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Based on record review and interview the facility failed to:

I. Assure that medical staff treatment modalities were included on the Master Treatment Plans (MTPs) of 7 of 8 active sample patients (A2, A9, B2, B11, B12, C3 and C5). The MTPs, developed the day of admission, also had no physician signatures. This failure results in the staff having to rely on oral communication regarding physicians' plans for treating each patient, a method that is unreliable and open to misinterpretation. It also can result in patients being denied a full spectrum of treatment modalities. (Refer to B118)

II. Assure that treatment groups met as scheduled for 8 of 8 active sample patients (A2, A9, A12, B2, B11, B12, C3 and C5) and 2 of 2 patients added to the sample (C1 and B5). The treatment staff also failed to provide alternative interventions for patients when the scheduled groups did not occur. When the group sessions did occur, they were often held in a small overcrowded room with 20 or more patients plus staff members and nursing students, with interruptions by nurses delivering medications to patients. The atmosphere in the groups precluded them providing a therapeutic setting from which patients could benefit. These failures result in patients being denied the opportunity to engage in a full range of active treatment modalities, potentially delaying recovery. (Refer to B125)

Based on record review and interview, the hospital failed to ensure that physician treatment responsibilities were identified on the Master Treatment Plans of 7 of 8 active sample patients (A2, A9, B2, B11, B12, C3 and C5). The MTPs, developed the day of admission, also had no physician signatures to indicate physician involvement. This failure results in the necessity for staff to rely on oral communication of the physicians' plans for treating each patient, a method that is unreliable and open to misinterpretation. It also can result in patients being denied a full spectrum of treatment modalities.

Findings include:

A. Record review

1. Patient A2 was admitted on 3/7/12. The Master Treatment Plan, dated 3/7/12, contained no physician interventions or a physician's signature.

2. Patient A9 was admitted on 3/11/12. The Master Treatment Plan, dated 3/11/12, contained no physician interventions or a physician's signature.

3. Patient B2 was admitted on 3/23/12. The Master Treatment Plan, dated 3/23/12, contained no physician interventions or a physician's signature.

4. Patient B11 was admitted on 3/17/12. The Master Treatment Plan, dated 3/17/12, contained no physician interventions or a physician's signature.

5. Patient B12 was admitted on 3/7/12. The Master Treatment Plan, dated 3/7/12, contained no physician interventions or a physician's signature.

6. Patient C3 was admitted on 3/12/12. The Master Treatment Plan, dated 3/12/12, contained no physician interventions or a physician's signature.

7. Patient C5 was admitted on 3/15/12. The Master Treatment Plan, dated 3/15/12, contained no physician interventions or a physician's signature.

B. Interview:

In an interview conducted on 3/28/12 at 8:30a.m., the Medical Director confirmed that the above Master Treatment Plans lacked physician interventions.

Based on observation and interview, the facility failed to assure that treatment groups met as scheduled for 8 of 8 active sample patients (A2, A9, A12, B2, B11, B12, C3 and C5) and 2 of 2 patients added to the sample (C1 and B5). The treatment staff also failed to provide alternative interventions for patients when the scheduled groups did not occur. When the group sessions did occur, they were often held in a small overcrowded room with 20 or more patients plus staff members and nursing students. Not enough seating was available so that some patients sat on the floor. Also, groups were interrupted by nurses delivering medications to patients. The group setting precluded a therapeutic experience for patients. These failures result in patients being denied the opportunity to participate in a full range of active treatment, potentially delaying recovery.

Findings include:

A. Observations

1. Review of the published activity schedules showed that 4 to 5 groups were scheduled for each day, Monday through Friday, for each of the three treatment units.

2. On 3/26/12 from 10 a.m. until 10:15a.m., the surveyor observed that the Geriatric PCU Nurses Group, scheduled to begin at 10a.m., did not meet. No alternative activity was provided. This resulted in a scheduled therapeutic activity not being provided.

3. On 3/26/12 from 11 a.m. until 11:15a.m., the surveyor observed that the Geriatric PCU Orientation and Current Events Group, scheduled to begin at 11a.m., did not meet. Sample patient C1 was observed sitting alone watching television. No alternative activity was provided. This resulted in a scheduled therapeutic activity not being provided.

4. During an observation on 3/26/12, a nutrition group was scheduled to take place on the PCU South Geriatric unit. When the surveyor approached RN A at 1:40p.m. and asked about the group, RN A replied, "We're not having it." When asked about groups scheduled for the afternoon, RN 1 said, "We may have a recovery group later."

5. During an observation on 3/27/12 at 9a.m., a Goals Group was held on the women's psychiatric care unit (PCU). Although the group was scheduled for the women's unit only, patients from the men's PCU and the Geriatric PCU units were also included. There were 21 patients present, and some patients had to stand or sit on the floor. The group was interrupted on 2 occasions by nurses calling patients out to receive medications. These circumstances resulted in an activity that was non-therapeutic and chaotic.

6. During an observation on 3/27/12 at 1:30p.m., a Recovery Specialist Group on anxiety and coping skills was held on the women's PCU. This activity was a combined group with patients attending from other units, thus contributing to overcrowding. Additionally there were 2 interruptions to the group process for medication administration to patients.

B. Interviews

1. In an interview on 3/26/12 at 10:40a.m., RN A acknowledged that the Geriatric PCU Nurse group did not meet and no alternative activity was provided.

2. In an interview on 3/26/12 at 11:05a.m., when the surveyor asked Patient C1 how the hospitalization was going, the patient stated, "It's an experience being here, there is absolutely nothing to do. I just sit around or read. Patients just walk around all day."

3. In an interview on 3/26/12 at 11:15a.m., RN A acknowledged that the Orientation and Current Events Group, scheduled for 11a.m., did not meet. RN A stated that giving medications took priority and that staff sometimes put on the television or give patients a newspaper to read.

4. In an interview on 3/27/12 at 9:30a.m., when the surveyor asked Patient B5 if the patient attended any groups, the patient stated, "I'm left alone in my thoughts. There is so much down time and the TV blares all day."

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

I. Assure the Medical Director adequately monitored physician participation in treatment planning. There were no medical staff treatment modalities on the Master Treatment Plans (MTPs) of 7 of 8 active sample patients (A2, A9, B2, B11, B12, C3 and C5). The MTPs, developed the day of admission, also had no physician signatures. These failures result in the staff having to rely on oral communication regarding physicians' plans for treating each patient, a method that is unreliable and open to misinterpretation. It also can result in patients being denied a full spectrum of treatment modalities. (Refer to B144-I)

II. Ensure that a thorough peer review was completed for one patient (E1) who died unexpectedly while in the hospital. Consequently, no analysis was done that might have identified practices or procedures that may have contributed to this adverse outcome or identified opportunities for improvement to potentially reduce the risk of similar occurrences in the future. (Refer to B144-III)

III. Assure the Director of Nursing (DON) provided sufficient monitoring of nursing staff's delivery of scheduled nursing treatment groups. The scheduled groups were not always provided, and there was no evidence of alternative interventions for the patients. This failure results in patients being denied a full spectrum of treatment modalities. (Refer to B148-I)

IV. Assure the DON adequately monitored the completion and signing of required nursing assessments. Specifically, 3 of 8 active sample patients' nursing assessments were completed by a licensed practical nurse (LPN) with no reviews and co-signatures by a registered nurse (RN) as required by hospital policy. Failure of an RN to verify the adequacy of nursing assessments completed by LPNs potentially leads to patient's treatment needs not being met. (Refer to B148-II).

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

I. Ensure that medical staff was included in treatment modalities on the Master Treatment Plans (MTPs) of 7 of 8 active sample patients (A2, A9, B2, B11, B12, C3 and C5). The MTPs, developed the day of admission, also had no physician signatures. This failure results in the staff having to rely on oral communication regarding physicians' plans for treating each patient, a method that is unreliable and open to misinterpretation. It also can result in patients being denied a full spectrum of treatment modalities. (Refer to B118)

II. Ensure that all active therapeutic efforts were consistently available to 8 of 8 sample patients (A2, A9, A12, B2, B11, B12, C3 and C5) and 2 of 2 patients added to the sample (C1 and B5). Scheduled treatment group sessions were cancelled without notice. Some group sessions were held in a small overcrowded room with 20 or more patients plus staff members and nursing students. Not enough seating was available so that some patients sat on the floor. Also, groups were interrupted by nurses delivering medications to patients. These failures result in patients' being denied the opportunity to participate in a full range of active treatment and could delay their recovery (Refer to B125)

III. Ensure that a thorough peer review was completed for one patient (E1) who died unexpectedly while in the hospital. Consequently, no analysis was done that might have identified practices or procedures that may have contributed to this adverse outcome or identified opportunities for improvement to potentially reduce the risk of similar occurrences in the future.

Findings include:

A. Record review

Patient E1 was a 43 year-old who was admitted on 7/14/11 with diagnoses of Schizophrenia, undifferentiated, chronic; hypertension; hyperlipidemia; diabetes mellitus; and hypothyroidism. According to the admission History and Physical, the patient was in stable medical condition when admitted. On 7/28/11, Patient E1 developed a fever of 102.2 degrees Fahrenheit, wheezing and a cough. A chest x-ray showed bilateral lung infiltrates. Patient E1 was prescribed an antibiotic, a bronchodilator, and an antipyretic (ordered by a Nurse Practitioner). The following day at the 1:45a.m. bed check, Patient E1 was found to be awake and sitting on the side of the bed, having removed his/her clothes. The nurse assisted the patient back to bed; there was no documentation of a call being placed to the doctor. On a routine bed check at 5:30a.m., Patient E1 was found to be cyanotic and unresponsive. CPR was begun at that time. Patient E1was transported by ambulance to a general hospital and was pronounced dead.

B. Interview

In an interview on 3/27/12 at 1:30p.m., the Director of Quality Improvement and Risk Management stated that he and the Medical Director had reviewed the record after the death and "signed off on it" without conducting a formal written review.

Based on observation, record/document review and interview, the Director of Nursing (DON) failed to adequately assure the quality of nursing on the Psychiatric Care Units (PCU). Specifically, the DON failed to:

1. Assure that scheduled nursing groups were consistently provided. Nursing groups were sometimes cancelled with no evidence that alternative activities were provided for patients. This deficiency results in patients being hospitalized without the opportunity to receive all therapeutic programming, potentially delaying recovery

Findings include:

A. Observations

1. On 3/26/12 from 10a.m. until 10:15a.m., the surveyor observed that the Geriatric PCU Nurses Group, scheduled to begin at 10a.m., did not meet. No alternative activity was provided. This resulted in a scheduled therapeutic activity not being provided.

2. On 3/26/12 from 11 a.m. until 11:15a.m., the surveyor observed that the Geriatric PCU Orientation and Current Events Group, scheduled to begin at 11a.m., did not meet. No alternative activity was provided. This resulted in a scheduled therapeutic activity not being provided.

B. Interviews

1. In an interview on 3/26/12 at 10:40a.m., RN A acknowledged that the Geriatric PCU Nurse group did not meet and no alternative activity was provided.

2. In an interview on 3/26/12 at 11:05a.m., when the surveyor asked Patient C1 how the hospitalization was going, the patients stated, "It's an experience being here, there is absolutely nothing to do. I just sit around or read. Patients just walk around all day."

3. In an interview on 3/26/12 at 11:15a.m., RN A acknowledged that the Geriatric PCU Orientation and Current Events Group, scheduled for 11a.m., did not meet. RN A stated that giving medications took priority and that staff sometimes put on the television or give patients a newspaper to read.


4. In an interview on 3/27/12 at 9:30a.m., the surveyor asked Patient B5 if s/he attended any groups. The patient stated, "I'm left alone in my thoughts. There is so much down time and the TV blares all day."

5. In an interview on 3/27/12 at 3:20p.m., the DON acknowledged that nursing groups do not always meet as scheduled.

II. Assure that nursing assessments conducted by LPNs were reviewed and co-signed by an RN as required by hospital policy. This failure potentially results in incomplete information for determining individual patients' treatment needs.

Findings include:

A. Policy Review

Nursing Admission Policy # 190-02, section VII (last revised October, 2010) states, "The Nursing assessment shall be completed by a licensed nurse within 8 hours of admission. If the assessment is completed by a Licensed Practical Nurse, then the assessment must be reviewed and signed by a Registered Nurse."

B. Record Review

1. For Patient A12 (admitted 3/23/12), the admission nursing assessment was completed by a licensed practical nurse (LPN) on 3/23/12 and had not been cosigned by a registered nurse (RN) as of 3/28/12.

2. For Patient B11 (admitted 3/17/12), the admission nursing assessment was completed by a licensed practical nurse (LPN) on 3/17/12 and had not been cosigned by a registered nurse (RN) as of 3/28/12.

3. For Patient C3 (admitted 3/12/12), the admission nursing assessment was completed by a licensed practical nurse (LPN) on 3/12/12 and had not been cosigned by a registered nurse (RN) as of 3/28/12.

C. Interview

During an interview on 3/27/12 at 4:15p.m., the Director of Nursing (DON) acknowledged that nursing assessments active sample patients A12, B11 and C3 were not cosigned by an RN as required by hospital policy.