "Aggression..." had no nursing intervention identified and for problem #4: "Psychosis..." the intervention was a nursing task written as an intervention statement.

5. Patient C5: The Master Treatment Plan included the following nursing treatment interventions with no delivery method and frequency of contact with the patient. Problem #1: "Danger to Self .." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills." Problem #2: "Depression..." - "Nursing Staff will assist patient in learning healthy coping skills for depression."

6. Patient C18: The Master Treatment Plan included the following nursing treatment intervention with no delivery method and frequency of contact with the patient included for interventions to be implemented by nursing staff. Problem #1: "Danger to Self..." - "Nursing Staff will encourage patient to express feelings and identify positive coping skills. Deep breathing, talking with staff."

7. Patient C34: The Master Treatment Plan included the following nursing treatment intervention with no delivery method and frequency of contact with the patient. Problem #2: "Depression..." - "Nursing Staff...Medication teaching will be done with patient."

B. Staff Interviews

1. During an interview on 3/6/12 at 11:45a.m. with RN1, the treatment plan for C18 was discussed. RN1 agreed that the interventions statements on the treatment plan did not specify method of delivery, frequency or focus of treatment.

2. During an interview on 3/6/12 at 2:30 with the Director of Risk Management and Director of Nursing, the treatment plans for B31, C5, C7 and C34 were discussed. The Directors agreed that the intervention statements on the treatment plans did not specify method delivery, frequency of contact or focus of treatment.

III. Failure of MTPs to include nursing treatment modalities/interventions

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A3 (2/23/12, updated 2/27/12); A20 (2/23/12 , updated 2/24/12); A41 (2/21/12); A53 (2/22/12, updated 2/23/12 & 2/27/12); B5 (2/22/12); B13 (2/23/12); B25 (2/28/12); B31 (2/27/12); C5 (2/29/12); C7 (2/29/12); C18 (2/24/12); & C34 (2/24/12). The MTPs did not contain treatment modalities/interventions to be implemented by nursing staff for Patient B5, B13, B25, B31, and C7.

1. Patient B5: There were no interventions checked from the preprinted list or hand written in by nursing staff included on the Master Treatment Plan for problem #1: "Danger to Self" and problem #2 - "Psychosis."

2. Patient B13: There were no interventions checked from the preprinted list or hand written in to be implemented nursing staff included on the Master Treatment Plan for problem #1: "Danger to Self." problem #2: "Psychosis" and problem #3 "Aggression."

3. Patient B25: There were no interventions checked from the preprinted list or hand written in to be implemented by nursing staff included on the treatment plan for problem #1: "Psychosis," problem #2: "Danger to Self" and problem #3: "Aggression."].

4. Patient B31: There were no interventions checked from the preprinted list or hand written in to be implemented by nursing staff for problem 3: "Aggression."

5. Patient C7: There were no interventions checked from the preprinted list or hand written in to be implemented by nursing staff included on the Master Treatment Plan for problem #1: "Danger to Self."

B. Staff Interviews:

During an interview on 3/6/12 at 2:30, the Director of Nursing acknowledged that the treatment plans for B5, B14, and B31 did not contain nursing interventions checked or written in to be implemented by nursing staff.








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