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Based on record review and staff interview, the facility failed to follow the Nursing Care Plan to provide adequate supervision to prevent an elopement for one patient (#6) in a total sample of 30 patients.

Findings include:

Patient # 6 was admitted to the facility with diagnoses including paranoid schizophrenia and delusional disorder. The plan of care for patient #6 included supervised off unit privileges which is no more than an eight patient to one unit staff member ratio when off the unit.

According to the facility investigation dated 2/24/14, the patient was noted to be missing from the facility unit at approximately 4:30 P.M. on 2/21/14, at which time a " Code Yellow " (missing person) was initiated. Prior to this time, Patient #6 had been taken off the unit for the 4:15 P.M. fresh air break. Patient #6 was on the way back to the unit, at which time she/he entered the dining room, obtained a beverage, and then proceeded to exit through the lobby door behind an employee.

On 2/26/14 at 1:30 P.M. Surveyor #1 watched the facility video recording of the event and observed patient #6 walking with 6 other patients back from the fresh air break at 4:31 P.M. All 6 patients were observed walking by the cafeteria, at which time patient #6 exited to the right, away from the group of patients, into the cafeteria. The remaining 6 patients continued walking to the elevator and proceeded to get into the elevator. During observation of the facility video recording by Surveyor #1 it revealed that the mental health worker was walking in front of the patients, not in the rear of the patients, so the patients could not be visualized as a group and account that all 7 patients were present. According to the escort policy, the staff member must be able to see all patients in front of them. Once the staff member and the 6 patients were on the elevator the Mental Health worker stuck his/her head out of the elevator to look down the hall and then closed the elevator door. Patient # 6 then came out of the cafeteria, proceeded to the lobby, walked out of the facility behind an employee and down the front stairs at 4:32 P.M. The reception desk was unmanned, as the receptionist had stepped away from the desk to do copying, according to the facility investigation.

Review of the medical record on 2/26/14 at 10:00 A.M., there was a physicians' order to discontinue 5 minute checks on 2/21/14 at 7:43 A.M. and institute 15 minute checks. There was also a physicians ' order on 2/21/14 to discontinue unit restriction and allow off unit privileges, however patient #6 was still considered an elopement risk.

Facility policy is that, no patient is allowed off the unit un-supervised. The facility policy also indicates there is no more than eight patients to one Mental Health worker when patients are taken off the unit.

On 2/21/14 at 4:30 P.M. patient #6 was noticed missing, at that time, all interventions were put into place according to facility policy regarding the elopement of a patient. The patient subsequently returned to the facility at approximately 10:49 P.M. on 2/21/14 after being medically cleared.

Review of documentation following the elopement included a report that the patient did not sustain any physical harm and did not exhibit any "apparent injuries or distress" as a result of the incident.

Review of the 2/26/14 documented interview conducted by the Unit Manager with the mental health worker states that he/she did not follow the escort policy by keeping the patients in her line of sight, i.e. walking behind the patients.

The Unit Manager stated at 1:15 P.M. on 2/26/14 for patient #6 the facility failed to provide adequate supervision to prevent the elopement of a patient.

Based on observation, record review and staff interview the facility failed to ensure the nursing staff documented the administration of regular insulin according to nursing policy for 1 of 30 sampled patients (#17).

Findings include:

During a medication pass, for Patient #17, on 2/25/14 at 10:45 A.M. the Surveyor observed Nurse #2 record the administration of regular insulin in the patient's electronic medication administration record (MAR). Nurse #2 was asked by the Surveyor if she was going to document on the MAR that she administered the regular insulin in the patient's right arm. Nurse #2 said she would document a note on the MAR where she administered the insulin because there was no other place to document sites of insulin administration.


The facility's policy and procedure, related to medication management and administration of insulin injections indicated to rotate the sites for insulin injections and document the site in the MAR.

Patient #17's MAR's, dated 2/23, 2/24 and 2/25/14 indicated that regular insulin was administered to the patient 4 times a day. However, the sites where Patient #17 received the regular insulin were not documented as required by facility policies and procedures.


The Surveyor interviewed the Chief Nursing Officer (CNO) at 9:00 A.M. on 2/26/14. The CNO said the sites of insulin administration should be documented in the patients medical record.

Based on record review and staff interview the facility failed to have medical progress notes that were comprehensive, detailed and pertinent regarding patient care in 2 (#6 and #17) of 30 active patient medical records.

Findings include:

1. For Patient #6 the medical progress notes lacked accurate, comprehensive information pertaining to patient care.

Patient #6 was admitted to the facility on 2/3/14 with paranoid schizophrenia and delusional disorder. The patient was admitted to the facility under a Section 12, which is an involuntary admission. The patient refused to sign any consents and refused to take any medications.

The facility proceeded to take the next step, which was to go to court and apply for a Rogers guardianship (A Rogers guardianship is a court appointed guardian who oversee's the patients psychotropic medication regime. The guardian ensures that the patient will take the medications, by mouth or by injection if needed). It was determined by the staff that patient #6 was incompetent.

The Rogers guardianship became effective on 2/18/14, and Patient #6 was first started on Risperdal and then began on Haldol (both drugs are antipsychotics).

Review of the medical record on 2/26/14 at 11:00 A.M. revealed the clinical nurse specialist indicated that the patient had impaired judgment and the patients behavior is considerably influenced by delusions and on 02/21/08 at 4:30 P.M., the patient had eloped from the facility.
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Review of the Medical Progress Notes on 2/8/14 and on 2/15/14 read as follows:
Pt with Schizophrenia, med compliant, no new issues, to continue on the meds

Review of the Medical Progress Note on 2/22/14 read as follows:
Pt with Schizophrenia, med compliant, no new issues, to continue on the meds

Interview with the Medical Director on 2/27/14 at 7:10 A.M. stated the notes lacked the comprehensive, detailed, pertinent information regarding patient #6.


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2. For Patient #17

The Medical History and Physical examination, dated 2/15/14 indicated Patient #17 was admitted to the facility with depression, psychosis and alcohol abuse. Patient #17 had a medical history that included non-insulin dependent diabetes mellitus and his/her medications included Metformin (oral antidiabetic).

The Physician Orders, dated 2/23/14 indicated that Regular Insulin was to be administered 4 times a day according to the result of a blood sugar level checked four times a day.

Medication Administration Records dated 2/23, 2/24 and 2/25/14 indicated Patient #17 was administered various amounts of Regular Insulin according to the Physician Order.

The Medical Progress Notes, dated 2/23/14 indicated that no information was documented as to the reason Patient #17 was started on a sliding scale of regular insulin.

Based on documentation, record review, observation and staff interview, the hospital failed to ensure that diet orders were complete and were communicated accurately to the Nutrition Services Department to ensure that diets were served as ordered for 8 sampled patients (#3, #5, #9, #10, #12, #23, #24 and #30) in a total sample of 30 patients.

1. On 2/24/14 from 11:45 A.M. to 12:15 P.M., the surveyor observed lunch being served in the hospital's cafeteria.

Review of the "Meal Service Protocol" for Cafeteria Service read that "Patients on a special diet will be identified by a colored wrist band that coincides with the therapeutic menu allowing the server to serve the proper menu items".

Review of the "Special Diet Identification Policy" read that "as the patients pass through the cafeteria serving line, the server will be able to identify the diet by glancing at the patient's wrist" and "at that point the server will check the therapeutic menu, and be able to serve the correct items and portion size for that diet".

Review of the "Physician Diet Orders Policy" read that "Diet/Appetite Sheets are used to communicate all diet orders to the Nutritional Services Department" and that "the completed Diet/Appetite Sheet is hand delivered to the Nutritional Services Department by the MHW (Mental Health Worker) escorting clients to the cafeteria for each scheduled meal service".

Review of the the 2 South and 3 South Diet/Appetite Sheets indicated that Patients #5, #9, #12 and #24 had the following diet orders:

--Patient #5 was on an 1800 ADA, Low Sodium, Low Cholesterol Diet and was "allergic to s/fish & nuts".
--Patient #9 was on an 1800 ADA, Low Sodium Diet.
--Patient #12 was on a "Vegan Diet".
--Patient #24 was on a regular diet.

The surveyor did not observe any of the above sampled patients on special diets wearing colored wrist bands. In addition, the Diet/Appetite Sheets were not given to the server until after the meals had been served. One of the three units, the Dual Diagnosis Unit, did not provide a Diet/Appetite Sheet to the server.

The surveyor asked the server if any of the patients indicated to him/her that they followed a special diet such as a diabetic diet. The server indicated "No".


2. On 2/25/14 at 11:00 A.M. and on 2/27/14 at 11:30 A.M., the surveyor reviewed the diet orders for Patients #3, #5, #9, #10, #12, #23, #24 and #30 with the hospital's Dietitian. Record review revealed the following:

a) Two sampled Patients (#5 and #30) had food allergies that were not included in the diet order and the Diet/Appetite Sheet used by the kitchen staff when serving meals:

Patient #5 had an allergy to seafood and nuts. The Nutrition consult dated 2/21/14 documented that the patient said that his/her allergy was to "seafood" only not nuts. The Dietitian documented: "amend diet order to include food allergy as above". As of 2/25/14, the diet order had not been amended to reflect the patient's updated food allergy.

Patient #30 had an allergy to "shellfish" that was not included in the diet order. The Dietitian said that the food allergy should be part of the diet order. The food allergy did not appear on the 2/24/14 and 2/25/14 Diet/Appetite Sheets used by the Nutrition Services staff for meal service.

b) Two sampled Patients (#3 and #24) did not have current diet orders. The Diet/Appetite Sheet used by the kitchen staff when serving meals indicated the patients were on a regular diet.

Patient #3 had no current diet order. The kitchen was serving the patient a "Regular" diet, although no order for a regular diet could be found.

Patient #24 did not have a current complete diet order. The diet order only read that the patient had an "allergy to seafood". The kitchen was serving the patient a "Regular" diet, although no order for a regular diet could be found.

c) One sampled Patient (#10) had a recommendation from the Dietitian for a diet texture change that was not addressed.

Patient #10 had a Nutrition Consult dated 2/23/14 that recommended a diet change to a dental soft diet due to missing dentures. As of 2/25/14, the diet order had not been changed. The kitchen was serving a Regular diet.

d) One sampled Patient (#23) had a lactose intolerance that was not included in the diet order and/or Diet/Appetite Sheet.

Patient #23 had documentation of lactose intolerance on the physician order sheet. However, the diet order read: "Regular Diet" and did not indicate a lactose intolerance. The Diet/Appetite Sheet used by the kitchen when serving meals did not indicate a lactose intolerance. On 2/25/14, the physician ordered a Nutrition Consult for the lactose intolerance.

e) One sampled Patient (#12) had a nutrition supplement added to the diet order that did not comply with the diet order.

Patient #12 had a diet order for a Vegan Diet. Ensure supplement, one to two cans per day, was added to the diet order. As Ensure contains a dairy ingredient (milk protein), it would not be allowed on a Vegan Diet.

3. On 2/27/14 at 10:30 A.M. during an interview, the Nursing Executive and the Chief Executive Officer (CEO) indicated that the Hospital would review the current system for informing the Nutrition Services Department of diet orders and food allergies.

On 3/3/14, the Chief Executive Officer (CEO) followed up with a formal action plan indicating that the Food Service Director (FSD) will print the Diet Report which includes the patient's name and specific diet from the electronic medical record prior to every meal. In addition, the Nutrition Services Department will note all allergies on the report prior to each meal. The Diet Report will be distributed to the serving staff and then to the Mental Health Workers prior to serving. The goal for the Diet Report is to include: diet, allergies and privilege level (on/off unit).

Based on observation, facility policy review and staff interview, the facility failed to ensure that proper infection control practices were followed for glucometer cleaning for 2 patients (# 1 and # 17) in a total sample of 30

Findings include:

1. For Patient #1,the facility failed to properly clean the blood glucose monitoring system utilized to obtain the CBG (capillary blood glucose) readings after patient use.

On 2/26/14 at 11:00 A.M., Nurse #3 was observed obtaining a CBG (capillary blood glucose) reading on patient #1 on 3S. Nurse #3 obtained a small basket from the shelf in the medication room. The basket contained a glucometer, single use lancets, strips and alcohol wipes. The glucometer is a blood glucose monitoring system utilized to obtain the CBG readings on patients. Nurse #3 put on a pair of gloves, then placed a glucose testing strip into the glucometer. Nurse #3 then wiped patient #1's finger with an alcohol wipe and performed the finger stick to test the blood sugar. The CBG result was 140 and no insulin coverage was needed. At this time Nurse #3 then placed the glucometer back into the basket, without cleaning the unit after patient use. Surveyor then asked Nurse #3 the procedure for cleaning the glucometer and Nurse #3 stated the unit is wiped after each use with alcohol wipes.

Surveyor confirmed the Glucometer must be cleaned after each use per the hospital Infection Control policy and per interview with the facility Infection Control Nurse.


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2. For Patient #17,the facility failed to properly clean the blood glucose monitoring system utilized to obtain the CBG (capillary blood glucose) readings after patient use.

During a medication pass, on 2/25/14 at 10:45 A.M. the Surveyor observed the following: 1.) Nurse #2, perform a capillary blood glucose test for Patient #17, prior to the administration of regular insulin, wearing gloves. After the glucometer resulted the blood glucose level, Nurse #2 reached into the clean supply basket for a band-aide with the now potentially contaminated gloves. After the band-aide was applied, Nurse #2 washed her hands, but failed to disinfect the glucometer devise before returning it to the basket.


The Hospital's policy and procedure, # IC-53, related to the prevention of infections from shared medical equipment indicated that a glucometer must be wiped down with antibacterial wipe or 70% isopropyl alcohol after each used by the registered nurse.

Based on staff interview and record review the facility failed to ensure that 1 of 30 patient records, (Patient #17) contained a comprehensive discharge plan which included timely referral to a medical provider and post-hospital services regarding Patient #17's diabetes.

Findings include:

The Nutrition Consult, dated 2/19/14, indicated that Patient #17 was a newly diagnosed (ten month ago) diabetic. The dietician recommended that Patient #17 obtain a glucometer and follow his/her blood sugar levels at home. The note indicated Patient #17 would benefit from further diabetic teaching and to follow-up with a nutritionist after discharge.


The Medical Doctor Discharge Summary, dated 2/25/14 indicated Patient #17 was admitted to the facility with depression, psychosis and alcohol abuse. There was no information regarding diabetes on the discharge plan.

The Surveyor interviewed the Mental Health Counselor at 12:00 P.M. on 2/25/14. The Mental Health Counselor said Patient #17 was being discharged on 2/26/14 and the patient had a follow-up primary care physician appointment on 4/30/14 for his/her medical problems.


The Surveyor interviewed Attending Psychiatrist #1 at 10:40 A.M. on 2/26/14. The Surveyor reviewed the Medical Doctor Discharge Summary with Attending Psychiatrist #1 and inquired as to the lack of information regarding diabetes. Attending Physiatrist #1 said he would add additional information to the discharge plan.

The Amended Medical Discharge Summary documented by Attending Psychiatrist #1, dated 2/26/14 at 11:47 A.M. indicated Patient #17 was advised to speak with his primary care physician regarding his/her diabetic management and included obtaining a glucometer to monitor his/her blood sugar and diabetic medications.

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

I. Ensure that all required components were included in the psychiatric evaluations (PEs) completed by medical staff. The PEs were missing the following required components: 1) a general statement regarding medical history for 2 of 8 active sample patients (B4 and C1) and 2) an inventory of the patient's assets to be used in the treatment of eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). These failures potentially impair the psychiatrist's ability to determine the impact of an acute or chronic medical condition on current psychiatric presentation and to identify patient assets that can assist in the treatment process. (Refer to B112 and B117)

II. Provide comprehensive Master Treatment Plans (MTPs) which were individualized, behavioral, and measurable with all necessary components for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). Specifically, the MTPs did not include the following: 1) observable, patient focused, measurable, and behaviorally stated goals (Refer to B121), 2) individualized treatment interventions (Refer to B122), and 3) the name and specific discipline responsible for each activity therapy (AT) intervention (Refer to B123). Failure to develop individualized MTPs 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.

III. Provide active treatment, including purposeful alternative interventions for four (4) of eight (8) active sample patients (A5, B3, C1, and C6). Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend groups. They spent many hours without any structured activity and occupied their time by sleeping or wandering around the hallways. Despite, inconsistent or lack of regular attendance in groups, master treatment plans were not revised to reflect individual treatment sessions instead of group treatment. 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)

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations were reviewed by a physician for two (2) of eight (8) active sample patients (B3 and B12). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice Registered Nurse (APRN) without documented physician review. This potentially results in the failure to have patient care provided under the direction and supervision of a physician.

Findings include:

A. Record Review

The Psychiatric Evaluations (dates in parentheses) for the following patients were completed by APRNs without documented authentication by a physician: Patient B3 (2/4/14) and Patient B12 (2/21/14).

B. Staff Interview

1. During an interview on 2/25/14 at 4:14 p.m., the Medical Director (also the Supervising Psychiatrist for these patients) acknowledged that the psychiatric evaluations for these patients did not contain documentation indicating there was physician authentication of these evaluations. He stated that the electronic record system did not provide a way to show that the psychiatric evaluation completed by the APRN had been reviewed and attested by the Supervising Psychiatrist.

2. During an interview on 2/26/14 at 10:00 a.m., the Risk Management/Quality Improvement Director stated that the facility did not have a policy on the authentication of psychiatric evaluations performed by APRNs. She stated that the facility only had a document regarding the scope of practice for APRNs.

Based on record review and interviews, the facility failed to ensure that psychiatric evaluations included a general medical history of inter-current medical problems for two (2) of eight (8) active patients (B4 and C1). This deficiency potentially results in the inability to assess the impact of an acute or chronic medical condition on current psychiatric presentation.

Findings include:

A. Record Review

1. For Patient B4, the section of the "Multidisciplinary Assessment Summary (MAS)" dated 2/22/14 completed and attested by the registered nurse reported, "Medically, pt [patient] has NIDDM [non-insulin dependent diabetes mellitus], HTN [Hypertension], High cholesterol, asthma..." The section of the MAS completed by the physician did not discuss or document these inter-current medical problems.

2. For Patient C1, the section of the "Multidisciplinary Assessment Summary (MAS)" dated 2/18/14 completed and attested by the registered nurse reported, "Chart shows multiple med [medical] dx [diagnoses] copd [Chronic Obstructive Pulmonary Disease], cad [Coronary Artery Disease], htn [Hypertension], hyperlipidemia, gerd [Gastroesophageal Reflux Disease], ethoh wd seiz [alcohol withdrawal seizure]." The section of the MAS completed by the physician discussed the alcohol withdrawal seizures but did not discuss or document any of the other inter-current medical problems.

B. Staff Interviews

During interview on 2/25/14 at 4:10 p.m. with the Medical Director, the inter-current medical problems pertinent to the current hospitalization of Patient B4 and C1 were discussed. He agreed that the section of the "Multidisciplinary Assessment Summary" completed by the physician or Advanced Practice Registered Nurse psychiatric evaluations did not document inter-current medical problems. The Director of Medical Records confirmed after checking the electronic medical record system that the information regarding was completed by the registered nurse at the time of admission.

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations included an inventory of specific patient assets for eight (8) of eight (8) sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). The failure to identify patient assets potentially impairs the psychiatrist's ability to plan and select treatment modalities that best utilize the patient's strengths.

Findings include:

A. Record Review

The admission psychiatric evaluations (dates in parentheses) for the following patients did not contain specific patient strengths or assets: Patient A5 (2/14/14), Patient A7 (2/23/14), Patient A10 (2/18/14), Patient B3 (2/4/14), Patient B4 (2/23/14), Patient B12 (2/21/14), Patient C1 (2/23/14), and Patient C6 (2/19/14).

B. Interview

During an interview with the Medical Director on 2/25/14 at 4:10 p.m., he acknowledged that the section of "Multidisciplinary Assessment Summary" completed by the physician and considered to be the psychiatric evaluation did not include specific patient strengths or assets to be used in the treatment of patients.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that included patient-related short and/or long-term goals ( called objectives in this facility) stated in measurable terms for seven (7) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, and C6). In addition, some of the goals were staff goals, not patient goals. Many of the problems listed on the plans were not clearly stated. These deficient practices hamper the ability of the treatment team to provide goal directed treatment to determine the effectiveness of interventions based on changes in patient behaviors.

Findings include:

A. Record Review

1. Facility policy number PC108, titled "Multidisciplinary Initial Treatment Plan and Update", last revised 2/10, stated: "An individualized treatment update is developed for each patient based on needs identified during the admission assessment." --- "At a minimum, the attending physician, nursing and social work [sic] contribute to the patient's care plan. Identify initial problems that are specific to the reason for hospitalization (done by the RN within eight hours of admission and the other disciplines next working day)." --- "Formulate a long-term outcome that describes behavior sought in order to be discharged. Goals should be based on patients identified strengths and disabilities. Formulate short-term measurable outcomes for each problem identified." This policy failed to provide sufficient information to guide clinical staff when formulating treatment goals, such as the expectation that goals should be formulated to be appropriate, patient-focused based on behaviorally-stated presenting symptoms, and easily understood by patients.

2. Active sample patient A5, MTP dated 2/20/14 had as a problem "suicide." Manifestation: "suicidal behavior as evidenced by various plans per record." The long-term goal/objective was "patient will be free of suicidal ideation's." The short-term objective was "Patient will develop a safety plan with nursing staff for 5 days." The problem and the long-term objective were not measurable. The short-term objective was a staff goal, and not patient goal. Staff goals are what they want the patient to achieve. Patient goals are patient behaviors to be achieved to help the patient reach a positive outcome.

For the problem of "depression" --- manifestations: "Depression as evidenced by agitation. Depression as evidenced by suicidal ideation." The long-term objective was "Patient will be free of depressive symptoms." The patient's specific symptoms of depression were not described. The short-term objectives for depression were: "Patient will comply with medication regimen and accept medications as ordered. Patient will address this issue in her aftercare plan." Both objectives were staff goals, and not patient goals.

3. Active sample patient A7, MTP dated 2/22/14, had as a problem "aggression/ violence." An immeasurable short-term objective was "Patient will be able to identify precipitants to aggressive behavior." For the problem of "Depression" --- as evidenced by agitation. Depression as evidenced by suicidal ideation. Depression as evidenced by depressed feeling, a immeasurable long term objective was - "Patient will be free of depressive symptoms." "Suicidal ideation" and "depressive symptoms" were not stated in measurable or behavioral terms."

4. Active sample patient A10, MTP dated 2/20/14, had as a problem "thought disorder." The immeasurable long-term objective was "Patient will be free of thought disorder symptoms. "For the problem of "mania" (poor sleep, racing thoughts, poor judgment), the long-term objective was, "Patient will have stable mood and clear thought process." The short-term objective was - "Patient's thought process will be reality based and coherent." Neither the problem nor the long and short-term objectives were measurable or behaviorally specific.

5. Active sample patient B3, MTP dated 2/20/14, had as a problem "thought disorder." An immeasurable long-term objective was "Patient is able to identify symptoms as evidence of a "thought disorder." The immeasurable short-term objective was "Patient will develop the ability to conduct a goal-directed conversation."

6. Active sample patient B4, MTP dated 2/21/14, had as a problem "Suicide." The immeasurable long-term objective was "Patient will be free of suicidal ideation's."

7. Active sample patient B12, MTP dated 2/22/14, had as a problem "mania." Specific behaviors of mania were not described on the MTP. The manifestations simply said "hx [history]." The immeasurable long-term objective was "patient will have stable mood and clear thought process." The immeasurable short-term objective was "patient will exhibit an understanding and comply with their medication regime." For the problem of "thought disorder"... manifestations - "hx [history]", the immeasurable long-term objectives were: "patient will be free of thought disorder symptoms. Patient is able to identify symptoms as evidence of a thought disorder. "

8. Active sample patient C6, MTP dated 2/18/14, had as problems "depression"..."as evidenced by suicidal ideation. This statement failed to describe specific thoughts as expressed by patient. Depression as evidenced by depressed feeling." This problem was not measurable or behaviorally descriptive. Immeasurable long-term objectives were: "Patient will be free of depressive symptoms; Patient will be able to identify symptoms as evidence of depression disorder."

B. Interview

1. On 2/25/14 at 1:30 p.m., the generic short and long-term objectives were discussed with the Nursing Director. She stated that the facility was told to use generalized objectives by other regulating bodies such as The Joint Commission.

Based on record review and interview, the facility failed to consistently develop for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1 and C6) Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of each patient. Interventions were stated as generic monitoring and discipline functions to be performed primarily by physicians, nurses and social workers. In addition, the plans failed to consistently state how these generic interventions would be delivered and how often they would be delivered. The interventions were actually discipline tasks written as treatment interventions. All patients were expected to attend all the groups listed on the unit schedule. However the MTPs did not include all the groups from the schedule. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy number PC108, titled "Multidisciplinary Initial Treatment Plan and Update," last revised "2/10," stated: "At minimum the attending physician, nursing, and social work [sic] contribute to the patient's care plan"..."Identify the multi-disciplinary staff/interventions that will assist the patient in meeting the short/long term outcomes." This policy did not provide sufficient information to guide clinical staff when writing treatment modalities.

2. The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (updated 2/20/14), A7 (2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/14, and C6 (2/18/14). This review revealed that the MTPs had the following routine generic discipline functions written as treatment interventions to be delivered by the psychiatrist, registered nurse (RN), social worker (SW). Additionally, many treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or 3) the focus or purpose of treatment related to the patient's presenting and behaviorally descriptive symptoms. Many interventions were identical or similarly worded.

a. Active sample patient A5 had a problem of "suicide." Generic staff interventions were:

"Nursing staff will maintain patient on appropriate level, i.e. 15 min [minute] suicide checks, 1:1 observation, day hall observation, to provide a safe environment and decrease suicide attempts."

"Psychiatrist will evaluate, prescribe, and monitor medications for suicidal depression."

"Social work will work with the patient and any outpatient supports to address this issue."

These statements written as treatment interventions were routine functions each staff member would do regardless of the patient's specific problems.

For the problem of depression, the generic staff interventions were as follows:

"Nursing staff will encourage attendance in community meetings, and groups daily."

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

"Social work will work with the patient and any outpatient supports to address this issue."

Most of the interventions lacked frequency or focus.

b. Active sample patient A7 had the following generic staff interventions for the problem of "aggression, violence":

"Nursing staff will provide individual medication education everyday."

"Psychiatrist will prescribe and monitor medications and provide psychoeducation to patient regarding their purpose, effects, and use."

These statements did not include whether they would be delivered in group or individual sessions and most lacked specific focus.

- For the problem of "depression," the generic staff interventions were:

"Nursing will encourage and supervise ADLs [activities of daily living] daily. Nursing staff will provide individual medication education to revise benefits and side effects of medications."

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

Most of these interventions lacked frequency.

- For the problem of "suicide," the generic interventions were:

"Nursing staff will maintain an appropriate precaution level; i.e. 15 minutes suicide checks."

"Psychiatrist will evaluate, prescribe, and monitor medications for suicide depression."

The latter intervention also lacked frequency.

c. Active sample patient A10 had the following generic staff interventions for the problem of " thought disorder " :

"Social worker will provide 1:1 reality-oriented counseling ..., structuring patient use of aftercare services and give the patient a place to discuss feelings and concerns."

"Psychiatrist will prescribe and monitor medications."

These interventions also lacked frequency of contact and delivery method.

- For the problem of "mania," the generic staff interventions were:

"Nursing staff will educate on rational benefits and side effects of medications."

"Psychiatrist will prescribe and monitor medication daily to reduce behavior."

The nursing interventions lacked frequency of contact and delivery method.

d. Active sample patient B3 had the following generic staff interventions for the problem of "thought disorder":

"SW [social worker] will meet with pt [patient] daily, monitor mood and ms [mental status], rounds, and collaborate with collaterals, groups."

"Group therapist will involve patient in activities in order to help patient develop some interests and leisure activities, and to deal with social isolation."

"Psychiatrist will prescribe and monitor medications, and provide psychoeducation to patient regarding their purpose, use, and side effects of medication." No modality (individual or group session) was included. The latter two (2) interventions also lacked frequency of contact.

e. Active sample patient B4 had the following generic interventions for the problem of "suicide."

"Nursing staff will encourage patient to verbalize feelings and thoughts and alternatives about suicide." No frequency was included.

"SW will meet with pt. [Patient] daily, monitor mood and ms [mental status], rounds, collaborate with collaterals, groups, treatment updates, groups, dc [discharge] planning."


f. Active sample patient B12 had the following generic interventions for the problem of "manic":

"Psychiatrist will prescribe and monitor medications daily to reduce manic behavior."

"Social worker will communicate with outside treaters/significant other to assess baseline and coordinate discharge planning."

"Group therapists will provide task oriented focus groups." The last two (2) interventions also lacked frequency.


g. Active sample patient C1 had the following generic interventions for the problem of "substance abuse":

" Nursing staff to provide recovery goals."

"Psychiatrist will provide order [sic] appropriate detoxification protocol. Psychiatrist will educate on relationships between substance abuse and physical/mental illness."

"Social work will provide education support, engage in recovery, encourage groups, and refer to recovery sources in community."

All the interventions above lacked individualized and specific focus of treatment for this patient.

h. Active sample patient C6 had the following generic interventions for the problem of "depression":

"Nursing staff will encourage attendance and supervise ADL's daily. Nursing staff will encourage attendance in community meetings and groups daily. Nursing staff will provide medication education to review benefits and side effects of medications. Nursing will initiate interactions with patient and encourage verbalization of feeling every shift."

"Psychiatrist will order appropriate detoxification protocol."

The above mentioned groups did not include a specific focus of treatment based on the patient's presenting symptoms of depression. The nursing intervention on medication education and the psychiatrist's intervention did not include a frequency of contact or delivery method.


B. Interviews

1. In an interview on 2/25/14 at 1:30 p.m., the generic interventions on the Master Treatment plans were discussed with the Nursing Director. She acknowledged that the interventions were generic but felt that they would get more specific as the treatment team refined each individual patient's needs.

2. In an interview on 2/24/14 at 12:10 p.m., with RN #6, Master Treatment Plans were discussed. RN #1 confirmed that generic interventions such as "administering medications as prescribed" and "monitor mood" were on the treatment plans.

3. During interview on 2/25/14 at 4:10 p.m., the Master Treatment plans were reviewed with the Medical Director. He agreed that the interventions contained clinical task such as prescribing medications rather than the specify modality used (individual or group session) to discuss the benefits, side effects, etc. of primary psychotropic medication(s).

Based on record review and interview, the facility failed to include the name and specific discipline responsible for each activity therapy (AT) intervention on the Master Treatment Plan (MTP) for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B12, C1, and C6). AT groups on the MTPs were under the general heading of " Group Therapy. " The groups listed on the Unit's activity schedules, to which all patients were expected to attend, contained a list of AT activities five (5) days per week, but these groups were not included on the MTPs. This practice makes it difficult to clearly monitor and hold responsible staff accountable for seeing that specific interventions are carried out.

Findings include:

A. Record Review

1. A review of the unit schedules for 2 South, 3 South, and Dual Diagnosis listed the following AT groups on one (1) or more as the schedules: Life Skills, Safety Tools, Movement Group, and Project Group.

2. None of the following eight (8) active sample patients' MTPs (dates of the MTPs in parenthesis) included specific activity therapy groups, along with the specific name of an accountable person to see that the groups were carried out: A5 (5/20/14), A7 (2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/1/0), and C6 (2/18/14).

B. Interview
In an interview on 2/25/14 at 11:45 a.m., the lack of activity therapy activities recorded on the MTPs was discussed with the Group Clinical Coordinator. She stated that her interventions fall under the "Group therapist" category, but she admits specific names of activity therapy staff were not included.

Based on record review, observation, and interview, the facility failed to provide active treatment, including purposeful alternative interventions for four (4) of eight (8) active sample patients (A5, B3, C1, and C6). Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend groups. They spent many hours without any structured activity and occupied their time by sleeping or wandering around the hallways. Despite, inconsistent or lack of regular attendance in groups, master treatment plans were not revised to reflect individual treatment sessions instead of group treatment. 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. Patient A5

1. Patient A5 was admitted on 2/13/14. The Psychiatric Evaluation, dated 2/13/14, documented a diagnosis of "Bipolar Disorder NOS [not otherwise specified]" and "Post Traumatic Stress Disorder." Chief compliant was "daughter's birthday yesterday - daughter not in her care. SI [suicidal ideations] with various plans urges to stab people in the face. Pt [patient] lost cell phone yesterday which was another trigger."..."Hx [history] of suicidal attempt by cutting forearm and overdosing on Tylenol"..."Behavior is considerably influenced by delusions of hallucinations or serious impairment in communication or judgment or inability to function in almost all areas."

2. The only modalities identified on patient A5's Master Treatment plan [MTP], updated 2/20/14, were general ones such as "Group Psychotherapy", "Community Meetings", "Groups", and "All Groups." Specific groups such as "Life Safety," "Art Therapy" and "Cognitive Therapy Groups" were not listed. The RN progress Summary on the MTP, dated 2/20/14, stated "[Patient] refused to meet with treatment team today and discuss [his/her] medication." "S/he does not attend groups."

3. A review of "General Group Therapy Notes," dated 2/17/14, cited the following:

- For "Group Therapy" held 11:15 a.m. to 12:00 p.m.: attendance - refused/alternatives offered. Alternative offered was: "Educational materials." The patient's "Safety Check Sheet" documented patient as in his/her room during this period.

- For the same group above at the same time on 2/18/14, the patient's attendance was documented as "refused/alternatives offered." Alternatives offered were: "educational materials, sensory tool item." No explanation of what these educational or sensory tool items consisted of was provided. No evidence that staff met with patient to discuss the materials was provided.

During "safety tool" group from 3:15 p.m. to 4:00 p.m., the patient refused to attend. Alternatives offered - "educational materials, sensory tool item."

- For "Group Therapy" on 2/19/14 for 11:15 a.m. to 12:00 p.m. and "Life Skills" group from 3:15 p.m. to 4:00 p.m., patient A5, who refused to attend, was offered the same alternatives as above. Patient was documented as being in hall at this time.

- For an "Art Therapy" group on 2/20/14 from 10:05 a.m. to 10:35 a.m., the patient was again offered the same alternatives as above. When s/he refused to attend the following groups on 2/21/14: "Life safety" group from 10:05 a.m. to 10:35 a.m., a "Life safety" group from 11:10 a.m. to 11:55 a.m., and a "Cognitive Therapy" group from 2:15 p.m. to 3:00 p.m., the same alternatives as listed above were offered. For the groups listed above, from 2/20/14 through 2/21/14, the patient was documented on the "Safety Check Sheets" as being either in his/her room or in the hall.

4. Patient A5 was observed in his/her bed on 2/25/14 at 11:10 a.m. with eyes closed during the "Music Therapy" group being held in the Dayroom of Unit 2 South.

5. In an interview on 2/25/14 at 10:00 a.m., the lack of alternatives for patients who were not attending groups was discussed with RN #7. She disagreed with the statement, saying "I think allowing the patients to sleep is an alternative."

6. In an interview on 2/25/14 at 11:00 a.m., the lack of group attendance of patient A5 was discussed with RN #4. She stated, "We try and encourage patients to attend the groups, but this patient can be disruptive in groups."

7. In an interview on 2/25/14 at 11:20 a.m., the lack of group attendance was discussed with MD#1. He stated, "[S/he] also refuses medications too." MD #1 stated that he felt patient A5's negative behavior will improve with medications and added that there is a court hearing on Thursday, 2/27/14, to obtain permission to force medications on patient.


B. Patient B3

1. Patient B3 was admitted on 2/4/14. The Psychiatric Evaluation, dated 2/4/14, documented a diagnosis of "Schizophrenia, Paranoid Type" "....with a chief compliant of paranoia and lack of self care....Pt [Patient] has not been taking medications because she believed that the pharmacy poisoned them."

2. The only modalities identified on patient B3's Master Treatment plan [MTP], 2/20/14, were general ones such as "Group Psychotherapy" on the "Modality Summary" and the summary also listed clinical departments such as "Nursing Services", "Social Work Services", and "Psychiatric Services" as modalities. The MTP also revealed that the patient was to attend "Safety Tool Group, Art Therapy, and Psychotherapy."

3. Patient B3 was observed in [his/her] a "DBT" group on 2/24/14 at 3:20 p.m. but left the group at 3:30 p.m. A group entitled "DBT" (Dialectical Behavior Therapy) listed on the "Inpatient Groups - 3 South Unit" was being held in the Dayroom.

4. A review of the "General Group Therapy Note" forms from 2/5/14 through 2/19/14 showed that Patient B3 refused to participate in the group held during most of this period with only 14 of 40 group notes reviewed showing that the patient attended groups. These notes showed documentation that alternative materials were given to the patient however; several notes did not specify what materials were given to the patient. There was no evidence at all documented to show that staff met with the patient individually to discuss the handouts or educational materials provided. Therefore, there was no documented evidence regarding the patient's response such as behavioral observations, attention span, and level of understanding or comprehension.

5. A review of the Master Treatment Plan updated on 2/20/14 did not show any revisions in the treatment modalities to reflect alternative individual treatment sessions with a frequency of contact, duration, and focus of treatment.

6. In an interview on 2/25/14 at 12:30 p.m. with the Director of Social Work, group attendance was discussed. She stated that group leaders were expected to provide handout material related to group being held. She agreed that individual contact with the patient showing the patient ' s response to these handouts should be documented and acknowledged that this documentation was not found in the electronic medical record.

7. In an interview on 2/25/14 at 2:15 p.m., the lack of group attendance of Patient B3 was discussed with RN #2. She confirmed that the patient had not been attending groups consistently and stated, "[Patient name] is still disorganized and has not been on medications. [Patient name] went to court last week." She also stated, "We ask patients to go to groups but we can't make them go."


C. Patient C1

1. Patient C1 was admitted on 2/18/14. The Psychiatric Evaluation, dated 2/18/14, documented a diagnosis of "Mood Disorder NOS [not otherwise specified]" and "Alcohol-Induced Mood Disorder." Chief compliant was "Pt [Patient] reports [s/he] took an od [overdose] of his prescription meds [medications]... hx [history] etoh [alcohol abuse] since teens."

2. The only modalities identified on patient C1's Master Treatment plan (MTP), 2/20/14, were general ones such as "Group Psychotherapy" on the "Modality Summary" and the summary also listed clinical departments such as "Nursing Services, Social Work Services, and Psychiatric Services" as modalities. Specific groups listed on the inpatient group schedule was not listed or attached to MTP. The MTP revealed that the patient was to attend "All Groups." According to the group schedule this would include four (4) groups per day Monday through Friday and three (3) groups on Saturday and Sunday.

3. Patient C1 was observed in [his/her] bed on 2/25/14 at 2:20 p.m. with eyes closed. A group entitled "DBT" (Dialectical Behavior Therapy) listed on the "Inpatient Groups - Dual Diagnosis Unit" was being held in the Dayroom of Unit 2 South. The surveyor made rounds with the Mental Health Worker and a total of eight (8) patients were found in bed. With a census of 11 patients, there were only three patients in the group. The "Patient Safety Check Sheet" showed that the patient was in her/his room while groups were being held 10:00 a.m. to 10:30 a.m. and from 1:30 p.m. to 2:45 p.m. on 2/24/14 and from 2:00 p.m. to 4:00 p.m. on 2/25/14.

4. A review of the "General Group Therapy Note" forms showed that Patient C1 refused to participate in the group held on 2/23/14 from 1:44 p.m. to 2:30 p.m. and on 2/24/14 from 1:15 to 2:00 p.m. and 2:15 p.m. to 3:00 p.m. These notes showed documentation that handouts were given to the patient. However, there was no evidence documented showing that staff met with the patient to discuss these handouts to determine and document the patient's response such as behavioral observations, attention span, and level of understanding or comprehension.

5. In an interview on 2/24/14 at 3:00 p.m., with RN #1, group attendance was discussed. RN #1 stated that patient C1 had not been attending groups regularly and remarked, "Some patients are just unmotivated. Mental Health Workers will go to each patient's room multiple times, but we can't get some patients to go to groups."

D. Patient C6

1. Patient C6 was admitted to 2/19/14. The Psychiatric Evaluation, dated 2/19/14, documented a diagnosis of "Bipolar Disorder, NOS." Chief compliant was "Relapse on Heroin..." "The patient reports sexually abuses as a child."..."Patient does have a history of major depression, current substance abuse, history of suicidal attempts."

2. The modalities identified on patient C6's MTP, dated 2/18/14 were "Safety Tool Group, Art Therapy, Music Therapy, Psychotherapy, Substance Abuse Groups, and all groups."

3. A review of "General Group Therapy Notes," dated 2/20/14, cited the following:

- "Group Therapy", held 1:15 p.m. to 2:00 p.m., attendance - "refused/alternatives." "Safety Check Sheets" documented that the patient was in the Dayroom from 1:15 p.m. to 1:30 p.m. and in bedroom from 1:30 p.m. to 2:00 p.m. during the time the group was held.

- For the same above group on 2/20/14 at the same time, the patient ' s " Safety Check Sheet " documented that s/he was primarily in his/her room during the time of the group.

- For the "Group Therapy" on 2/22/14 from 10:00 a.m. to 10:30 a.m., the patient had been documented to "refused/alternatives offered." Alternative offered - "Educational materials."

- For the "SWG" [social work group] on 2/22/14 from 11:00 a.m. to 11:45 a.m., the patient's attendance was cited as "refused/alternatives offered." Alternatives offered - "Educational material, sensory tool item." The patient was charted on "Safety Check Sheet" as being in room or hallway.

- For the "SWG" on 2/22/14 from 1:45 p.m. to 2:30 p.m., the patient's attendance was cited as "refused/alternative offered." The alternatives were the same as above. For the same time period, the patient's "Safety Check Sheet" stated the patient was either in the dayroom or hallway.

- For 2/23/14, patient was cited on "Safety Check Sheet" as being in his/her room or hallway during "Group Therapy" from 10:00 a.m. to 10:30 a.m. His/her attendance "refused/alternatives offered." Alternatives were "Educational materials."

- During 11:00 a.m. to 11:45 a.m., a "Life Safety" Group, the patient was documented as "attended" even though the "Safety Check Sheet" cited the patient as being in bedroom from 11:15 a.m. to 11:30 a.m., and in "hallway" from 11:30 a.m. to 12:00 p.m.

- From 1:44 p.m. to 2:30 p.m., a "Social Work" group cited that the patient refused to attend. Alternatives offered- "Art supplies, sensory tool item."

- For the "Life Safety" group, dated 2/24/14 from 10:40 a.m. to 11:25 a.m., the patient's attendance was documented as "refused/alternatives offered." Alternative offered - "Educational materials, sensory tool item." The "patient's Safety Check Sheet" cited the patient as either being in the dayroom or in bedroom.

- The patient was observed refusing two other therapy groups on 2/24/14 which included one group held from 1:15 p.m. to 2:00 p.m. and the other group from 2:15 p.m. to 3:00 p.m.


4. On 2/24/14 at 1:00 p. m., patient C6 was being interviewed by the surveyor in the dayroom, where scheduled groups are held. When asked what s/he thought of the groups, the patient stated, "They are boring." Patient C6 admitted that s/he did not attend most groups because s/he wanted to go home. When patients started coming into the room for groups, patient C6 got up saying, "I'm going to my room to sleep." At 2:50 p.m., when the surveyor checked to see what the patient was doing, s/he was observed in bed with the top covers drawn up to her/his neck with eyes closed. It should be noted that the census on the dual unit on 2/24/14 was 11. Only three (3) patients attend the 1:15 p.m. group. Eight (8) patients were observed in bed with eyes closed.

5. In an interview on 2/25/14 at 10:00 a.m., the lack of patient C6's attendance in groups was discussed with RN #7. She stated, "We encourage all patients to attend group, but we can't force them."

6. In an interview on 2/25/14 at 1:30 p.m., the lack of many patients attending groups was discussed with the Nursing Director. She stated that the treatment teams meet daily to discuss patients' progress and steps are taken to move patients' from immediate needs and abilities forward. The Nursing Director was also reminded that nothing could be found in the Master Treatment plans of the above mentioned patients to acknowledge that these patients were not routinely attending groups and what specific alternative approaches/revisions would be taken to address each of the four (4) patients' individual problems in this area. She agreed that this step was not included in the plans. She stated that presently the group leaders include alternatives in their group progress notes.

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

I. Ensure that psychiatric evaluations were reviewed by a physician for two (2) of eight (8) active sample patients (B3 and B12). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice nurse without documented physician review. This potentially results in the failure to have patient care provided under the direction and supervision of a physician. (Refer to B110)

II. Ensure that psychiatric evaluations included a general medical history of inter-current medical problems for two (2) of eight (8) active patients (B4 and C1). This deficiency potentially results in the inability to assess the impact of an acute or chronic medical condition on current psychiatric presentation. (Refer to B112)

III. Ensure that psychiatric evaluations included an inventory of specific patient assets for eight (8) of eight (8) sample patients (A5, A7, A10, B3, B4, B12, C1, and C2). The failure to identify patient assets potentially impairs the treatment team's ability to choose treatment modalities that best utilize the patient's strengths. (Refer to B117)

IV. Provide Master Treatment plans that included patient-related short and/or long-term goals (called objectives in this facility) stated in measureable terms for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). In addition, some of the goals were staff goals, not patient goals. Many of the problems listed on the plan were not clearly stated. These deficient practices hamper the ability of the treatment team to provide goal directed treatment to determine the effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

V. Provide 7 of 8 active sample patients (A5, A7, A10, B3, B12, C1, and C6) with Master Treatment Plans (MTPs) which included individualized interventions that stated specific treatment modalities, with a frequency and focus of treatment to be delivered by physicians. Instead, the MTPs included routine physician functions written as treatment interventions. This deficiency results in the facility not clearly delineating the role of physicians in the treatment of patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A5 (updated 2/20/14), A7 (2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/14, and C6 (2/18/14). This review revealed that the MTPs had the following routine generic psychiatrist functions written as treatment interventions. Additionally, many treatment plans did not include: 1) how the intervention would be delivered (individual or group sessions); 2) the frequency of contact and/or the focus of treatment. Many interventions were identical or similarly worded.

1. Active sample patient A5, MTP, had a problem of "suicide." Generic physician ntervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for suicidal depression."

This statement written as a treatment intervention was generic and a routine function that the psychiatrist would do regardless of the patient's specific problems.

For the problem of depression, the generic physician intervention was as follows:

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

2. Active sample patient A7, MTP, had the following generic physician intervention for the problem of "aggression, violence":

"Psychiatrist will prescribe and monitor medications and provide psychoeducation to patient regarding their purpose, effects, and use." The latter part of this statement did not include frequency of contact or the delivery method.

- For the problem of "depression," the generic physician intervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for depression."

- For the problem of "suicide," the generic intervention was:

"Psychiatrist will evaluate, prescribe, and monitor medications for suicide depression."

3. Active sample patient A10, MTP, had the following generic physician intervention for the problem of "thought disorder":

"Psychiatrist will prescribe and monitor medications."

- For the problem of "mania," the generic physician intervention was:

"Psychiatrist will prescribe and monitor medication daily to reduce behavior."

4. Active sample patient B3, MTP, had the following generic physician intervention for the problem of "thought disorder":

"Psychiatrist will prescribe and monitor medications, and provide psychoeducation to patient regarding their purpose, use, and side effects of medication." No modality (individual or group session) was included.

5. Active sample patient B12, MTP, had the following generic physician intervention for the problem of "manic":

"Psychiatrist will prescribe and monitor medications daily to reduce manic behavior."

6. Active sample patient C1, MTP, had the following generic physician intervention for the problem of "substance abuse":

"Psychiatrist will provide order [sic] appropriate detoxification protocol. Psychiatrist will educate on relationships between substance abuse and physical/mental illness."

7. Active sample patient C6, MTP, had the following generic physician intervention for the problem of "depression":

"Psychiatrist will order appropriate detoxification protocol."

B. Interview

During interview on 2/25/14 at 4:10 p.m., the Master Treatment plans were reviewed with the Medical Director. He agreed that the interventions contained clinical task such as prescribing medications rather than individualized treatment interventions based on the patient's presenting symptoms. He acknowledged that the intervention did not contain the modality used (individual or group session) to discuss the benefits, side effects, etc. of primary psychotropic medication(s) prescribed.

VI. Provide active treatment, including purposeful alternative interventions for four (4) of eight (8) active sample patients (A5, B3, C1, and C6). Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend groups. They spent many hours without any structured activity and occupied their time by sleeping or wandering around the hallways. Despite, inconsistent or lack of regular attendance in groups, master treatment plans were not revised to reflect individual treatment sessions instead of group treatment. 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)

Based on record review and interview, the Nursing Director failed to ensure that nursing interventions on the Master Treatment plans for six (6) of eight (8) active sample patients (A5, A7, A10, B4, C1, and C6) were individualized to meet specific patient needs. Most nursing interventions were generic routine tasks that would be performed regardless of the different patients ' problems and needs. This failure results in Master Treatment Plans that fail to reflect an individualized approach to patient care and fail to guide the nursing staff in providing treatment with a specific focus.

Findings include:

A. Record Review

1. Active sample patient A5, Master Treatment Plans (MTP), updated 2/20/14, had a problem of "suicide." Nursing staff interventions:

"Nursing staff will maintain patient on appropriate level, i.e. 15 min [minutes] suicide checks, 1:1 observations, day hall observations to provide a safe environment and decrease suicide attempts."

For the problem of "Depression," the generic nursing staff intervention was as follows:

"Nursing staff will encourage attendance in community meetings, and groups daily." The intervention lacked frequency and focus.


2. Active sample patient A7, MTP dated 2/22/14, had the following generic nursing intervention for the problem of "aggression, violence":

"Nursing staff will provide individual medication education every day." This intervention lacked specific focus of treatment and delivery method.

- For the problem of "Depression," the generic nursing interventions were:

"Nursing will encourage and supervise ADLs [activities of daily living] daily. Nursing staff will provide individual medication education to review benefits and side effects of medications."

- For the problem of "suicide," the generic nursing intervention was:

"Nursing staff will maintain an appropriate precaution level; i.e. 15 minutes suicide checks."


3. Active sample patient A10, MTP dated 2/20/14, had the following generic nursing intervention for the problem of "mania," the generic nursing intervention was:

"Nursing staff will educate on rational benefits and side effects of medications."


4. Active sample patient B4, MTP dated 2/21/14, had the following generic nursing intervention for the problem of "suicide":

"Nursing staff will encourage patient to verbalize feelings and thoughts and alternatives about suicide." No frequency listed.


5. Active sample patient C1, MTP dated 2/20/14, had the following generic nursing intervention for the problem of "substance abuse":

"Nursing staff to provide recovery goals."


6. Active sample patient C6, MTP dated 2/18/14, had the following generic nursing interventions for the problem of "depression":

"Nursing staff will encourage attendance and supervise ADLs daily. Nursing staff will encourage attendance in community meetings and groups daily. Nursing will initiate interactions with patient and encourage verbalization of feeling every shift."

B. Interview

In an interview on 2/25/14 at 1:30 p.m., the generic interventions on the Master Treatment plans were discussed with the Nursing Director. She acknowledged that the interventions were generic but felt that they would get more specific as the treatment team refined each individual patient's needs.

Based on record review and interviews, the Director of Social Services failed to monitor and evaluate the appropriateness of social services. Specifically, the Director of Social failed to ensure that social work interventions on the Master Treatment plans for six (6) of eight (8) active sample patients (A5, A10, B3, B4, B12, and C1) were individualized to meet specific patient presenting problems or needs. Most social work interventions were generic routine tasks that would be performed regardless of the different patients ' problems and needs. This deficiency potentially hampers the quality and appropriateness of the social services delivered to patients.

Findings include:

A. Record Review

1. Active sample patient A5, Master Treatment Plans (MTP), updated 2/20/14, had a problem of "suicide." The generic social worker interventions was:

"Social work will work with the patient and any outpatient supports to address this issue." The social work intervention was a generic (routine function) each social worker would do regardless of the patient's specific problems.

For the problem of depression, the generic social work intervention was as follows:

"Social work will work with the patient and any outpatient supports to address this issue."

2. Active sample patient A10, MTP dated 2/20/14, had the following generic social work intervention for the problem of "thought disorder":

"Social worker will provide 1:1 reality-oriented counseling ..., structuring patient use of aftercare services and give the patient a place to discuss feelings and concerns."

3. Active sample patient B3, MTP dated 2/20/14, had the following generic social work intervention for the problem of " thought disorder " :

"SW [social worker] will meet with pt [patient] daily, monitor mood and ms [mental status], rounds, and collaborate with collaterals, groups."


4. Active sample patient B4, MTP dated 2/21/14, had the following generic social work interventions for the problem of "suicide."

"SW will meet with pt. daily, monitor mood and ms [mental status], rounds, collaborate with collaterals, groups, treatment updates, groups, dc [discharge] planning."


5. Active sample patient B12, MTP dated 2/22/14, had the following generic social work interventions for the problem of "manic":

"Social worker will communicate with outside treaters/significant other to assess baseline and coordinate discharge planning."


6. Active sample patient C1, MTP dated 2/20/14, had the following generic interventions for the problem of "substance abuse":

"Social work will provide education support, engage in recovery, encourage groups, and refer to recovery sources in community."

This generic social work statement written as a treatment intervention did not include a frequency of contact and lacked specific focus of treatment for this patient.


B. Interview

During interview on 2/25/14 at 12:30 p.m., with the Director of Social Worker, the Master Treatment Plans were discussed. She stated that social workers do not conduct groups but were involved in individual and family meetings with patients and acknowledged that some social interventions were functions that social workers would perform regardless of patients' presenting symptoms.

Based on record review and interview, the facility failed to ensure that Activity Therapy Assessments were implemented for eight (8) of eight (8) active sample patients (A5, A7, A10, B3, B4, B12, C1, and C6). Despite the fact that all patients were expected to participate in all activity groups offered on each unit, no activity assessment was done. This failure results in activity therapy staff providing groups not based on assessed needs of each patient, making it difficult to provide specific individual focus for each patient in the group.

Findings include:

A. Record Review

1. None of the following 8 active sample patients (date of Master Treatment plan in parenthesis) included specific activity intervention on the Master Treatment plan: A5 (updated 2/20/14), A7 2/22/14), A10 (2/20/14), B3 (2/20/14), B4 (2/21/14), B12 (2/22/14), C1 (2/20/14) and C6 (2/18/14).

B. Interview

In an interview on 2/25/14 at 11:45 a.m., the lack of an Activity Therapy assessment in the patients' charts was discussed with the Group Clinical Coordinator. She admitted that her staff did not do patient assessments. When asked how her staff found out the problems and needs of the patients that attended their groups, the Coordinator stated, "They read the patients' charts and rotate attending treatment team rounds."