HospitalInspections.org

Based on interview and record review, the facility failed to ensure safe and appropriate seclusion for 2 of 30 patients based on the facility's policy.

Findings include:

A review of two patients seclusion records revealed the facility did not take vital signs as required by facility policy for one patient who was on seclusion for 127 minutes and another patient who was on seclusion for 240 minutes.

Vital signs were not conducted at least every two hours as indicated in the policy titled, "Restraints; Seclusions; Protective Holds."

The Director of Nursing confirmed that vital signs had not been taken as required by the facility policy for two patients.

Based on interview, clinical record review and document review, the facility did not ensure clinical records were legible and complete for 13 of 30 patients (Patient #7, #8, #9, #12, #13, #14, #15, #19, #22, #25, #10, #30 and #29.)

Findings include:

The facility's policy titled, "Progress Record Documentation," stated in part: "It is the policy of Spring Mountain Treatment Center to maintain a complete and accurate medical for each individual patient. Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be concise, timely, legible, accurate and complete."

On 1/7/16 the Director of Nursing was interviewed. The Director acknowledged illegible clinical records was a problem at the facility.

Patient #7

Patient #7 was admitted to the facility on 1/3/16, with diagnoses that included schizophrenia. A review of the patient's clinical record on 1/6/16, was conducted. The document titled, "De-escalation strategies - Safety Assessment," was blank. The statement "Pt (patient) is unable to complete form in English," was written on the document.

The document was reviewed with the Director of Nursing on 1/6/16. The Director indicated the form should have been filled out either by the nurse after reviewing the form with the patient or by using the telephonic translation service.

Patient #8

Patient #8 was admitted to the facility on 1/5/16, with diagnoses that included detoxification from alcohol. The patient's clinical record was reviewed on 1/7/16, and revealed the document titled, "Medical Consultation," dated 1/5/16, included illegible words under the headings "Diagnosis/Significant Findings" and "Plan."

Patient #9

Patient #9 was admitted to the facility on 12/31/16, with diagnoses that included schizoaffective disorder. The patient's clinical record was reviewed on 1/7/16, and revealed the document titled, "Acute Psychiatric Progress Note," dated 1/4/16, included 13 of 13 illegible words under the heading, "Clinical Interview/Narrative Update/Justification for Continued Stay."

Patient #12

Patient #12 was admitted to the facility on 12/1/15, with diagnoses that included psychosis. The patient's clinical record was reviewed on 1/7/16, and revealed the document titled, "Acute Psychiatric Progress Note," dated 12/1/15, contained illegible entries.

Patient #13

Patient #13 was admitted to the facility on 11/3/15, with diagnoses that included major depressive disorder. The patient's clinical record was reviewed on 1/7/16, and revealed the document titled, "Medical Consultation," contained illegible entries.

Patient #14

Patient #14 was admitted to the facility on 11/1/15, with diagnoses that included bipolar disorder. The patient's clinical record was reviewed on 1/7/16, and revealed the document titled, "Medical Consultation," dated 11/1/15, contained illegible entries.

Patient #15

Patient #15 was admitted to the facility on 7/14/15, with diagnoses that included paranoid schizophrenia. On 7/22/15, Patient #15's physician wrote an order that stated, "Pt (patient) may shave. D/C (discontinue) (illegible) 16 mg (milligrams) QHS (every bedtime)." On 7/24/15, Patient #15's physician wrote an order that stated, "Haldol 5 mg (milligrams) Benadryl 50 mg Ativan 2 mg STAT Increase (illegible) to 32 mg." No route of administration was given for these medications.


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Patient #19

Review of the medical record for Patient #19 revealed documentation regarding Eighth Judicial District Family Court for another patient (Unsampled Patient #31) was included in the medical record. Court documents regarding an involuntary admission that were provided to the facility from a local hospital had Patient #19 name hand written on the top of the document, however, Patient #31 medical record information was on the lower section of the document. On 1/7/16, the Chief Nursing Officer revealed the facility was not aware of the documents for one patient located in another patient's medical record.

Review of the Acute Psychiatric Progress Note, dated 1/5/16, revealed the clinical interview, treatment plan, social academic history, and discharge goals were illegible.

Patient #22

Review of the Acute Psychiatric Progress Note, dated 1/5/16, revealed the clinical interview, discharge plan/goals, treatment plan and discharge plan were illegible.

Patient #25

Review of the Acute Psychiatric Progress Note, dated 1/5/16, revealed the clinical interview, discharge plan/goal, social/academic history, assets/strengths, formulation and discharge goals were illegible.

Patient #10

Review of the Acute Psychiatric Progress Note, dated 1/6/16 and 1/7/16, revealed the clinical interviews, discharge plans, and treatment plans were illegible.


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Patient #30

Patient #30 was admitted on 1/5/16, with diagnoses including bipolar disorder.

Review of Patient medical record revealed the following:

- An "Initial Treatment Plan" lacked documented evidence of the "Staff Printed Name, Signature and Credentials, Date and Time" of the staff member who completed the patient's treatment plan.

- A form entitled, "Patient Observation Rounds," had an area designated to document the precaution type, which included Suicide, Assault/Homicidal, Fall, Sexual Aggression, AWOL(absent without leave)/Elopement, Sexual Victimization, Gym Restriction, Medically Complex, Allergies, and Special Diet. The form lacked documented evidence of type of precaution to use during the patient observation round for Patient #30.

On 1/7/16 at 3:45 PM, a Registered Nurse (RN) explained the patient's initial treatment plan was completed by the admitting nurse and should have been signed and dated at the time of admission. The RN confirmed the "Patient Observation Rounds" form was not complete. The RN verbalized, "It should have included the precaution type."

Patient #29

Patient #29 was admitted on 12/26/15, with diagnoses including unspecified psychosis and major depressive disorder.

On 1/7/16, review of Patient #29's MAR revealed a RN did not consistently document when medications refused by the patient on the patient's MAR. The MAR was left blank on dates indicated for the following medications:

-Megace 40 milligrams (mg) QDay (every day) to be given at 8:00 AM for failure to thrive. The MAR lacked documented evidence the medication was refused 12/27/15 - 1/7/16.

-Megace 80 mg QDay to be given at 0800 for failure to thrive. The MAR lacked documented evidence the medication was refused from 12/27/15 through 1/7/16.

- Megestrol Oral Suspension 80 mg to be given at 8:00 AM for failure to thrive. The MAR lacked documented evidence the medication was refused on 1/1/16.

-Depakote 250 mg QHS (at bedtime) to be given at 8:00 PM for mood. The MAR lacked documented evidence the medication was refused on 12/29/15 and 12/30/15.

-Seroquel 100 mg QAM (in the morning) to be given at 8:00 AM for psychosis. The MAR lacked documented evidence the medication was refused on 12/29/15, 12/30/15 and 1/7/16.

- Seroquel 300 mg QHS to be given at 8:00 PM for psychosis. The MAR lacked documented evidence the medication was refused on 1/1/16, 1/2/16 and 1/7/16.

-Remeron 15 mg QHS to be given at 8:00 PM for mood. The MAR lacked documented evidence the medication was refused from 12/26/15 through 1/7/16.

-Cogentin 1 mg BID (twice daily) to be given at 8:00 AM and 8:00 PM for extrapyramidal side effects (EPS- physical symptoms, including tremor, slurred speech). The MAR lacked documented evidence the medication was refused on 12/29/15 and 12/30/15 at 8:00 AM; and on 1/1/16, 1/2/16 at 8:00 PM.

On 1/7/16 at 2:15 PM, a Registered Nurse explained when a patient refused medications a verbal notification would have been given to the physician during the treatment session. The RN confirmed a patient's refusal of a medication should have been documented on the MAR and in the nursing progress notes.

On 1/7/16 at 4:05 PM, the Chief Nursing Officer indicated the expectation was for the nurses to document in the MAR and the nursing notes when a patient refused a medication.

Facility policy entitled, "Medications Refused by Patient," Policy No.: MM.030, Last Reviewed/ Revised 11/15, indicated the following:

"Policy:
Nursing staff will document medications refused by the patient on the patient's MAR (Medication Administration Record).

Procedure:
1. If a medication is refused by the patient, the RN (Registered Nurse) will note "refused" on the MAR and noted (sic) the refusal in a progress note."

Based on observation, interview and document review, the facility failed to ensure medications were properly stored and labeled; and failed to ensure floor stock medications contained the open and expirations dates were not available for patient use.

Findings include:

On 1/6/16 at 10:20 AM, an inspection of the North Unit Medication Room revealed the following:

-A medication cart labeled Unit II contained one (1) Quetiapine Fumarate 100 mg tablet was observed in an unlabeled drawer separated from the perforated blister package. The medication lacked documented evidence of a patient identification label.

-An opened 4-oz (ounce) bottle of Q-dryl (Diphenhydramine Hydrochloride-Antihistamine) Allergy Relief Oral Solution was stored in a cabinet. The bottle had a yellow sticker attached with a space to write the date opened, expiration date, and the initials of the person who opened the bottle. The yellow sticker lacked documented evidence of when the Q-dryl was opened, the expiration date and the initials of the person who opened the medication. The spaces on the sticker were blank.

-Four open 4-oz bottles of Hydrogen Peroxide 3% (percent) solution was stored a cabinet. The bottles of hydrogen peroxide did not contain a yellow sticker (to write the date opened, expiration date, and the initials of the person who opened the bottle).

On 1/6/16 at approximately 10:30 AM, a Registered Nurse (RN) explained each medication drawer designated for patient use was should have been labeled with a patient's name to store their individual medications. The RN verified the unmarked drawer was not designated for patient use. The RN confirmed the medication should not have been in the drawer. The RN identified the Q-dryl and Hydrogen Peroxide as floor stock and acknowledged the bottled were open. The RN confirmed the yellow sticker observed on the Q-dryl should have been filled out with the date the medication was opened, expiration date, and the initials of the person who opened the bottle. The RN verbalized any opened bottled of medication should have contained a yellow sticker with a date to know when it was opened. The RN indicated the bottles without yellow stickers should have been thrown away.

On 1/6/16 at 10:55 AM, an inspection of the Unit I Medication Cart in the Medication Room on the South Unit revealed following medications in unlabeled drawers.

6th drawer, in the middle row of the cart:
- One Mirtazapine (Remeron) 30 milligram (mg) tablet; the blister packet was half opened.
- Two Sertraline 25 mg tablets.
- Two Risperidone (Risperdal) 0.5 mg tablets.
- Two Prazosine Hydrochloride (HCL) 1 mg tablets.
- One Vitamin D3 tablet, a supplement.
-Two empty Buspirone HCL 10 mg packets.

The tablets were separated from their perforated blister packages and lacked evidence of a patient identification label.

5th drawer, on the left side of the cart:
-A plastic zipper lock bag with a patient label containing three blister packets stored in a drawer along with an empty medication cup and two empty pill packets.

On 1/6/16, in an interview with a Registered Nurse (RN) immediately after the observation, the nurse confirmed the medications should not have been stored in the unlabeled medication drawer. The RN indicated the medication would be discarded. The acknowledged a patient's medication was in an unlabeled drawer with an empty medication cup and two empty pill packets. The RN identified the patient as an active patient and confirmed it should have been stored in the patient's labeled drawer.

On 1/6/16 at 11:00 AM, an inspection of the Unit I Medication Cart on the South Unit revealed an active patient's medication drawer that contained a medication cup with a single blue tablet inside the cup. A Register Nurse (RN) identified the medication as being Adderal and indicated the patient had not received the medication. The RN explained the Adderal was only available in on the Adolescent Unit and not dispensed to the other Units. The RN confirmed the Adderal should have been given at the time it was pulled from the other unit.

Facility policy entitled, "Ordering, Transcribing and Administration of Medication," Policy No.: MM.024, Revised 7/15 indicated the following:

"...III. Administering
...B. Preparation ...2. ...Medications may never be pre-poured (taken out of packet) prior to ordered administration times; i.e. medications remain in their original package until the nurse administers the medication ... 9. ...Individual patient medications are stored for each patient in their own individually labeled container ..."

Based on observations, staff and patient interviews, medical record review and facility document review, there was a systematic failure of the facility to provide medical records that documented comprehensive assessment and the treatment given to patients by the facility staff who provided the services. Specifically, the facility failed to:

I. Provide social work assessments that included conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A12, A15, B10, C4, C5,c13, D6, and D13). As a result, the treatment team did not have necessary social work information and evaluation of social functioning level to utilize in developing treatment and discharge planning. (Refer to B108)

II. Ensure that complete, thorough, and legible psychiatric evaluations were documented for eight (8) of eight (8) active sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). Failure to provide the necessary information to justify the diagnosis impedes the ability of the treatment team to formulate a meaningful plan of care designed to meet the patient's unique needs. (Refer to B110)

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

A. Clearly defined problem statements written in behavioral and descriptive terms for 8 of 8 active sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). (Refer to B119)

B. Individualized short-term and long-term goals for four (4) of eight (8) active sample patients (A12, B10, C4 and D13). (Refer to B121)

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient ' s presenting psychiatric problems for seven (7) of eight (8) active sample patients (A12, A15, B10, C4, C5, D6, and D13). (Refer to B122)

D. The name and discipline responsible for seeing that each specific intervention on the Master Treatment Plans were carried out for five (5) of eight (8) active sample patients (A12, A15, C4, D6, and D13). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

IV. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to one (1) of six (6) active sample patients (A15) on the Adult North Unit who was unwilling to participate and/or attend groups. In addition, the facility failed to ensure that patients on two of the Adult Units (North and South) received sufficient hours of therapeutic activities and sufficient number of therapeutic groups to accommodate up to 32 patients on the North and 26 patients on the South Unit. Failure to provide active treatment results in the affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125-I)

V. Ensure that requirements to use the least restricted interventions were maintained for one (1) of five (5) non-sample patients (G3) selected to review episodes of seclusion and restraint. Specifically, Patient G3 was kept in seclusion without a documented justifiable cause. The use of seclusion without documented justification that the continued use of this procedure was based on behaviors reflecting patient's possible continued violence towards others results in a violation of the patient ' s right to freedom of movement. (Refer to B125-II)

V. Ensure that discharge summaries were dictated, translated, and filed within 30 days of discharge, per hospital policy, in three (3) of five (5) discharge records reviewed (E1, E3, and D4). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plans with outpatient providers. (Refer to B133)

Based on record review and interview, the facility failed to provide social work assessments that included conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources, support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). Instead, the psychosocial assessment contained a summary of the patient's clinical presentation without identifying how this information was related to discharge and aftercare planning. In addition, the social work role only identified a list of treatment modalities without identifying the focus of treatment and discharge planning needs. As a result, the treatment team did not have necessary social work information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include sufficient social work information regarding conclusions and recommendations, or a specific and description of the social worker's role in treatment and discharge planning based on each patient's presenting symptoms and needs: Patient A12 (12/16/15), A15 (12/31/15), B10 (12/23/15), C4 (12/22/15), C5 (12/30/15), C13 (12/29/15), D6 (12/29/15), and D13 (12/29/15).

B. Staff Interview

During an interview with the Director of Social Work on 1/5/16 at 11:45 a.m., she acknowledged that the Psychosocial Assessments for active sample patients A12, A15, B10, and B13 lacked sufficient information regarding conclusions and recommendations that reflected anticipated steps for discharge, or a description of the social work role in treatment or discharge planning that included the focus of treatment and discharge planning based on each patient's need.

Based upon record review and interview, the facility failed to ensure that complete, thorough, and legible psychiatric evaluations were documented for eight (8) of eight (8) active sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). Evaluations failed to include sufficient documentation of specific information regarding patients' clinical presentation, including signs, symptoms, precipitating factors, and course of illness that formed the basis for diagnosis (es) and the proposed treatment of patients. Failure to provide the necessary information to justify the diagnosis impedes the ability of the treatment team to formulate a meaningful plan of care designed to meet the patient's unique needs.

A. Record Review

1. Patient A12 was admitted on 12/15/2015 with a diagnosis of Schizophrenia, Undifferentiated Type. A psychiatric evaluation dated 12/11/15 was mostly illegible. The section titled: "Past Psychiatric History" contained words that appeared to read: "Inpt Tx [Inpatient Treatment]" was the only information documented. The template instruction was, "Include; why patient is being readmitted, what could have caused the patient to regress, and what will be done to promote a more successful outcome." The section titled, "Mental Status Exam" was a preprinted checklist of options. The following options were checked: "Thought Process: Concrete, Delusion: paranoid, and Suicide: Plan." The sections titled, "Immediate Treatment Plan" and "Discharge Goals" were completely illegible. There was no individualized description of specific clinical findings and/or content added related to this patient.

2. Patient A15 was admitted on 12/30/2015 with a diagnosis of Schizoaffective Disorder. The psychiatric evaluation was dated 12/30/15 with most of the handwritten sections illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained very brief and illegible content: "Reason for Hospitalization; Past Psychiatric History; Family History; Medical History; Immediate Treatment Plan; and "Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist of options with the following options checked: "Hallucinations: Auditory Hallucinations; Thought Process: Concrete; Delusion: Paranoid; and Suicide: Thought, Plan, Intent." There was no individualized description of specific findings and/or content added related to this patient.

3. Patient B10 was admitted on 12/20 /2015 with a diagnosis that was illegible on the psychiatric evaluation dated 12/21/15. Most of the handwritten sections were illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained very brief and illegible content: "Reason for Hospitalization; Past Psychiatric History; Family History; Medical History; Formulation; Immediate Treatment Plan; and "Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist of options. The following options were checked: "Thought Process: Concrete and Hallucination: Auditory Hallucinations." For Suicide: both "None" and "Thought" were checked. There was no individualized description of specific clinical findings and/or content added related to this patient.

4. Patient C4 was admitted on 12/19/2015 with a diagnosis that was mostly illegible on the psychiatric evaluation was dated 12/30/15. Most of the handwritten sections were illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained very brief and illegible content: "Reason for Hospitalization; Past Psychiatric History; Medical History; Immediate Treatment Plan; and Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist of options with the following options checked: "Behavior: Disengaged; Mood: [illegible]; Thought Process: Concrete; Delusion: Paranoid; and Suicide: Thought, Plan, Intent." There was no individualized description of specific clinical findings and/or content added related to this patient.

5. Patient C5 was admitted on 12/28/2015 with a diagnosis of Bipolar Disorder, Mixed. The Psychiatric Evaluation dated 12/28/15 with most of the handwritten section illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained brief and illegible content: "Reason for Hospitalization; Past Psychiatric History; Family History; Substance Abuse; Medical History; Immediate Treatment Plan; and Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist with the following options checked: Mood: [illegible]; "Thought Process: Appropriate; and Suicide: Thought." There was no individualized description of specific clinical findings and/or content added related to this patient.

6. Patient C13 was admitted on 12/28/2015 with a diagnosis of Bipolar Disorder I [illegible]. The psychiatric evaluation was dated 12/29/15 with most of the handwritten sections illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained brief and illegible content: "Reason for Hospitalization; Past Psychiatric History; Social/Academic History; Formulation; Immediate Treatment Plan; and " Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist with the following options checked. "Behavior: withdrawn; Mood: [illegible]; Thought Process: Appropriate; and Suicide: Thought, Plan, Intent." There was no individualized description of specific clinical findings and/or content added related to this patient.

7. Patient D6 was admitted on 12/28/2015 with a diagnosis of Schizoaffective Disorder. The psychiatric evaluation was dated 12/29/15 with most of the handwritten sections illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained very brief and illegible content: Reason for Hospitalization; "Past Psychiatric History; Family History; Developmental History; Medical History; Formulation; Social/Academic History; Immediate Treatment Plan; and Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist of options. The following options were checked: "Behavior: withdrawn; Mood: [illegible]; Thought Process: Concrete; and Suicide: Thought." There was no individualized description of specific clinical findings and/or content added related to this patient.

8. Patient D13 was admitted on 12/28 /2015 with a diagnosis of Mood Disorder, Not Otherwise Specified. The psychiatric evaluation was dated 12/29/15 with most of the handwritten sections illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the following sections contained brief and illegible content: "Reason for Hospitalization; Social/Academic History; Family History; Assets/Strength; Formulation; Immediate Treatment Plan;" and "Discharge Goals." The section titled, "Mental Status Exam" was a preprinted checklist of options. The following options were checked: "Behavior: Disengaged; Mood: [illegible]; and Thought Process: Concrete." There was no individualized description of specific clinical findings and/or content added related to this patient.

B. Interview

During interview on 1/5/16 at 1:30 p.m. with the Medical Director, the psychiatric evaluations for active sample patients A12, A15, B10, and D13 were discussion. He agreed that psychiatric evaluation were illegible and would be difficult for clinical staff to use in formulating treatment plans. He stated, "I am aware of the illegibility. I am working on this." He also stated that he meets with MDs regarding illegible psychiatric evaluations and will required that they be dictated in some cases.

Based on record review and staff interview, the facility failed to ensure that the psychiatric evaluations included specific patient assets for eight (8) of eight (8) sample patients (A12, A15, B10, C4, C6, C13, D6, and D13). The failure to identify patient strengths impairs the treatment team's ability to choose treatment modalities that best utilize the patient's attributes in therapy.

Findings are:

A. Record Review

1. Patient A12's psychiatric evaluation, dated 12/15/15, under the section titled "Assets/Strengths" contained only one non-specific patient asset, "Mother" that was not meaningful for treatment planning. The psychiatric evaluation failed to include specific information useful in treatment planning such as, mother will visits three (3) times a week and will take patient home when ready for discharge.

2. Patient A15's psychiatric evaluation, dated 12/30/15, under the section titled "Assets/Strengths" contained documentation that was illegible.

3. Patient B10's psychiatric evaluation, dated 12/21/15, under the section titled "Assets/Strengths" contained a non-specific patient asset, "good health" that was not individualized and meaningful for treatment planning.

4. Patient C4's psychiatric evaluation, dated 12/15/15, under the section titled "Assets/Strengths" contained a non-specific patient asset, "good health" that was not individualized and meaningful for treatment planning.

5. Patient C5's psychiatric evaluation, dated 12/28/15, under the section titled "Assets/Strengths" contained only a non-specific patient asset, "Father supportive" that was not individualized and meaningful for treatment planning.

6. Patient C13's psychiatric evaluation, dated 12/29/15, under the section titled "Assets/Strengths" contained the non-specific patient word, "Resourceable [sic]." There was no information provided to show how this would be useful in treatment planning.

7. Patient D6's psychiatric evaluation, dated 12/29/15, under the section titled "Assets/Strengths" the documentation was illegible and therefore not meaningful for treatment planning.

8. Patient D13's psychiatric evaluation, dated 12/29/15, under the section titled "Assets/Strengths" contained documentation that was illegible.

B. Interview

During interview on 1/5/16 at 1:30 p.m. with the Medical Director, the psychiatric evaluations for active sample patients A12, A15, B10, and D13 were discussion. He agreed that assets on psychiatric evaluations were illegible and when readable did not address the strengths the patients would bring to treatment.

Based on record review and interview, the facility failed to ensure that treatment interventions were assigned to all clinical discipline involved in active treatment. Specifically, Master Treatment Plans (MTPs) did not include active treatment interventions to be implement by the attending psychiatrist for five (5) of eight (8) active sample patients (A12, A15, B10, C4, and C5) and registered nurses for three (3) of eight (8) active sample patients (A15, B10, and C5). There were no active treatment interventions included at all for the psychiatrist and registered nurse related to the identified psychiatric problem statements on these MTPs. Failure to provide the specific active treatment interventions to be implemented by all clinical staff potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. A review of MTPs for Patients A12, A15, B10, C4, and C5 revealed that the attending psychiatric had no active treatment interventions at all assigned for the identified psychiatric problems.

2. A review of MTPs for Patients A15, B10, and C5 revealed that the registered nurse had no active treatment interventions for the identified psychiatric problems.

B. Interviews

1. In an interview on 1/5/16 at 1:30 p.m. with the Medical Director, the Master Treatment Plans for active sample patients A12, A15, and B10 were discussion. He acknowledged the there were no active interventions included on treatment plans to be implemented by the psychiatrist.

2. In an interview on 1/5/16 at 3:10 p.m., active treatment interventions on MTPs assigned to nursing were discussed with the Director of Nursing. She did not dispute the findings.

Based on record review, document review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) clearly defined problem statements written in behavioral and descriptive terms. Specifically, MTPs included problem statements with diagnoses and/or generic symptoms instead of specific individualized and descriptive clinical symptoms or behaviors for seven (7) of eight (8) active sample patients (A12, A15, B10, C4, C5, D6, and D13). These failures can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

1. Patient A12's MTP, dated 12/15/15, had the following psychiatric problem statement identified: Problem #1: "Depressed Mood with Suicidality - Behavioral Manifestations/Observations: Pt [Patient] presented w/ [with] depression w/ [with] SI [Suicidal Ideation]." Problem #2: "Psychotic Behaviors/Out of Contact with Reality - Behavioral Manifestations/Observations: Pt [Patient] reports AH [Auditory Hallucinations], pt. [patient] has hx [history] of bizarre behavior. Problem #1 statement was a diagnostic term that failed to describe how "Depressed Mood" and "Suicidality" was precisely manifested by the patient. Problem #2 was a generalized behavior with no descriptors to show how the patient precisely manifested bizarre and psychotic behaviors including the content of auditory hallucinations and how they affected the patient.

2. Patient A15's MTP, dated 12/30/15, had the following psychiatric problem statement identified: Problem #1: "Depressed Mood with Suicidality - Behavioral Manifestations/Observations: Pt [Patient] admitted to [Facility's name] due to severe depression with suicidal ideation." This problem statement was a diagnostic term that failed to describe how "Depressed Mood" and "Suicidality" was precisely manifested by the patient.

3. Patient B10's MTP, dated 12/20/15, had the following psychiatric problem statements identified: Problem #1: "Psychotic Behaviors/Out of Contact with Reality - Behavioral Manifestations/Observations: Pt [Patient] has hx [history] of Schizophrenia." Problem #2: "Depressed Mood with Suicidality - Behavioral Manifestations/Observations: Pt [Patient] has hx [history] of Suicidal Ideation." These problem statements were diagnostic terms that failed to describe psychotic behaviors and depressed mood and specify how they were precisely manifested by the patient.

4. Patient C4's MTP, dated 12/19/15, had the following psychiatric problem statement identified: Problem #1: "Psychotic Behaviors/Out of Contact with Reality - Behavioral Manifestations/Observations: Pt [Patient] admitted for bizarre and psychotic behaviors." This problem statement contained diagnostic terms that failed to describe bizarre and psychotic behaviors and specify these behaviors were precisely manifested by the patient.

5. Patient C5's MTP, dated 12/28/15, had the following psychiatric problem statement identified: Problem #1: "Psychotic Behaviors/Out of Contact with Reality - Behavioral Manifestations/Observations: Problem-Depressed Mood with Suicidality
Behavioral Manifestations/Observation: Pt [Patient] plan to commit suicide by overdosing on Seroquel and Trazadone. This problem statement was a diagnostic term that failed to describe how "Depressed Mood" and "Suicidality" was precisely manifested by the patient."

6. Patient D6's MTP dated 12/28/15 had the following psychiatric problem statement identified: Problem #1: "Aggressive/Assaultive Behavior - Behavioral Manifestations/Observations: Pt [Patient] admitted to acute unit after demonstrating increased assaultive bx [behavior] [illegible] family & professional staff by kicking, [illegible], hitting. Pt [Patient] also is combative & threatening toward peers." This problem statement was mostly descriptive but contained several illegible words.

7. Patient D13's MTP dated 12/28/15 had the following psychiatric problem statement identified: Problem #1: "Aggressive/Assaultive Behavior - Behavioral Manifestations/Observations: Pt [Patient] demonstrating 'Explosive' bx [behavior] toward & peers at [Name of Facility]." This problem statement failed to describe aggressive, assaultive, and explosive behaviors and how these were precisely manifested by the patient.

B. Document Review

The facility failed to follow their own policy titled, "Interdisciplinary Treatment Plan," Policy No: PC.013 last revised 12/14, which stipulated that, "All problems are stated in specific behavioral terms as identified in assessments. Avoid using nursing diagnosis or similar labels. Behaviors should be written in terms understandable to the patient."

C. Interview

During interview on 1/5/16 at 1:30 p.m. with the Medical Director, the psychiatric problem statements on the Master Treatment Plans for active sample patients A12, A15, B10, and D13 were discussion. He did not dispute that problems statements were not individualized and descriptive of each patient's presenting symptoms.

Based on record review, document review, and interview, the facility failed to consistently provide and document on the Master Treatment plans (MTPs) individualized short-term and long-term goals for four (4) of eight (8) active sample patients (A12, B10, C4 and D13). Specifically, the preprinted MTPs listed goals that did not relate to clearly defined behavioral problems. In addition, one (1) of eight (8) active sample patients (C13) did not have an available MTP as of 1/4/16. These failures result in Master Treatment plans that fail to identify expected treatment outcomes in a manner that can be defined and understood by treatment staff and the patients.

Findings include:

A. Record and Document Review

1. The facility's Policy no: PC. 013, titled "Interdisciplinary Treatment Plan" reviewed/revised 12/14 stated, "All goals, both long-term and short-term, must be well written in behavioral and measureable terminology that is related to the problem identified in the assessments and through the patient's hospitalization. If the problems are stated in behavioral terms, you can often review the problem to identify the goal"---"The long-term goals are the discharge goals and should match the discharge criteria established by the physician. The short-term goals should be related to the long-term goals." Because the MTPs were pre-printed and based on specific problems, the goals were similar or identical on all patients with the same problems and not based on the individual needs of each patient.

2. Patient A12, MTP dated 12/15/15 had as a problem: "Depressed mood with suicidality." Behavioral manifestations/observations: "Pt. [patient] presented w [with] depression w/SI [with suicidal ideations]."

Long-term Goals/Discharge Criteria
- "Patient will rate depression as 8 on a scale of 1 -10 for at least 7 days."
- "Patient will not verbalize intent to harm-self for 7 days prior to discharge."
- "Patient will develop written plan for ensuring own safety outside of hospital that may include follow-up appointments."
- "Patient and/or caregiver will report that steps have been taken to deny the patient access to weapons or other methods of self-harm."

Short-term Goals/Objectives:
- "Patient will report SI thoughts/impulses/urges to staff before acting on them."
- "Patient will report they no longer have intent of acting on 'wish' to be dead."
- "Patient will demonstrate interest in social activities by joining/initiating social activity without staff encouragement."
The lack of descriptive, observable behaviors manifested by the patient makes it difficult for staff to evaluate and document evidence that the patient's depression and suicidal thoughts were improving.

For the problem: "Psychotic behaviors/out of contact with reality." Behavioral manifestations/observations: "Pt. reports AH [auditory hallucinations], his hx [history] of bizarre behavior."

Long-term Goals/Discharge Criteria
- "Patient will be free from hallucinations for 4 days prior to discharge."
- "Patient will be free from delusional thoughts that interfere with functioning for 4 days prior to discharge."
- "Patient will be able to attend to matter at hand and not demonstrate tangential thought/speech for 3 days prior to discharge."

Short-term Goals/Objectives
- "Patient will demonstrate hallucinatory episodes to 4 times per day."
- "Patient will demonstrate decreased reaction to internal stimuli to 4 times per day."
- "Patient will be able to sit in chair for 50 minutes during group or individual conversation."
- Pt. will participate in treatment team."

The specific bizarre behavior or the specific auditory hallucination that the patient was experiencing was not described, making it difficult for staff to evaluate any changes or improvements in what the patient was experiencing. The two (2) Long-Term Goals of patient being free of auditory hallucinations and delusional thoughts were not measurable as written.

3. Patient B10, MTP dated 12/20/15, had as a problem: "Psychotic behaviors/out of contact with reality." Behavioral manifestations/observations: "Pt. has hx [history] of schizophrenia."

Long-term Goals/Discharge Criteria:
- "Patient will be free from hallucinations for 4 days prior to discharge."
- "Patient will be free from delusional thoughts that interfere with functioning for 4 days prior to discharge."
- "Patient will be able to attend to matter at hand and not demonstrate thought/speech for 6 days prior to discharge."

Short-term Goals/Objectives:
- "Patient will demonstrate decreased hallucinatory episodes to 4 times per day."
- "Patient will demonstrate decreased reaction to internal stimuli to 4 times per day."
- "Patient will be able to sit in chair for 50 minutes during group or individual conversation."
- "Pt. will participate in safe discharge planning."
The lack of descriptive, observable behaviors for the problem of "Psychotic behaviors/out of contact with reality" made it difficult for staff to evaluate and document evidence that the patient's behaviors were improving. The statement of "pt. has history of schizophrenia" did not provide any additional information for staff to be consistent in determining changes in the patient's behavior. The two (2) Long-Term Goals of patient being free of auditory hallucinations and delusional thoughts were not measurable as written.

For the problem: "Depressed mood with suicidality," Behavioral manifestations/observations: "Pt. has hx of SI."

Long-term Goals/Discharge Criteria:
- "Patient will rate their depression level as 8 on scale of 1 -10 for at least 4 days."
- "Patient will not verbalize intent to harm-self for 3 days prior to discharge."
- "Patient will develop written plans for ensuring own safety outside hospital that may include follow-up appointments, medication management, daily check-ins, emergency support phone numbers, etc."
- "Patient and/or caregiver will report that steps have been taken to deny the patient's access to weapon or other methods of self-harm."

Short-term Goals/Objectives:
- "Patient will report S/I thoughts/urges to staff before acting on them."
- "Patient will report command hallucinations to staff before acting on them."
- "Patient will report they no longer have intent of acting on " will " to be dead."
- "Patient will seek out staff daily to check-in R/T [Related To] suicidal ideation."
- "Patient will verbalize what s/he has to live for and cite future goals/desires."
- "Patient will demonstrate interest in social activities by joining/initiating social activity."

The lack of descriptive, observable behaviors in the problem statement above makes it difficult for clinical staff to consistently evaluate any changes or improvement in patient behaviors.

4. Patient C4, MTP dated 12/14/15, had as a problem: "Psychotic behavior out of contact with reality." Behavior manifestations/observation: "Pt. admitted for bizarre and psychotic behaviors!"

For the problem: "psychotic behaviors/out of contact with reality." Behavioral manifestations: "Pt. reports AH [auditory hallucinations], his hx [history] of bizarre behavior."

Long-term Goals/Discharge Criteria:

- "Patient will be free from hallucinations for 3 days prior to discharge."
- "Patient will be free from delusional thoughts that interfere with functioning for 3 days prior to discharge."
- "Patient will be able to attend to matter at hand and not demonstrate thought/speech for 3 days prior to discharge."

Short-term Goals/Objectives:

- "Patient will demonstrate decreased hallucinatory episodes 2 times per day."
- "Patient will able [sic] to make simple decisions about discharge."
- "Patient will be able to complete ADLs [Activities of Daily Living] without interference from hallucinations or delusions."

The lack of descriptive, observable behaviors manifested by the patient makes it difficult for staff to evaluate and document evidence that the patient's bizarre behaviors, whatever they are, have improved.

5. Patient C13 did not have a MTP as of 1/4/16. A treatment plan was submitted by the facility on the day of the patient's discharge on 1/5/16.

6. Patient D13, MTP dated 12/28/15, had as a problem: "Aggressive/assaultive behavior." Behavioral manifestations/observations: "Pt. demonstrating 'explosive' bx [behavior] towards staff & [and] peers @ [at] [name of facility]."

Long-term Goals/Discharge Criteria:

- "Patient will deny homicidal thoughts for 2 days prior to discharge."
- "Patient will make no threats of harm to others for 2 days prior to discharge."
- "Patient will not demonstrate threatening or assaultive behaviors towards peers or staff for 2 days prior to discharge."
- "Patient will fully cooperate with treatment for 2 days prior to discharge."

Short-term Goals/Objectives:

- "Patient will not assault peers or staff for 8 consecutive hours/days."
- "Patient will reframe from use of inappropriate or offensive language for 3 days."
- "Patient will be able to complete family session without making threats of harm to family member."
- "Patient will deny homicidal thoughts for 3 days."
- "Patient will present to individual or group therapist 3 triggers of his anger and 3 appropriate means of managing those triggers."
- "Patient will not verbally lash out/threaten others for 3 days."

The lack of specific descriptive, observable behavior of the patient's 'explosive' behavior, for example patient striking out or yelling, makes it difficult for all clinical staff to be consistent in evaluating any changes or improvement in patient's behavior.

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the situation of short and long-term goals not relating to the identified problems on the MTP was discussed with the Nursing Director. She did not dispute the findings.

Based on record review, document review, and interview, the facility failed to ensure that the treatment plan interventions for seven (7) of eight (8) active sample patients (A12, A15, B10, C4, C5, D6 and D13) addressed their specific treatment needs. The pre-printed forms listed interventions that were either stated as generic discipline functions or modalities without a specific focus. These failures result in a lack of staff coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

A. Record and Document Review

1. Facility policy no.: PC 013, reviewed/revised: 12/14, titled "Interdisciplinary Treatment Plan", stated: "The treatment plan should be measurable in order for the staff to determine the patient is improving in treatment, the staff must be able to measure improvement." "The interventions include specific action on activity, the focus of the intervention."

2. Patient A12
The Master Treatment plan (MTP), dated 12/15/15, listed the following generic, routine discipline functions and/or modalities without a specific focus for the problem: "Depressed mood with suicidality."

- "Psycho-educational groups related to depressed mood." Focus - "patient education."

- "Process group therapy" - focus - "process feelings."

- "Individual therapy" - focus - "process feelings."

- "Time outs in: designated area" - focus - "pt. [patient] safety."

For the problem: "Psychotic behaviors/out of contact with reality," the "modalities/activities" were:

- "Process group therapy" - focus - "process feelings."

- "Individual therapy" - focus - "process feelings."

- "Family therapy" - focus - "collateral info [information]."

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem(s) of the patient to be addressed in each modality.

3. Patient A15
The Master Treatment plan, dated 12/30/15 listed the following generic, routine discipline functions, and/or modalities without a specific focus for the problem: "Depressed mood with suicidality":

- "Psycho-educational groups related to: Depressed mood - focus - pt. education."

- "Process group therapy " - focus - "identify coping skills."

- "Family/caregiver therapy " - focus - "collateral information."

- "Individual therapy" - focus - "collateral information."

- "Individual therapy" - focus - "process feelings."

- "Time out in" - focus - "pt. safety."

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem(s) of the patient to be addressed in each modality.

4. Patient B10
The MTP, dated 12/20/15, listed the following generic, routine discipline functions, and modalities without a specific focus for the problem: "Psychotic behaviors/out of contact with reality":

- "Process group therapy" - focus - "process feelings."

- "Individual therapy" - focus - "process feelings."

- "Family therapy" - focus - "collateral info."

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem of the patient to be addressed in each modality.

5. Patient C4
The MTP, dated 12/19/15, listed the following generic, routine discipline functions, and/or modalities without a specific focus for the problem: "Psychotic behaviors/out of contact with reality":

- "Special precautions: q15 [every 15 minutes], level of observation." "SP [Suicide Precautions], AP [Assaultive Precautions], fall" - focus - "patient safety."

- "Individual psychiatric session with patient" - focus - "medication management, assess mental status."

- "Administer routine medications at dosage and schedule ordered and PRN [as needed] medications for: Psychotic behavior" - focus - "Treatment management of Psychotic Behaviors"

- "Psycho-educational groups related to: Psychotic behaviors" - focus - "patient education."

- "Process group therapy" - focus - "identify coping skills."

- "Activity therapy groups" - focus - "identify coping skills."

- "Individual therapy" - focus - "process feelings."

- "Family therapy" - focus - "collateral information."

- "Time out in" - focus - "pt. safety."

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem of the patient to be addressed in each modality.

6. Patient C5
The MTP, dated 12/28/15, listed the following generic, routine discipline functions, and/or modalities without a specific focus for the problem: "depressed mood with suicidality":

- "Psycho-educational groups related to: depressed mood" - focus - "patient education."

- "Process group therapy" - focus - none listed.

- "Activity therapy groups" - focus - none listed.

- "Individual therapy" - focus - none listed.

The modalities were either generic and routine discipline function or discipline task. The focus that was listed did not relate to specific problem of the patient to be addressed in each modality.

7. Patient D6
The MTP, dated 12/28/15, listed the following generic, routine discipline functions, and/or modalities without a focus for the problem: "Aggressive/assaultive behavior":

- "Psycho-educational groups related to: increased aggression" - focus - "patient education."

- "Process group therapy" - focus - "problem ID's [identifies] coping skills."

- "Activity therapy groups" - focus - "creative expression."

- "Family therapy with" - focus - "conflict resolution & [and] communication."

- "Individual therapy" - focus - "process emotions."

- "Time out in quiet room" - focus - "safety".

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem of the patient to be addressed in each modality.

8. Patient D13
The MTP, dated 12/28/15, listed the following generic, routine discipline functions, and/or modalities without a focus for the problem: "Aggressive/assaultive behavior":

- "Special precautions: AP [Assault Precaution] level of observation q15" - focus - "pt. safety."

- "Order medications and titrate dosage as needed" - focus - "treatment of increased aggression."

- "Order medication - related lab work and review as completed" - focus - "monitor from [illegible word]."

- "Assess mental status as related to special precautions" - focus-Assess patient's increased aggression."

- "Administer routine medication at dosage and schedule ordered and PRN medication for: increased aggression" - focus - "Treatment of increased aggression."

- "Psycho-educational groups related to: increased aggression" - focus - "patient education."

- "Process group therapy" - focus - "problem ID's, coping skills."

- "Activity therapy groups" - focus - "creative expression."

- "Family therapy with" - focus - "conflict resolution & communication."

- "Individual therapy" - focus - "process emotions."

- "Time outs in quiet room" - focus - "safety."

The modalities were either generic and routine discipline function or discipline task. The focuses did not relate to specific problem of the patient to be addressed in each modality.

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the generic routine discipline interventions on the Master Treatment plan was discussed with the Director of Nursing. She did not dispute the findings.

Based on record review, document review, and interview, the facility failed to consistently identify the name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for five (5) of eight (8) active sample patients (A12, A15, C4, D6, and D13). The responsible staff column frequently listed the discipline, i.e. RN [registered nurse], LSW [licensed Social Worker, MD [Doctor], Activity Therapy, without putting the name of the person. This practice results in the facility's inability to clearly monitor staff accountability for seeing that specific interventions are carried out.

Findings include:

A. Record and Document Review

1. Facility policy no.: PC 013, reviewed/revised 12/14, titled "Interdisciplinary Treatment Plan," stated: "The interventions include"---"the person(s) responsible, including credentials and discipline."

2. Patient A12
The Master Treatment plan (MTP), dated 12/15/15, listed the following staff interventions associated with the problem "depressed mood with suicidality":
"Psycho-educational groups related to depressed mood, process group therapy, activity therapy group, family/caregiver therapy, individual therapy" - none of these interventions listed a name or discipline responsible for seeing that they were carried out. "Time outs in designated area" - MHT, RN were listed.

3. Patient A15
The MTP, dated 12/30/15 had the following staff intervention for the problem "depressed mood with suicidality" - "time outs in". "Nursing task" - "MHT, RN"

4. Patient C4
The MTP, dated 12/19/15, had the following staff interventions for the problem "psychotic behaviors/out of contact with reality" - "activity therapy groups" - "AT staff" "Time outs in" - "MHT, RN"

5. Patient D6
The MTP, dated 12/28/15, had the following staff interventions for the problem "aggressive/assaultive behavior" - "psycho-educational groups related to increased aggression" - "clinical"
"Progress group therapy" - "clinical"
"Family therapy with" - "clinical"
"Individual therapy" - "clinical"
"Time out in quiet room" - "clinical & nursing"

6. Patient D13
The MTP, dated 12/29/15, had the following staff interventions for the problem "aggressive/assaultive behavior":
"Psycho-educational groups related to depressed aggression" - "clinical"
"Process group therapy" - "clinical"
"Activity therapy groups" - "activity therapist"
"Family therapy with" - "clinical"
"Individual therapy" - "clinical"
"Time out in quiet room" - "clinical & nursing"

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the lack of responsible staff names on many Master Treatment plans was discussed with the Nursing Director. She agreed that the names should be included on the plans.

Based on record review, interview, and observation, the facility failed to ensure that the nursing group included on the unit schedule were documented with sufficient information regarding specific topics discussed, and the patients' behavior during group, and their response to the group intervention, including level of participation, understanding, and specific comments of four (4) of eight (8) active sample patients (A12, A15, B10, and D13). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

1. A review of the facility's "Programming Schedule" for Adult North, South, and Children Units reflected a "RN Group" scheduled 7 days per week for 45 minutes. All patients were reportedly expected to attend these groups.

2. A review of the Master Treatment Plans revealed that the "RN Group" listed on the schedule and attended by active sample patients A12 and B10 on 1/4/16 was not included on the treatment plan.

3. A review of the "Nursing Progress Note" contained a section titled, "Time of Nursing Group" with a section for "RN signature for Group." This section included a checklist with a list of topics and a checklist related to the patient's participation and revealed the following findings: a. Patient A12 - A review of documentation regarding group attendance for 12/28 -12/30/15 and 1/4/16 revealed on 12/28/15 that the topic was "Diagnosis Education" and the participation was "Attentive." There was no description of what diagnosis was discussed. In addition, there was no information regarding the patient's behavior during group, comments made during the group, and level of understanding. On 12/29/15, the only documentation was the time of group at 10:05 a.m. and the RN's signature. On 12/30/15, the topic checked was "Medication Education" and the participation was "Attentive." There was no description of what medication(s) were discussed. In addition, there was no information regarding the patient's behavior during group, comments made during the group, and level of understanding.

b. Patient A15 - A review of documentation regarding group attendance for 1/4/16 revealed that the topic was "Coping Skills" and the participation was "Attentive." The documentation included the time of group at 10:05 a.m. and the RN's signature. There was no description of what was discussed. In addition, there was no information regarding the patient's behavior during group, comments made, and level of understanding. The surveyor observed this group it was actually not started until 10:15 a.m. The registered nurse (RN#1) who led the group discussed positive thinking and distributed a handout titled, "Positive thinking: Stop negative self-talk to reduce stress." Patient A15 did not participate in the discussion but entered the group at 10:25 a.m. and left at 10:30 a.m. This information was not documented at all. Another RN, RN#2 documented and signed for the group but was not present during the group session.

c. Patient B10 - A review of documentation regarding group attendance for 12/28 -12/30/15 revealed that on 12/28/15 that the topic was "Coping Skills" and the participation was "Active" and "Attentive." There was no description of the coping skills discussed during group. The documentation showed that a handout was given however there was no information provided regarding the title of the handout. In addition, there was no information regarding the patient's behavior during group, comments made, and level of understanding. On 12/30/15, the topic checked was "Medication Education" and the participation was "Attentive." There was no description of what medication(s) were discussed. In addition, there was no information regarding the patient's behavior during group, comments made during the group, and level of understanding.

d. Patient D13 - A review of documentation regarding group attendance for 12/29 -12/30/15 and 1/4/16 revealed on 12/29/15 that the topic was "Coping Skills" and the participation was "Distracted." There was no description of the coping skills discussed during group. In addition, there was no information regarding the patient's behavior during group, comments made during the group, and level of understanding. On 12/30/15, the topic checked was "Healthy Lifestyle" and the participation was "Active" and "Attentive." There was no description of what specific information regarding a healthy life was discussed. In addition, there was no information regarding the patient's behavior during group, comments made during the group, and level of understanding. On 1/4/16, there was no documentation regarding attendance or non-attendance in the RN group.

B. Interviews and Observation

1. During observations on 1/4/16 at 10:15 a.m., Patients A5, A6, and A7 attended the "RN Group" listed on the "Adult North Unit Programming Schedule" and was conducted by RN#1. During interview on 1/4/16 at 11:10 a.m., RN#1 reported that each RN was assigned a list of patients and they were responsible for the documenting the RN group for their patients.

2. In an interview on 1/5/16 at 11:05 a.m. with RN#3, group treatment notes were reviewed. He agreed that the group treatment notes were not detailed and did not contain the specific information or the patient's response to group interventions. He also acknowledged that the patient's response to the intervention did not include the patient's behaviors during group, level of understanding, and specific comments made during the group sessions.

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

I. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to one (1) of six (6) active sample patients (A15) on the Adult North Unit who was unwilling to participate and/or attend groups. Specifically, this patient spent many hours without any appropriate alternative structured therapy or activities. In addition, the facility failed to ensure that patients on two of the Adult Units (North and South) received sufficient hours of therapeutic activities and sufficient number of therapeutic groups to accommodate up to 32 patients on the North Unit and 26 patients on the South Unit. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

Findings include:

A. Record and Document Review

The Adult North Unit Programming Schedule the following groups were scheduled: Discharge Group from 8:30 a.m. - 9:00 a.m.; RN Group from 10:05 a.m. - 11:05 a.m.; Process Group from 11:15 a.m. - 12:15 p.m.; Recreation Therapy from 1:50 p.m. - 2:50 p.m.; and Process Group from 3:00 p.m. - 4:00 p.m. A review of the Patient Observation Rounds sheets, from December 30, 2015 to January 5, 2016 revealed the following findings for Patient A15:

a. On 12/31/15, the Patient Observation Round sheets showed that Patient A15 was in his/her room during group times from 8:30 a.m. - 8:45 a.m.; from 10:45 a.m. - 11:15 p.m.; from 11:15 to 12:30 p.m.; and from 3:00 p.m. to 4:15 p.m.

b. On 1/2/16, the Patient Observation Round sheets showed that Patient A15 was in his/her room during group times from 8:30 a.m. - 8:45 a.m.; from 10:45 a.m. - 11:15 p.m.; from 11:15 to 12:15 p.m.; and from 3:00 p.m. to 4:15 p.m.

c. On 1/3/16, the Patient Observation Round sheets showed that Patient A15 was in his/her room during group times 11:00 a.m. - 11:15 a.m.; from 11:45 a.m. - 12:15 p.m.; from 1:45 p.m. to 2:30 p.m.; and from 3:00 p.m. to 4:15 p.m.

d. On 1/4/16, the Patient Observation Round sheets showed that Patient A15 was in his/her room during group times from 8:30 a.m. - 8:45 a.m.; from 11:05 a.m. - 12:15 p.m.; from 1:45 to 2:30 p.m.

2. Documentation regarding the non-participation in group treatment was as follows:

a. The "Patient Observation Progress Note - MHT/CNA - 0700 - 1530" Sheets revealed the following findings: [The actual time of documentation was not noted.]

- On 1/2/15 documented, "...Stayed to [him/herself]."

- On 1/4/16 documented, "[Patient name] gave no problem. [S/he] slept most of the day..."

b. The "Adult Group Progress Note" Sheet documented by social work staff revealed the following findings: [There was no time to show when the group progress note was actually documented. The form primarily contained the preprinted group start time.]

- On 12/30/15 (Group start time - 11:15 a.m.) documented, "...sat in group but did not share or participate."

- On 1/1/16 (Group time - 12:00 p.m. - 1:00 p.m.) documented, "...left the group as soon as the meditation came to an end..."

- On 1/2/16 (Group start time - 11:15 a.m.) documented, "...would walk in and out group..."

- On 1/3/16 (Group start time - 11:15 a.m.) documented, "...stated [s/he] does not like people touching [him/her]. Pt. [Patient] provided no other participation during group."

- On 1/4/16 at 4:10 p.m., documented, "Patient presented as irritable and pre-occupied."

Out of the possible process groups offered from 12/30/15 to 1/4/16, the patient did not actively or consistently participate but was noted as coming in and out of the group, leaving early, not engaging or refusing to attend.

c. The "Adult Group Progress Note" Sheet documented by activity therapy staff revealed the following findings: There was no time to show when the group progress note was actually documented. The form primarily contained the preprinted group start time.]

- On 12/30/15 (Group start time - 6:40 p.m.) documented, "Refused."

- On 12/31/15 (Group start time - 6:40 p.m.) documented, "Refused." "Pt. [Patient did not attend AT [activity Therapy] because [s/he] was sleeping. An alternative New Year's resolution worksheet was offered. [Note: There was no documentation reflecting whether the patient completed the worksheet or whether staff spent time with the patient to assist him/her.]

- On 1/2/16 (Group start time - 1:50 p.m. and 6:40 p.m.) documented, "Refused." "Pt. [Patient] refused group. Alternate programming was provided." [Note: There was no documentation regarding what alternate was provided and whether staff spent time with the patient to assist him/her.]

- On 1/3/16 (Group start time - 1:50 p.m. and 6:40 p.m.) documented, "Refused." "Pt. [Patient] refused group. Alternate programming was provided." [Note: There was no documentation regarding what alternate was provided and whether staff spent time with the patient to assist him/her.]

- On 1/4/16 (Group start time - 1:50 p.m.) documented, "Refused." "...Pt. [Patient] refused to join the group activity because [s/he] wanted to sleep. Pt. [Patient] given an alternate worksheet activity called Motivators." Note: There was no documentation regarding the patient's level of understand or whether staff spent time with the patient to assist him/her.]

3. The form titled, "Updates - Master Treatment Plan" dated 1/5/16 did not provide information regarding the patient's lack of and/or inconsistent participation in the group treatment program. Additionally, the plan was not revised to include individual contact with patient to ensure his/her involvement in alternative active treatment measures.

B. Observations of Active Treatment Groups

1. During observation on 1/4/16 at 10:15 a.m., a RN Group was conducted by RN#1 with 13 of 32 patients attending. There was no other group held during this time period. The group room only had 15 chairs for patients. RN#1 had patients taking terms reading a handout. One patient was sleeping and no attempt was made to involve this patient in the discussion. Patients not attending the group were either in their rooms, with treatment team or in the hallway.

2. During observation on 1/4/16 from 11:20 p.m. to 12:00 p.m., a Recreation Therapy Group was conducted by SW#1 with 11 out of 26 patients attending. There was no other group held during this time period. Patients were in and out of the group with only seven (7) patients remaining at 11:55 a.m. Patients not attending the group was either in their rooms or in the hallway.

3. During observation on 1/4/16 from 1:30 p.m. to 2:05 p.m., a Process Group was conducted SW#1 with 10 of 26 patients attending. [Note: Group was scheduled to start at 1:15 p.m.]. Patients were asked to state something they want to accomplish during the week or month. Two patients left soon after the group started.

4. During observation on 1/4/16 from 4:00 p.m. to 4:30 p.m., a RN Group was conducted RN #4 with 9 out of 26 patients attending. Note: Group was scheduled to start at 3:40 p.m.]. A handout regarding Challenges was discussed. Two patients were sleeping and one patient had his/her head on the table. No attempt was made to involve these patients in the discussion.

C. Interviews

1. In an interview on 1/4/16 at 11:05 a.m. with RN#1, after the RN Group, the surveyor noted that only 13 of 32 patients attended the group. She confirmed that all patients were expected to attend the group but sometimes they don't attend. She reported that MHT assist in getting patients to the group. When asked about Patient A15, she had to confirm that the patient did not attend the group by asking the Mental Health Technician (MHT), since there was no attendance sheet completed by patients or group leader.

2. In an interview on 1/4/16 at 12:01 p.m., AT#1 admitted that all patients did not attend the group activity and reported that MHTs will help to get patients to groups. She stated that eight (8) to 10 patient was considered a good group attendance.

3. In an interview on 1/4/16 at 2:10 p.m., after a group session, SW#1 was asked about the group room not being large enough to accommodate all patients on the units and procedure for assigning patients to the morning or afternoon process group. She noted that patients were not assigned and confirmed that all patients were expected to attend. She stated that additional chairs would be added to accommodate patients but acknowledged that 26 patients would be a very large group.

4. In an interview on 1/4/16 at 2:20 p.m., Patient A15 stated, "I go to group sometimes. Don't like to go because it's the same thing over and over."

II. Ensure that requirements to use the least restricted interventions were maintained for one (1) of five (5) non-sample patients (G3) selected to review episodes of seclusion and restraint. Specifically, Patient G3 was kept in seclusion without a documented justifiable cause. The use of seclusion without documented justification that the continued use of this procedure was based on behaviors reflecting patient's possible continued violence towards others results in a violation of the patient's right to freedom of movement.

Findings include:

A. Record and Document Review

1. Facility policy, no PC 186, titled "Restraints, Seclusion, Protective/holds," reviewed/revised 5/15, stated: "The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff "--- "restraints or seclusion will be discontinued as soon as possible."

2. Per "restraints/seclusion order record," dated 11/14/15 at 6:00a.m., patient G3 was placed in seclusion at 6:04a.m. for "aggressive [sic], unable to redirect, pt. [patient] attempted to jump into nurses station A and released at 10:00a.m. Criteria for release: pt. to remain calm and cooperative." The "patient observation rounds" record, which was used in place of the form used to record patients' behavior while in seclusion/restraint, documented the following:
6:00 a.m. - "Awake, uncooperative and out of control"
6:15 a.m. and 6:30 a.m. - "Sleeping"
7:15 a.m. and 7:30 a.m. - "Awake"
7:45 a.m. to 8:45 a.m. - "Sleeping"
9:00 a.m. - "Awake, cooperative"
9:15 a.m. - 10:00 a.m., when patient was documented as released from seclusion - "awake." Per documentation, the patient had met the requirements for release (calm and cooperative for over 3 hours prior to being released from seclusion.

3. The "Nursing Progress Note" sheet, dated 11/14/15 at 3:00 p.m., documented that "Pt. remained in isolation room [used for seclusion] until nearly noon." There was no other documentation about the patient's behavior in seclusion or why the patient remained in seclusion after quieting down.

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the unnecessary continuation of the seclusion for patient G3 was discussed with the Nursing Director. It was also pointed out that the note failed to mention any details of the seclusion. She stated that the nursing note was a shift note and note expected of the nurse when writing a progress note on a patient's behavior while in seclusion. She stated seclusion notes are written in a separately. The Nursing Director stated that a note on the seclusion should have been done.

Based on record review, document review, and interview, the facility failed to ensure that discharge summaries were dictated, translated and filed within 30 days of discharge, per hospital policy, in three (3) of five (5) discharge records reviewed (E1, E3, and D4). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plans with outpatient providers.

Findings include:

A. Record and Document Review

1. Facility policy no: PC. 067, reviewed/revised: 10/15, titled "Continuing Care Plan - Discharge Planning," stated: "When a patient is discharged or transferred, the hospital gives information about the care, treatment and services provided to the patient to other service providers who will provide the patient with care, treatment or services." There was no mention of how soon after a patient is discharged from the facility, a discharge summary by the physician should be completed. The CEO [Chief Executive Officer] stated on 1/4/16, at the CMS entrance meeting, that discharge summaries are expected to be completed within thirty days after a patient leaves the facility.

2. The following discharge records (date of discharge in parenthesis) of three (3) of five (5) records reviewed 1/4/16 for compliance with facility policy and procedure did not have a discharge summary within the time frame stated by the CEO: E1 (12/3/15), E3 (12/1/15), and E4 (12/3/15).

B. Interview

In an interview on 1/6/16 at 1:00 p.m., the failure of three discharge summaries being completed within 30 days of discharge was discussed with the Medical Director. He stated, "I'm surprised. I've never been told that before. We have a high completion rate here."

Based on observations, record review, document review, and interview, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Ensure that complete, thorough, and legible psychiatric evaluations were documented for eight (8) of eight (8) active sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). Failure to provide the necessary information to justify the diagnosis impedes the ability of the treatment team to formulate a meaningful plan of care designed to meet the patient ' s unique needs. (Refer to B110)

II. Ensure that treatment interventions were assigned to all clinical discipline involved in active treatment. Specifically, Master Treatment Plans (MTPs) did not include active treatment interventions to be implement by the attending psychiatrist for five (5) of eight (8) active sample patients (A12, A15, B10, C4, and C5). There were no active treatment interventions included at all for the attending psychiatrist related to the identified psychiatric problem statements on these MTPs. Failure to provide the specific active treatment interventions to be implemented by all clinical staff potentially results in inconsistent and/or ineffective treatment. (Refer to B118)

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

A. Clearly defined problem statements written in behavioral and descriptive term for X of 8 active sample patients (A12, A15, B10, C4, C5, C13, D6, and D13). (Refer to B119)

B. Individualized short-term and long-term goals for four (4) of eight (8) active sample patients (A12, B10, C4 and D13). (Refer to B121)

C. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems. (Refer to B122)

D. The name and disciplines responsible for seeing that each specific intervention on the Master Treatment plans were carried out for five (5) of eight (8) active sample patients (A12, A15, C4, D6, and D13). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

IV. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to one (1) of six (6) active sample patients (A15) on the Adult North Unit who were unwilling to participate and/or attend groups. In addition, the facility failed to ensure that patients on two of the Adult Units (North and South) received sufficient hours of therapeutic activities and sufficient number of therapeutic groups to accommodate up to 32 patients on the North and 26 patients on the South Unit. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125-I)

V. Ensure that requirements to use the least restricted interventions were maintained for one (1) of five (5) non-sample patients (G3) selected to review episodes of seclusion and restraint. Specifically, Patient G3 was kept in seclusion without a documented justifiable cause. The use of seclusion without documented justification that the continued use of this procedure was based on behaviors reflecting patient's possible continued violence towards others results in a violation of the patient's right to freedom of movement. (Refer to B125-II)

VI. Ensure that discharge summaries were dictated, translated, and filed within 30 days of discharge, per hospital policy, in three (3) of 5 discharge records reviewed (E1, E3, and D4). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plans with outpatient providers. (Refer to B133)

Based on record review and interview, the Nursing Director failed to monitor and evaluate the quality of nursing input in treatment plan development by nursing staff. Specifically, the Nursing Director failed to:

I. Ensure that treatment interventions were assigned to all clinical discipline involved in active treatment. Specifically, Master Treatment Plans (MTPs) did not include active treatment interventions to be implement by registered nurses for three (3) of eight (8) active sample patients (A15, B10, and C5). There were no active treatment interventions included at all for registered nurses and other nursing staff related to the identified psychiatric problem statements on these MTPs. Failure to provide the specific active treatment interventions to be implemented by nursing staff potentially results in inconsistent and/or ineffective treatment. (Refer to B118)

II. Ensure that nursing interventions for five (5) of eight (8) active sample patients (A12, A15, C4, D6, and D13) addressed their specific treatment needs. The pre-printed forms listed interventions that were either stated as generic discipline functions or modalities without a specific focus. These failures result in a lack of staff coordination in providing individualized treatment, potentially delaying patient improvement and discharge from the hospital.

Findings include:

1. Facility policy no.: PC 013, reviewed/revised: 12/14, titled "Interdisciplinary Treatment Plan", stated: "The treatment plan should be measurable in order for the staff to determine the patient is improving in treatment, the staff must be able to measure improvement." "The interventions include specific action on activity the focus of the intervention."

2. Patient A12, MTP dated 12/15/15, listed the following generic, routine discipline function and/or modality without a specific focus for the problem: "Depressed mood with suicidality." - Nursing intervention - "Time outs in: designated area" - focus - "pt. [patient] safety." The modality was a generic and routine discipline function or discipline task. The focus did not relate to specific problem of the patient to be addressed in the modality.

3. Patient A15, MTP dated 12/30/15 listed the following generic, routine discipline function and/or modality without a specific focus for the problem: "Depressed mood with suicidality":
- Nursing Intervention - "Time out in" - focus - "pt. safety." The modality was either generic and routine discipline function or discipline task. The focus did not relate to specific problem of the patient to be addressed in the modality.

4. Patient C4, MTP dated 12/19/15, listed the following generic, routine discipline function, and/or modality without a specific focus for the problem: "Psychotic behaviors/out of contact with reality":
- Nursing intervention - "Time out in" - focus - "pt. safety."
The modality was either generic and routine discipline function or discipline task. The focus did not relate to specific problem of the patient to be addressed in the modality.

5. Patient D6
The MTP, dated 12/28/15, listed the following generic, routine discipline function, and/or modality without a focus for the problem: "Aggressive/assaultive behavior":
- Nursing intervention - "Time out in quiet room" - focus - "safety."
The modality was either generic and routine discipline function or discipline task. The focus did not relate to specific problem of the patient to be addressed in the modality.

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the generic routine nursing discipline interventions on the Master Treatment plan were discussed with the Director of Nursing. She did not dispute the findings.

III. Ensure that nursing staff identify the name of nursing discipline responsible for seeing that each specific intervention on the Master Treatment plans was carried out for five (5) of eight (8) active sample patients (A12, A15, C4, D6, and D13). The responsible staff column frequently listed the nursing discipline as "RN" [registered nurse] and/or MHT (Mental Health Technician} without putting the name of the person. This practice results in the facility's inability to clearly monitor staff accountability for seeing that specific interventions are carried out.

Findings include:

A. Record Review

1. Patient A12
The MTP, dated 12/15/15, listed the following nursing staff intervention associated with the problem "depressed mood with suicidality":
- Nursing intervention - "Time outs in designated area" - MHT, RN were listed.

2. Patient A15
The MTP, dated 12/30/15 had the following nursing staff intervention for the problem "depressed mood with suicidality" - "time outs in"
- Nursing intervention - "Nursing task" - "MHT, RN"

3. Patient C4
The MTP, dated 12/19/15, had the following staff nursing intervention for the problem "psychotic behaviors/out of contact with reality" -
- Nursing intervention - "Time outs in" - "MHT, RN"

4. Patient D6
The MTP, dated 12/28/15, had the following staff intervention for the problem "aggressive/assaultive behavior" - psycho-educational groups related to increased aggression - "clinical"
- Nursing intervention - "Time out in quiet room" - "clinical & nursing"

5. Patient D13
The MTP, dated 12/29/15, had the following nursing staff intervention for the problem "aggressive/assaultive behavior":
- Nursing intervention - "Time out in quiet room" - "clinical & nursing"

B. Interview

In an interview on 1/5/16 at 3:10 p.m., the lack of responsible staff names on many Master Treatment plans was discussed with the Nursing Director. She agreed that the names should be included on the plans.

IV. Ensure that the nursing group included on the unit schedule were documented with sufficient information regarding specific topics discussed, and the patients' behavior during group, and their response to the group intervention, including level of participation, understanding, and specific comments of four (4) of eight (8) active sample patients (A12, A15, B10, and D13). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

Based on record review and interviews, the Director of Social Services failed to:

I. Provide social work assessments that included conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources, support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A12, A15, B10, C4, C5, C13, D6 and D13). Instead, the psychosocial assessment contained a summary of the patient's clinical presentation without identifying how this information was related to discharge and aftercare planning. In addition, the social work role only identified a list of treatment modalities without identifying the focus of treatment and discharge planning needs. As a result, the treatment team did not have necessary social work information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that active treatment intervention statements on MTPs to be delivered by social workers for seven (7) of eight (8) active sample patients (A12, A15, B10, C4, C5, D6 and D13) addressed their specific treatment needs. The pre-printed forms listed interventions that were either stated as generic social work functions or modalities without a specific focus. This failure results in a lack of coordinated social work practice in providing active treatment interventions, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)