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Based on observation, document review, policy review and interview, the hospital failed to promote and protect the rights of each patient as evidenced by the failure to provide care in a safe setting, failure to notify all admitted patients of their rights prior to providing care and failure to include the patient in the care planning process.

The cumulative effects of these deficient practices place all patients at risk for serious illness, injury and/or death, places patients at risk of insufficient information to make decisions directly affecting their choices of care and places patients at risk for the inability to determine individual goals, actions, and interventions necessary to improve their mental health and successful hospital dismissal.

Findings Include:

1. The hospital failed to ensure patients receive care in a safe setting as evidenced by, the hospital's failure to ensure staff followed the infection control program for the prevention of and transmission of infections, including COVID-19, for five of five current patients and failed to ensure the plan of care was reviewed and updated for one of one patients with multiple falls. (Refer to A0144 and A0749)

2. The hospital failed to notify all admitted patients of their rights prior to providing care. (Refer to A0117)

3. The hospital failed to include the patient in the care planning process. (Refer to A0130)

Based on observation, policy reviews, interviews, the hospital failed to ensure an active hospital-wide program for the surveillance, prevention, and control of healthcare-acquired infections, and other infectious diseases, and for the optimization of antibiotic use through stewardship, as evidenced by failing to employ methods for preventing and controlling the transmission of infections within the hospital.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

The surveyor notified the hospital that an IJ existed on 11/20/20 at 4:20 PM, related to 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship. The IJ remained in place and was not removed prior to exit on 11/20/20 at 5:50 PM.

Findings Include:

1. The hospital failed to protect two of five patients (Patient 1 and Patient 3) and seven staff (Staff D, Director of Nursing (DON), Staff F, Social Worker (SW), Environment of Care Manager (EOCM), two unidentified registered nurses (RNs) and two unidentified mental health technicians (MHTs) from transmission of COVID-19. (Refer to A0749)

2. The hospital failed to provide patients with masks to wear when around other people or to require them to practice social distancing. (Refer to A0749)

3. The hospital staff failed to perform hand hygiene per hospital policy as observed during medication administration. (Refer to A0749)

4. The hospital fail require staff to wear the appropriate PPE, according to current Centers for Disease Control and Prevention (CDC) guidelines. Observation showed staff wearing cloth masks, which is inconsistent with the guidelines. (Refer to A0749)

5. Hospital staff failed to wear the recommended masks and failed to appropriately cover their nose and mouth. (Staff observed with cloth mask that did not cover their nose). (Refer to A0749)

6. The COVID-19 Infection Control Plan does not specify the type of mask(s) to be worn by staff or the patients. (Refer to A0749)

7. The hospital failed to ensure the medical director was aware of his responsibilities and failed to notify the medical director in a timely manner of the COVID-19 positive staff member who potentially exposed all four patients admitted to the hospital at the time and all staff working with the infected staff member. (Refer to A0749)

8. The hospital failed to have a qualified Infection Preventionist to initiate the COVID-19 Pan Flu Plan. (Refer to A0748)

9. The hospital failed to initiate increased cleaning procedures as directed by Staff A, Chief Executive Officer (CEO) after one staff member tested positive for COVID-19 on 11/19/20. (Refer to A0749)

10. The hospital failed to ensure one of two agency Registered Nurses (RN) and one of two activity staff had documented infection control and COVID-19 training. (Refer to A0749)

11. The hospital failed to ensure a system was in place to track all infection surveillance, prevention and antibiotic use. (Refer to 770)

12. The hospital failed to ensure a qualified infection control officer (ICO) (past or present) audited the adherence of infection prevention and control policies and procedures by hospital staff to prevent and control the spread of hospital acquired infections (HAIs). (Refer to A0776)

Based on record review, policy review, observation, and interview, the hospital failed to ensure medical records showed the degree and intensity of the treatment provided to four of four sample patients (Patient 1, Patient 2, Patient 3, and Patient 4).

The cumulative effects of this deficient practice places patients at risk for needs not being identified and addressed, delay in improvement and extend the length of hospitalizations.


Findings Include:


l. The hospital failed to develop and document a Multidisciplinary Treatment Plan (MTP) based on the individual needs of 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for Psychiatric Evaluations and MTP's, from a total sample of 19 patients.

Specifically, each patient had the same two problems identified on their MTP's along with unmeasurable goals that did not address the patients' reasons for admission and an absence of interventions to meet the goals. Failure to individualize the patients' MTP's leads to needs not being identified and addressed which can delay the patients' recovery and extend the length of hospitalization. (Refer to A1640)

2. The hospital failed to provide Multidisciplinary Treatment Plans (MTP's) that contained patient-related short-term goals (STGs) and long-term goals (LTGs) stated in observable, measurable, behavioral terms for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for MTP's, from a total sample of 19 patients. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to increase patient stays beyond the resolution of the behaviors requiring admission. (Refer to A1642)

3. The hospital failed to develop treatment interventions based on the individual needs of patients for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for MTP's, from a total sample of 19 patients. Treatment interventions in the Master Treatment Plan (MTP) listed only routine/generic discipline functions rather than individualized treatment options or failed to include interventions for the identified goals. This practice has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to A1643)

4. The hospital failed to provide active therapeutic treatment for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for active treatment, from a total sample of 19 patients. Except for one psychotherapy group led by the social worker and one nursing group led by a Licensed Practical Nurse (LPN), the remainder of the daily groups were led by activity staff and consisted of only leisure activities. In addition, Patient 2 rarely attended groups but instead stayed in bed. There were no alternative therapeutic activities provided for Patient 2 and the Master Treatment Plan (MTP) failed to address the patient's non-attendance. 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 A1650)

Based on record review, observations, and interviews, the hospital failed to:

1. Based on document review and interview, the hospital failed to ensure the physician provided oversight of the treatment and care to patients at the frequency, level, and intensity necessary for psychiatric hospitalization, and failed to have a current contract for the Medical Director/Psychiatrist. Specifically, there was no physician on-site to provide, direct, review, and supervise psychiatric treatment and medical direction to the hospital. Instead, the only physician contact with patients for psychiatric care was via electronic telecommunication (a telemedicine process) who's Temporary Emergency Privileges had not been renewed since 07/31/20 per Medical Staff Bylaws.

Failure to have consistent on-site supervision and direction of each patient's treatment, has the potential to compromise the patients' recovery, potentially delaying their timely discharge. (Refer to A1690)


2. Ensure that the Director of Nursing (DON) had a master's degree in psychiatric/mental health nursing and could not document evidence of consultation from a nurse with a master's degree in psychiatric/mental health nursing.

Failure to have a DON with the education, knowledge and experience in providing nursing service to psychiatric inpatients can lead to an inability to monitor the care delivered by nursing staff which can potentially lead to a provision of care that hinders rather than facilitates the patients' recovery process. (Refer to A1701)

3. Provide a therapeutic activity program that met the individualized needs of 4 of 4 current sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed to ensure that active treatment was being provided, from a total sample of 19 patients. Specifically, all the observed activities provided to the patients by the Activity Coordinators consisted of only leisure activities. There were no scheduled therapeutic activity groups designed to improve the patients' functioning. Instead, the groups consisted of movies, board games, videos, and putting puzzles together.

Failure to provide a therapeutic activity program hinders the ability of the patients to develop and maintain skills that will assist them post-discharge and can prolong recovery and hospitalization. (Refer to A1720)

4. Ensure consistent availability and provision of individualized therapeutic activities and rehabilitative services based on patient needs for 4 of 4 active current patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed to ensure that active treatment was being provided, from a total sample of 19 patients. The Master Treatment Plans (MTPs) did not list specific groups that had been assigned to individual patients according to their needs and all activity groups were identified as "Activity Group" with no identification of the focus.

In addition, the focus of some groups was planned after the patients were in attendance and were at times cancelled due to lack of staff or other work assignments. This lack of consistency and focus fails to provide patients with needed therapeutic interactions to deal with problems that made hospitalization necessary and can negatively impact placement and prolong discharge. (Refer to A1725)

5. Provide professional therapeutic staff that could design and implement structured therapeutic activities. The activity staff consisted of Staff N and Staff O, both listed as Activity Coordinators on the hospital's organizational chart. Staff N did not have experience or education in activity therapy and Staff O had a Certificate of Completion from "We Care Online" that acknowledged 45 hours of study for "Activity Director." The certificate was for long-term care patients and had been earned when Staff O was a CNA at a nursing home. Both Staff N and Staff O had been Mental Health Technicians at the hospital prior to becoming Activity Coordinators and were the only activity therapy staff employed.

Failure to have qualified activity staff who have knowledge and education on how to plan activity programs for acute psychiatric patients, results in a lack of structured therapeutic groups/activities designed to assist the patient in meeting goals which can delay the patients' recovery and potentially extend their hospital stay. (Refer to A1726)

Based on record review and document review the hospital failed to notify all admitted patients of their rights prior to providing care for one of four current patients (Patient 3). Failure of the hospital to provide patient rights and education regarding their rights to every patient admitted to the facility placed all patients at risk of lacking sufficient information to make medical decisions directly affecting their choices of care.


Findings Include:


Document review of the hospital admission packet showed patients are given a written copy of "A Summary of The Rights of Persons with Mental Illness in Kansas" published by the Disability Rights Center of Kansas, Inc. which provides information regarding voluntary and involuntary admission to a psychiatric hospital. Also included in the admission packet are authorization/consent forms including the hospital care consent, memorandum of understanding, request for voluntary admission, and involuntary hold notice.

Review of Patient 3's medical record showed she was an involuntary admission on 11/12/20 with a diagnosis of paranoid schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior) and a history of delusions, anxiety, and depression. The medical record failed to show evidence she received patient rights information, failed to show evidence of receipt or refusal of patient rights information, and failed to show signed or documentation of refusal to sign consents regarding patient rights information.

During an interview on 11/17/20 at 2:30 PM, Patient 3 stated she was admitted to the hospital as an involuntary admission and she objected to her admission and that she did not need to be admitted. She refused to further discuss her hospitalization stating this surveyor could speak with her lawyer for further information. She did state that she would be filing complaints against the hospital. She was further observed handing a written complaint to Staff A, CEO.

During an interview on 11/17/20 at 4:00 PM Staff D, Director of Nursing (DON) stated that the admission process includes obtaining patient signatures for consent of admission and reviewing patient rights with the patient.

Based on observation, medical record review, and interview the hospital failed to include the patient in the care planning process in two of four current medical records reviewed (Patient 1 and Patient 2). Failure to include patients in the care plan process placed patients at risk of inability to determine individual goals, actions, and interventions necessary to improve their mental health and successful hospital dismissal.


Findings Include:


Document review of the hospital policy titled, "Plan of Care" revised 11/2016 showed every patient is to have an individualized care plan that identifies patient strengths, preferences and goals identified through the screening process. Patient care decisions are collaborative with short and long-term care goals, objectives, and interventions identified.

The policy further showed patient needs are identified from information contained on the initial intake from and initial nursing assessment, care and treatment decisions are made with input from all disciplines providing care and services to the patient, and the planning includes the development of treatment goals with objectives.

Finally, the policy showed, patient family participation in care planning is to be documented.

The policy failed to provide provision of specific patient participation in care planning, documentation of patient participation, or options to allow the patient to participate.

Review of the hospital policy titled "Plan of Care-Protocol for Development of the Multidisciplinary Treatment Plan from the Multidisciplinary Integrated Assessment (MIA)", revised 01/24/17 showed the treatment plan review is to include the degree of patient and/or significant others participation in the plan.


1. Review of Patient 1's medical record showed he was admitted involuntarily on 11/03/20 with a diagnosis of bipolar disorder (mental disorder with periods of depression or abnormally elevated mood), major depression (MDD), insomnia (inability to sleep), Parkinson's (degenerative neurological disorder), unsteady gait, dysphagia (difficulty swallowing), hypothyroidism (low thyroid hormone level), and frequent falls.

Review of Patient 1's treatment plan identified two problems.

a. Psychosis evidenced by hallucinations, visual delusions, and paranoia (mental condition characterized by delusions of persecution, unwarranted jealousy, or exaggerated self-importance) with goals and timeframes for resolution identified as patient will have a decrease in delusions, will be medication compliant within two days, and will be free of aggression within five days. Interventions included the patient will learn at least two new coping skills.

b. Fall precautions evidenced by confusion, disorientation, and high fall risk score. Goals and timeframes established were Patient 1 would prevent falls for the duration of the hospitalization. No documentation was included to show how fall prevention and patient education would occur.

Neither problem was updated or showed evidence of Patient 1's participation in developing the problem, goal, or intervention in the medical record during his admission.


2. Review of Patient 2's medical record showed an involuntary admission on 11/07/20 with a diagnosis of paranoid psychosis, anxiety disorder, obsessive compulsive disorder (OCD) (pattern of unwanted thoughts and fears that lead to repetitive behaviors), anemia (low iron blood count), and functional bowel disorder.

Review of Patient 2's treatment plan identified three problems.

a. Problem one, no delusional or paranoid ideations or psychosis. The intervention was for Patient 2 to attend and participate in at least 75% of the group activities for 45 minutes, 7 to 10 times a week. The initial target date was 11/12/20.

b. Problem two was falls with the intervention identified was he would be free from falls for the duration of the hospitalization and the assessment risk of falls (ARF) would be performed weekly.

c. Problem three was to discharge Patient 2 home with his wife and he would have access to community mental health services. No interventions or time frames were identified.

None of the problems were updated or showed evidence of Patient 2's participation in developing the problem, goal, or intervention in the medical record during his admission.


During an interview on 11/17/20 at 2:45 PM, Staff F, Social Work (SW) stated she meets daily with the discharge planner to review patients pending discharge status. She stated if the patient is not meeting goals, it will be brought to the attention of the psychiatrist for review. Patients who do not meet goal will be considered for remaining in the hospital for further treatment. She stated part of her responsibilities is to complete her section of the MIA including the treatment plan with goals and interventions. She stated that is based on her assessment of the patient and the initial nursing assessment, she does try to include the patient in setting goals and interventions. Finally, she stated the patient is assessed by telemedicine weekly by the psychiatrist and the goals and interventions along with progress are reviewed at that time with the patient, DPOA or family if acceptable, however she stated there is no documentation of the extent of the involvement.

During an interview on 11/17/20 at 4:00 PM Staff D, Director of Nursing (DON) stated the nursing care plan is updated daily with changes in goals, interventions, and progress noted. She further stated the patient is to be part of the goal setting and determining progress toward goals.

Based on observation, document review, policy review and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by, the hospital's failure to ensure staff followed the infection control program for the prevention of and transmission of infections, including COVID-19, for five of five current patients and failed to ensure the plan of care was reviewed and updated for one of one patients with multiple falls (Patient 11). Failure to ensure staff follow the infection control program places patients at risk of exposure to COVID-19 resulting in serious illness and/or death and failure to update the care plan with interventions to prevent falls places patients at risk for injury and/or death.


Findings Include:


1. During an interview on 11/20/20 at 7:45 AM, Staff A, CEO stated that a staff member (Staff P, Agency registered nurse (RN), who worked night shift on Tuesday 11/17/20 to Wednesday morning on 11/18/20, tested positive for COVID-19. He indicated that Staff P is asymptomatic.

Review of Patient 1's medical record showed an involuntary admission on 11/03/20. Patient 1 had a negative COVID-19 test prior to admission to the hospital. The facility tested Patient 1 for COVID-19 on 11/20/20 after exposure to Staff P (17 days after admission). Patient 1's test was positive for COVID-19 on 11/20/20.

Review of Patient 3's medical record showed an involuntary admission on 11/12/20. Patient 3 had a negative COVID-19 test prior to admission to the hospital. The facility tested Patient 3 for COVID-19 on 11/20/20 after exposure to Staff P (8 days after admission). Patient 3's test was positive for COVID-19 on 11/20/20.


2. Review of the "Freedom Behavioral Hospital COVID 19 Pan Flu Plan" updated 09/07/20, showed, Freedom Behavioral Health will make every effort to maintain a distance of at least 6 ft in accordance to social distancing requirements.

Observation on 11/17/20 at 2:45 PM in the activity room showed Patient 1, 3, and 4 and Staff F, SW, present sitting around a table within three feet of each other, watching television. None of the patients wore face masks. No hand sanitizer or cleaning supplies were available in the room.

Observation on 11/18/20 at 3:20 PM, showed Patient 1 and Patient 3, in the group room with Staff O, Activities Coordinator. It was snack time and both patients were eating a Rice Krispy snack. Patient 1 and Patient 3 were not socially distanced but sitting close together at the end of the table. There was no attempt by Staff O, to ensure that the patients were at least six feet apart even though there were other seats available at the table.

Observation on 11/20/20 at 10:00 AM, showed Staff D, DON and Staff T, RN, in the nurse's station wearing cloth face masks and within three feet of each other, not maintaining social distancing.

The hospital failed to ensure patients wore masks when around other patients or staff and failed to maintain social distancing.


3. Review of the hospital policy titled "Hand Hygiene - CDC [Centers for Disease Control and Prevention], effective September 2016 and revised November 2016, showed ". . . All staff will use the hand-hygiene techniques ". . . before each patient encounter . . . after coming in contact with patient's intact skin . . . after working on a contaminated body site and then moving to a clean body site on the same patient . . . always after removing gloves or facemask. . ."

Observation on 11/17/20 at 11:07 AM showed Staff U, Agency RN, administering medications to Patient 4. Staff U, used gloved hands to remove a medicated patch from Patient 4's right shoulder, she reapplied a new patch to his left shoulder, then she administered oral medications from a plastic medication cup to Patient 4 with the same gloved hands. She then returned to the medication room and opened the medication room door without removing her contaminated gloves or performing hand hygiene contaminating the door handle.

Observation from 11:07 AM to 11:25 AM showed Staff U, RN, frequently maneuvering her face mask with her contaminated gloved hands throughout Patient 4's medication administration. Several times during the observation, Staff U, had her nose exposed from her face mask.

During an interview on 11/17/20 at 11:25 AM, Staff U, Agency RN acknowledged that the observations made during the medication administration for Patient 4 were breaches in infection control practice.

Observation on 11/18/20 at 8:33 AM showed Staff M, Licensed Practical Nurse (LPN) arrived at the door of the nursing station wearing a glove on one hand while holding a cup of water. She removed the glove and opened the nursing station door without performing hand hygiene.

During an interview on 11/18/20 at 8:35 AM, Staff M LPN, stated that when she was observed at the nursing station door on 11/18/20 at 8:33 AM, she had come from a patient's room after having administered medications. She stated she should have performed hand hygiene after removing her gloves and prior to touching the nursing station door.

Observation on 11/18/20 at 9:00 AM showed Staff M LPN, administering medications to Patient 2. Staff M, LPN administered medications to Patient 2 with gloved hands. She then removed a medication patch from Patient 2's shoulder and attached a new patch with her gloved hands. Staff M, LPN then wrote on the medication administration record with her pen while wearing contaminated gloves.

During an interview on 11/18/20 at 9:09 AM, Staff M LPN stated she was supposed to remove her gloves and perform hand hygiene before documenting, and she didn't know why she didn't do that.

Observation on 11/19/20 At 11:57 AM showed an unidentified staff directing patients to the dining room for lunch. She wrote notes in a notebook with gloved hands. She then handed cups to patients lined up at the ice/water dispenser without removing her gloves and performing hand hygiene. Staff A, CEO told the unidentified staff that gloves need to be worn when dispensing ice/water into the cups. So, she took the cups back from the patients, restacked them, and dispensed the ice/water for the patients without changing her gloves or performing hand hygiene. Then, this staff member took dirty paper towels that the patients had dried their hands with and threw them in the trash. She then handled the notebook, a pen, and keys with the same dirty gloves. Lastly, she served meals to the patients without performing hand hygiene or changing gloves. During this time, the staff member did not encourage the patients to socially distance.

Observation on 11/19/20 at 11:57 AM, showed Staff A, CEO wiping a table with a paper towel with a gloved hand and placing the dirty paper towel into a pocket. Staff A then served food to patients without performing hand hygiene or changing gloves.

The hospital failed to ensure staff performed hand hygiene per policy.


4. Review of the CDC, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" Updated Nov. 4, 2020 showed the following:

HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.

When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.

Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Cloth mask: Textile (cloth) covers that are intended for source control. They are not personal protective equipment (PPE) and it is uncertain whether cloth face coverings protect the wearer.

Observation on 11/17/2020 at 11:00 AM and on 11/20/2020 at 9:55 AM, Staff U was wearing a cloth mask.

Observation on 11/17/20 at 11:30 AM showed Staff D, DON kept adjusting her cloth face mask with her hands while in the hallway near the nursing station.

Observation on 11/17/20 at 2:45 PM, showed Staff F, SW in the activity room with Patient 1, 3, and 4, wearing a cloth mask.

Observation on 11/19/20 at 11:05 AM, showed Staff F, SW, in the conference room, wearing a cloth mask.

Observation on 11/19/20 at 10:15 AM, Staff D, DON, in the conference room, wearing a cloth mask.

Observation on 11/19/2020 at 11:57 AM, showed an unidentified staff directing patients to the dining room for lunch wearing a cloth mask.

Observation on 11/20/20 at 10:00 AM showed Staff D, DON and Staff T, RN in the nursing station wearing cloth face masks.

The hospital failed to have the staff wear facemasks per CDC recommendations.



5. Review of a hospital policy titled, "Infection Prevention and Control Plan" and the document "Freedom Behavioral Hospital COVID 19 Pan Flu Plan" updated 09/07/20, showed no evidence that the policy addressed the proper use and wearing of face masks or PPE.

Observation on 11/17/2020 at 11:00 AM, showed Staff U, RN, administering medications to Patient 4. Staff U was wearing a cloth mask over her mouth but under the nose. With gloved hands Staff U, touched the mask several times, and touched her glasses and face. During an interview during this time Staff U stated that she needed to remove the mask for Patient 4 to hear.

Observation on 11/19/20 at 4:20 PM showed Staff B, Health Information Manager's (HIM) cloth face mask continuously falling with her nose exposed, and she continuously touched it to replace it over her nose.

Observation on 11/20/2020 at 9:55 AM, Staff U, RN, was wearing a cloth mask under her nose. When asked about the mask, Staff U pulled the mask up over her nose. The mask was observed to be loose and fall under Staff U's nose several times.

Observation on 11/20/20 at 11:20 AM, showed Staff B, HIM entering the conference room with her nose uncovered and exposed from her face mask.

During an interview on 11/20/20 at 12:05 PM, Staff D, DON, stated staff should wear their face mask covering the nose and mouth.

Observation on 11/20/20 at 4:08 PM, showed Staff Z, Certified Nursing Assistant (CNA) entering the locked nursing unit wearing a yellow isolation gown. Further observation at 4:10 PM, showed Staff Z, CNA getting water from the sink near the conference room which is located outside the locked nursing unit while still wearing a yellow isolation gown.

During an interview on 11/20/20 at 4:10 PM Staff Z, CNA, stated that she had come from the locked nursing unit (where 2 patients had recently been diagnosed with COVID-19) with the same isolation gown that she wore on the nursing unit.

Observation on 11/20/20 at 4:20 PM, showed Staff A, CEO, appeared at the conference room door wearing a yellow isolation gown, mask, face shield, and gloves. Staff A CEO, had come from the locked nursing unit where two patients had recently been diagnosed with COVID-19. During the observation Staff A, CEO, offered no comment when informed that he should not exit the patient care unit wearing the PPE he was wearing around COVID-19 positive patients.

The hospital failed to ensure that staff wore PPE correctly.


6. Review of Patient 11's medical record revealed that the patient was admitted on 10/23/20 with a diagnosis of bipolar disorder mixed with psychosis. The patient was admitted from a medical hospital after regaining consciousness from an unresponsive episode and becoming aggressive and agitated.

The patient had a history of knee replacement, used a wheelchair for mobility and was seen by multiple staff to take self out of the wheelchair and get on the floor. The patient was assessed as a high risk for falls and was placed on falls precautions. The patient was aggressive and cursed at staff.

The Master Treatment Plan (MTP), dated 10/23/20, listed Falls Precautions as a problem due to confusion, poor balance, and poor judgment. There were no interventions listed to assist staff in dealing with Patient 11. Patient 11 had several falls during this hospitalization: 10/24/20, 10/25/20, 10/26/20, and 11/09/20. Review of the MTP revealed that there was no review/modification of the plan after any of the falls. The MTP remained the same as it was on 10/23/20 and did not include interventions.

The nursing staff notified the medical doctor and assessed the patient after each fall and documented that no injuries were noted. However, the patient was sent to the Emergency Department (ED) on 11/07/20 after complaining of back pain and was diagnosed with a closed pelvic fracture and a closed sacral fracture.

The MTP was not reviewed/modified after the ED diagnoses. The documented fall on 11/09/20 was a behavioral issue where the patient did not want to go to group and slid out of the wheelchair onto the shower room floor without injury.

The hospital failed to update Patient 11's plan after any of the four falls documented during his admission. Failure to update the fall care plan led to multiple falls during his admission and the patient being diagnosed with a closed pelvic and sacral fracture.

Based on record reviews, policy review, observation, and interview, the hospital failed to ensure the Director of Nursing (DON) assigned nursing care to qualified staff as evidenced by one agency Registered Nurse (RN) of two agency RNs (Staff U, RN) failinged to have documented evidence of orientation and demonstrated competency evaluated by a hospital-employed RN prior to providing patient care. This failure had the potential to affect the care provided to the current five inpatients and any future patient admitted to the hospital.

Findings Include:

Review of the "Agency Orientation Guidelines" showed "All agency staff that is scheduled to work at the facility will be provided an orientation to the facility prior to working. The first time an agency staff is scheduled to work they will arrive to the unit at least 1.5 [one hour 30 minutes] prior to the shift to complete the hands on orientation with the staff, this is in addition to the pre-training time prior to arriving for the shift. ... . . The DON is responsible for finalizing the orientation process and determining if the agency staff displays an appropriate level of knowledge to work. ... . . Orientation/Competencies: ... ... 3. Skills check list must be completed. 4. Complete the Falls Prevention Program Competency. 5. Complete the 1 to 1 [one-to-one] Observation orientation. ... . ."

Observation on 11/17/20 from 11:07 AM to 11:35 AM showed Staff U, Agency RN administered medication to Patient 4.

Observation on 11/20/20 showed Staff U, RN working on the locked unit of the psychiatric hospital.

Review of Staff U, RN's personnel file showed she was contracted on 11/11/20. Review of the "Training & [and] Acknowledgement For:.. . . . Documentation in patient charts," "Nursing Seclusion and Restraint Competency Test," and "Code-Blue Guidelines Competency" showed Staff U RN signed each form on 11/16/20 with no documented evidence of a signature and date for the trainer.

Review of Staff U, RN's "Drug Screen Competency Nursing Department, Clinical Institute Withdrawal Assessment of Alcohol Scale, Braden Scale and Integumentary Competency, Capillary Blood Glucose Competency, Non-Contact Infrared Body Thermometer (CK-t1501) Skills Competency, Pulse Oximetry Competency, Oral Nasal Suctioning Competency, Administering Oxygen By Nasal Cannula Or Mask, AIMS [abnormal involuntary movement scale] Competency, and EKG [electrocardiogram] Competency" showed each competency could be evaluated by "A) Written Test, B) Observation, C) Interview/Oral test, D) Supervised Performance." There was no documented evidence that the evaluation method, the evaluator's initials, whether competent or needs practice, the trainer signature, and date were documented on each competency form. Staff U RN Agency signed each form on 11/16/20.

Review of Staff U, RN's "PPD [purified protein derivative] Mantoux Testing Competency" (used to determine if a patient has tuberculosis) and the "Nebulizer Competency" showed the method of evaluation was by interview/oral test and not observation or supervised performance. Review of "The F.R.E.E.D.O.M Skills Competency" (used to evaluate an approach to the safe management of agitated behaviors) showed Staff U, RN was evaluated by oral understanding rather than by observation of performance.

Review of Staff U, RN "Competency Skills Checklist Position Registered Nurse / Licensed Practical Nurse" showed no documented evidence that following items had been evaluated for competency: initial psychiatric assessment, initial Medicare certification form, long term goals, short term goals, individualized interventions, assessing of effectiveness of interventions, treatment plan updates, multidisciplinary treatment team, first dose documentation, types, uses, and side effects of psychotropic, performance improvement process, nursing policies/procedure book, infection control/employee health policies and procedures, hospital policies and procedures, personnel policies and procedures, nursing assignments/delegation of duties, pain assessment scale and reassessment, limit setting/consistency, therapeutic milieu, and professional boundaries. Hoyer lift, acceptance/documentation of verbal orders, transcription/implementing of orders, adverse medication reaction, narcotic count responsibilities, routes: types, uses, and side effects of, PPD, documentation of medications, PRN [as needed] medications, suicide precautions, and one-to-one protocol. Further review showed the items that were evaluated were done by oral evaluation/supervision, except medication administration which was done by observation.

Review of Staff U, RN 's personnel file showed no documented evidence of falls prevention program competency and one-to-one observation of orientation and competency as required by the "Agency Orientation Guidelines."

During an interview on 11/19/20 at 3:25 PM, Staff C, Human Resources (HR) reviewed the findings listed above with the surveyor. She stated the documented findings above were accurate, and there was no documented evidence that the orientation and competency had been completed for Staff U RN Agency.

Based on observation, document review, policy review, and interview, the hospital failed to evaluate and reduce the number of verbal and telephone orders written for medications and treatments for four of four current patients (Patient 1, Patient 2, Patient 3, and Patient 4) and two of three discharged patients (Patient 7 and Patient 8). Failure by the hospital to evaluate the frequency of verbal and telephone orders received by nursing staff and failure to restrict verbal and telephone orders placed all patients at risk increased medication and treatment errors resulting in delayed and failed treatment and risk of adverse reactions.

Findings Include:

Review of a hospital policy titled "Decreasing Medication Errors" revised 11/2016 showed all verbal orders will include the read-back verification process. The policy does not limit the frequency of verbal and telephone medication orders.

Review of the physician schedule showed Staff I, Psychiatrist is located out of state and communicates by telephone and conducts weekly team meetings and patient assessments by telemedicine. Staff H, Medical Doctor is scheduled to be physically present in the hospital to perform admission assessments. Staff G, Advanced Practice Registered Nurse (APRN) is scheduled for hospital rounds every Tuesday, Wednesday, and Friday.


Review of Patient 1's medical record showed an involuntary admission on 11/03/20 with diagnosis of bipolar disorder (mental disorder with periods of depression or abnormally elevated mood), major depressive disorder (MDD), insomnia (inability to sleep), and previous psychiatric history. His medical diagnosis included Parkinson's (degenerative neurological disorder), unsteady gait, dysphagia (difficulty swallowing), hypothyroidism (low thyroid hormone level), and hypertension (elevated blood pressure).

Review of the admission orders, showed the orders as telephone orders, and included a mechanical soft diet, vital signs twice daily (BID), observation every 15 minutes, recreational activity, and lab work, urinalysis, electrocardiogram (EKG), and continuation of home medications. The ordering physician failed to sign the admission orders.

Further review of physician orders showed telephone or verbal orders were taken by nursing staff on 11/04/20 for Tylenol 325mg, two as needed (prn) every eight hours for elevated temperature and lab test, and 11/05/20 for Zyprexa 10 mg at bedtime (HS).

The physician failed to sign the telephone/verbal orders.


Review of Patient 2's medical record, showed an involuntary admission 11/07/20, with diagnosis of major depressive disorder (MDD), paranoid psychosis, anxiety disorder, and obsessive/compulsive disorder (OCD). His medical diagnosis included anemia, hypertension, and functional bowel disorder.

Review of the admission orders, showed the orders as telephone orders, that included vital signs twice daily (BID), regular diet, fall precautions, observation every 15 minutes, and recreational/activity therapy. The ordering physician failed to sign the admission orders.

Further review of physician orders showed telephone or verbal orders were taken by nursing staff on 11/08/20, 11/09/20, 11/13/20, 11/14/20 three times and 11/16/20.

The ordering physician failed to sign the telephone/verbal orders.



Review of Patient 3's medical record showed an involuntary admission on 11/12/20, with a diagnosis of paranoid schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior) and a history of delusions, anxiety, and depression. Her medical diagnosis included hypertension (elevated blood pressure) and a current urinary tract infection (UTI).

Review of the admission orders, showed the orders as telephone orders, that included vital signs twice daily (BID), weight at admission and weekly, regular diet, fall precautions, observation every 15 minutes, and recreational leisure, social activity, and education groups, and supportive group psychotherapy. The ordering physician failed to sign the admission orders.

Further review of physician orders showed telephone or verbal orders were taken by nursing staff on 11/12/20, Cephalexin, (antibiotic to treat the UTI), 11/14/20 for Norvasc (medication to treat high blood pressure) and twice on 11/19/20 for change in Zyprexa (a medication to treat psychosis) orders.

The ordering physician failed to sign the telephone/verbal orders.


Review of Patient 4's medical record showed a voluntary admission on 11/11/20, with diagnoses of schizoaffective disorder (mental disorder characterized by abnormal thought process and unstable mood), bipolar type (mental disorder with periods of depression or abnormally elevated mood) and psychotic (inability to determine what is real) disorder due to another medical condition with delusions. Medical history reveals a history of chronic depression, anxiety and dementia (chronic or persistent disorder of the mental process marked by memory disorders, personality changes, and alteration in reasoning). His medical diagnoses include Huntington's disease (neurodegenerative disorder of the central nervous system characterized by unwanted movements, behavioral, and psychiatric disturbances and dementia), coronary artery disease (damage or disease to major blood vessels) (CAD), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). The patient presented with increased tremors. His durable power of attorney (DPOA) requested the admission after Patient 4 exhibited increased agitation and physical aggression toward his wife.

Review of the admission orders, showed the orders as telephone orders, that included oxygen saturation every four hours, BID vital signs, regular diet, fall precautions, observations every 15 minutes, therapeutic recreational leisure/ social activity and education groups, individual therapy, supportive group psychotherapy, and activity educational group. The ordering physician failed to sign the admission orders.

Further review of physician orders noted nursing staff accepted physician telephone or verbal orders on 11/11/20, 11/12/20, 11/15/20, 11/16/20, and 11/18/20.

The ordering physician failed to sign any of the telephone/verbal orders.


Review of Patient 7's discharged medical record showed 18 of 63 (29%) of the physician's orders were telephone/verbal orders.

Review of Patient 8's discharged medical record showed four of seven (58%) of the physician's orders were telephone/verbal orders.


During an interview on 11/18/20 at 1:30 PM Staff M, Licensed Practical Nurse (LPN) stated she began employment 10/27/20 and currently has been responsible for medication administration. She stated medication orders from Staff I, Psychiatric MD and Staff H, MD are most frequently oral or telephone orders, however the APRN's generally write their own orders.

During an interview on 11/18/20 at 3:00 PM Staff D, Director of Nursing (DON) stated she was aware orders are most often either telephone or verbal orders and the policy is to read the orders back for verification.

Based on observation, document review, and interview, the hospital failed to provide pharmaceutical services that meets the needs of the hospital as evidenced by the nursing staff performing medication overrides from the Automated Dispensing Machine (ADM) 361 times between 07/01/20 and 11/16/20, resulting in medication errors. Failure to provide sufficient pharmaceutical services placed all patients at risk of heightened medication administration with adverse reactions and delayed treatment.

Findings Include:

Document review of the policy titled "Automated Dispensing Cabinets-General", revised 11/2016, showed, Nursing Services and Pharmacy Department staff will follow the policies and procedures for the automated dispensing machine(s) (ADM) to ensure the safe and accurate dispensing of medications, accountability of controlled substances and other medications, accurate patient billing, patient confidentiality, medication security and to ensure compliance with state and federal rules and regulations...

Review of a document titled, "Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes," showed, the override function allows a nurse to remove a medication from the machine before a pharmacist reviews the order. The purpose of the override function is to allow access to medications in urgent/emergent situations... ...Administering medications prior to a pharmacist review increases the risk of medication errors.

During an interview on 11/19/20 at 1:40 PM Staff V, Corporate Pharmacist stated his company has contracted with the hospital for four years to provide remote pharmacy services including medication order reconciliation and approving medications for nursing administration. He stated the remote pharmacist is available 8:00 AM to 6:00 PM and 7:00 PM to 10:00 PM, 9:00 AM to 6:00 PM weekends and holidays and a pharmacist is on call after hours.

The procedure for processing medication orders starts when the nurse faxes via dedicated phone line the order to the pharmacy. He stated once the order is received it takes anywhere from 11 to 20 minutes for pharmacy review and order entry into the automated dispensing machine (ADM) so the nurse can administer the medication without performing an override. He further stated a menu screen on the computer will alert the hospital staff the order was received and in process. He agreed that nursing should not be allowed to "dispense" medications from the ADM by using the override ability prior to pharmacy review completion. He further stated the process of medication overrides is "discouraged" and it should only be used in the case of medications needed immediately for uncontrolled patient behaviors. He clarified medical medications such as diabetic medications and anti-hypertensive are not considered an emergency and should not be taken from the ADM until the authorization is completed by the pharmacist. He considered that to be a "communication issue" between the pharmacy and nursing. He further stated the overrides are reviewed by pharmacy weekly and acknowledged there continues to be a high incidence and a solution to resolve it has not been found.


A. Review of an untitled medication error report with dates of 04/22/20 through 10/22/20, showed 23 medication errors effecting 11 patients. Eleven of the 23 medication errors were related to overrides. Six of the 11 patients listed on the medication error report were affected by override medication errors.


1. One patient was given Risperdal (a medication used to treat psychosis), Depakote (a medication used to treat psychosis) and an Exelon Patch (a medication used to treat memory loss) on 07/21/20 without orders.

2. One patient was given two unspecified medications on 08/10/20 at the wrong time.

3. One patient was given an antibiotic on 09/09/20 after it had been discontinued.

4. One patient was given Flomax (a medication used to treat urinary retention) at the wrong frequency on 09/11/20.

5. One patient was given the improper dose of Metformin (a medication to lower blood sugar levels), once on 09/30/20 and twice on 10/01/20.

6. One patient was given the improper dose of Bupropion (a medication used to treat depression) on 10/22/20.



B 1. Review of the medication overrides for 07/01/20 through 07/31/20 revealed a total of 60 medication overrides by nursing staff and of the 60 overrides, six occurred outside the normal pharmacy hours and six of the medication overrides could impact patient behaviors requiring immediate administration resulting in increased patient and staff safety.

B 2. Review of the medication overrides for 08/01/20 through 08/31/20 revealed a total of 91 medication overrides by nursing staff and of the 91 overrides, 20 occurred outside the normal pharmacy hours and 21 of the medication overrides could impact patient behaviors requiring immediate administration resulting in increased patient and staff safety.

B 3. Review of the medication overrides for 09/01/20 through 09/30/20 revealed a total of 95 medication overrides by nursing staff and of the 95 overrides, 21 occurred outside the normal pharmacy hours and 15 could impact patient behaviors requiring immediate administration resulting in increased patient and staff safety.

B 4. Review of the medication overrides for 10/01/20 through 10/30/20 revealed a total of 81 medication overrides by nursing staff and of the 81 overrides, 11 occurred outside the normal pharmacy hours and 27 could impact patient behaviors requiring immediate administration resulting in increased patient and staff safety.


During an interview on 11/18/20 at 1:30 PM Staff M, Licensed Practical Nurse (LPN) stated when new medication orders are obtained, the order is stamped, dated and faxed to the remote pharmacy using the dedicated fax machine. The remote pharmacy is responsible for reviewing the medication orders and entering them into the medication dispensing machine (ADM). Once entered the machine, the medication can be removed by the nursing staff for administration. She stated there is a way to override the machine to administer medications that have not been reviewed and approved by pharmacy, however she stated she has never overridden the machine and does not know what the process is.

Based on observation, policy review and interview, the hospital failed to ensure an individual, who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program. Failure to have a qualified infection control preventionist has the potential to place patients at risk for the spread of infectious diseases resulting in serious illness and/or death.

Findings Include:

Review of the hospitals "Infection Prevention and Control Plan" showed the ultimate goal is to prevent the spread of pathogens (bacteria, virus or other organisms that cause disease) ...

...The infection control officer (ICO) is responsible for the development, implementation and enforcement of policies and procedures related to Infection Prevention and Control and updating as needed. The ICO and all hospital personnel are responsible for being familiar and complying with the Infection Prevention and Control Plan and all associated policies. The infection control officer is responsible for the surveillance, data gathering, aggregation and analysis of all infection prevention and control data.

Review of the hospital's 2020 organizational chart, showed the DON also functioned as the hospital's infection control officer.

Review of the Governing Body board meeting minutes from 05/08/20 through 10/30/20 lacked evidence of the appointment of an ICO, although there were six Directors of Nursing (DON) during this same period of time.

Review of Staff D, Registered Nurse (RN), Director of Nursing's (DON) personnel file lacked any evidence that she had any training, experience or education in infection control and prevention. Staff D does not have the qualifications needed to be the hospital's infection control officer (ICO).

During an interview on 11/19/20 at 10:15 AM, Staff D, DON stated that she has not had any work experience or training related to infection control. She stated that she was informed of "COVID stuff" when she was hired. She stated that she has not seen the DON job description and was not fully aware of the ICO duties.

During an interview on 11/18/20 at 4:50 PM, Staff A, Chief Executive Officer (CEO) stated that they do not have a job description for the ICO and that it was incorporated in the DON and the Assistant DON (ADON) job descriptions.

Review of the DON and ADON job descriptions lacked evidence of the ICO job responsibilities.

The hospital failed to appoint a qualified ICO to implement and enforce policies and procedures related to prevention of the transmission of COVID-19 or to conduct any audits, surveillance and data gathering related to infection prevention.

Based on document review and interview, the hospital failed to ensure a system was in place to track all infection surveillance, prevention and antibiotic use. Failure of the hospital to ensure systems are in place to monitor infections inhibits the hospital's ability to implement a successful infection prevention program placing patients at risk for contracting hospital acquired infection.

Findings Include:

Review of the hospitals "Infection Prevention and Control Plan" showed the ultimate goal is to prevent the spread of pathogens (bacteria, virus or other organisms that cause disease)...

During an interview on 11/20/20 at 3:40 PM, Staff A, CEO, stated that two of the five current patients (Patient 1 and Patient 3) tested positive for COVID-19.

Review of Patient 1's medical record showed an involuntary admission on 11/03/20. Patient 1 had a negative COVID-19 test prior to admission to the hospital. The facility tested Patient 1 for COVID-19 on 11/20/20 after exposure to Staff P (17 days after admission). Patient 1's test was positive for COVID-19 on 11/20/20.

Review of Patient 3's medical record showed an involuntary admission on 11/12/20. Patient 3 had a negative COVID-19 test prior to admission to the hospital. The facility tested Patient 3 for COVID-19 on 11/20/20 after exposure to Staff P (8 days after admission). Patient 3's test was positive for COVID-19 on 11/20/20.

Review of a document titled, "Antimicrobial Stewardship Log" provided by Staff A, CEO, showed the log identified two patients that had urinary tract infections in July 2020. The log failed to show any other surveillance activities since July 2020. The log failed to show any surveillance activities to prevent the spread of pathogens including COVID-19, and failed to show monitoring of fever, respiratory illness, or any other signs and symptom of COVID-19 for any of the current or past patients.

The hospital failed to provide any evidence of a system to monitor and track infection surveillance, infection prevention and antibiotic use.

Based on observation, document review, policy review and interview, the hospital failed to ensure a qualified infection control officer (ICO) (past or present) audited the adherence of infection prevention and control policies and procedures by hospital staff to prevent and control the spread of hospital acquired infections (HAIs). This deficient practice places patients at risk for the spread of hospital acquired infectious diseases resulting in serious illness and/or death.

Findings Include:

Review of the hospitals "Infection Prevention and Control Plan" showed the ultimate goal is to prevent the spread of pathogens (bacteria, virus or other organisms that cause disease) ...

...The infection control officer (ICO) is responsible for the development, implementation and enforcement of policies and procedures related to Infection Prevention and Control and updating as needed. The ICO and all hospital personnel are responsible for being familiar and complying with the Infection Prevention and Control Plan and all associated policies. The infection control officer is responsible for the surveillance, data gathering, aggregation and analysis of all infection prevention and control data.

During an interview on 11/20/20 at 7:45 AM, Staff A, CEO stated that a staff member (Staff P, Agency registered nurse (RN), who worked night shift on Tuesday 11/17/20 to Wednesday morning on 11/18/20, tested positive for COVID-19. He indicated that Staff P is asymptomatic. He stated that five staff who worked with the positive staff member had been placed on quarantine.

During an interview on 11/20/20 at 3:40 PM, Staff A, CEO, stated that two of the five current patients (Patient 1 and Patient 3) tested positive for COVID-19. Staff A stated that no other staff had been tested for COVID-19 at this time.


Review of Patient 1's medical record showed an involuntary admission on 11/03/20. Patient 1 had a negative COVID-19 test prior to admission to the hospital. The facility tested Patient 1 for COVID-19 on 11/20/20 after exposure to Staff P (17 days after admission). Patient 1's test was positive for COVID-19 on 11/20/20. Due to the length of Patient 1's admission, it is likely that Patient 1's COVID-19 infection came from exposure to a hospital Staff member or from another patient.


Review of Patient 3's medical record showed an involuntary admission on 11/12/20. Patient 3 had a negative COVD-19 test prior to admission to the hospital. The facility tested Patient 3 for COVID-19 on 11/20/20 after exposure to Staff P (8 days after admission). Patient 3's test was positive for COVID-19 on 11/20/20. Due to the length of Patient 3's admission, it is likely that Patient 3's COVID-19 infection came from exposure to a hospital Staff member or from another patient.

The hospital failed to provide surveillance or audits of hospital staff for the adherence to infection control policies and procedures. When asked for an infection control surveillance reports for the last six months, the CEO provided a document titled, "Antimicrobial Stewardship Log." The log identified 2 patients that had urinary tract infections in July 2020.

During an interview on 11/19/20 at 10:15 AM, Staff D, Registered Nurse (RN), Director of Nursing (DON) stated that she has not had any work experience or training related to infection control. She stated that she was informed of "COVID stuff" when she was hired. She stated that she has not seen the DON job description and was not fully aware of the ICO duties.

Review of Staff D's personnel file lacked any evidence that she had any training, experience or education in infection control and prevention. Staff D does not have the qualifications needed to be the hospital's infection control officer (ICO).


During an interview on 11/18/20 at 4:50 PM, Staff A, Chief Executive Officer (CEO) stated that they do not have a job description for the ICO and that it was incorporated in the DON and the Assistant DON job descriptions.

Review of the DON and ADON job descriptions lacked evidence of the ICO job responsibilities.


The hospital failed to appoint a qualified ICO to implement and enforce policies and procedures related to prevention of the transmission of COVID-19 or to conduct any audits, surveillance and data gathering related to infection prevention.

Based on medical record review, policy review, and interview, the hospital failed to provide Multidisciplinary Treatment Plans (MTPs) that contained patient-related short-term goals (STGs) and long-term goals (LTGs) stated in observable, measurable, behavioral terms for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for MTPs, from a total sample of 19 patients. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to increase patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

Review of the hospital policy, titled, "Plan of Care-Protocol for Development [sic] of the Multidisciplinary Treatment Plan from the Multidisciplinary Integrated [sic] Assessment (MIA)," revised 1/24/17, stated that the multidisciplinary plan of care format includes, "Long Term and short term goals that reflect measurable desired behavior changes ..."


1. Review of the Medical Record (MR) for Patient 1 showed the MTP, found under the Treatment Plan tab, dated 11/04/20, listed for the problem, "Alteration of thought processes," with the non-measurable LTG goal, "Pt [patient] will have a decrease in delusions."

2. Review of the MR for Patient 2 showed the MTP, found under the Treatment Plan tab, dated, 11/09/20, listed for the problem, "Disturbance of thought process," with the non-measurable, non-observable STG, "Realize not everyone is ill, or contagious by 5 days."

3. Review of the MR for Patient 3 showed the MTP, found under the Treatment Plan tab, dated 11/13/20, listed for the problem, "Disturbance of thought processes," with the non-measurable, non-behavioral STG, "Pt will have decreased suspicion of staff in 1-3 days."

4. Review of the MR for Patient 4 showed the MTP, found under the Treatment Plan tab, dated 11/13/20, listed for the problem, "Disturbance of thought processes," with the non-measurable STG, "Decrease in delusional thoughts by 7 days."


During an interview on 11/19/20 at 10:00 AM, Staff D, Director of Nursing (DON), agreed that the shared STGs and LTGs were not measurable, observable, or behavioral for Patient 1, Patient 2, Patient 3, and Patient 4.

Based on medical record review, policy review, and interview, the hospital failed to develop treatment interventions based on the individual needs of patients for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for MTPs, from a total sample of 19 patients. Treatment interventions in the Master Treatment Plan (MTP) listed only routine/generic discipline functions rather than individualized treatment options or failed to include interventions for the identified goals. This practice has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:


The hospital policy, titled, "Plan of Care-Protocol for Development [sic] of the Multidisciplinary Treatment Plan from the Multidisciplinary Integrated [sic] Assessment (MIA)," revised 01/24/17, stated that the multidisciplinary plan of care format would contain "Treatment interventions that are specific to meeting the short term and long term goals."


1. Patient 1's MTP, found under the Treatment Plan tab, dated 11/04/20, listed the short-term goal (STG), "Practice and learn at least two new coping skills a day to reduce urges for agitation and symptoms of psychosis."

There were no physician interventions for this goal. The generic nursing interventions for this goal were, "Pt (Patient) to attend groups and follow participation and schedule," and "Pt to display med (medication) compliance during this admission."

The preprinted "Focus" section of the MTP showed that the generic nursing modality "Administration/Monitoring of Medications As Ordered" had been circled to indicate that this was a nursing intervention.

The generic Clinical Care Services (Social Work) intervention was, "Attend and participate in at least 75% of groups and individual therapy."

2. Patient 2's MTP, found under the Treatment Plan tab, dated 11/09/20, listed the STG, "Realize not everyone is ill, or contagious by 5 [five] days." There were no nursing interventions listed for this goal.

The physician interventions listed the unrelated interventions, "observations/precaution levels."

The generic Clinical Care Services (Social Work) intervention was, "Attend and participate in at least 75% of groups and therapy."

3. Patient 3's MTP, dated 11/13/20, found under the Treatment Plan tab, listed the STG, "Pt will have decreased suspicion of staff in 1-3 days." There were no physician or nursing interventions listed for this goal.

4. Patient 4's MTP, found under the Treatment Plan tab, dated 11/13/20, listed the STG, "Decrease in delusional thoughts by 7 [seven] days." There were no interventions listed for any disciplines for this goal.


During an interview on 11/19/20 at 10:00 AM, Staff D, Director of Nursing (DON), agreed that the shared interventions were either absent or generic interventions that would be provided to all patients.

Based on record review, document review, observation, and interview, the hospital failed to provide active therapeutic treatment for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for active treatment, from a total sample of 19 patients. Except for one psychotherapy group led by the social worker and one nursing group led by a Licensed Practical Nurse (LPN), the remainder of the daily groups were led by activity staff and consisted of only leisure activities.

In addition, Patient 2 rarely attended groups but instead stayed in bed. There were no alternative therapeutic activities provided for Patient 2 and the Master Treatment Plan (MTP) failed to address the patient's non-attendance. 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:

Review of the "Documentation: Clinical Services" sheets (group attendance) showed that all four patients (Patient 1, Patient 2, Patient 3, and Patient 4) were assigned to the same groups. Review of the sheets from 11/10/20-11/16/20 showed the following activity groups were offered to all patients:

11/10/20- 9:00 AM-10:00 AM listening to music/snacks; 10:00 AM-11:00 AM watching TV and cartoons; 2:00 PM-3:00 PM board games, cards.

11/11/20- 9:00 AM-10:00 AM hangman/coping skills; 11:00 AM-12:00 noon walk the halls; 2:00 PM-3:00 PM movie time.

11/12/20- 9:00 AM-10:00 AM coping skills activities; 11:00 AM-12:00 noon walk the halls; 2:00 PM-3:00 PM movie.

11/13/20- 9:00 AM- 10:00 AM music/snacks; 2:00 PM-3:00 PM listen to music.

11/14/20- 9:00 AM-10:00 AM music/snacks; 10:00 AM-11:30 AM music video and scrabble; 2:00 PM-3:00 PM music video and jigsaw puzzle; 8:00 PM-8:45 PM Planet Earth video.

11/15/20- 9:00 AM- 10:00 AM earth documentary; 10:00 AM-11:00 AM church service, documentary video; 2:00 PM-3:00 PM music video, jigsaw puzzle;8:00 PM-8:45 PM watch video.

11/16/20- 9:00 AM-10:00 AM no group due to short staff; 11:00 AM- 12:00 noon movie time; 2:00 PM-3:00 PM-music and games.

Review of the Patient Activity Schedule showed that one psychotherapy group per day (Monday-Friday-facilitated by Staff F, Director of Social Services), was scheduled for the patients on the unit. There was no evidence on the "Documentation: Clinical Services" sheets that the psychotherapy group was held on 11/09/20, 11/10/20, 11/12/20 or 11/18/20. The schedule also listed two Licensed Practical Nurse (LPN) groups a day with one being scheduled at 3:00 PM and one at 8:00 PM. There was no evidence on the "Documentation: Clinical Services" sheets that the 3:00 PM nursing group was held from 11/10/20-11/16/20. The remaining scheduled groups were assigned to the activity staff. The groups were identified only as "activity group" on the schedule and did not indicate the content or focus of the groups.

Review of the Medical Record (MR) for Patient 2 found the MTP under the Treatment Plan tab, dated 11/04/20, listed the nursing interventions "Pt [Patient] to attend groups and follow participation and schedule." The Clinical Care Services intervention was, "Attend and participate in at least 75% of group and individual therapy."

Patient 2 was scheduled for 28 groups from 11/12/20 to 11/18/20. Review of the "Documentation: Clinical Services" sheets (group attendance) showed that Patient 2 did attend five of the 28 groups (18%) and partially attended two other groups. In addition, Patient 2 refused four of the four 1:1 therapy sessions with Staff F, Director of Social Services on 11/11/20, 11/13/20, 11/16/20, and 11/17/20.

Although the physician progress notes for Patient 2 on 11/14/20 and 11/17/20 addressed the patient's lack of group participation, the MTP did not address the lack of group participation and there were no alternative therapeutic activities assigned.

Observations related to Patient 2 included the following:

1. Observation on the unit on 11/17/20 at 1:15 PM, showed that Patient 2 was in bed. An activity group was being held in the group room.

2. Observation on the unit on 11/17/20 at 2:15 PM, showed that Patient 2 was in bed. An activity group was being held in the group room.

3. Observation on the unit on 11/17/20 at 3:20 PM, showed that Patient 2 was in bed. Snacks were being provided in the group room.

4. Observation on the unit on 11/18/20 at 9:30 AM, showed that Patient 2 was in bed. An activity group was being held in the group room.

5. Observation on the unit on 11/18/20 at 10:05 AM, showed that Patient 2 was in bed. An activity group was being held in the group room.

6. Observation on the unit on 11/18/20 from 1:10 PM-3:00 PM showed that Patient 2 was in bed. Although an activities group was scheduled for 1:00 PM and 2:00 PM, neither group was held.

7. Observation on the unit on 11/18/20 at 3:15 PM, showed that Patient 2 was in bed. A nursing group was being held in the group room.

During an interview on 11/17/20 at 1:40 PM, Staff D, Director of Nursing (DON), when asked about Patient 2, who was in bed instead of in group, stated that they encouraged patients to go to group but they didn't lock the doors (to keep them out of bed).

During an interview on 11/17/20 at 3:20 PM, Staff N, Activities Coordinator (AC) stated that Patient 2 had not been attending groups for a few days.

During an interview on 11/18/20 at 10:35 AM, Staff O, Activities Coordinator stated that one day Patient 2 would come to group and the next day he would not.

Based on record review and interview, the hospital failed to ensure consistent availability and provision of individualized therapeutic activities and rehabilitative services based on patient needs for 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed to ensure that active treatment was being provided, from a total sample of 19 patients. The Master Treatment Plans (MTP's) did not list specific groups that had been assigned to individual patients according to their needs and all activity groups were identified as "Activity Group" with no identification of the focus.

In addition, the focus of some groups was planned after the patients were in attendance and were at times canceled due to lack of staff or other work assignments. This lack of consistency and focus fails to provide patients with needed therapeutic interactions to deal with problems that made hospitalization necessary and can negatively impact placement and prolong discharge.

Findings Include:

1. Review of the Medical Record (MR) for Patient 1 showed the MTP, found under to Treatment Plan tab, dated 11/04/20, had listed as an intervention, "Attend and participate in at least 75% of group and individual therapy." There was no mention of specific groups.

2. Review of the MR for Patient 2 showed the MTP, found under to Treatment Plan tab, dated 11/09/20, had listed as an intervention, "Attend and participate in at least 75% of groups and therapy." There was no mention of specific groups.

3. Review of the MR for Patient 3 showed the MTP, found under to Treatment Plan tab, dated 11/13/20, had listed as an intervention, "Pt[Patient] will attend and participate in at least 75% of groups and therapy to work towards TX [treatment] goals, improve [unreadable word] and decrease [unreadable word] symptoms." There was no mention of specific groups.

4. Review of the MR for Patient 4 showed the MTP, found under to Treatment Plan tab, dated 11/13/20, had no interventions listed pertaining to groups or anything else.

During an interview on 11/17/20 at 1:15 PM, Staff N, Activity Coordinator (AC) stated that she let the patients decide what to watch on television for the group, although the group was scheduled as a "Walk It Program."

During an interview on 11/17/20 at 3:05 PM, Staff D, Director of Nursing (DON), when asked who would be running the 3:00 PM "Nursing Group," stated that LPN's ran that group. When surveyor reminded her that an LPN was not working that day, Staff D, DON stated, "We'll have to figure out what to do."

During an interview on 11/17/20 at 3:20 PM, Staff N, AC was in the group room with Patient 1 and Patient 3 who were eating snacks. Staff N, AC stated that she was running behind and just got to giving out the snacks. When asked about the Nursing Group, she responded that they had to do something to occupy the patients' time when the LPN wasn't there. The patients left the group room at 3:30 PM.

During an interview on 11/18/20 at 1:30 PM, Staff D, DON, when asked about the scheduled 1:00 PM "Walk It Program," stated that she had never seen that group being held.

During an interview on 11/19/20 at 10:00 AM, Staff D, DON stated that she "stayed out" of the groups and the group schedule and did not get involved unless she had to.

During an interview on 11/19/20 at 11:00 AM, Staff F, Director of Social Services, stated that although she supervised the Activity Coordinators (Staff N, AC and Staff O, AC) she did not observe their groups.

Based on document review, observation, and interview, the hospital failed to provide professional therapeutic staff who were qualified to provide structured therapeutic activities to meet the needs of each patient. Failure to have qualified activity staff who have knowledge and education on how to plan activity programs for acute psychiatric patients, results in a lack of structured therapeutic groups/activities designed to assist the patient in meeting goals which can delay the patients' recovery and potentially extend their hospital stay.

Findings Include:

Review of the Activity Coordinator /Recreational Coordinator Job Description stated, "The Activity Therapist [sic] participates as a member of the treatment team; formulating goals and interventions based off the identified needs of the patients' condition and recommends appropriate recreational activity."

The activity staff consisted of Staff N and Staff O, both listed as Activity Coordinators (AC) on the hospital's organizational chart. Staff N, AC and Staff O, AC were the only activity therapy staff employed.

Review of Staff N's, AC personnel record revealed that she had been employed at the hospital as a Mental Health Technician (MHT) for two months. There was no documented evidence of an application, job description, or history of experience/education in activity therapy.

Review of Staff O's, AC personnel record revealed that he had been employed at the hospital as a MHT for seven months. The record contained a Certificate of Completion from "We Care Online" that acknowledged Staff O had completed 45 hours of study for "Activity Director." The certificate was for providing activities for long-term care patients, not acute psychiatric patients, and had been earned when Staff O was a CNA at a nursing home, prior to hospital employment.

Review of the Patient Activity Schedule showed that only one Psychotherapy Group per day (facilitated by Staff F, Director of Social Services), was scheduled for the patients on the unit. The schedule also listed two Licensed Practical Nurse (LPN) groups a day with the remainder of scheduled groups (six groups) assigned to the activity staff. The groups were identified only as "activity group" on the schedule and did not indicate the content or focus of the groups.

During an interview on 11/17/20 at 1:15 PM, Staff N, AC, when asked about her role stated, "We keep them busy to keep their minds off their problems." She further added that she does that with movies, board games, and puzzles.

During an interview on 11/18/20 at 2:40 PM, Staff O, AC, stated that he was the Activity Director. The surveyor asked if he was an OT (Occupational Therapist) or RT (Recreational Therapist and he responded, "I don't even know what that means." Staff O, AC shared that he had a certificate that he got while working at the nursing home and he was the Activity Director there. When asked what he did as the Activity Director at the nursing home, he stated that he took the residents out to eat, shopping, and provided movie nights with popcorn. When asked about Staff N, Activity Coordinator, Staff O stated that she did not have a certificate, but they had the same job duties only on different days.

During an interview on 11/19/20 at 11:00 AM, Staff F, Director of Social Services, stated that she supervised both Activity Coordinators. She acknowledged that she did not have a background or knowledge of activity therapy but had been told by the CEO that Staff O's certificate qualified him to do the activity groups. She stated that although she supervised both Staff N, AC and Staff O, AC, she had not sat in on their groups.

Based on record review and interview, the hospital failed to develop and document a Multidisciplinary Treatment Plan (MTP) based on the individual needs of 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed for Psychiatric Evaluations and MTPs, from a total sample of 19 patients.

Specifically, each patient had the same two problems identified on their MTPs along with unmeasurable goals that did not address the patients' reasons for admission and an absence of interventions to meet the goals. Failure to individualize the patients' MTPs leads to needs not being identified and addressed which can delay the patients' recovery and extend the length of hospitalization.

Findings Include:

1. Medical Record review of Patient 1's Psychiatric Evaluation, found under the Assessment tab, dated 11/05/20 showed that involuntary admission was necessary due to Patient 1 trying to find knives in the nursing home to harm peers, staff, and self.

The MTP, dated 11/04/20, identified the problems needing to be addressed as, "Alteration of thought processes," and "Fall Precautions." Although there was no indication that Patient 1 had been physically aggressive in the nursing home, the non-measurable short-term goal was listed as, "Pt [Patient] is to be free of aggressive behaviors in 5 days."

2. Medical Record review of Patient 2's Psychiatric Evaluation, found under the Assessment tab, dated 11/09/20, showed that the patient was admitted due to delusional thoughts (false, fixed beliefs that cannot be contradicted by reality) and paranoid thinking (irrational distrust or suspicion of others).

The MTP, dated 11/09/20, identified the problems needing to be addressed as, "Disturbance of thought process," and "Fall Precautions." The non-measurable, non-observable goal for Patient 2 was, "Believe that [patient] is safe and not in danger by 5 days."

3. Medical Record review of Patient 3's Psychiatric Evaluation, found under the Assessment tab, dated 11/14/20, showed that admission was for believing people are trying to kill patient, spray painting the garage door and harassing daughter at work.

The MTP, dated 11/13/20, identified the problems needing to be addressed as, "Disturbance of thought processes," and "Fall Precautions." The goal for Patient 3 was, "Pt will have decreased suspicion of staff in 1-3 days." This non-measurable, goal did not have physician or nursing interventions and did not address the reasons for admission.

4. Medical Record review of Patient 4's Psychiatric Evaluation, found under the Assessment tab, dated 11/12/20, was admitted due to increased agitation and paranoid behavior. The MTP, dated 11/13/20, identified the problems needing to be addressed as, "Disturbance of thought processes," and "Fall Precautions."

The goal for Patient 4 was "Decrease in delusional thoughts by 7 days." There were no interventions to indicate what the professional staff would do to assist the patient in reaching this goal nor were there indicators on how the goal would be measured.

During an interview on 11/19/20 at 10:AM, Staff D, Director of Nursing (DON), agreed that the problems were all the same for the four active sample patients. She further stated that the former DON (whose last day was 11/17/20) had insisted on every patient having the same identified problems and shared that she thought the treatment plans should be revamped and made more individualized.

Based on document review and interview, the hospital failed to ensure the physician provided oversight of the treatment and care to patients at the frequency, level, and intensity necessary for psychiatric hospitalization, and failed to have a current contract for the Psychiatrist/Medical Director. Specifically, there was no physician on-site to provide, direct, review, and supervise psychiatric treatment and medical direction to the hospital. Instead, the only physician contact with patients for psychiatric care was via electronic telecommunication (a telemedicine process) who's Temporary Emergency Privileges had not been renewed since 07/31/20 per Medical Staff Bylaws.
Failure to have consistent on-site supervision and direction of each patient's treatment, has the potential to compromise the patients' recovery, potentially delaying their timely discharge.

Findings Include:

Review of a document titled, "Physician Coverage Agreement," dated July 30, 2020, ...Exhibit A, Contracted Services, Freedom Behavioral Hospital of Topeka, showed:
(a) Evaluation for admission or appropriated level of care and appropriately treat or otherwise manage the care of patients requiring psychiatric and related medical services and physician care ...
...(d) As needed, provide psychiatric evaluation, admission notes, progress notes, medication reconciliation on patients and discharge summaries and notes.
(e) Serve as the Medical Director of the psychiatric unit in which it operates an inpatient geriatric psychiatric program.

The document was signed by Staff I, there was not a date to show when the document was signed.
Review of four of four current patients' (Patient 1, Patient 2, Patient 3, and Patient 4), Multidisciplinary Treatment Plans (MTP), showed each patient had the same two problems identified, unmeasurable goals that did not address the patients' reasons for admission, and there was an absence of interventions to meet those goals. Each patients' MTP failed to show patient-related short-term goals (STGs) and long-term goals (LTGs) in observable, measurable, or behavioral terms. Individual Treatment interventions were not developed based on the needs of the patients. The MTP's for each of the four patients listed only showed routine/generic discipline functions rather than individualized treatment options and/or failed to include interventions for the identified goals. There were limited active therapeutic treatment programs for the four current patients. There was only one psychotherapy group led by the social worker and one nursing group led by a Licensed Practical Nurse (LPN), the remainder of the daily groups were led by activity staff and consisted of only leisure activities.

During an interview on 11/19/20 at 10:00 AM, Staff D, Director of Nursing (DON), stated that the nursing staff had a "big responsibility" related to patients' treatment plans and the treatment team meetings. She stated that "it feels different not having a psychiatrist on site." Staff D, clarified that she had previously worked in a behavioral health unit with a psychiatrist on site.

Observation of the treatment team meeting on 11/19/20 at 1:00 PM, showed Staff D, Registered Nurse (RN), Director of Nursing (DON), Staff F, Director of Social Services, Staff Y, Case Manager, and Staff O, Activities Coordinator (AC), in person and Staff I, Psychiatrist, via telecommunication. Discussion was held between staff in attendance regarding Patient 2. Staff F, reported that Patient 2, spends most of his time in his room, declines one on one activities, does not participate or engage in group activities. Staff Y, stated that Patient 2's discharge date is 11/27/20, and is to return home with his son. She also stated that he has improved and has been out of bed more since Monday. Staff D, stated that Patient 2 has not been taking his medications and isolates in his room. Staff D, RN then reviewed Patient 2's medications. Staff D stated that she had talked to the medical doctor regarding Patient 2's blood pressure medications. After the review of Patient 2's medications, Staff I, Psychiatrist gave a verbal order for Haldol (a medication used to treat psychosis) 0.5 mg at bedtime, to "help get rid of the delusions."

Patient 2 was then brought into the room, sat in a chair in the middle of the room facing the telemedicine screen. Staff I asked Patient 2 how he was sleeping, how was his appetite and a series of questions to determine Patient 2's orientation. Patient 2 was able to name the correct year, president and his location. During Staff I's questioning, he would interrupt Patient 2 before he could complete his sentence or respond. Staff I asked Patient 2 what he could do for him, Patient 2 responded that he doesn't want to take all the medications, and wants to be left alone, but knows he can't. Staff I stated that he would see what he could do, then told Patient 2 to have a good afternoon, dismissing him from the meeting.

Patient 2 was in the treatment team meeting for approximately 10 minutes. Immediately after Patient 2 left the meeting, the group then began discussing Patient 15 who was admitted 11/18/20.

There was no discussion of updating the MTP goals or interventions related to Patient 2's disturbance of thought process, other than to prescribe Haldol.

Review of the document titled, "Freedom Behavioral, Emergency Temporary Privilege" showed Staff I, requested privileges for General Psychiatry, Geriatric Psychiatry, Addictive Medicine, Psychology Services, Psychopharmacology, General Pharmacology, and Psychotherapy. The document also showed, "I agree to be bound by the hospital and medical staff bylaws, rules and regulations of Freedom Behavioral Hospital."

Review of the Governing Body meeting minutes dated 07/31/20, showed the Governing Body granted temporary emergency privileges to Physician I, Psychiatrist to provide psychiatric treatment of patients and to act as the Medical Director for the hospital via electronic telemedicine.

Review of the "Medical and Professional Staff Organization Bylaws" Article 7 (VII) Clinical Responsibilities, Section 7.3 "In all cases, Temporary Responsibilities shall be granted for a specific period of time, not to exceed 30 days. After that period of time the Practitioner may request a renewal of Temporary Responsibility for another specific period of time...

As 11/20/20, the hospital had not received Staff I's application packet and there is no evidence Staff I's, Temporary Emergency Privileges were renewed.

During a telephone interview on 11/19/20 at 3:53 PM, Staff I, Psychiatrist, stated that he provides service to the hospital about eight hours a week, he sees patient during treatment team meetings on Thursdays and will do admissions on Mondays. When asked how he ensures that the active treatment plans for patients are effective, or if changes need to be made, he stated that changes are based on the report from the nurse. Although there is evidence that a collaborative practice agreement exists between the Staff G, Psychiatric Mental Health Nurse Practitioner (PMHNP) and Staff I, Staff I stated that he did not have a collaborative agreement with anyone at the hospital.

During an interview on 11/19/20 at 4:20 PM, Staff B, Health Information Manager (HIM) stated that Temporary Emergency Privileges were granted to Staff I, Psychiatrist on 07/31/20, because the hospital was "running out of time to get someone credentialed" to provided psychiatric services. She stated that Staff I was sent an application packet at the time of the temporary appointment, and that she resent on 08/17/20 because they had not received it from Staff I.

During a subsequent telephone interview on 11/20/20 at 11:03 AM, Staff I, Psychiatrist stated that his role as the Medical Director of the hospital is to take care of the patients when they come in and to meet with the treatment team. He stated that he was not told anything about the Medical Director position and he had not received a job description. Staff I, stated that he was not told that he supervises anyone, including the medical doctor. He stated that he has not participated in the development of policies and that he has not had a need to participate in the Quality Improvement programs. Staff I, stated that he did not participated in the development of the hospitals COVID-19 Pan Flu Plan, and that he has not been notified of any COVID-19 positive staff or patients in the hospital.

Based on document review and interview, the hospital failed to have a Director of Nursing (DON) with a master's degree in psychiatric/mental health nursing and could not provide documented evidence of consultation from a nurse with a master's degree in psychiatric/mental health nursing. Failure to have a DON with the education, knowledge and experience in providing nursing service to psychiatric inpatients can lead to an inability to monitor the care delivered by nursing staff which can potentially lead to a provision of care that hinders rather than facilitates the patients' recovery process.

Findings Include:

Review of the Director of Nursing Job Description showed, under the "Preferred Knowledge, Skills, and/or Experience Required," that the education preferred was, "Master's Degree in Psychiatric Nursing, expect to see evidence of experience and on-going training in Psychiatric Nursing. Documented consultation from a nurse with a Masters' in Psychiatric Nursing constitutes on-going training."

Review of Staff D's, Director of Nursing (DON) resume, obtained from Staff C, Human Resources, revealed that Staff D, DON had one year of experience as a psychiatric staff nurse and one year, five months experience as a psychiatric case manager. She was hired at Freedom Behavioral Hospital on 11/03/20 as the Assistant Director of Nursing (ADON) and was placed in the DON position on 11/17/20.

During an interview on 11/18/20 at 4:50 PM, Staff A, Chief Executive Officer (CEO), stated that there is no documentation to show that there has been communication or consultation between the DON (past or current) and a registered nurse who has a master's degree in psychiatric/mental health nursing.

During an interview on 11/19/20 at 10:00 AM, Staff D, DON stated that she did not have a master's degree in psychiatric/mental health nursing. She further stated that she had not seen a DON job description that specified qualifications/consultation and did not know that she would have to consult with a master's prepared psychiatric nurse.

Based on observations and interviews, the hospital failed to provide a therapeutic activity program that met the individualized needs of 4 of 4 sample patients (Patient 1, Patient 2, Patient 3, and Patient 4) whose records were reviewed to ensure that active treatment was being provided, from a total sample of 19 patients.

Specifically, all the observed activities provided to the patients by the Activity Coordinators consisted of only leisure activities. There were no scheduled therapeutic activity groups designed to improve the patients' functioning. Instead, the groups consisted of movies, board games, videos, and putting puzzles together. Failure to provide a therapeutic activity program hinders the ability of the patients to develop and maintain skills that will assist them post-discharge and can prolong recovery and hospitalization.

Findings Include:

1. Observation in the unit group room on 11/17/20 at 1:15 PM showed Patient 1, Patient 3, and Patient 4 watching a video. When asked by the surveyor if this was the "Walk It Program" that was scheduled for this time, Staff N, Activities Coordinator (AC) responded that she allowed the patients to pick what they wanted to do and one of the patients, Patient 4, liked car shows so that was what they were watching. Patient 1 was sitting with closed eyes, Patient 3 was working with a puzzle, and Patient 4 was watching the video.

2. Observation on the unit on 11/17/20 at 1:45 PM showed that the unit did not post an activity schedule nor could Staff U, RN produce one. The smoking breaks (5 per day) and snack times (3 per day) were posted in large print in the nursing station and on the group door.

3. Observation in the unit group room on 11/18/20 at 9:30 AM showed that a video of country music was playing on the television. The schedule simply listed "Activity Group." Patient 1 and Patient 4 were in the group and both had their eyes closed. Staff O, AC was watching the television but was not interacting with the patients.

4. Observation in the unit group room on 11/18/20 at 10:05 AM showed that Staff O, AC was still in the room and the country music was still playing. When asked who was leading the 10:00 AM "Psychotherapy Group" Staff O, AC stated that Staff F, Director of Social Services was supposed to lead it, but she was not there. Staff Y, Case Manager (CM), came into the group room and told Staff O, AC that Staff F, Director of Social Services would not be in for her group because she was at the doctor and that he would need to cover until she came in. Staff M, LPN came into the room and asked if anyone needed anything. Staff O, AC, pointed to Patient 4 and said, "He needs a cigarette in about 15 minutes." Staff Y, CM returned and informed Staff O, AC that Staff F, Director of Social Services would not be coming to work that day. There were no observed therapeutic interactions between Staff O, CM and the patients during this group time.

During an interview on 11/17/20 at 1:20 PM, Staff N, AC, when asked about her role as Activity Coordinator, stated that she kept them busy to "...keep their minds off their problems."

During an interview on 11/17/20 at 3:30 PM, Patient 1, when asked "How do you spend your days," answered, "Don't do much." When asked about what they did in group, Patient 1 responded, "Color and watch tv shows."