HospitalInspections.org

Based on document review and interview, it was determined that 1 of 9 (Pt #6) clinical records reviewed the Hospital failed to ensure physician orders were followed as written.

Findings include:

1. Pt #6 was a 58 year old female admitted on 11/24/14 with a diagnoses of Schizoaffective Disorder and Obesity. Physician order dated 12/12/14 at 10:20 AM stated "Food and Fluid intake monitoring".

2. The clinical record of Pt #6 was reviewed at Stevenson Hall on 1/6/15 at 12:30 PM with the Clinical Nurse Manager (E #5). From 12/12/14 at 12:00 PM until 12/29/14 at 12:20 PM there were 42 food and fluid entries not documented on the Food and Fluid Log.

3. An interview was conducted on 1/6/15 at 12:45 PM with E #5. E #5 stated there were 42 food and fluid entries not documented on the Food and Fluid Log.

Based on document/record review, and staff interview, it was determined in 1 of 8 patient's (Pt #10) the Hospital failed to ensure the psychosocial assessment was completed in a timely manner per Hospital policy, potentially affecting all patients receiving care. (current census 132)

Findings include:

1. A review of Hospital policy "Psychosocial Assessments" (revised 6/30/14) was conducted on 1/7/15 at 3:00 PM. Under "Psychosocial Assessment Process B." it indicated "A Psychosocial Assessment will be completed on all individuals admitted to the hospital by the third day of admission."

2. The medical record of Pt #10 was reviewed on 1/6/15 at 10:45 AM. Pt #10 was involuntarily admitted on 12/23/14 due to suicidal ideation. Documentation on the "Psychosocial Assessment" indicated it was completed by the social worker (E #7) on 12/29/14, six days after admission.

3. On 1/6/15 at 10:50 AM an interview with the Quality Manager from Central Office (E #2) was conducted. E #2 confirmed the psychosocial assessment on Pt #10 was completed on 12/29/14, six days after admission and verbalized the assessment should have been done within three days of admission.

Based on observation and interview it was determined the Hospital failed to retain medical records for five years, potentially affecting all patients receiving care at the Hospital (current census 132 patients).

Findings include:

1. On 1/6/15 at 2:00 PM a request was made for copies of the medical record for Pt #7. The Hospital was unable to provide copies of the paper portion of the medical record because it was sent to another facility.

2. On 1/7/15 at 9:50 AM an interview with the Director of Quality (E #4) was conducted. E #4 indicated the Hospital used both electronic and paper form of medical record. E #4 indicated Pt #7 was transferred to another facility on 1/6/15 and the paper portion of the medical record was sent with the patient and not available. E #4 indicated when patient's are transferred from the Hospital to another state mental health facility, the entire medical record (original paper portion) is forwarded to the receiving facility and no copies of the paper medical record are maintained on site. E #4 also indicated the electronic medical record is maintained but the paper portion of the medical record is retrievable, when needed, by contacting the receiving facility and asking for the paper portion of the medical record. E #4 indicated that "95% of the patients that we transfer return to our facility so we get the complete medical record when the patient returns." E #4 indicated "this practice was driven by a Department of Mental Health practice."

Based on document review and staff interview, it was determined in 1 of 1 Controlled Substance Log dated 11/11/14 - 1/5/15 reviewed on Lincoln North Unit, the Hospital failed to ensure the accuracy of controlled medication inventory (Lorazepam 2 mg oral). This had the potential to effect all 26 patients (census) on Lincoln North Unit.

Findings include:

1. Hospital Policy "Pharmaceutical Services", (revised 9/19/14) was reviewed on 1/7/15 at 2:30 PM. Under "III. Nursing Medication Rooms, B", the policy stated..."A count for accuracy of inventory is taken by the incoming and outgoing personnel at change of each shift."

2. During a tour of Lincoln North Unit on 1/5/15 at 11:00 AM a physical count of Lorazapam 2 mg, oral was completed with a total count of 43 tablets. The Controlled Substance Log inventory count for Lorazapam 2 mg, oral was 44 tablets.

3. A interview with Clinical Nurse Manager (E #1) was completed on 1/8/15 at 11:30 AM. E #1 stated "a miss count occured on 1/2/15 on the 3 PM to 11 PM shift. There was no medication missing, staff continued to annotate the controlled substance log with the wrong number for ten shifts."

Based on document review, observation and interview, it was determined in one (1) of one Dietary Department, the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment, potentially affecting all patients and staff receiving dietary food services in the Hospital.

Findings include:

1. Hospital policy "FOOD STORAGE" (revised 2/28/14) was reviewed on 1/5/15 at 11:00 AM. Under "5." it indicated Bulk foods (such as beans, oats, rice, etc.) when opened, shall be placed in plastic barrels with airtight lids. These containers must be labeled."

2. On 1/5/15 at 11:00 AM a tour of the Dietary Department was conducted with (E #1). During the tour, in one (1) of three (3) coolers, there were three (3) containers of oatmeal, five (5) bags of tortilla shells, and one (1) bag of bacon with no label, indicating what the food items were.

3. On 1/5//15 at 11:10 AM an interview with the Food Service Supervisor (E #1) was conducted. E #1 confirmed the food was not labeled and verbalized it should have been.

4. On 1/5/15 at 11:00 AM a tour of the Dietary Department was conducted with (E #1). During the tour, one (1) of one (1) table top, commercial can opener blade had old dried food particles on it.

5. On 1/5//15 at 11:10 AM an interview with the Food Service Supervisor (E #1) was conducted. E #1 verbalized the can opener was dirty and should have been cleaned after every use.

6. Hospital policy "PERSONAL HYGIENE & HEALTH OF DIETETIC PERSONNEL" (revised 2/28/14) was reviewed on 1/5/15 at 10:00 AM. Under "6." it indicated "Hair is to be restrained and entirely covered to keep it from contacting exposed food, utensils, equipment and food contact surfaces. Effective hair restraints include hairnets, bouffant bonnets which are disposable and provided by the hospital, beard cover and clothing that covers body hair."

7. On 1/6/15 at 11:00 AM a tour of the Dietary Department was conducted with the Quality Manager, Central Office (E #2). During the tour the Food Service Supervisor (E #1) was behind the food line serving food while wearing a baseball cap and not wearing a hairnet.

8. On 1/6/15 at 11:10 AM an interview with E #2 was conducted. E #2 confirmed E #1 was wearing a ball cap and verbalized E #1 should have been wearing a hair net.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 5 & 6, 2015, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 5 &6, 2015, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated January 6, 2015.

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

I. Consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (B14, B21, C10, C17, D4, D22, E4, and E9). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to consistently state the frequency of contact, specific focus for interventions, and whether interventions would be delivered in groups or individual sessions. These deficiencies result in treatment plans that failed 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 result in inconsistent and/or ineffective treatment. (Refer to B122)

II. Ensure that active treatment measures were available for four (4) of eight (8) active sample patients (C10, C17, D4, and D22) who were unwilling or unable to attend groups or were sufficiently impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. 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)

III. Ensure that patients received treatment in a therapeutic environment without disruption and intimidation by Patient C23 and Patient I1 for all patients on two (2) of six (6) treatment units (Lincoln Hall, South and Stevenson Hall). These patients were allowed to remain on co-ed units where they created a frightening and disruptive unit environment by displaying threatening and assaultive behaviors toward other patients without all necessary interventions being attempted (such as 1:1 or 2:1 staffing, separation from other patients, etc.). (Refer to B125 II)

Based on record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (B14, B21, C10, C17, D4, D22, E4, and E9). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to consistently state the frequency of contact, specific focus for interventions, and whether interventions would be delivered in groups or individual sessions. These deficiencies result in treatment plans that failed 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 result in inconsistent and/or ineffective treatment.

Findings include:

1. Failure to include individualized treatment interventions on MTPs.

A. Record review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): B14 (10/6/14), B21 (9/17/13), C10 (10/14/10), C17 (9/10/14 & 9/12/14), D4 (10/8/10 & 4/7/11), D22 (12/2/14), E4(10/8/12), and E9 (912/17//14). This review revealed the MTPs had routine and generic statements (assist, provide, and encourage) and/or generic that discipline functions written as treatment interventions to be delivered by nursing, psychiatrist, and social service. Additionally, treatment plans did not always include the frequency of contact and some interventions were identically worded for several of the sample patients. Listed below are the generic lists of intervention by discipline in regards to the identified problem for eight (8) of eight (8) sample patients. These statements were not individualized and are routine functions of the disciplines that would be provided for any patient regardless of presenting symptoms.

1. Active sample patient B14 had a problem of "Altered thought process)." With the following intervention:

Nursing: "Encourage participation in unit groups, and off- unit groups, when appropriate privileges are obtained." "Administer medication as ordered and monitor effects/side effect."

Psychiatric: "Prescribe psychotropic medications."

Social Service: "Provide supportive counseling, including reality orientation."

2. Active sample patient B21, MTP, dated 9/17/13 has the problems of "Auditory Hallucination, Suicidal attempt and depression."

Nursing: "Provide a safe environment and ensure Mr. R is safe from harm to self or others." "Staff will make daily room checks to help ensure a safe living environment for Mr. R and to check for any contraband and/or unsafe items, and as required by Mr. R's privilege level which is determined by the psychiatrist with input from administrative staff. Mr. R will be strongly encouraged by staff to stay in the milieu, during daytime hours."

Psychiatric: "Prescribe psychotropic medication."

Social Services: "Provide supportive counseling, including reality orientation."

3. Active sample patient C10, MTP, dated 10/14/10 has the problems of "Altered thoughts process," "Agitation" "Poor Insight into Mental Illness," and "History of sexually inappropriate behavior."

Nursing: "Encourage participation in incentive program." "Assist Mr. H with developing and following proper diet." "Provide health education to Mr. H regarding mental illness, physical health, treatment needs and treatment compliance." "Assist Mr. H as needed in completion of ADL's." "Monitor ADL's - nutrition and sleep pattern." "Encourage participation in unit based groups." "Administer medications as ordered and monitor effects/side effects."

Psychiatric: "Psychiatrist will order medications and monitor dosage and effectiveness." "Psychiatrist will assess Mr. H on the unit for clinical stability and prescribe medication and treatment regimen as indicated." "Psychiatrist will also complete a suicide risk assessment prior to discharge." "Prescribe psychotropic medications."

Social Service: "Will provide case management assistance in regards to discharge planning."

4. Active sample patient C17, MTP, dated 9/10/14 has the problems of "Altered Thought Process," and "Unfit to stand trial."

Nursing: "RN will administer medications as ordered by MD and monitor for benefits and side effects." "Encourage participation in unit groups, and off - unit groups, when appropriate privileges are obtained; verbally reinforce positive coping skills." "Encourage Ms. L to talk with staff and seek assistance as needed for symptom management and effects of medications."

Psychiatric: "Psychiatrist will assess Ms. L. on the unit for clinical stability and prescribe medication and treatment regimen as indicated."

Social Service: "Individual counseling to provide support, address social stressors; and to address coping skills."

5. Active sample patient D4, MTP, dated 10/8/10 has the problems of " Delusional, " Erratic Behaviors, "History of Aggression."

Nursing: "Encourage Ms. C to talk with staff and seek assistance as needed for symptoms management and effects of medications." "Staff will provide 24 hour supervision and monitor Ms. C for any incidences of symptoms or behaviors interfering in safe/healthy daily activities or interactions with others, and if observed, will provide support and prompting to Ms. C to utilize coping skills (particularly the comfort room) and provide for the safety of Ms. C. and others in least restrictive means possible utilizing her preference for intervention (Personal Safety Plan)

Psychiatrist: "Provide education regarding benefits and side effects of psychotropic medications and evaluate the effectiveness of prescribed medications on at least weekly basis."

6. Active sample patient D22, MTP, dated 12/2/14 has the problems of "Homelessness," "Suicidal Ideation with a plan," and "Aggression."

Nursing: "Nursing staff will encourage Mr. S. to use learned positive coping skills on the unit, promoting an ability to not self-harm or engage in suicidal gestures as response to stressful situations." Unit staff will monitor and note the level of reality-based conversation and level of irritability or anxiety." "Unit staff will prompt, when needed, for the use of positive coping skills and anger management techniques in order to avoid any incidents of physical aggression." "Encourage participation in unit groups, and off - unit groups, when appropriate privileges are obtained; verbally reinforce positive coping skills." "Encourage Mr. S. to talk with staff and seek assistance as needed for symptom management and effects of medication." "Assist Mr. S., as needed in completion of ADL's." "Administer medications as ordered and monitor effects/side effects." "Nursing staff will encourage the use of learned anger management techniques and positive coping skills in order to avoid physical aggressions or threats of physical aggression."

Psychiatric: "The psychiatric will continue to made adjustments and changes to the medication regime as necessary; to help Mr. S. show improved stability and decrease in aggressive behaviors." "Psychiatrist will meet with Mr. S. at least 1 x weekly to assess for clinical progress and recommended treatment regimen." "Psychiatrist will assess and encourage medication compliance and emphasize the need for continued compliance in the community."

7. Active sample patient E4, MTP, dated 10/8/10 has the problem of "Paranoia."

Nursing: "Encourage participation in incentive programs." "Administer medications as ordered and monitor effects/side effects." "Encourage Ms. F. to talk with staff and seek assistance as needed for symptom management and effects of medication." "Nursing staff will encourage Ms. F. to use learned anger management techniques and positive coping skills in order to avoid physical aggression." "Monitor ADL's - nutrition, and sleep pattern."

Psychiatric: "Psychiatrist will meet with Ms. F. at least 1x weekly to assess for clinical progress and recommend treatment regimen." "Psychiatrist will order medication and monitor dosage and effectiveness."

8. Active sample patient E9, MTP, dated 12/17/14 has the problems of "Suicidal Ideation," "Depression."

Nursing: "Administer medications as ordered and monitor effects/side effects."

Psychiatric: "Psychiatrist will order medications and monitor dosage and effectiveness."

B. Interviews

1. In an interview on 1/6/15 at 3:00 p.m., the generic interventions on the Master Treatment Plans were discussed with the Director of Nursing. She acknowledged that interventions on the MTP's were generic and routine discipline functions. She stated, "I understand that the interventions listed are staff duties, but the treatment coordinator are responsible for inputting information on the plan."

2. In an interview on 1/6/15 at 3:50 p.m. with Clinical Nurse Manager #1 and Clinical Nurse Manager # 2 the generic interventions on the MTP's were discussed. Clinical Nurse Manager #1 stated "I see what you are saying, I agreed the interventions are task oriented." Clinical Nurse Manager #2 stated agreement by saying "I see what you are saying."

3. In an interview on 1/7/15 at 10:30 a.m. with the Director of Social work treatment interventions were discussed. She stated that "we are continuously working to make the plan more individualized."

4. During an interview with the Medical Director on 1/7/15 at 12:30 p.m., she acknowledged that the interventions on the treatment plans were generic and not specific for Patients B14, B21, C10, C17, D4, D22, E4, and E9.

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

I. Ensure that active treatment measures were available for four (4) of eight (8) active sample patients (C10, C17, D4, and D22) who were unwilling or unable to attend groups or were sufficiently impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. 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.

II. Ensure that patients received treatment in a therapeutic environment without disruption and intimidation by Patient C23 and Patient I1 for all patients on two (2) of six (6) treatment units (Lincoln Hall, South and Stevenson Hall). These patients were allowed to remain on co-ed units where they created a frightening and disruptive unit environment by displaying threatening and assaultive behaviors toward other patients without all necessary interventions being attempted (such as 1:1 or 2:1 staffing, separation from other patients, etc.).

Findings include:

I. Active Treatment

A. Patient C10

1. Observation

During an observation at the time of the scheduled "Relaxation Group" on 1/6/15 at 9:45 a.m., Patient C10 was observed sitting and looking out the window wearing headphones.

2. Record Review

a. Patient C10 was admitted on 9/28/98 as "Unfit to Stand Trial" on charges of Aggravated Criminal Sexual Assault and later changed to Not Guilty by Reason of Insanity on 4/24/00. Patient C10 was transferred to another facility on January 2010 after sexually assaulting a staff member. Patient C10 was transferred back to the facility for the current admission on 10/14/10. The Annual Update of Psychiatric Evaluation dated 10/13/14 stated the diagnoses included "Schizoaffective Disorder, bipolar type" and "Antisocial Personality Disorder." The interventions for the Problems of " Not-Guilty by Reason of Insanity," "Altered Thought Process," "Agitation," and "History of Sexually Inappropriate Behavior" included: "WRAP Group," "Stress management," "Communication Skills," "Moving Forward," and "Health Education Group." The only individual intervention was "Social Worker will meet at least 1x monthly to provide" education, treatment, and recovery planning.

b. The Group Notes from 11/28/14 to 12/25/14 documented that Patient C10 attended only 12 groups. In four (4) of these groups, Patient C10 was described as having "major difficulties attending, concentrating" and in four (4) others was described as "easily distracted." Behaviors in these groups included "very loud and distracting," "sleepy and seemed disinterested," "[Patient C10] continued to talk throughout group and was redirected back to topic several times," "seemed easily distracted," "did not speak - walked and paced - expressionless," and "seemed to be preoccupied in thought."

3. Interview

During an interview with MD 1 on 1/7/15 at 9:15 a.m., he stated that the primary interventions for Patient C10 were group therapies. He stated that Patient C10 was at the lowest privilege level and could only attend groups on the unit. He acknowledged that few medication adjustments had been made during the previous year and stated that the last significant medication change had been about two (2) years previously.

B. Patient C17

1. Observation

a. During an observation at the time of the scheduled "Relaxation Group" on 1/6/15 at 9:50 a.m., Patient C17 was observed lying in her/his bed.

b. During an observation at the time of the "Moving Forward" group on 1/5/15 at 1:50 p.m., Patient C17 was lying in her/his bed. During an interview with Group Leader 1 on 1/5/15 at 2:20 p.m., she stated that Patient C17 had only attended this group once and had remained "quiet and to [her/himself]" during the Moving Forward group.

2. Record Review

a. Patient C17 was admitted on 9/10/14 as "Unfit to Stand Trial" on misdemeanor charges of Criminal Trespass. The Comprehensive Psychiatric Evaluation dated 9/10/14 stated the diagnoses included "Schizophrenia." The interventions for the Problems of "Altered Thought Process" and "Unfit to Stand Trial" included: "WRAP Group," "Stress management," "Communication Skills," "Moving Forward," "Legal Realities," and "Health Education Group."

b. The Group Notes from 10/20/14 to 12/10/14 documented that Patient C17 attended only 11 groups. In two (2) of these groups, Patient C17 was described as having "major difficulties attending, concentrating" and in all of the others was described as "easily distracted." Behaviors in these groups included "She was quiet," "Followed along with handout - did not join the class discussion," "appears easily distracted," "sat at table reading book, seemed to be disengaged in group material," and "sat quietly without expression."

c. Interview

During an interview with MD 1 and the Medical Director on 1/7/15 at 9:15 a.m., MD 1 acknowledged that Patient C17 was not suitable for group therapy and had not been attending groups. The Medical Director stated "it's hard to make them go." They acknowledged that no alternative interventions had been provided when Patient C17 refused to participate in group treatments.

C. Patient D4

1. Observation

a. Observing the Stress Management unit group on 1/5/15, 1:45 - 2:15 p.m., conducted by the unit Clinical Director, a Licensed Clinical Social Worker (LCSW). Active sample patient D4 was not in attendance. Sample patient D4 had refuses attending the group but was observed sitting in a small day room just around the corner from the large day room where the group was been held. As the surveyor approached, D4 starts speaking loudly stating "I do not want to speak to you anyone."

b. On 1/6/15 the Lincoln North unit had a census was 26 patients. Eleven patients were observed in bed during the centralized psychosocial program and unit group's hours of 9:30 - 11:15 a.m.

2. Record Review

Active sample patient D4 was admitted on 10/8/10, group notes for the period 11/7/14 to 1/6/15 revealed attendance of 10 groups in a two months period. Case Management notes for 1/5/15, stated "participation in clinical groups continues to be low." "Sits in the small TV area but will not walk over to the large TV area." "Today was offered worksheet since he/she declined to attend, and refused the worksheet as well." "States doesn't need information because [he/she] is leaving today."

3. Interview

On 1/5/15 at 1:14 p.m. active treatment for sample patients D4 was discussed with Clinical Nurse Manager 2. She acknowledges that Sample patient D4 refuses to attend offered groups frequently but is observed to sit close to area where the group is occurring. Staff encourages D4 regularly to attend groups and on rare occasion she will attend. Alternative treatment activity since November 2014 is to give D4 a copy of the information shared in the group sessions. She acknowledged alternative active treatment is not available for patients who refuse to attend scheduled unit groups.

D. Patient D22

1. Observation

a. Observing the Stress Management unit group on 1/5/15, 1:45 - 2:15 p.m., conducted by the unit Clinical Director, a Licensed Clinical Social Worker (LCSW). Active sample patients D22 was not in attendance.

b. Active sample patient D22 was observed coming from the rest room area during the Stress Management unit group on 1/5/15, 1:14-2:25 p.m. Sample patient went and sit on the outer circumference of the group and did not actively participate in the group.

2. Record Review

Active sample patient D22 was admitted on 12/2 /14, group notes for the period 12/3/14 - 1/6/15 revealed attendance of 13 groups over a one month period. Groups are scheduled on the unit two times in a day 10:35-11:15 a.m. and 1:45 - 2:15 p.m., patients are expected to attend each group session.

3. Staff Interview

In an interview on 1/7/15 at 11:15 Stevenson unit Clinical Director active treatment for active sample Patient D22 was discussed. She states sample Patient D22 are encouraged to attend assigned groups. Since November 2014 has developed an engagement status program in which the social worker meet 1:1 with sample Patient D22 to share information discussed in the groups that was missed.

E. Additional Staff Interviews

1. During a walk-through on the Lincoln North unit with the Clinical Nurse Manager 1 on 1/6/15 at 9.55 a.m. active treatment was discussed. He states the patients are encouraged by staff to attend groups but some refused. He states "it is extremely difficult to engage the patient to attend groups especially when they know they will be release by the courts soon." He acknowledged alternative active treatment programs are not available for the patients that repeatedly refused to attend group.

2. In an interview on 1/6/15 at 3:00 p.m., the lack of active treatment for patients who refused to attend scheduled unit or centralized activities were discussed with the Director of Nursing. She acknowledged the need to provide alternative programming for the patients who routinely refuse to attend groups. She stated that Psychosocial Services is hiring a social worker to assist the units if proving alternative programming to meet the needs of these patients.

3. During an interview with Unit Director 1 and the Director of Psychosocial Rehabilitation on 1/7/15 at 11:30 a.m., they acknowledged that there was no alternative treatments for patients who are unable or refuse to attend group therapy other than medication and monthly meetings with the social worker.

II. Therapeutic Environment

A. Patient C23

1. Record Review

a. A review of the Comprehensive Psychiatric Evaluation dated 12/22/14 at 3:30 p.m. stated that Patient C23 was admitted to Lincoln Hall, South, for "Fitness restoration," "charged with 2 counts of Aggravated Battery." Diagnoses included "Schizophrenia," "Alcohol Dependence vs. Abuse," and "Marijuana Abuse." The Evaluation stated "it was reported by nursing staff that [s/he] was agitated on the unit at times after [s/he] came in. In addition, [s/he] touched and grabbed the female nursing staff. The staff have concern that [s/he] may wonder [sic] into other's room and have inappropriate behaviors." "Recommendations" included "However, it was reported that [s/he] was touching female staff and was loud and agitated on the unit. The staff also has concerns that [s/he] may get into other patient's [sic] rooms. So [s/he] is put on frequent observations [every 15 minutes] for inappropriate behavior."

b. The Psychosocial Assessment dated 12/22/14 stated "Since admission [s/he] has been agitated, and threatening others to fight. [S/he] has also been sexually inappropriate, making inappropriate comments to others, and also having grabbed the buttocks of a nurse a couple times on the date of admission."

c. The HCR-20 (Historical, Clinical, Risk Management-20) assessment of risk for violence completed by the psychologist on 12/24/14 stated that Patient C23 "has at minimum a MODERATE RISK of violent behavior. Appropriate precautions should be followed given [her/his] risk for violence."

d. The Master Treatment Plan, dated 12/22/14, reviewed 1/5/15, included the following problems: #3 "Aggression" and #4 "Sexually Inappropriate Behavior." A review of the MTP following the discharge of Patient C23 did not document any changes in the interventions for the problem of "Aggression" or "Sexually Inappropriate Behavior" during this hospitalization.

e. Progress and Incident Notes

1) The Nursing Progress Note dated 12/18/14 at 4:44 p.m. stated "Since admission, [s/he] has been agitated, threatening to fight others."

2) The Nursing Progress Note dated 12/18/14 at 4:44 p.m. stated "[Patient C23], shortly after admission, grabbed the buttocks of a nurse. [S/he] also grabbed her again, even after [s/he] was told [her/his] behavior was inappropriate. [S/he] has been making inappropriate comments to both female peers and staff."

3) The Nursing Progress Note dated 12/22/14 at 10:25 a.m. stated "Pt. was verbally aggressive to staff and peers on several occasions today, threatening to 'beat you ass [sic]' and challenging CNM [clinical nurse manager] to 'fight me.' [S/he] was loud and threatening at dinner."

4) The Nursing Progress Note dated 12/23/14 at 9:22 p.m. stated "Pt. has required redirection several times today for sexually inappropriate language and touching directed at female peers and staff. One peer voiced fear of leaving [her/his] room if [s/he] did not stop [her/his] sexually inappropriate language."

5) The Psychiatric Progress Note dated 12/24/14 at 10:35 a.m. stated "Patient has been sexually inappropriate since admission...Several placements failed in the past due to aggressive behavior...Currently has aggravated assaults."

6) The Nursing Progress Note dated 12/24/14 at 9:03 p.m. stated "Pt. continues to exhibit sexually inappropriate behaviors making lewd comments and touching staff and peers inappropriately despite repeatedly being told it is unacceptable behavior by staff."

7) The Nursing Progress Note dated 12/25/14 at 9:42 p.m. stated "Pt. has been labile and agitated today. [S/he] has been aggressive with peers and attacked a staff member requiring writer to call a code and give emergency medication...is intrusive, going into other patient's rooms, closing their doors, taking their things etc. and does not take redirection well despite staff trying different approaches."

8) The Nursing Incident Note dated 12/27/14 at 8:25 a.m. stated "[Patient C23] was in dining area, threatening peers, loud, agitated, disruptive, confrontational with [fe/male] peer ([Patient C16]) swinging fists and arms at peer without physical contact from across the table, when [fe/male] peer got up, patient chasing peer across [sic] the day area to try to punch him..."

9) The Nursing Incident Note dated 12/28/14 at 4:35 p.m. stated "Pt. had grabbed a peer by [her/his] buttocks and then attempted to grab writer's chest and buttocks when [s/he] was redirected. Pt. then went down the hall into peers rooms and took money and other items. Peers crowded around pt. in the hall threatening [her/him] if [s/he] did not give items back, pt. became very agitated shouting profanities at them and threatening to 'kick you [sic] asses'."

10) The Nursing Progress Note dated 12/28/14 at 6:42 p.m. "Pt. grabbed a peer ([Patient C1]) by [her/his] buttocks today and when told to stop [s/he] repeated the behavior. When this writer attempted to redirect him, pt. tried to grab writer's chest and buttocks. [S/he] was verbally sexually inappropriate as well saying 'I want a piece of ass you bitch!' Pt. becomes physically aggressive when [s/he] is redirected for [her/his] behaviors."

11) The Psychiatric Progress Note dated 12/29/14 at 9:44 a.m. stated "Patient remains non redirectable...Exchanged blows with peer as a result of [Patient C23]'s stealing behaviors."

12) The Nursing Progress Note dated 12/29/15 at 6:28 p.m. stated "Pt. has exhibited sexually inappropriate behaviors throughout the week, both verbal and physical. [S/he] has grabbed peer and staff by the buttocks and attempted to grab female staff member's chest. [S/he] grabbed this writer's hand during med pass and attempted to kiss it. [S/he] would not let go when writer requested him to do so. [S/he] refers to female staff and peers as 'babe' and 'hon' and makes lewd statements such as 'I want a piece of ass' to staff and peers."

13) The "Request for Transfer to Chester Mental Health Center" dated 12/29/14 stated that Patient C23 had "shown problematic behaviors since admission, including inappropriate sexual statements and behaviors (grabbing at both female staff and peers) as well as agitation and threatening behaviors." Patient C23 "has also been going into others' rooms taking their belongings." Patient C23 "has not responded to redirection regarding [her/his] inappropriate behaviors." Patient C23 "is in need of a maximum secure unit, without females due to [her/his] ongoing sexual inappropriateness; as well as [her/his] ongoing agitation; threatening behaviors." The "Accounting of the most serious event that triggered this referral" section stated that Patient C23 "has continued to show inappropriate behaviors during the time since [her/his] admission here; since 12/22/14; rather than one particular specific incident." "In addition to all the incidences as described above, [s/he] has continued to make sexually inappropriate comments to both female peers and staff throughout his/her hospitalization." The only "Attempted Interventions" noted were "regularly prescribed medications, prn medications, counseling; regular redirection by staff; frequent observations for inappropriate behaviors."

14) The Nursing Progress Note dated 12/31/14 at 9:00 a.m. stated "[Patient C23] was observed making repeated profane, hypersexual comments toward and attempting to make physical contact with peer [Patient C15], much to [her/his] dismay. Peer made several attempts to avoid [Patient C23], who remained in pursuit. Peer admonished [Patient C23] in an attempt to divert [her/his] attention from [her/him], to no avail...Will continue reminding [Patient C23] that touching peers, particularly [fe/male] peers is not permissible."

15) The Nursing Progress Note dated 1/1/15 at 8:35 a.m. stated "Stood behind female peer at medication window and fondling buttocks. Peer adamantly told him to stop and move away, but did not move away until RN directed him to do same."

16) The Nursing Progress Note dated 1/2/15 at 8:00 a.m. stated "...no change in overall condition, remains irritable and unpredictable, sexually inappropriate with female peers, rubbing back of female peer [Patient C12], remains confrontational with male peers especially..."

17) The Nursing Progress Note dated 1/3/15 at 10:59 p.m. stated "Sexually preoccupied with no respect of boundaries especially female peers. At approximately 0850 this morning [Patient C22] female peer was at medication station. [Patient C22] asked RN 'Who is behind me?' [Patient C23] was behind [Patient C22]. [Patient C22] then stated 'He just touched my ass.' [Patient C23] was instructed to move away, and did not redirect, but [Patient C22] was finished at med window and left area. Taunting peer and in face of [fe/male] peer [Patient C22] just prior to lunch. [S/he] did not redirect, but other peer left area. Has been verbally redirected from attempts to enter all female peers rooms on several occasions thru both 7-3 and 3-11 shifts today. At approximately 0720 this pm came out of [her/his] room clad in underwear. Walked to desk area then when redirected to own room did the following. Walked back down hall towards own room then pulled down underwear and turned to expose buttocks to peers in hallway...At 2245 this RN and 2 STA's [security therapy aide] were required to assist female peer...when sitting in TV area MR [main room]. [Patient C23] had [her/his] hand on [her/his] breast and would not stop until staff in area next to [her/him] and [another patient] was able to move away. "

18) The Nursing Progress Note dated 1/4/15 at 11:55 a.m. stated "Ongoing reports of repeated redirection away from rooms of female peers. Was in female peer [Patient C1]'s room @ 0940 when peer heard 'Get out of here!' As [s/he] passed door. [Another patient] opened door and told [Patent C23] to leave [Patient C1]'s room. [Another patient] reported [s/he] left room and [s/he] reported this all to desk manager. Shift coordinator updated and security requested by RN to unit at 1030 to inform of [Patient C23]'s sexual preoccupation and unpredictable behaviors at 0810. [Patient C1] reported in interview with security by stating 'he snuck into my room and was touching my butt and would not leave. [S/he] left when [s/he] told [her/him] to get out.' "

19) The Nursing Progress Note dated 1/4/15 at 11:00 p.m. stated "Security staff was reportedly on unit earlier today to interview all female patients (secondary to literally each one of them voicing complaints that they have experienced unwanted inappropriate sexual advances/physical contact/sexually explicit comments from [Patient C23]."

20) The Nursing Incident Note dated 1/5/15 at 8:50 a.m. stated "Patient sexually assaulted 2 female peers on unit today, groping them and touching them in a sexual manner on legs and breasts this am, one patient screamed out and the other female told staff of such."

21) The Psychiatric Progress Note dated 1/5/15 at 1:30 p.m. stated that Patient C23 "remains aggressive on the unit, grabbed and assaulted several females on the unit...Claims women were [her/his] girlfriends and goes into their room at night...Difficult to manage on Co-ed unit."

g. The Nursing Transfer Notes dated 1/6/15 stated that Patient C23 was "very sexual towards females and was transferred to another facility on 1/6/15 at 8:00 a.m."

h. A review of the physician orders indicated that Patient C23 was only observed every 15 minutes until 1/5/15 at 9:41 a.m. when [s/he] was placed on "1:1 observation with male staff due to sexual behaviors."

2. Patient Interviews

a. During an interview with Patient C1 on 1/6/15 at 10:05 a.m., s/he stated that Patient C23 "grabbed my butt." S/he stated that it occurred "a few days ago." S/he stated that s/he "told staff" but that staff "did nothing but told [him/her] not to do it again." S/he stated that Patient C23 "scared me." Patient C1 acknowledged that the behaviors demonstrated by Patient C23 were frightening to [her/him] and disruptive to the unit. Patient C1 was unable to identify specific interventions by the facility to prevent Patient C23's disruptive and frightening behaviors.

b. During an interview with Patient C12 on 1/6/15 at 10:20 a.m., s/he stated that Patient C23 "grabbed my breast" approximately 2 days previously. S/he stated that s/he told Patient C23 to "get [his/her] hands off me." S/he stated that unit staff "just sat there." S/he stated that Patient C23 was sexually inappropriate since [her/his] admission and "came in like that, a horney old [wo/man]." Patient C12 acknowledged that the behaviors demonstrated by Patient C23 were frightening to [her/him] and disruptive to the unit. Patient C12 was unable to identify any interventions by the facility that were successful in preventing Patient C23's disruptive and frightening behaviors.

c. During an interview with Patient C15 on 1/6/15 at 10:10 a.m., s/he stated that Patient C23 "tried to touch me" and "called me hon." S/he acknowledged that Patient C23 made [him/her] feel "nervous" and that s/he "didn't know what [s/he] was going to do." Patient C15 acknowledged that the behaviors demonstrated by Patient C23 were frightening to [her/him] and disruptive to the unit. Patient C15 was unable to identify any interventions by the facility that were successful in preventing Patient C23's disruptive and frightening behaviors.

d. During an interview with Patient C17 on 1/6/15 at 9:55 a.m., s/he stated that Patient C23 came into [her/his] room on 1/4/15 while [s/he] was making up [his/her] bed and "kissed me on the cheek." S/he stated s/he "pushed [him/her] out the door." S/he stated that Patient C23 "scared me." Patient C17 stated that s/he hit Patient C23's hand the previous day "because [s/he] was trying to touch me." Patient C17 acknowledged that the behaviors demonstrated by Patient C23 were frightening to [her/him] and disruptive to the unit. Patient C17 was unable to identify any interventions by the facility that were successful in preventing Patient C23's disruptive and frightening behaviors.

e. During an interview with Patient C22 on 1/6/15 at 10:00 a.m., s/he stated that Patient C23 "tried grabbing my chest as soon as [s/he] got here. Calling me baby and that [s/he] loved me." S/he acknowledged s/he was "upset" by Patient C23. Patient C22 stated that Patient 23 "tried to touch me in certain [sexual] ways." S/he stated that s/he "told all the staff " and staff " told [him/her] not to do that to me. " S/he acknowledged that s/he was "afraid" because of the behaviors of Patient C23. Patient C22 acknowledged that the behaviors demonstrated by Patient C23 were frightening to [her/him] and disruptive to the unit. Patient C22 was unable to identify any interventions by the facility that were successful in preventing Patient C23's disruptive and frightening behaviors.

3. Staff Interviews

a. During an interview with MHT 1 on 1/6/15 at 10:25 a.m., s/he stated that Patient C23 "would say inappropriate [sexual] things" to female staff and patients. S/he stated that unit staff attempted to have Patient C23 follow a different schedule than the other patients but "that only lasted a day." S/he acknowledged that the 15-minute checks on patients allowed time for patients to engage in inappropriate activities with each other between checks.

b. During an interview with Nurse Manager 1 on 1/7/15 at 11:10 a.m., he acknowledged that there was no documentation of additional staff being assigned to the unit for the management of Patient C23's behaviors until Patient C23 was placed on 1:1 observation on 1/5/15.

c. During an interview with MD 1 and the Medical Director on 1/7/15 at 9:15 a.m., MD 1 stated that Patient C23 had displayed multiple aggressive behaviors during [her/his] hospitalization including sexualized touching of other patients. MD 1 stated that patients were instructed to call or seek staff for help if Patient C23 went into their bedroom. MD 1 stated that 1:1 observation for Patient C23 would have needed to be the same sex as Patient C23 due to Patient C23's sexualized behaviors. MD 1 stated that in order to assign a same-sex staff for 1:1 observation on a 24 hour basis "would have been almost impossible" and "there is not enough male staff." The Medical Director stated "that is the issue that makes us hesitant [to order 1:1 observation]."

d. During an interview with the CEO on 1/7/15 at 12:45 p.m., he acknowledged that he understood the issue of protecting other patients from the intrusive behaviors of Patient C23 especially towards other patients of the opposite sex. He stated that the facility was considering establishing a unit with only one sex to address this issue.

B. Patient I1

1. Medical Record Review

a. A review of the Comprehensive Psychiatric Evaluation dated 8/5/14 at 1:55 p.m. stated that Patient I1 was admitted to Stevenson Hall "with a court order from [another facility] where [s/he] was admitted after [s/he] became physically aggressive with [her/his] family. During [her/his] admission there, [s/he] was physically aggressive to peers and staff, and destroyed property. [s/he] is on probation for Aggravated Battery." The History of Present Illness stated "Per records from [another facility], on the unit, on 07-23-2014, [s/he] assaulted a female patient whom [s/he] hit with [her/his] closed fist in the face. On 07-25-2014, [s/he] lunged at staff and tried to strike staff with a closed fist. On 07-27-2014, [s/he] lunged at a female peer with fists clenched...On 07-29-2014, [s/he] threatened to choke [her/his] psychiatrist..." Diagnoses included "Psychosis, not otherwise specified." "Recommendations" included "Because [s/he] has a history of severe violence, [s/he] will be placed on frequent observations [observed every 15 minutes]."

b. The Master Treatment Plan, dated 8/4/14, reviewed 8/13/14, included the problem of "Aggression." The MTP did not document any changes in the interventions for the problem of "Aggression" during this hospitalization.

c. Progress and Incident Notes

1) The Nursing Progress Note dated 8/10/14 at 2:47 p.m. stated "Writer was also notified by staff that [another patient] accused patient of hitting him. Incident was not witnessed by staff."

2) The Nursing Progress Note dated 8/11/14 at 12:36 a.m. stated "Patient continues to show signs of aggression and doesn't appear ready to be ready for discharge."

3) The Nurse Incident Note dated 8/16/14 at 10:00 p.m. stated "[Patient I1] entered a female peer's room several times during the shift and threw dirty socks at her. As a result of this behavior, [s/he] was moved to room 123 and closely monitored to ensure that [s/he] did not attempt to go to the peer's room again. Staff on the unit reportedly overheard him making sexual comments to the peer during dinner."

4) The Nursing Progress Note dated 8/18/14 at 12:59 p.m. stated "...[another patient] was in line and [Patient I1] had [her/his] pants down very low and kept trying to touch [her/him] which was unwanted by the peer. [Patient I1] was redirected at which time [s/he] said something to another [patient] and [s/he] touched [her/his] genital area which [s/he] was thrusting out with pants low. [Another patient] was redirected and said [s/he] was sorry but [Patient I1] asked [her/him] 'to give [her/him] a blow job.' "

5) The Case Management Notes completed by the social worker dated 8/19/14 at 11:00 a.m. stated "Writer saw him in the mileu [sic] yesterday and [s/he] had [her/his] shorts pulled down low enough to expose [her/his] underwear and was requesting sexual acts from female peers, followed by comments that [s/he] need to 'F**k a female peer. [Her/his] behavior has been both inappropriate and disruptive to the unit..."

6) The Nurse Incident Note dated 8/22/14 8:38 p.m. stated "Patient was observed by writer talking with [another patient] telling him that [s/he] was a 'Sexual Predator'..."

7) The Nurse Incident Note dated 8/23/14 at 11:05 p.m. stated "Patient continues to pace the unit toward [another patient] room when advised by staff to not do so checking to see patient location. Patient has asked staff on several occasions where patient is and [s/he] knows [s/he] isn't in [her/his] room...Patient given EFM [emergency forced medication] because patient is sexually aggressive and pacing unit in a 'stalking' manner looking for [another patient] whom had to be moved because of patients behavior."

8) The Nursing Progress Note dated 8/23/14 10:15 p.m. stated "Patient was observed walking up the hallway from the men's shower calling female peers 'bitches.' Patient was then observed coming out of [another patient] room in which [s/he] was said to have hit [another patient] in right forearm no injury noted to either patient. Patient then proceeded to go back toward [another patient] room with a pillow and a code blue had to be called patient refused to follow staff command to stop."

9) The Nursing Progress Note dated 8/24/14 10:20 a.m. stated "Offers little dialogue, has been sexually aggressive in the last 24 hours."

10) The Nursing Progress Note dated 8/25/14 at 2:00 p.m. stated "He has made sexually inappropriate statements and has displayed unpredictable behavior...[Patient I1] is difficult to redirect and has been mostly uncooperative with care."

11) The Nursing Progress Note dated 8/25/14 10:00 a.m. indicated that Patient I1 remained on 15 minute observation.


d. The "Request for Transfer to the Chester Mental Health Center" dated 8/25/14 stated that Patient I1 "has demonstrated repeated episodes of agitation, physical aggression, and sexually inappropriate behaviors...incidents of aggression date back to [her/his] admission date of 08/04/12." The Request for Transfer stated that on 8/26/14, Patient I1 "attacked a peer, putting [her/him] in a choke hold and throwing [her/him] to the floor." The "Expected Benefit of Transfer" included "a higher level of security than McFarland MHC is able to provide in order to protect staff and other patients." The answer to the question of "What were the resulting injuries/damages?" was "Staff and peers are traumatized and fearful of [her/his] presence on the unit."

e. The Discharge Summary for Patient I2 dated 9/11/14 at 3:30 p.m. stated that Patient I2 "reported feeling unsafe and that is what [s/he] focused on in the meeting [with the psychiatrist" and "[s/he] talked about feeling unsafe here..."

2. Document Review

a. A review of the "Organizational Response for Incident #208337" to the Joint Commission, incident date 8/19/14, stated in the "Complaint Summary" the following: "I was a patient at McFarland for depression over eight (8) days, from 8/19/2014 until my discharge 8/27/14. Over the eight (8) days a male p

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

I. The MTPs for eight (8) of eight (8) active sample patients (B14, B21, C10, C17, D4, D22, E4, and E9) identify interventions for the psychiatrist that were individualized. This results in the facility not delineating the role of the physician in the treatment of patients.

Findings include:

A. Record review

1. Active sample Patient B14, MTP dated 10/6/14 had a problem of "Altered thought process." The only intervention for the psychiatrist was "Prescribe psychotropic medications."

2. Active sample Patient B21, MTP dated 9/17/13, had the problems of "Auditory Hallucination, Suicidal attempt and depression." The only intervention for the psychiatrist was "Prescribe psychotropic medication."

3. Active sample Patient C10, MTP dated 10/14/10, had the problems of "Altered thoughts process," "Agitation" "Poor Insight into Mental Illness," and "History of sexually inappropriate behavior." The only interventions for the psychiatrist were "Psychiatrist will order medications and monitor dosage and effectiveness." "Psychiatrist will assess Mr. H on the unit for clinical stability and prescribe medication and treatment regimen as indicated." "Psychiatrist will also complete a suicide risk assessment prior to discharge." "Prescribe psychotropic medications."

4. Active sample Patient C17, MTP dated 9/10/14, had the problems of "Altered Thought Process," and "Unfit to stand trial." The only intervention for the psychiatrist was "Psychiatrist will assess [Patient C17] on the unit for clinical stability and prescribe medication and treatment regimen as indicated."

5. Active sample Patient D4, MTP dated 10/8/10, had the problems of "Delusional," Erratic Behaviors, "History of Aggression." The only intervention for the psychiatrist was "Provide education regarding benefits and side effects of psychotropic medications and evaluate the effectiveness of prescribed medications on at least weekly basis."

6. Active sample Patient D22, MTP dated 12/2/14, had the problems of "Homelessness," "Suicidal Ideation with a plan," and "Aggression." The only interventions for the psychiatrist were "The psychiatric will continue to made adjustments and changes to the medication regime as necessary; to help [Patient D22] show improved stability and decrease in aggressive behaviors." "Psychiatrist will meet with [Patient D22] at least 1 x weekly to assess for clinical progress and recommended treatment regimen." "Psychiatrist will assess and encourage medication compliance and emphasize the need for continued compliance in the community."

7. Active sample Patient E4, MTP dated 10/8/10, had the problem of "Paranoia." The only intervention for the psychiatrist was "Psychiatrist will meet with [Patient E4] at least 1x weekly to assess for clinical progress and recommend treatment regimen." "Psychiatrist will order medication and monitor dosage and effectiveness."

8. Active sample Patient E9, MTP dated 12/17/14, had the problems of "Suicidal Ideation," "Depression." The only intervention for the psychiatrist was "Psychiatrist will order medications and monitor dosage and effectiveness."

B. Staff Interview

During an interview with the Medical Director on 1/7/15 at 12:30 p.m., she acknowledged that the psychiatric interventions on the treatment plans were generic and not specific for Patients B14, B21, C10, C17, D4, D22, E4, and E9.

II. Ensure that active treatment measures were available for four (4) of eight (8) active sample patients (C10, C17, D4, and D22) who were unwilling or unable to attend groups or were sufficiently impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. 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)

III. Ensure that patients received treatment in a therapeutic environment without disruption and intimidation by Patient C23 and Patient I1 for all patients on two of six treatment units (Lincoln Hall, South and Stevenson Hall). These patients were allowed to remain on co-ed units where they created a frightening and disruptive unit environment by displaying threatening and assaultive behaviors toward other patients without all necessary interventions being attempted (such as 1:1 or 2:1 staffing, separation from other patients, etc.). (Refer to B125 II)

Based on observation, record review and interview, the Director of Nursing failed to ensure:

1. The MTPs for eight (8) of eight (8) active sample patients (B14, B21, C10, C17, D4, D22, E4, and E9) identify nursing interventions that were individualized and has specific frequency for care. These failures can result in fragmented nursing care and non-compliance with planned treatment interventions putting the patient at risk for adverse treatment outcomes. (See B122, and B125)

A. Interview

1. In an interview on 1/6/15 at 3:00 p.m., the generic interventions on the Master Treatment Plans were discussed with the Director of Nursing. She acknowledged that interventions on the MTP's were generic and routine discipline functions. She stated, "I understand that the interventions listed are staff duties, but the treatment coordinator are responsible for inputting information on the plan."

2. In an interview on 1/6/15 at 3:00 p.m., the lack of active treatment for patients who refused to attend scheduled unit or centralized activities were discussed with the Director of Nursing. She acknowledged the need to provide alternative programming for the patients who routinely refuse to attend groups. She stated that Psychosocial Services is hiring a social worker to assist the units if proving alternative programming to meet the needs of these patients.

II. Ensure that active treatment measures were available for four (4) of eight (8) active sample patients (C10, C17, D4, and D22) who were unwilling or unable to attend groups or were sufficiently impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. 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)

III. Ensure that patients received treatment in a therapeutic environment without disruption and intimidation by Patient C23 and Patient I1 for all patients on two of six treatment units (Lincoln Hall, South and Stevenson Hall). These patients were allowed to remain on co-ed units where they created a frightening and disruptive unit environment by displaying threatening and assaultive behaviors toward other patients without all necessary interventions being attempted (such as 1:1 or 2:1 staffing, separation from other patients, etc.). (Refer to B125 II)