HospitalInspections.org

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

I. Ensure that the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (E8, E12, E15, N3, N9, W2, W7 and W11) identified individualized interventions to address the patients' presenting problems. The preprinted Master Treatment plans were categorized by problems and placed on individual treatment plan sheets. These master treatment plans contained generic and routine functions without including specific focus and/or needs to customize any one patient's interventions from those of other patients who had been assigned the same identified problem. These failures result in a 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 for 1 of 1 active sample patient (E12) who reported being placed in a physical hold on 8/21/11 in the "early afternoon." There was no physician's order on E12's doctor's order sheet as of 4:00p.m. on 8/22/11 (the following day) nor was there any required documentation for the hold except for a registered nurse's progress note documenting that the "pt [patient] was held." Use of restraints without a physician's order and lack of adequate documented justification is a violation of a patient's right to be free of restriction of movement and is unsafe practice which can result in serious harm to patients. (Refer to B125)

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (E8, E12, E15, N3, N9, W2, W7 and W11) identified individualized interventions to address patients' presenting problems. Even specific problems (such as active sample Patient E12's complaint of being injured during a physical hold) were not addressed on the patients' treatment plans. The preprinted Master Treatment Plans were categorized by problems and placed on individual treatment plans sheets. These plans contained generic and routine functions without including specific focuses and/or needs to customize one patient's interventions from other patients' who had been assigned the same identical problem. These failures result in a 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

1. The face page of each patient's Master Treatment Plan listed all his or her identified problems. A preprinted sheet for each problem was selected from an existing collection of preprinted master treatment plans organized by the identified problems. Each sheet had a title such as: "depression", "anxiety" or "altered thoughts", and contained a checklist of interventions for the titled problem. Staff made a check mark next to the selected interventions without writing in additional information to customize the treatment for any patient to differentiate it from that of any other patient with the same identified problem.

2. The Master Treatment plans (MTPs) of active sample patients E8, E12, N9, W2, W7 and W11had the same or very similar generic interventions for the problem of "depression":

a. Patient E8, MTP dated 8/16/11 -

MD/LIP (physician or licensed independent practitioner) Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues",
"Obtain blood levels to determine appropriate medication dosage as needed."

Nursing Interventions:
"Monitor and document sleeping and eating patterns",
"Monitor and redirect the client on daily grooming and hygiene."

Social Work Intervention:
"Education groups on managing illness, disease process",
"Encourage pt [patient] to keep a journal of automatic thoughts associated with depressive feelings."

Therapeutic Recreation Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide structured activities to increase problem solving abilities in group or individual settings."

b. Patient E12, MTP dated 8/16/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"Medication management at dosage and schedule prescribed to improve mood and decrease self-harm thoughts/behaviors",
"History and physical performed to assess any co morbid medical issues."

Nursing Interventions:
"Monitor and redirect the client on daily grooming and hygiene",
"Monitor and document sleeping and eating patterns."

Social Work Intervention:
"Psych education groups to develop self-care, coping skills."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide structured activities to increase problem solving abilities in group or individualized settings."

c. Patient N9, MTP dated 8/19/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues."
"Medication management at dosage and schedule prescribed to improve mood and decrease self-harm thoughts/behaviors."

Nursing Interventions:
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and document sleeping and eating patterns."

Social Work Interventions:
"Education groups on managing illness/disease process",
"Psych education groups to develop self-care/coping skills."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks."

d. Patient W2, MTP dated 8/20/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues."

Nursing Interventions:
"Nursing assessment to determine suicidality, mood, and patient perception of medication effectiveness",
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and redirect the client on daily grooming and hygiene."

Social Work Interventions:
"Education groups on managing illness/disease process",
"Psych education groups to develop self-care/coping skills."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks."

e. Patient W7, MTP dated 8/19/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues."

Nursing Interventions:
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and redirect the client on daily grooming and hygiene",
"Monitor and document sleeping and eating patterns."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks."

f. Patient W11, MTP dated 8/20/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues",
"Obtain blood levels to determine appropriate medication dosage as needed."

Nursing Intervention:
"Nursing assessment to determine suicidality, mood, and patient perception of medication effectiveness."

Social Work Intervention:
"Process groups to provide patient [blank space]."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks."

3. The Master Treatment plans (MTPs) of active sample patients E15 and N3 listed the following generic interventions for the problem titled "altered thoughts":

a. Patient E15, MTP dated 8/17/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues",
"Obtain blood levels to determine appropriate medication dosage as needed."

Nursing Interventions:
"Goals and wrap up groups to assist patient in setting productive and obtainable goals",
"Monitor and document sleeping and eating patterns."

Social Work Interventions:
"Patient education regarding illness to promote self care and independence in group sessions or 1:1 [one to one]",
"Process groups to provide patient [blank space]."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks in group sessions or 1:1."

b. Patient N3, MTP dated 8/16/11 -

MD/LIP Interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications",
"History and physical performed to assess any co morbid medical issues."

Nursing Interventions:
"Goals and wrap up groups to assist patient in setting productive and obtainable goals",
"Monitor and document sleeping and eating patterns."

Social Work Interventions:
"Patient education regarding illness to promote self care and independence in group sessions or 1:1",
"Psycho education groups to develop self-care and copying skills."

Therapeutic Recreational Interventions:
"Recreational therapy groups to educate on the importance of leisure/life strategies",
"Provide opportunities for success oriented tasks in group sessions or 1:1."

B. Interviews

1. In an interview on 8/23/11 at 10:00a.m., the generic treatment interventions on the MTP of active sample patient W2 were discussed with RN1. When asked if the preprinted interventions on the plans were individualized, RN1 stated, "Not really. They (interventions) are all the same."

2. In an interview on 8/23/11 at 1:00p.m., the generic interventions on all 8 active sample patients' Master Treatment Plans were discussed with the Nursing Director and the Performance Improvement Director, who was responsible for developing the pre-printed treatment plans. Both the Nursing Director and the Performance Improvement Director acknowledged the above findings and agreed that re-education of staff on treatment plan development was needed.

3. In an interview on 8/23/11 at 2:30p.m., the Master Treatment Plans of all 8 active sample patients (E8, E13, E15, N3, N9, W2, W7 and W11) were reviewed with the Medical Director. The Medical Director acknowledged that the interventions listed on the plans were generic and not individualized for the patients.

Based on interviews and record review, the facility failed to ensure proper use and documentation of a restraint procedure for 1 of 1 active sample patient (E12) who reported being placed in a physical hold on 8/21/11. (The patient could not remember the exact time of the physical hold, but stated it occurred during the early afternoon of that day). There was no physician's order on E12's doctor's order sheet as of 4:00p.m. on 8/22/11 (the following day). There was not any required documentation in the patient's record for the hold except for one RN [registered nurse] note dated 8/21/11 at 3:30p.m. documenting that the "pt [patient] was held by [his/her] hands." Use of restraints without a physician's order and lack of adequate documented justification is a violation of a patient's rights to freedom of movement and is unsafe practice which can result in serious harm to patients. (Refer to B125)

Findings include:

1. In an interview on 8/22/11 at 9:40a.m., the Nursing Director was asked to provide a copy of the facility's seclusion and restraint policy/procedure, along with a list of all patients who had been placed in seclusion and/or restraints during the period of July 21, 2011 through August 21, 2011. The DON stated, "We haven't had any (seclusion/restraints) during that period of time." When asked if this included physical holds, the DON said "Yes."

2. In an interview on 8/22/11 at 10:45a.m., active sample Patient E12 was asked if s/he had ever been placed in seclusion or restraint at this facility. The patient answered "Yes." The patient stated s/he had been hitting on the walls "after lunch" and added, "Three or four staff grabbed me and put me face down on the floor. Two (staff) held my hands behind my back and 1 or 2 others sat on my feet." When asked when this incident had occurred, patient E12 stated, "Yesterday (8/21/11)." When asked what time the incident had occurred and for how long, patient E12 replied, "I don't remember the exact time, but it was early in the afternoon." E12 added that/ s/he had a history of a dislocated shoulder (left) in the past and that the physical hold caused the shoulder pain to return. S/he stated that s/he had asked several times for some medication for the shoulder pain.

3. A review of the patient's MAR (Medication Administration Record) revealed that the patient had received Motrin 600mg, Tylenol 500mg, and Elavil 10mg on 8/21/11 at 8:45p.m. for pain.

4. Active sample Patient E12's chart was reviewed on 8/22/11 around 11:00a.m. for any documentation of the physical hold. The physician's order sheet, dated 8/21/11 at 2:15p.m. contained a verbal order for "Geodon 20mg [milligrams] im [intramuscular], Benadryl 50mg im, Ativan 2mg im.x1 [times one]. NOD [nurse on duty] call MD [doctor] after 15 min [minutes] of injection. [sic] No documentation of the incident (physical hold) was found in the Physician's Progress notes.

5. A review of a RN's progress note, dated 8/21/11 at 3:30p.m., revealed the following information on E12's behavior and treatment: "Pt c/o [complained of] feeling anxious. Staff attempted to discuss [with] pt other ways/non pharmacological ways to deal with [his/her] anxiety. Pt began to pace up and down the hallway ....Pt began hitting the door....Cursing, hollering and hitting the wall....Pt was held by [his/her] hands by 2 staff members to protect [him/her]. MD was notified and orders given. After pt was informed that [s/he] would be getting an injection, [s/he] agreed that [s/he] would stop hitting the wall and staff released [him/her]."

6. Facility policy, No: CTS-031, titled "Seclusion and Restraint", revised 3/11, states, "Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff or others"... "Restraints shall not be used in a manner which causes undue physical discomfort or harm to the patient." Definition of a restraint was stated as "Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely"... "Holding the patient against his or her will during a 'therapeutic hold' is considered a restraint."

7. In an interview on 8/22/11 at 1p.m., MHT1 (mental health technician) was asked if s/he had been on duty on 8/21/11 when patient E12 had been placed in a physical hold. MHT1 stated, "Yes." S/he stated that s/he (MHT1) was on break, and that when s/he returned to the east unit, 3 MHTs were holding patient E12 upright against a wall. According to MHT1, two of three MHTs were holding patient E12's arms - one MHT on each side -- and the third MHT was holding the patient's feet. MHT1 stated that s/he did not witness E12 lying face down on the floor.

8. In a telephone interview on 8/21/11 at 4:45p.m., MD1 stated that he was called on the afternoon of 8/21/11 regarding Patient E12. MD1 stated that he was told by the RN (registered nurse) that patient E12 was acting aggressively and was currently on the floor. MD1 stated that he ordered medication and told the RN to restrain the patient if medication was not effective. MD1 stated he later received a phone call from the RN stating that the medication had been effective and the situation had been resolved. MD1 stated that he had not been told by the nurse that E12 had already been restrained. MD1 stated he had never issued orders for a manual hold or any other kind of restraint for patient E12.

9. In an interview on 8/23/11 at 9a.m., the CEO (Chief Executive Officer) reported that on 8/22/11, hospital leaders had reviewed the incident in which patient E12 was manually held on 8/21/11 at 2:15p.m. The CEO stated that hospital leaders had not received an Incident Report to review because the supervising RN went home sick on 8/21/11 prior to completing an Incident Report. The CEO and PI Director presented the surveyors with an Incident Report completed by LPN1 on 8/23/11 at 9a.m. which described the incident type as "patient out of control." The Incident Report did not indicate that the patient was held or restrained, nor did the incident report note the time of the incident. The CEO and PI Director stated that upon review of the incident, they had determined that the patient had been placed in a manual (physical) hold on 8/21/11 at 2:15p.m., and that this should have been treated as a restraint according to the hospital wide training conducted for all staff in July of 2011 on hospital policy CTS-031 titled "Seclusion and Restraint."

The Performance Improvement Director presented surveyors with a document titled "Highlight of CMS Regulations regarding Restraint and Seclusion" which he had developed for the July 2011 hospital-wide training on restraints. The PI Director stated that policy CTS-031 and the highlight document made it clear that manual holds such as the one employed on 8/21/11 with patient E12 constituted a restraint. The CEO also stated that he had reviewed the training records for the staff involved in the 8/21/11 incident and found that they had all been retrained in July 2011 on the proper use of manual holds and restraints. The CEO stated that the hospital was having difficulty communicating the idea to staff that manual holds, "even for a few seconds like patient E12, other than escorts" are to be treated as a restraint episode. (A review of E12's rounds sheet for 8/21/11 documented that the patient was yelling and screaming from 2:15p.m. to 2:30p.m., fifteen minutes after initiation of the physical hold). The CEO stated that the incident involving patient E12 should have generated an Incident Report, and been treated as a restraint episode with a physician's order, and the restraint documentation required by hospital policy CTS-031 "Seclusion and Restraint." The CEO acknowledged that these requirements were not met in the 8/21/11 incident involving patient E12. The CEO stated that this incident "had fallen through the cracks."

10. In an interview on 8/23/11 at 11:30a.m., the Medical Director stated that hospital leaders had met the evening of 8/22/11 after learning that the restraint episode had occurred to review the incident of 8/21/11 involving patient E12. The Medical Director stated that hospital leaders had determined that the incident of 8/21/11 constituted a restraint according to hospital policy, and that there was no physician's order or nursing documentation of a manual restraint. The Medical Director stated that hospital leaders had determined a breakdown in communications had occurred because the incident was not reported to MD1 on 8/21/11 as a hold, so no order was issued for a restraint. The Medical Director stated that this incident had "fallen through the cracks." The Medical Director was asked whether the hospital's medical staff participated in the hospital-wide training on seclusion and restraint which occurred in July of 2011. The Medical Director stated that medical staff did not participate in a formal training session.

11. In an interview on 8/23/11 at 1:00p.m., the incident of the physical hold for patent E12 was discussed with the Nursing Director. The DON stated that she was not aware of the physical hold until 8/22/11. She also said that RN2, who was charge nurse on East Unit during the time of the hold, had not been to a retraining update session since April 2011. According to this information, all staff had not received the July 2011 retraining on restraints.

Based on record review and interview, the Medical Director and the Nursing Director failed to ensure that all clinical staff responsible for following facility seclusion/restraint policy and procedure compliance received retraining in this area by July 21, 2011 as previously stated by the facility's administrative staff. The facility also failed to report on injury to the patient from the hold and failed to ensure that procedures for the proper use of seclusion/restraint were in place for 1 of 1 active sample patient E12 who was placed in a physical hold on 8/21/11 at 2:15p.m. The facility also failed to evaluate whether the patient had sustained any physical harm from the hold. The use of restraints by untrained staff, lack of ongoing monitoring of staff involved in initiating restraints and lack of adequate documentation and justification for a restraint in a patient's medical record is a violation of a patient's right to be free of restriction of movement. These failures are also unsafe clinical practices which can lead to serious physical harm to patients. (Refer to B144 for failures related to the Medical Director and to B148 for failures related to the Nursing Director).

Based on record review and interview, the Medical Director failed to ensure the quality and appropriateness of physician services. Specifically, the Medical Director failed to:

I. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (E8, E12, E15, N3, N9, W2, W7 and W11) identified individualized interventions to address the patients' presented problems. The preprinted Master Treatment Plans were categorized by problems. The plans were placed on individual treatment plan sheets. These plans contained generic and routine functions without including specific focuses and/or needs to customize one intervention from another for the same identified problem. These failures result in a 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 for 1 of 1 active sample patient (E12) who reported being placed in a physical hold on 8/21/11, with subsequent exacerbation of pain from a previous shoulder injury. Record review revealed there was no physician's order for the restraint on E12's doctor's order sheet as of 4:00p.m. on 8/22/11, nor was there any required documentation for the physical hold (restraint) except for a RN's [registered nurse] note dated 8/21/11 at 3:30p.m., documenting that "pt [patient] was held by his hands by 3 staff members to protect him." Use of restraints without a physician's order and adequate documented justification is a violation of a patient's rights to be free from restricted movement and is an unsafe clinical practice which can result in serious harm to the patient. (Refer to B125)

Based on record review and interview, the Director of Nursing failed to ensure quality of nursing services. Specifically, the Nursing Director failed to:

I. Ensure that all nursing staff had attended in-service training related to seclusion and restraint prior to the July 21, 2011 deadline date established by the Administrative staff. The DON also failed to monitor nursing staff to ensure that seclusion/restraint procedures were carried out per facility policy. Specifically, nursing staff carried out a restraint procedure for a patient (E12) without proper use and documentation of the restraint. These failures place patients at risk for potential harm and they violate patient's right to be free of restraint without adequate justification.

Findings include:

A. Interviews and Document Review

1. In an interview on 8/22/11 at 9:40a.m., the Nursing Director was asked to provide a copy of the facility's seclusion and restraint policy/procedure, along with a list of all patients who had been placed in seclusion and/or restraints during the period of July 21, 2011 through August 21, 2011. She stated, "We haven't had any during that period of time." The Nursing Director was then asked if this answer included physical holds and she said, "Yes."

2. In an interview on 8/22/11 at 10:45a.m., active sample Patient E12 was asked if s/he had ever been placed in seclusion or restraint at this facility. S/he stated, "Yes." The patient stated s/he had been hitting on the walls "after lunch. The patient said "Three or 4 staff grabbed me and put me face down on the floor. Two (staff) held my hands behind my back and 1 or 2 others sat on my feet." When asked when this incident had occurred, patient E12 stated, "Yesterday (8/21/11)." When asked what time this incident had occurred and for how long, patient E12 stated, "I don't remember the exact time, but it was early in the afternoon." E12 added that/ s/he had a history of a dislocated shoulder (left) in the past, and that the hold caused the shoulder pain to return. S/he stated s/he had asked several times for some medication for the shoulder pain.

3. Review of the patient's MAR (Medication Administration Record) showed that the patient had received Motrin 600mg, Tylenol 500mg, and Elavil 10mg on 8/21/11 at 8:45p.m. for pain.

4. In an interview on 8/23/11 at 9a.m., the CEO (Chief Executive Officer) reported that on 8/22/11 hospital leaders had reviewed the incident in which patient E12 was manually held on 8/21/11 at 2:15p.m. The CEO stated that hospital leaders had not received an Incident Report to review because the supervising RN went home sick on 8/21/11 prior to completing an Incident Report. The CEO and PI Director presented surveyors with an Incident Report completed by LPN1 on 8/23/11 at 9a.m. which described the incident type as "patient out of control." The Incident Report did not indicate that the patient was held or restrained, nor did the incident report note the time of the incident. The CEO and PI Director stated that upon review of the incident, they had determined that the patient had been placed in a manual hold on 8/21/11 at 2:15p.m., and that this should have been treated as a restraint according to the hospital wide training conducted for all staff in July of 2011 on hospital policy CTS-031 titled "Seclusion and Restraint."

5. The Performance Improvement Director presented surveyors with a document titled "Highlight of CMS Regulations regarding Restraint and Seclusion" which he had developed for the July 2011 hospital-wide training on restraints. The PI Director stated that policy CTS-031 and the highlight document made it clear that manual holds such as the one employed on 8/21/11 with patient E12 constituted a restraint. The CEO stated that he had reviewed the training records for the staff involved in the 8/21/11 incident and found that they had all been retrained in July 2011 on the proper use of manual holds and restraints. The CEO stated that the hospital was having difficulty communicating the idea to staff that manual holds, "even for a few seconds like patient E12, other than escorts" are to be treated as a restraint episode. (A review of E12's rounds sheet for 8/21/11 documented that the patient was yelling and screaming from 2:15p.m. to 2:30p.m., fifteen minutes after initiation of the physical hold). The CEO stated that the incident involving patient E12 should have generated an Incident Report, and been treated as a restraint episode with a physician's order, and the restraint documentation required by hospital policy CTS-031 "Seclusion and Restraint." The CEO acknowledged that these requirements were not met in the 8/21/11 incident involving patient E12. The CEO stated that this incident "had fallen through the cracks."

6. In an interview on 8/23/11 at 1p.m., the incident of the physical hold for patent E12 was discussed with the Nursing Director. The DON stated that she was not aware of a hold until 8/22/11. The DON also stated that RN2, who was charge nurse on East Unit during the time of the physical hold, had not been to a retraining update session since April 2011.According to this information, all staff had not been received the retraining on restraint procedures by the July 2011 as reported earlier.

B. Record Review

A review of an RN's progress note, dated 8/21/11 at 3:30p.m., revealed the following information on E12's behavior and treatment: "Pt c/o [complained of] feeling anxious. Staff attempted to discuss [with] pt other ways/non pharmacological ways to deal with [his/her] anxiety. Pt began to pace up and down the hallway ...Pt began hitting the door...Cursing, hollering and hitting the wall...Pt was held by [his/her] hands by 2 staff members to protect [him/her]. MD was notified and orders given. After pt was informed that s/he would be getting an injection, s/he agreed that s/he would stop hitting the wall and staff released [him/her].

II. Ensure that Master Treatment Plans of 6 of 8 active sample patients (E8, E12, N9, W2, W7 and W11) identified individualized nursing interventions to address patients' presented problem. The preprinted Master Treatment Plans were categorized by problems and placed on individual treatment plan sheets. These plans contained generic and routine nursing functions including generic focus. Nursing needs to customize one patient's intervention from others with the same identified problem were not present in the record. These failures result in a lack of guidance to staff in providing individualized nursing interventions and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

1. Patient E8, MTP dated 8/16/11 -
Nursing Interventions:
"Monitor and document sleeping and eating patterns",
"Monitor and redirect the client on daily grooming and hygiene."

2. Patient E12, MTP dated 8/16/11 -
Nursing Interventions:
"Monitor and redirect the client on daily grooming and hygiene",
"Monitor and document sleeping and eating patterns."

3. Patient N9, MTP dated 8/19/11 -
Nursing Interventions:
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and document sleeping and eating patterns."

4. Patient W2, MTP dated 8/20/11 -
Nursing Interventions:
"Nursing assessment to determine suicidality, mood, and patient perception of medication effectiveness",
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and redirect the client on daily grooming and hygiene."

5. Patient W7, MTP dated 8/19/11 -
Nursing Interventions:
"Patient education through group sessions related to efficacy and side effects of medication",
"Monitor and redirect the client on daily grooming and hygiene",
"Monitor and document sleeping and eating patterns."

6. Patient W11, MTP dated 8/20/11 -
Nursing Intervention:
"Nursing assessment to determine suicidality, mood, and patient perception of medication effectiveness."

B. Interview

In an interview on 8/23/11 at 1:00p.m., the generic interventions on all 6 active sample patients' Master Treatment Plans were discussed with the Nursing Director and the Performance Improvement Director, who was responsible for developing the pre-printed treatment plans. They both agreed with the findings and stated that constant re-education of staff on treatment plan development was needed.