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Based on observation, record review and staff interview, the facility failed to provide all groups scheduled for patients on the Lower Treatment Unit (LTU) and the Upper Treatment Unit (UTU). During the survey 4 groups chosen for observation on the LTU, a long term care unit with a census of 25, did not meet. One group chosen from the UTU, an acute care unit with a census of 19, did not meet. This lack of active treatment potentially delays patients' progress towards discharge. (Refer to B125)

Based on record review, policy review and interview, the hospital failed to provide psychiatric evaluations that reported memory function in measurable terms for 7 of 8 sample patients (A1, A2, A4, B1, B2, C1 and C2). This compromises the database from which diagnoses are determined and from which improvements in response to treatment are assessed.

Findings include:

A. Record Review

1. Patient A1 (Admitted 04/21/10) received a psychiatric evaluation on 4/21/10. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing in the dictated Psychiatric Evaluation signed on 05/03/10.

2. Patient A2 (Admitted on 11/20/07) received an annual updated psychiatric evaluation on 11/05/09. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing.There also was no notation of memory in the dictated Psychiatric Evaluation of 11/05/09.

3. Patient A4 (Admitted on 07/23/09) received a psychiatric evaluation on 07/24/09. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing. There also was no notation of memory in the dictated Psychiatric Evaluation. The annual update due 07/24/10 was not yet in the medical record.

4. Patient B1 (Admitted on 07/13/10) received a psychiatric evaluation on 7/14/10. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing. There also was no notation of memory in the dictated Psychiatric Evaluation signed on 07/21/10.

5. Patient B2 (Admitted on 07/15/10) received a psychiatric evaluation on 07/15/10. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing. There also was no notation of memory in the dictated Psychiatric Evaluation signed on 7/22/10.

6. Patient C1 (Admitted on 07/10/10) received a psychiatric evaluation on 07/10/10. The section on memory in the handwritten data was not completed, and there was no other evidence of memory testing. There also was no notation of memory in the dictated Psychiatric Evaluation signed on 07/14/10.

7. Patient C2 (Admitted on 02/12/10) received a psychiatric evaluation on 02/12/10. There were circles on the handwritten evaluation of memory documenting that some elements of memory were evaluated. There was no record of how the patient's memory was tested. There also was no information about memory testing in the dictated Psychiatric Evaluation signed on 3/6/10.

B. Policy Review

A review of hospital policy, MSO.00.33 last revised on 7/21/09, revealed the following statement: "a detailed assessment of patient's emotional, cognitive, perceptual, behavioral and intellectual status, which must address: ...4. Memory."

C. Interview

In interview on 08/04/10, at 8:45 a.m., the Interim Medical Director agreed that the Psychiatric Evaluation should include the method by which memory was tested. He also concurred that memory testing was required in hospital policy.

Based on record review and interview, the facility failed to provide psychiatric evaluations that contained an assessment of patient strengths/assets in descriptive terms that could inform treatment planning for 6 of 8 active sample patients (A1, A3, A4, B1, C1 and C2). This failure results in treatment plans and treatment modalities that are compromised by not considering factors useful to the patient in formulating and achieving treatment goals.

Findings include:

A. Record Review

1. Patient A1, admitted on 04/21/10, received a psychiatric evaluation on 4/21/10. The evaluation did not contain an inventory of strengths/assets.

2. Patient A3, admitted on 03/24/10, received a psychiatric evaluation on 03/24/10. The listed patient "needs and assets" were "medication management, case management, encouragement to agree with placement." These were staff interventions, not the strengths and assets that the patient brings to treatment. No personal strengths/assets were listed.

3. Patient A4, admitted on 07/23/09,) received a psychiatric evaluation on 07/24/09. The listed patient "needs and assets" were "as mentioned, he is NGRI, but states he feels 'ok' about the transfer to Choate." No personal strengths/ or assets were noted.

4. Patient B1, (admitted on 07/13/10, received a psychiatric evaluation on 7/14/10. The listed patient needs and assets were "he will require an inpatient stay for the diagnostic evaluation and stabilization of his mood." No personal strengths/assets were noted.

5. Patient C1, admitted on 07/10/10, received a psychiatric evaluation on 07/10/10. The listed patient "needs and assets" were "the patient is currently physicallystable and has no major medical illnesses." These are not personal assets that the patient brought to treatment. No personal strengths/assets/assets were noted.

6. Patient C2, (admitted on 02/12/10, received a psychiatric evaluation on 02/12/10. The evaluation did not contain an inventory of strengths/assets.

B. Policy Review

The facility policy MSO.00.033 dated 07/21/09 states that the psychiatric evaluation "must include a listing of social/personal and/or interpersonal strengths and assets useful to the patient in formulating and achieving treatment goals."

C. Interview

In a telephone interview on 08/04/10 at 8:45 a.m., the Medical Director agreed that the psychiatric evaluation should contain an inventory that describes personal and interpersonal strengths/assets useful to the patient in formulating treatment goals. The Medical Director also noted that this is required by hospital policy.

Based on observation, record review and interview, the facility failed to provide all groups listed on the units' treatment lists to the patients. During the time of the survey, 5 scheduled group activities which were chosen to be observed were not held. Four of these groups were for patients on the Lower Treatment Unit, a unit for chronic patients with a census of 25 of the current facility-wide census of 47. Failure to provide scheduled groups potentially delays patients' progress in meeting their treatment goals.

Findings include:

A. The Lower treatment Complex generates a general activities list. Patients are then encouraged to attend groups as they seem appropriate for individual patients, but patients are not assigned to any particular groups. Since the groups did not meet, it was not possible to know who would have attended had the groups met.

Observations:

A. Lower Treatment Unit

1. On 8/2/10 at 11:30a.m., while on the Lower Treatment Complex (LTC) the surveyor reviewed a printed activities schedule for the unit. The schedule listed "Community Meeting" for 11:30a.m. to 12:00p.m. When attempting to observe the meeting, the surveyor was told by Mental Health Technician (MHT) A that the meeting time had been changed to 11:00a.m. The MHT further acknowledged that patients had not been informed of the change.

2. On 8/3/10 at 8:45a.m. when on the LTC, the surveyor entered the room to observe a scheduled "Wrap Review" group. MHT B was sitting in the room. When asked if "Wrap Review" would meet, MHT B stated "We talk if anyone shows. Things have changed and not many (patients) attend groups anymore."

3. On 8/3/10 at 9:05 a.m., the surveyor and MHT A made rounds on the LTC. The surveyor and MHT counted 12 of the 25 LTC patients (A1, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, and A14) in bed.

4. On 8/3/10 at 9:30a.m. the surveyor entered the LTC day room to observe the scheduled "Simple Fitness" group. When asked about the group at 9:45a.m., MHT A acknowledged the group did not meet.

5. On 8/3/10 at 10:15 a.m. the surveyor attended the "Reflections Group" on the LTC. Patients were eating snacks and drinking soda. When asked the meaning of the name "Reflections Group," MHT B stated "It sounds better than sodee (sic) break or snack break." When asked the purpose of the group, MHT B stated "I don't know; talk and eat snacks, I guess."

B. On 08/02/10, at 3:10, while on the Upper Treatment complex (UTC), the surveyor reviewed the printed activities schedule for patient C2. This patient was scheduled for "Seniors Group" which was supposed to occur on Redbud Lower (RBL) where Rehabilitation Services are housed. The surveyor went to RBL to inquire about the group and was told by Rehabilitation Staff that the group was not going to be held because the employee who usually ran the group was not working that day. When the surveyor returned to the unit, the unit staff were unaware of the schedule change and were waiting for the Rehabilitation Staff to come to get the patient.

Interviews

1. On 8/3/10 at 9:15a.m. the surveyor asked MHT A why nearly half of the patients were still in bed at 9:00a.m. The MHT replied that most of the patients were too sick physically and/or mentally to participate in groups. She stated that patients are not always encouraged to attend groups.

2. On 8/3/10 @ 11:30 a.m., after discussing the above observations and comments by nursing staff with the surveyor, the Director of Nursing (DON) acknowledged that groups do not always meet as scheduled.

Based on observation and interview, it was determined that the Medical Director failed to monitor the quality and appropriateness of medical and psychiatric care for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, C1 and C2). Specifically, the Medical Director failed to:

I. Ensure that psychiatric evaluations for 7 of 8 sample patients (A1, A2, A4, B1, B2, C1 and C2) contained an assessment of memory function and a description of the methodology used for the assessment. This failure compromises the database from which diagnoses are determined and from which improvements in response to treatment are assessed. (Refer to B116)

II. Ensure that psychiatric evaluations for 6 of 8 active sample patients (A1, A3, A4, B1, C1 and C2) contained an assessment of patient strengths/assets in descriptive terms that could inform treatment planning. This failure results in treatment plans and treatment modalities that are compromised by not considering factors useful to the patient in formulating and achieving treatment goals. (Refer to B117)

In an interview on 08/04/10 at 0845, the Medical Director agreed with the findings as noted above findings. He agreed that the staff were not fully compliant with the hospital policy MSO.00.033, dated 07/21/09 with respect to the Psychiatric Evaluation.

Based on observation and interview, it was determined the Director of Nursing failed to monitor and ensure the quality and appropriateness of nursing services provided on the Lower Treatment Complex (LTC) unit. Specifically, the Director of Nursing failed to ensure that all nursing groups were actually held as scheduled, and ensure that all scheduled nursing groups were led by qualified nursing staff.

Failure to provide scheduled groups potentially delays patients' progress in meeting their treatment goals. Failure to ensure provision of adequate training and monitoring of nursing interventions hampers staff's ability to provide consistent and focused treatment for patients.

Findings include:

A. Observation

1. On 8/2/10 at 11:30a.m., while observing on the Lower Treatment Complex (LTC) the surveyor reviewed a printed activities schedule for the unit. The schedule listed "Community Meeting" for 11:30a.m. to 12:00p.m. When attempting to observe the meeting, the surveyor was told by Mental Health Technician (MHT) A that the meeting time had been changed to 11:00a.m. The MHT further acknowledged that patients had not been informed of the change.

2. On 8/3/10 at 8:45 a.m. while observing on the LTC, the surveyor entered a room to observe a scheduled "Wrap Review" group. MHT B was sitting in the room. When asked if "Wrap Review" would meet, MHT B stated "We talk if anyone shows. Things have changed and not many (patients) attend groups anymore."

3. On 8/3/10 at 9:05a.m., the surveyor and MHT A made rounds on the LTC. The surveyor and MHT counted 12 of the 25 LTC patients (A1, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13 and A14) in bed.

4. On 8/3/10 at 9:30a.m. the surveyor entered the LTC day room to observe the scheduled "Simple Fitness" group. When asked about the group at 9:45a.m., MHT A acknowledged the group did not meet.

5. On 8/3/10 at 10:15a.m. the surveyor attended the "Reflections Group" on the LTC. Patients were eating snacks and drinking soda. When asked the meaning of the name "Reflections Group", MHT B stated "It sounds better than sodee (sic) break or snack break." When asked the purpose of the group, MHT B stated "I don't know; talk and eat snacks, I guess."

B. Interviews

1. On 8/3/10 at 9:15a.m. the surveyor asked MHT A why nearly half of the patients were still in bed at 9:00a.m. The MHT replied that most of the patients were too sick physically and/or mentally to participate in groups. MHT A also stated that patients are not always encouraged to attend groups.

2. On 8/3/10 at 11:30a.m., after discussing the above observations and comments by nursing staff, the Director of Nursing (DON) acknowledged that nursing groups do not always meet as scheduled. In the same interview, the DON stated that nursing staff were not always trained to conduct groups.