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Based on observation, record review, staff interviews and policy review, the facility failed to:

I. Ensure that the Master Treatment Plans of 9 of 9 active sample patients (A1, A3, A11, A12, A15, B4, B14, C1 and C3) identified individualized and focused interventions to address patients' presenting problems and treatment goals. The preprinted Master Treatment Plans (MTPs) contained generic and routine functions, incorrectly listed as individualized interventions, for nursing and recreational therapy. The frequency of staff contact with patients and the method of delivery for interventions (individual or group sessions) also were not specified for recreational therapy interventions on the MTPs of 5 of 9 active sample patients (A11, A12, A15, B4 and C1), and for nursing interventions on the MTPs of 4 of 9 active sample patients A3, A12, B14 and C3). In addition, there were no "MD/LIP [Licensed Independent Professional]" interventions checked or handwritten on the MTPs for 7 of 9 active sample patients (A1, A3, A11, A12, A15, B4 and B14) and no Social Work interventions on the MTPs of 3 of 9 active sample patients (A11, A12 and A15). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

II. Ensure proper use and documentation of a restraint procedure and seclusion for 1 of 1non-sample patient (A7). Specifically, staff used unsafe and unapproved techniques to physically restrain Patient A7 who was also placed in seclusion. Because registered nurses and staff did not consider the physical hold and seclusion to be restrictive procedures, no physician's order was obtained and the required seclusion and restraint documentation was not completed on the day of the incident. Use of restraint and seclusion without adequate documented justification is a violation of patient rights. Use of unapproved restraint techniques also is an unsafe nursing practice which can result in serious outcomes for patients. (Refer to B125-I)

III. Provide sufficient active treatment measures for 5 of 5 active sample patients A1, A3, A11, A12 and A15) on the Acute Adult Unit [East Unit]. Specifically, treatment modalities listed on the patients' Master Treatment Plans and on the unit schedule were not offered, and staff was unclear regarding who was responsible for the treatment groups listed on the schedule. In addition, there were no recreational or activity therapy modalities offered during evening hours which focused on developing optimal levels of physical and psychosocial functioning. These failures can result in the delay of patients' improvement and their timely discharge (Refer to B125-II)

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations were completed and available to unit staff within 60 hours of admission for 1 of 9 active sample patients (B4). Failure to complete timely psychiatric evaluations compromises the staff's ability to establish or rule out active psychiatric pathology and potentially results in delayed treatment and prolonged hospitalization.

Findings include:

A. Record Review

The psychiatric evaluation for patient B4 admitted 06/01/11 was blank under the following sections: (Legal) Status, Past Psychiatric Medications and Response, and Diagnostic Impressions. On 06/07/2011, the facility provided an updated copy of the psychiatric evaluation with data included on the sections previously left blank; however, the patient was discharged on 06/06/2011.

B. Staff Interview

In an interview on 06/07/11 at 9:15a.m., Physician 1, the treating physician for patient B4, confirmed that the psychiatric evaluation was not completed in a timely manner and stated, "We were swamped. It has since been completed."

Based on record review and staff interview, the facility failed to develop a Master Treatment Plan that contained a substantiated diagnosis for 1 of 9 active sample patients (B4). This failure hinders the treatment team's ability to deliver clinically focused treatment.

Findings include:

A. Record Review

The Diagnosis section (Axes I - V) of Patient B4's Master Treatment Plan, dated 06/03/11, contained no data.

B. Staff Interview

In an interview on 06/07/11 at 2:30p.m., the Director of Social Services confirmed that the diagnosis section of patient B4's Master Treatment Plan had been left blank. The Director of Social Services stated that the diagnosis was typically drawn from the diagnosis on the psychiatric evaluation which had not been completed in a timely manner for patient B4.

Based on record review, observation and interview, the facility failed to ensure that the Master Treatment Plans of 9 of 9 active sample patients (A1, A3, A11, A12, A15, B4, B14, C1 and C3) identified individualized and focused interventions to address patients' presenting problems and treatment goals. The preprinted Master Treatment Plans (MTPs) contained generic and routine functions, incorrectly listed as individualized interventions for nursing and recreational therapy. The frequency of staff contact with patients and the method of delivery for the interventions (individual or group sessions) also were not specified for recreational therapy on the MTPs of 5 of 9 active sample patients (A11, A12, A15, B4 and C1), and for nursing interventions on the MTPs of 4 of 9 active sample patients (A3, A12, B14 and C3). In addition, there were no "MD/LIP [Licensed Independent Professional]" interventions checked or handwritten on the MTPs for 7 of 9 active sample patients (A1, A3, A11, A12, A15, B4 and B14) and no Social Work interventions on the MTPs of 3 of 9 active sample patients (A11, A12 and A15). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (5/20/11), A3 (5/26/11), A11 (6/3/11), A12 (6/6/11), A15 (6/4/11), B4 6/3/11), B14 (6/3/11), C1 (6/3/11) and C3 (6/2/11).

1. Four sample patients (A11, A15, C1 and C3) had the following generic, routine, and unfocused nursing interventions checked for the problem "Ineffective Individual Coping": "Provide safe structured milieu daily for 7 days" and "Assess behavior, compliance, appetite, mood, sleep, and cognitive ability daily for 7 days."

2. Four sample patients (A3, A12, B14, and C3) had all or some of the following generic, routine, and unfocused nursing interventions checked for the problem "Risk for violence - self": "Check client and patient for potentially destructive implements"; "Maintain every fifteen minute watch"; "Create a safe environment for client"; "Evaluate the seriousness of suicidal ideation for intent and plan"; "Refrain from judgment, preaching, and shocked facial expression"; "Accept and validate the client's thoughts and feelings"; "Assist client in formulating attainable goals"; "Listen actively to client"; "Reassure client that there is hope"; "Praise client for attempts at positive self-evaluation, self-control, and realistic goal-setting"; and "Orient client to reality as required."

3. Three sample patients (A1, A12 and A15) had the following generic, routine, and unfocused nursing and recreational therapy interventions checked for the problem "Altered Thought Process": "Nursing staff: Offer frequent, brief, non-threatening contact every shift to establish trust; Avoid arguing with patient's delusional system, however, reorient to reality as needed; and Medication administration as ordered. Evaluate and report side effects to attending psychiatrist." TR [Therapeutic Recreational] staff: "Assure patient of safety and provide a safe environment."

4. Two sample patients (A1 and C1) had all or some of the following generic, routine, and unfocused nursing interventions checked for the problem "Potential for Violence - other": "Assess the patient's potential for violence and past history q shift"; "Maintain patient's personal space (i.e. allow 5 times greater space)"; "Set limits"; "Provide environment that provides safety and reduces agitation" and "Acknowledge feelings."

5. Five sample patients (A11, A12, A15, B4 and C1) had the following recreational therapy intervention with no frequency of contact and no specified modality for the problem "Ineffective Individual Coping": "TR [Therapeutic Recreational] staff will provide coping skill training."

6. For the problem, "Risk for Violent - Self" the following interventions had no frequency of contact and no specified modality (individual or group):

Four sample patients (A3, A12, B14 and C3) with an intervention assigned to nursing; "Nursing will: Educate the patient and family about medication and treatment and elicit their feedback."

Two sample patients (A3 and C3) with an intervention assigned to recreational therapy; "TR [Therapeutic Recreation] staff will provide structured activities to increase self-esteem."

7. Seven sample patients (A1, A3, A11, A12, A15, B4 and B14) had no checked or handwritten MD/LIP interventions on the preprinted Master Treatment Plan for any of the listed problems.

8. Three sample patients (A11, A12,and A15) had no checked or handwritten interventions on the preprinted Master Treatment Plan to be implemented by the Social Worker for the following listed problems: "Ineffective Individual Coping" - Patient A11; "Risk for Violence - self" - Patient A12; and "Altered Thought Process" - Patient A15.

B. Staff Interviews

1. In an interview on 6/7/11 at approximately 2:45p.m., with the Director of Nursing, the treatment plans for patients A1, A3, A11, A12 and A15 were reviewed. The Director of Nursing acknowledged that the treatment plans contained generic, routine nursing functions written as interventions. She stated they had revised the treatment plan and taken these statements [generic and routine] out but had not implemented the plan yet.

2. In an interview on 6/7/11 at 3:55p.m., with the Director of Recreational Therapy, the Master Treatment Plans for patients A1, A3, A11, A12, and A15 were reviewed. The Director of Recreational Therapy agreed that some of the interventions assigned to Recreational therapy did not state whether they would be delivered in group or individual sessions and did not specify the frequency of contact. The Director of Recreational Therapy also acknowledged that many of the RT interventions on the treatment plans were generic recreational therapist functions.

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

I. Ensure proper use and documentation of a restraint procedure and seclusion for 1 of 1non-sample patient (A7). Specifically, staff used unsafe and unapproved techniques to physically restrain Patient A7 who was also placed in seclusion. Because registered nurses and staff did not consider the physical hold and seclusion to be restrictive procedures, no physician's order was obtained, and the required seclusion and restraint documentation was not completed on the day of the incident. Use of restraint and seclusion without adequate documented justification is a violation of patient rights. Use of unapproved restraint techniques also is an unsafe nursing practice which can result in serious outcomes for patients.

Findings include:

A. Observation

During an observation on 6/7/11 at approximately 2:05p.m., on the acute Adult unit (East Unit), three staff members were struggling to physically restrain non-sample Patient A7. The patient was taken to the seclusion room which was near the nursing station. The staff attempted to get the patient to stay in the seclusion room but he continued to resist. A code was then called and the patient was placed in a manual hold (restraint) by four staff -- one staff person on each extremity. There was no designated leader to coordinate the restraint situation and ensure that appropriate physical intervention techniques were employed. First, the patient was picked up and held by arms and feet with his head toward the floor in an uncoordinated manner. The patient was then placed on the restraint bed. When the patient attempted to get up, a staff member placed his [staff's] arms under the patient's arms, and lifted the patient back onto the restraint bed. The surveyor also observed that other patients were not supervised by staff from approximately 2:00p.m. through 2:15p.m. (during the restraint procedure). At approximately 2:20p.m., Patient A7 was on the restraint bed in the seclusion room with the door open. One staff person was outside the seclusion room. When the patient attempted to come out of the seclusion room, the staff used his body to block the door and would not allow the patient to leave the room. The staff closed the seclusion door and stayed inside the room with the patient.

B. Document Review

1. A review of the Patient A7's medical record on 6/7/11 at 4:10p.m. revealed that the physical hold (restraint) had not been documented. There was no MD order; no seclusion and restraint form was completed, and no one-hour face-to-face assessment was conducted by a physician, Licensed Independent Practitioner, or trained registered nurse (RN).

2. The "Daily Nursing Progress Notes" Form recorded by a registered nurse on 6/7/11 at "1130" [11:30a.m.] stated, "Q15 minute check in process for pt [patient] safety. Pt [patient] attending group with minimal participation." There was no documentation on the "Daily Nursing Process Notes" regarding the circumstances regarding Patient A7 being restrained physically, the medications given, or the patient's placement in the seclusion room, or the 1:1 observational status.

3. A review of "Policy No: CTS-031 - Seclusion and Restraint" revealed the following stipulation: "...Holding a patient in a manner that restraints the patients' [sic] movement against the patients' [sic] will is considered physical restraint..." The policy also stated, "Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving..."

4. A staff debriefing with the MHTs involved in Patient A7's physical restraint of 6/7/11 did not occur until 6/8/11. The MHT assigned to do the observation when the patient was in seclusion was not on duty on 6/8/11 when the debriefing occurred for other staff involved in the restraint procedure. The "Staff Debriefing" Form, dated 6/7/11 and signed by the Director of Nursing and Risk Manager on 6/7/11 and three other staff on 6/8/11, noted the following: "No code leader clearly identified - staff communication during episode limited, in need of improvement. MHTs during episode not communicating effectively - did not understand role in using CPI [Crisis Prevention Institute] techniques - CPI technique not properly utilized - pt [patient] picked up and carried."

C. Staff Interviews

1. In an interview on 6/7/11 at 4:15p.m., with RN3, the surveyor asked if RN2 had reported, during the change of shift report, that non-sample Patient A7 had been restrained. RN3 stated "No." RN3 stated that information received during shift report was that the patient was "uncooperative and didn't want to take his medications." RN3 confirmed that there was no MD order found on the "Physician's Orders" Form and also confirmed that the required seclusion and restraint documentation was not found in the patient's medical record.

2. In an interview on 6/7/11 at 4:20p.m., the Director of Nursing was asked about the seclusion and restraint documentation for non-sample Patient A7. She responded, "I understood the patient was in the quiet room with the door open." When asked about the physical hold and the face-to-face assessment of the patient, the DON stated, "I was with the patient. I can do the paperwork as a late entry." When asked about the staff person using his own body to prevent the patient from leaving the seclusion room and then closing the door, the DON acknowledged that this was seclusion and said, "The door is supposed to be left open."

3. In an interview on 6/7/11 at 4:30p.m., Case Manager 1 was asked if the technique used by the nursing staff was an approved physical intervention technique. Case Manager 1 said, "No." Case Manager 1 stated that all staff received "CPI" [Crisis Prevention Institute] training. Case Manager1 also submitted two pictures of the techniques that staff had been trained to use to safely restrain a patient. When asked if these techniques are considered restraints, Case Manager 1 said, "They are."

4. In an interview on 6/7/11 at 5:30p.m., the CEO stated that he agreed that the techniques used during the incident on the unit involving Patient A7 were physical restraints. He had witnessed the event on the unit and stated, "I told [Risk Manager's name] to debrief the staff because of problems with techniques used during the incident."

5. In an interview on 6/8/11 at approximately 9:40a.m., RN2 was asked about the incident with Patient A7. RN2 stated that she was under the impression that it was not a physical restraint, "As long as, we are holding the patient to keep him from harming himself." RN2 stated that she did not know she had to call an MD or complete the seclusion and restraint paperwork for the incident.

6. In an interview on 6/8/11 at 10:05a.m., with MHT5, when discussing the physical holds used during the incident with non-sample Patient A7, MHT5 stated, "It was not what we were shown to do." MHT5 confirmed that techniques used were not approved techniques.

7. In an interview on 6/8/11 at 10:20a.m., RN1 stated, "After thinking about it, we should have called the MD." When asked about the lack of documentation in the medical record regarding the physical hold and seclusion, RN1 stated, "It's like they [staff] don't realize this [referring to the physical hold] was a restraint." RN1 also stated, "[MHT's name] is new and probably didn't realize that preventing the patient from leaving and closing the door was seclusion."

II. Provide sufficient active treatment measures for 5 of 5 active sample patients (A1, A3, A11, A12 and A15) on the Acute Adult Unit [East Unit]. Specifically, nursing treatment modalities listed on these patients' Master Treatment Plans and on the unit schedule were not offered as scheduled. Staff was unclear about who was responsible for the groups listed on the unit schedule. In addition, there were no recreational or activity therapy groups offered during the evening hours which focused on developing optimal levels of physical and psychosocial functioning. These failures can result in delayed improvement of the patients' level of functioning.

Findings include:

A. Observations

1. During an observation on 6/6/11 from 10:40a.m. to 11:20a.m. in the day room on the Adult East Unit, Patients A1, A3, A11 and A12 and 9 other non-sample patients were sitting in the dayroom. Two non-sample patients appeared to be watching a movie while 4 other non-sample patients and Patient A12 were sitting with their eyes closed. Patient A11 was sitting at a table talking with 3 other non-sample patients, and A1 and A3 were walking in and out of the room. A "Relaxation Group" was on the "Adult East Program Schedule" for 10:30a.m. to 11:30a.m. to be conducted by a MHT. However a movie was being shown. When asked if this was the relaxation group, MHT1 stated "No." MHT1 was not sure about what was scheduled and stated, "I'm going to get a relaxation tape." MHT1 stopped the movie at approximately 11:00a.m. and inserted another video tape that played music. One patient seemed confused and asked if they were going to see the rest of the movie. There was no response by MHT1 to explain why the video tape was changed.

2. During an observation on 6/6/11 at approximately 1:50p.m. on the Adult East Unit, Patients A11 and A12 were sitting in the day room. "Exercise" was on the "Adult East Program Schedule" for 1:30p.m. to 2:30p.m. When asked about this group, MHT2 stated, "We never did the exercise group. RT [Recreational Therapy] is supposed to do this." When the surveyor informed MHT2 that the schedule showed that the MHT was assigned to the group, MHT2 stated, "This must be new."

3. During an observation on 6/6/11 at 3:40p.m. on the Adult East Unit, "Exercise" was on the "Adult East Program Schedule" for 3:30p.m. to 4:30p.m. When asked where this group was being held, MHT4 stated that the group was not being held. MHT4 stated that patients were in their bedrooms to "get the unit calmed down." MHT4 also stated there were several agitated patients.

4. During an observation on 6/7/11 at 1:30p.m. on the Adult East Unit, Patient A1 was in his room, and Patients A11 and A12 were in the dayroom. "Medication Education - Depression" was on the "Adult East Program Schedule" for 1:30p.m. to 2:15p.m. According to the schedule, this group was to be conducted by the registered nurse who was in the nursing station. At 1:50p.m., the registered nurse was still sitting in the nursing station. When the surveyor asked about the group, RN2 stated, "We are going to do the group now." RN2 entered the day room at approximately 1:55p.m., attempted (without success) to get a videotape started, and left the room. This scheduled medication education group was not held because of a psychiatric emergency involving non-sample Patient A7 which RN2 had to address.

5. During an observation on 6/7/11 at 4:10p.m. on the Adult East Unit, "Medication ED - Depression" was on the "Adult East Program Schedule" for 3:30p.m. to 4:30p.m. When the surveyor asked RN3 about the scheduled group, RN3 looked confused and stated, "This is not the group I do." RN3 pulled out a schedule and pointed to the "Community/Goals Group - Wrap up." RN3 stated, "I have never done this group [Med Ed]."

6. In summary, many of the active treatment sessions scheduled and assigned to nursing staff on the Adult East Unit were not held. During observations on 6/6/11, the "Relaxation Group was held for only 30 minutes after surveyor inquiry, and the exercise groups scheduled for 1:30p.m. and 3:30p.m. were not held. On 6/7/11, only three of the six scheduled groups were held ("Community/Goals Group" - [MHT], "Process Group" - [Social Work], and "Rec [recreation] Therapy" - [RT]). The other scheduled groups -- "Relaxation Group" - [MHT] scheduled for 10:30a.m., "Medication Educ. - Depression" - [RN] scheduled at 1:30p.m. and "Med ED" - [RN] scheduled at 3:30p.m. -- were not held. The one to one sessions and groups identified on the patients' MTPs were not documented in the medical records as being offered or provided to patients.

B. Document Review

1. A review of the "Adult East Program Schedule" revealed that most of the sessions on the program schedule were assigned to the "MHT" [Mental Health Technician] -- four sessions 7 days per week. Two sessions were assigned to both the RN and MHT 7 days per week. Two sessions were assigned to the RN two times per week and one session on Saturday. There was one session assigned to Social Work 7 days per week, and one session assigned to Recreational Therapy 6 days per week (Monday - Saturday). There were no Recreational Therapy activities listed on the schedule after 3:30p.m.

2. A review of the Master Treatment Plans for Patients A1, A3, A11 and A12 revealed the following interventions with the registered nurse as the staff member responsible:

Patients A3 and A12 - for the Problem "Risk for Violence - Self, the intervention assigned to the registered nurse was "Educate the patient and family about medication and elicit their feedback."

Patients A3 and A11- for the Problem "Ineffective Individual Coping" the interventions assigned to the RN were: "Educate on the importance of compliance with medication and treatment by having 1:1 interaction with pt [patient] daily for 45 minutes (Patient A3) 30 minutes (Patient A11) per day" and "Education groups on managing illness (45 minutes) 30 minutes 14x a week for 7 days."

3. The review of the medical records for Patients A1, A3, A11 and A12 revealed that no nursing treatment notes that documented whether these active treatment measures (1:1 and groups sessions) were offered or provided to patients as stipulated on the Master Treatment Plans.

4. Review of the facility's policy/procedure entitled "Scope of Services" revealed the following statement under "Programs": "Comprehensive treatment oriented activities are provided by a multidisciplinary staff. Clinical staff provides group therapy, family therapy, activity therapy, recreational therapy, and psychoeducation services." All of these services were provided by the facility except activity therapy.

C. Interviews

1. In an interview on 6/6/11 at approximately 2:10p.m. with Patient A11, the surveyor asked about activities provided on the unit. Patient A11 said that she goes to all groups and stated. "There is a lot of sitting around doing nothing." When asked about activities on the weekend, Patient A11 stated that there is different staff on the weekend. She also stated, "Saturday was good. Sunday [6/5/11] was a disaster." Patient A11 stated that there were not a lot of activities and patients were upset.

2. In an interview on 6/7/11 at 11:00a.m., Patient A15 was asked about activities and what the staff had done to help him. Patient A15 stated that the staff had "Done nothing to help me." Patient A15 also stated he was taking "Cogentin and Risperdal." When the surveyor asked if staff had discussed the benefits and side effects of these medications with him, Patient A15 said "No."

3. In an interview on 6/7/11 at approximately 2:40p.m., the "Adult East Program Schedule" was reviewed and discussed with the Director of Nursing. The Director of Nursing acknowledged that sessions listed on the schedule to be conducted by MHTs and the RN should have been provided as scheduled.

4. During an interview on 6/7/11 at 3:55p.m., the Director of Recreational Therapy confirmed that there were no recreational activities scheduled on the evening shift and that RT activities were only available on Saturday for the weekend.

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

I. Ensure that psychiatric evaluations were completed and available to unit staff within 60 hours of admission for 1 of 9 active sample patients (B4). Failure to complete timely psychiatric evaluations compromises the staff's ability to establish or rule out active psychiatric pathology, potentially resulting in delayed treatment and prolonged hospitalization. (Refer to B111)

II. Ensure that the Master Treatment Plan for 1 of 9 active sample patients (B4) contained a substantiated diagnosis. This failure hinders the treatment team's ability to deliver clinically focused treatment. (Refer to B120)

III. Ensure that the Master Treatment Plans of 9 of 9 active sample patients (A1, A3, A11, A12, A15, B4, B14, C1 and C3) identified individualized and focused interventions to address patients' presenting problems and treatment goals. The preprinted Master Treatment Plans (MTPs) contained generic and routine functions, incorrectly listed as individualized interventions, for nursing and recreational therapy. The frequency of staff contact with patients and the method of delivery for the interventions (individual or group sessions) also were not specified for recreational therapy interventions on the MTPs of 5 of 9 active sample patients (A11, A12, A15, B4 and C1), and for nursing interventions on the MTPs of 4 of 9 active sample patients A3, A12, B14 and C3). In addition, there were no "MD/LIP [Licensed Independent Professional]" interventions checked or handwritten on the MTPs for 7 of 9 active sample patients (A1, A3, A11, A12, A15, B4 and B14) and no Social Work interventions on the MTPs of 3 of 9 active sample patients (A11, A12 and A15). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

IV. Ensure proper use and documentation of a restraint procedure and seclusion for 1 of 1non-sample patient (A7). Specifically, staff used unsafe and unapproved techniques to physically restrain Patient A7 who was also placed in seclusion. Because registered nurses and staff did not consider the physical hold and seclusion to be restrictive procedures, no physician's order was obtained and the required seclusion and restraint documentation was not completed on the day of the incident. Use of restraint and seclusion without adequate documented justification is a violation of patient rights. Use of unapproved restraint techniques also is an unsafe nursing practice which can result in serious outcomes for patients. (Refer to B125-I)

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Ensure that Master Treatment Plans of 9 of 9 active sample patients (A1, A3, A11, A12, A15, B4, B14, C1, and C3) identified individualized and focused nursing interventions to address the patients' presenting problems and treatment goals. The preprinted Master Treatment Plans (MTPs) contained generic and routine nursing functions incorrectly listed as interventions. The frequency of contact and the method of delivery (individual or group sessions) also were not specified for nursing interventions on the MTPs of 4 of 9 active sample patients (A3, A12, B14 and C3). These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A1 (5/20/11), A3 (5/26/11), A11 (6/3/11), A12 (6/6/11), A15 (6/4/11), B4 6/3/11), B14 (6/3/11), C1 (6/3/11) and C3 (6/2/11).

1. Four sample patients (A11, A15, C1 and C3) had the following generic routine and unfocused nursing interventions for the problem "Ineffective Individual Coping": "Provide safe structured milieu daily for 7 days" and "Assess behavior, compliance, appetite, mood, sleep, and cognitive ability daily for 7 days."

2. Four sample patients (A3, A12, B14, and C3) had all or some of the following generic and unfocused nursing interventions for the problem "Risk for violence - self": "Check client and patient for potentially destructive implements"; "Maintain every fifteen minute watch"; "Create a safe environment for client"; "Evaluate the seriousness of suicidal ideation for intent and plan"; "Refrain from judgment, preaching, and shocked facial expression"; "Accept and validate the client's thoughts and feelings"; "Assist client in formulating attainable goals"; "Listen actively to client"; "Reassure client that there is hope"; "Praise client for attempts at positive self-evaluation, self-control, and realistic goal-setting"; and "Orient client to reality as required."

3. Three sample patients (A1, A12 and A15) had the following generic, routine, and unfocused nursing interventions checked for the problem "Altered Thought Process": "Offer frequent, brief, non-threatening contact every shift to establish trust"; "Avoid arguing with patient's delusional system, however, reorient to reality as needed"; and "Medication administration as ordered. Evaluate and report side effects to attending psychiatrist."

4. Two sample patients (A1 and C1) had the following generic routine, and unfocused nursing interventions checked for the problem "Potential for Violence - other": "Assess the patient's potential for violence and past history q shift"; "Maintain patient's personal space (i.e. allow 5 times greater space)"; Set limits"; "Provide environment that provides safety and reduces agitation"; and "Acknowledge feelings."

B. Staff Interview

In an interview on 6/7/11 at approximately 2:45p.m. with the Director of Nursing, the treatment plans for patients A1, A3, A11, A12 and A15 were reviewed. The Director of Nursing acknowledged that the treatment plans contained generic nursing functions written as interventions.

II. Ensure the proper use and documentation of a restraint procedure and seclusion for 1 of 1non-sample patient (A7) by nursing staff. Specifically, nursing staff used unsafe and unapproved techniques to physically restrain Patient A7 who was also placed in seclusion. Because registered nurses did not consider the physical hold and seclusion to be restrictive procedures, no physician's order was obtained, and the required seclusion and restraint documentation was not completed on the day of the incident. Use of restraint and seclusion without adequate documented justification violates patients' rights. Using unapproved restraint techniques and allowing the staff to remain alone in the seclusion room with a potentially agitated patient who was not in restraints are also unsafe nursing practices which can result in serious and dangerous outcomes for patients and staff. (Refer to B125-I)

III. Provide adequate nursing interventions for 5 of 5 active sample patients (A1, A3, A11, A12 and A15) on the Acute Adult Unit [East Unit]. Specifically, the nursing treatment modalities listed on these patients' Master Treatment Plans and on the unit schedule were not offered as scheduled. Nursing staff was unclear about who was responsible for the groups listed on the unit schedule. These failures can result in delayed improvement of the patients ' level of functioning.

Findings include:

A. Observations

1. During an observation on 6/6/11 from 10:40a.m. to 11:20a.m. in the day room on the Adult East Unit, Patients A1, A3, A11 and A12 and 9 other non-sample patients were sitting in the dayroom. Two non-sample patients appeared to be watching a movie while 4 other non-sample patients and Patient A11were sitting with their eyes closed. Patient A11 was sitting at a table talking with 3 other non-sample patients and A1 and A3 were walking in and out of the room. A "Relaxation Group" was on the "Adult East Program Schedule" for 10:30a.m. to 11:30a.m. to be conducted by a MHT. However a movie was being shown. When asked if this was the relaxation group, MHT1 stated, "No;" MHT1 was not sure about what was scheduled and stated, "I'm going to get a relaxation tape." MHT1 stopped the movie at approximately 11:00a.m. and inserted another video tape that played music. One patient seemed confused and asked if they were going to see the rest of the movie. There was no response by MHT1 to explain why the video tape was changed.

2. During an observation on 6/6/11 at approximately 1:50p.m. on the Adult East Unit, Patients A11 and A12 were sitting in the day room. "Exercise" was on the "Adult East Program Schedule" for 1:30p.m. to 2:30p.m. When asked about this group, MHT2 stated, "We never did the exercise group. RT [Recreational Therapy] is supposed to do this." When the surveyor informed MHT2 that the schedule showed that the MHT was assigned to the group, MHT2 stated, "This must be new."

3. During an observation on 6/6/11 at 3:40p.m. on the Adult East Unit, "Exercise" was on the "Adult East Program Schedule" for 3:30p.m. to 4:30p.m. When asked where this group was being held, MHT4 stated that the group was not being held. MHT4 stated that patients were in their bedrooms to "get the unit calmed down." MHT4 also stated there were several agitated patients.

4. During an observation on 6/7/11 at 1:30p.m. on the Adult East Unit, Patient A1 was in his room, and Patients A11 and A12 were in the dayroom. "Medication Education - Depression" was on the "Adult East Program Schedule" for 1:30p.m. to 2:15p.m. According to the schedule, this group was to be conducted by the registered nurse who was in the nursing station. At 1:50p.m., the registered nurse was still sitting in the nursing station. When the surveyor asked about the group, RN2 stated, "We are going to do the group now." RN2 entered the day room at approximately 1:55p.m., attempted (without success) to get a videotape started, and left the room. This scheduled medication education group was not held because of a psychiatric emergency involving non-sample Patient A7 which RN2 had to address.

5. During an observation on 6/7/11 at 4:10p.m. on the Adult East Unit, "Medication ED - Depression" was on the "Adult East Program Schedule" for 3:30p.m. to 4:30p.m. When the surveyor asked RN3 about the scheduled group, RN3 looked confused and stated, "This is not the group I do." RN3 pulled out a schedule and pointed to the "Community/Goals Group - Wrap up." RN3 stated, "I have never done this group [Med Ed]."

6. In summary, active treatment sessions assigned to nursing staff on the Adult East Unit schedule and on MTPs were not held or documented as offered and provided. During observations on 6/6/11 the "Relaxation Group was held for only 30 minutes after surveyor inquiry, the exercise groups scheduled for 1:30p.m. and again for 3:30p.m. were not held. On 6/7/11, the only nursing group held was the "Community/Goals Group" - [MHT]. The "Relaxation Group" - [MHT] scheduled for 10:30a.m., "Medication Educ. - Depression" - [RN] scheduled at 1:30p.m. and "Med ED" - [RN] scheduled at 3:30p.m. were not held. The one to one sessions and groups identified on the MTPs were not documented in the medical records as being offered or provided to patients.

B. Document Review

1. A review of the "Adult East Program Schedule" revealed that most of the sessions on the program schedule were assigned to the "MHT" [Mental Health Technician] -- four sessions 7 days per week. Two sessions were assigned to both the RN and MHT 7 days per week. Two sessions were assigned to the RN two times per week and one session was assigned on Saturday.

2. A review of the Master Treatment Plans for Patients A1, A3, A11 and A12 revealed the following interventions with the registered nurse as the staff member responsible:

Patients A3 and A12 - for the Problem "Risk for Violence - Self, the intervention assigned to the registered nurse was "Educate the patient and family about medication and elicit their feedback."

Patients A3 and A11- for the Problem "Ineffective Individual Coping" the interventions assigned to the RN were: "Educate on the importance of compliance with medication and treatment by having 1:1 interaction with pt [patient] daily for 45 minutes (Patient A3) 30 minutes (Patient A11) per day" and "Education groups on managing illness (45 minutes) 30 minutes 14x a week for 7 days."

3. The review of the medical records for Patients A1, A3, A11, A12 and A15 revealed no nursing treatment notes, documenting whether active treatment measures (1:1 and group sessions) were offered and provided to patients as stipulated on the Master Treatment Plans.

C. Interviews

1. In an interview on 6/6/11 at approximately 2:10p.m. with Patient A11, the surveyor asked about activities provided on the unit. Patient A11 said that she goes to all groups and stated. "There is a lot of sitting around doing nothing." When asked about activities on the weekend, Patient A11 stated that there is different staff on the weekend. She also stated, "Saturday was good. Sunday [6/5/11] was a disaster." Patient A11 stated that there were not a lot of activities and patients were upset.

2. In an interview on 6/7/11 at 11:00a.m., Patient A15 was asked about activities and what the staff had done to help him. Patient A15 stated that the staff had "Done nothing to help me." Patient A15 also stated he was taking "Cogentin and Risperdal." When the surveyor asked if staff had discussed the benefits and side effects of these medications with him, Patient A15 said "No."

3. In an interview on 6/7/11 at approximately 2:40p.m., the "Adult East Program Schedule" was reviewed and discussed with the Director of Nursing. The Director of Nursing acknowledged that sessions listed on the schedule to be conducted by MHTs and the RN should have been provided as scheduled.

IV. Deploy adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Mental Health Technicians (MHTs) on the Adult East Unit to provide nursing care, supervise, and monitor patients. This staffing pattern results in the lack of active treatment provided by registered nurses and lack of direction and supervision of paraprofessional staff in the provision of nursing care, potentially resulting in an unsafe environment for patients. (Refer to B150)

Based on observations, document review and interviews, the facility failed to deploy adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Mental Health Technicians (MHTs) on the Adult East Unit to provide nursing care, supervise, and monitor patients. This staffing pattern results in the lack of active treatment provided by registered nurses and lack of direction and supervision of paraprofessional staff in the provision of nursing care, potentially resulting in an unsafe environment for patients.

Findings include:

A. Observations

1. Observations were conducted on the Adult East Unit at the following times:

6/6/11: 9:40a.m. to 11:30a.m.; 12:50p.m. to 4:30p.m.
6/7/11: 8:20a.m. to 11:40a.m., 12:40a.m. to 2:35p.m.; 3:30p.m. to 4:40p.m.
6/8/11: 9:40a.m. to 10:30a.m.

These observations revealed that the registered Nurse (RN) remained in the Nursing Station most of the time and provided little or no supervision for MHTs working with patients who had acute psychiatric problems. The RN duties included completing nursing assessments, admitting and discharging patients, attending treatment planning meetings, charting nursing notes, handling psychiatric emergencies, assisting physicians, and answering phones (there was no unit clerk). Licensed Practical Nurses (LPN) duties included administering medications, transcribing and charting medication orders, and related clinical treatment duties.

2. During an observation on 6/7/11 at 1:30p.m. on the Adult East Unit, Patient A1 was in his room; Patients A11 and A12 were in the dayroom. "Medication Education - Depression" was on the "Adult East Program Schedule" for 1:30p.m. to 2:15p.m. According to the schedule, this group was to be conducted by the registered nurse who was in the nursing station. At 1:50p.m., the registered nurse was still sitting in the nursing station. When the surveyor asked about the group, RN2 stated, "We are going to do the group now." RN2 entered the day room at approximately 1:55p.m., attempted (without success) to get a videotape started, and left the room. The scheduled medication education group was not held because of a psychiatric emergency involving non-sample Patient A7 which RN2 had to address.

B. Document Review

1. A review of staffing for a one-week period (5/31/11 - 6/6/11) revealed a census ranging from 17 to 20 patients on the Adult East Unit with staffing as follows:

Day shift - 1 RN, 1 LPN and 3 or 3.5 MHTs for 5 of 7 shifts; 1 RN, 1 LPN, and 4 MHTs for 1 of 7 shifts; 1 RN, 1 LPN and 2 or 2.5Night shift - 1 RN, .5 LPN and 1 MHT for 7 of 7 shifts.

2. A Nursing Needs Assessment completed on 6/6/11, the first day of the survey, recorded no patients with a potential for assaultive behavior and no actively assaultive patient within the previous 48 hours. However, this information was inconsistent with psychiatric nursing care problems on the patients' treatment plans that included "Potential for Violence - other" for Patients A1 and A3. In addition, this information was also inconsistent with the "Incident/Occurrence Report" dated 6/4/11 that revealed a physical altercation between Patients A1 and A3 resulting in injuries to Patient A3 and a unit staff member.

3. The Nursing Needs Assessment also revealed:

a. Two patients who were experiencing active hallucination and delusions. These patients required close monitoring by nursing staff. In addition, Patient A1 was on 1:1 observation during the morning of 6/6/11 and was changed to line of sight. Patient A3 was also on line of sight on 6/6/11.

b. The following nursing care problems: One patient was on a detox protocol; 2 patients were classified as being a low risk for suicide. Six patients were admitted within the last 48 hours; 1 patient was on assault precautions; 1 patient on elopement precautions; 3 patients were on fall precautions and 1 patient was on line of sight.

c. The average number of admissions per week during May 2011 was 5 patients on the day shift; 4 patients on the evening shift, and 7 patients on the night shift. The average number of transfers to and from the unit per week was 13 patients on the evening shift. The average number of discharges per week was 3 on the day shift and 4 on the evening shift.

4. A review of a document submitted by the Director of Nursing showing census-based staffing and showed the following staffing for the Adult East Unit: Day and evening shifts -- 1 RN, 1 LPN and 1 MHT for a census up to 16 patients, and 1 RN, 1 LPN and 2 MHTs for a census 17 and over. Night shift --1 RN and 1 MHT for a census of 1 to 22 patients. Although the document listed patient acuity and workload factors, it did not show how the staff would be increased based on these factors.

5. In summary, these data reflect a staffing pattern that was inadequate because of the following factors: high patient acuity; high census; a heavy RN workload; and no supervisor scheduled on the night shift. These factors created the need for additional RN staff on the day and evening shifts to accomplished active treatment measures scheduled and maintain safety. Additional staff was needed on the night to maintain safety and to have adequate coverage for staff breaks.

C. Staff Interviews

1. During an interview on 6/7/11 at approximately 2:45p.m. with the Director of Nursing, the staffing pattern for the Adult East Unit was discussed. The Director of Nursing confirmed the high patient acuity on the unit and stated that MHTs were added to account for the acuity. However, the Director of Nursing acknowledged that the RN staff was not increased to adjust for patient acuity. When asked about the adequacy of RNs coverage on the day and evening shift and overall staffing on the night shift, the Director of Nursing acknowledged that the night shift staffing was questionable [referring to only 1 RN and 1 MHT scheduled) when the census goes up. The DON stated that there was currently no supervisor for the night shift.

2. During an interview on 6/8/11 at approximately 9:40a.m., when asked about adequacy of staff (number and type of staff) on the Adult East Unit, RN2 stated, "I could have used another RN yesterday." RN2 stated that she was very busy with patient discharges, transfers and an admission. RN2 acknowledged that because of the high patient acuity and workload, she was not able to conduct the medication education group scheduled on 6/7/11 at 1:30p.m.