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Based on record review and interview, the facility failed to provide psychiatric evaluations that reported intellectual functioning, memory functioning, and orientation in measurable terms for 6 of 8 sample patients (A1, A5, A7, B2, B4 and B12). This compromises the database from which diagnoses are determined and from which improvements in response to treatment are assessed.

Findings include:

A. Record Review

1. Patient A1 (Admission date 02/12/11) received a psychiatric evaluation on 02/12/11. Intellectual functioning is described as "appears below average". Orientation was described as "he is alert and oriented." There was no description of the method by which these functions were evaluated.

2. Patient A5 (Admission date 01/9/11) received a psychiatric evaluation on 01/12/11. He is described as "well oriented x3." There was no description of the method by which these functions were evaluated.

3. Patient A7 (Admission date 01/30/11) received a psychiatric evaluation on 02/02/11. The patient was described as electively mute and uncooperative with the exam except that she wrote "Once in a while thoughts of hurting myself, but not as often as usual." There was no evidence of attempts to repeat the exam later or to further communicate in writing with the patient to complete the assessment.

4. Patient B2 (Admission date 02/09/11) received a psychiatric evaluation on 02/10/11. The evaluation of memory was recorded as "immediate, recent and remote intact." Orientation was described as "well oriented x 3 spheres." Intelligence was described as "average." There was no description of the method by which these functions were evaluated.

5. Patient B4 (Admission date 02/08/11) received a psychiatric evaluation on 02/08/11. The evaluation of memory was recorded as "immediate, recent and remote intact." Orientation was described as "well oriented x 3 spheres." Intelligence was described as "average." There was no description of the method by which these functions were evaluated.

6. Patient B12 (Admission date 02/11/11) received a psychiatric evaluation on 02/13/11. The evaluation of memory was recorded as "memory for immediate, recent and remote events is a little impaired." Orientation was described as "alert and oriented x3." There was no assessment of intellectual functioning listed. There was no description of the method by which these functions were evaluated.

B. Staff Interview

In an interview on 02/15/2011 at 10:00a.m., the Medical Director agreed that the assessments of intellectual functioning for the 6 active sample patients above were not consistent with what is expected. He noted that there is still training to be done to ensure full compliance. He also stated that he prefers to have the formal mental status exam documented on a template that guides the assessment methodology.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included and inventory of patient assets in a descriptive fashion for 6 of 8 active sample patients (A1, A4, A5, A7, B9 and B12). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.

Findings include:

A. Record Review

1. Patient A1 (Admission date 02/12/11) received a psychiatric evaluation on 02/12/11. There was no inventory of patient strengths/assets.

2. Patient A4 (Admission date 02/08/11) received a psychiatric evaluation on 02/08/11. The only strength listed was "supportive care system" which is not a personal attribute of the patient.

3. Patient A5 (Admission date 01/9/11) received a psychiatric evaluation on 01/12/11. The only strength listed was "supportive care system" which is not a personal attribute of the patient.

4. Patient A7 (Admission date 01/30/11) received a psychiatric evaluation on 02/02/11. The only strength listed was "supportive care system" which is not a personal attribute of the patient.

5. Patient B9 (Admission date 01/29/11) received a psychiatric evaluation on 01/29/11. There was no inventory of patient strengths/assets.

6. Patient B12 (Admission date 02/11/11) received a psychiatric evaluation on 02/11/11. There was no inventory of patient strengths/assets.

B. Staff Interview

In an interview on 02/15/11 at 10:00a.m., the Medical Director acknowledged the missing inventory of assets.

Based on record review and interview, the facility failed to provide interventions that were individualized and included a specific focus and purpose for 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12).These patients' Master Treatment Plans contained lists of modalities (individual therapy, group therapy, family therapy), or current psychiatric techniques without specifying a focus for treatment. In addition, the plans contained generic nursing tasks written as interventions and interventions assigned to nursing and recreational therapy staff with no focus of treatment. They also failed to specify whether interventions would be delivered in individual or group sessions. These deficiencies result in treatment plans that do not provide guidance to in delivering consistent and effective treatment related to the patients' problems and goals.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (2/15/11); A4 (2/11/11); A5 (2/12/11); A7 (2/9/11); B2 (2/12/11); B4 (2/11/11); B9 (2/1/11) and B12 (2/14/11). This review revealed that:

1. For "Psych [Psychiatric] Problem #1," Patients A1, A4, A5, and A7 all had the following identical or similarly worded interventions listed on the Master Treatment Plan with no focus of treatment to address the patients' individual needs. They also failed to specify the modality (individual or group sessions): Each patient had different "AED" [as evidenced by]" for the problem listed.
Therapist Interventions: "Cognitive Behavior Techniques" was listed two times for two separate short-term goals. "Medication Education" was listed for one short-term goal.

Doctor/RN [Registered Nurse] Intervention: "Medication Management" was listed for Patients A4 and A5). "Medication Consultation" listed for Patients A1 and A7 and assigned only to the doctor. The modality listed was "consult" for both of these interventions. (Individual or group contact not specified). There were no registered nurse interventions listed for Patients A1 and A7.

Recreational Therapist Intervention: "recreation therapy" or "expressive therapy". The modality listed was "RT." (Individual or group contact not specified.)

2. Patients A4 and A5 had the following generic nursing task listed as an intervention under "Psych Problem #1": MHT Intervention: "Supervision." The modality listed was "Milieu."

3. For "Psych Problem #2," Patients A1 and A7 both had identical or similarly worded interventions listed on the Master Treatment Plan. Each patient had different "AED" [as evidenced by]" for the problem listed.

Therapist Interventions: "Cognitive Behavioral Therapy" was listed three times each for three separate short-term goals.

MHT [Mental Health Technician] Intervention: "Supervision" (nursing task) was listed only for Patient A1. The modality was listed as "milieu."

4. For "Psych Problem #2, both Patients A4 and A5 had the following identical intervention listed with no focus of treatment to address patients' individual needs. Each patient had different "AED" [as evidenced by]" for the problem listed.

Therapist Interventions: "Client centered" was listed three times for three separate short-term goals.

5. For "Psych Problem #1," Patients B2, B4, B9, and B12 had the following identical or similarly worded interventions listed on the master treatment with no focus of treatment to address patients' individual needs and/or modality that specified whether the contact would be delivered in individual or group sessions. Patient B4 had these same interventions listed for all three problems on the Master Treatment Plan. Each patient had different "AED" [as evidenced by]" for the problem listed.

QMHP [Qualified Mental Health Professional] Intervention: "Individual, Family, Group Therapy." The modality for listed was "PCT/SOT" [Patient Centered Therapy [sic].

MHT Intervention: "Rehabilitation." The modality was listed as "psychoed" [psycho-education]. (Individual or group contact not specified)

Recreational Therapist Intervention: "Recreation." The modality was listed as "express therapy" [sic]. (Individual or group contact not specified)

Doctor/RN Intervention: "Medication management." The modality was listed as "Rounds." (Individual or group contact not specified)

6. For the "Medical Problem List," Patient B4 & B12 had the following identical or similarly worded nursing tasks listed as interventions: RN/LPN Intervention: "RN/LPN will administer medications as prescribed by MD/PA." "Administer pain meds as ordered by physician."

B. Staff Interviews

1. During an interview on 2/14/11 at 3:55p.m., SW1 confirmed that the intervention statements on the Master Treatment Plans did not include the focus of treatment based on each patient's individual needs.

2. During an interview on 2/15/11 at 10:40a.m., RN2 confirmed that there was no focus of treatment for interventions, and that the treatment plans did not specify whether the nursing intervention would be conducted in an individual or group session. She stated, "RNs are responsible for the "Preliminary Treatment Plan" but not the other plan - just the medical section."

Based on record review and interview, the facility failed to ensure that the name and discipline of staff responsible for interventions was listed on the Master Treatment Plans of 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12). The Master Treatment Plans only listed the discipline responsible for each intervention. This practice potentially results in lack of staff accountability for interventions.

Findings include:

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A1 (2/15/11); A4 (2/11/11); A5 (2/12/11); A7 (2/9/11); B2 (2/12/11); B4 (2/11/11); B9 (2/1/11) & B12 (2/14/11). The review revealed that the name of the person responsible for interventions listed on the plans was not recorded.

B. Staff Interviews

1. During an interview on 2/14/11 at 3:55p.m., SW1 confirmed that the name of the therapist was not recorded for interventions listed on the Master Treatment Plans.

2. During an interview on 2/15/11 at 10:40a.m., RN2 confirmed that the name of the RN and MHT responsible for nursing interventions on the Master Treatment Plans were not recorded.

Based on record review and staff interview, the facility failed to ensure proper documentation of a chemical restraint for 1 of 1 non-sample patient (C1) chosen for review of seclusion and restraint procedures. This failure results in a restriction of patients' rights without adequate documented justification.

Findings include:

A. Record Review

1. A review of the "Seclusion/Restraint: Adolescent & Children's Residential" Form revealed that the face-to-face assessment section of "Form W247" was partially completed and there was no "Assessor" signature, date or time recorded. The following sections were not completed: "I. Placement, III. Clinical Justification, VI. Patient's Condition and VII. Documentation Review."

2. A review of the electronically recorded notation of seclusion and restraint in the Client Information System (CIS) revealed no recording of the face-to-face assessment of Patient C1 as required by policy.

B. Policy Review

The hospital's "Policy #307.2: Seclusion/Restraint - Adolescent & Child Acute" was reviewed. Section B. "Physician, PA, NP, or RN Assessor Responsibilities" stipulates, "1. Provides a "face to face" assessment with the patient within one hour of the placement of the patient in seclusion or restraint ..." "Enter electronic progress notes stating, "See hard copy of S/R Progress Note in the medical record."

C. Staff Interviews

1. In an interview on 2/15/11 at 2:30p.m., RN2 confirmed that the face-to-face assessment for patient C1 was partially completed and there was no signature, date and time of the assessment recorded. She stated that the face-to-face assessment is usually completed by a registered nurse from another unit and not the unit where the restraint occurred.

2. In a discussion on 4/15/11 at 4:30p.m., the Director of Nursing stated that documentation of the face-to-face assessment must be included in CIS. She was unable to locate documentation of the face-to-face assessment for Patient C1 in the medical record or electronic record system. She confirmed that RNs were responsible for conducting the required one-hour face-to-face assessments after an episode of seclusion and restraint. She stated that there is no MD in the hospital in the evening.

Based on record review, policy review and interview, the facility failed to provide discharge plans which specified the dates and times of follow-up appointments for 5 of 5 discharged patients (D1, D2, D3, D4 and D5). Failure to provide patients specific information needed for follow up requires patients, who may still be compromised in their ability to act for themselves, to negotiate with agencies or offices for follow-up care. This can result in the patients not receiving follow-up care.

Findings include:

A. Record Review

1. Patient D1 was discharged on 11/30/10 with follow up to be at Indian Health Care Reserve Center. No appointment date or time was provided.

2. Patient D2 was discharged on 11/30/10 with follow up to be at Family and Children's Services. No appointment date or time was provided.

3. Patient D3 was discharged on 11/27/10 with follow up to be at Robert Youth Center in Davenport Iowa. No appointment date or time was provided.

4. Patient D4 was discharged on 11/27/10 with follow up to be at Family and Children's Services. No appointment date or time was provided.

5. Patient D5 was discharged on 01/05/11 with follow up to be at Parkside Outpatient. No appointment date or time was provided.

B. Staff Interview

In an interview on 2/15/11 at 9:30a.m., the Director of Social Services agreed that the policy is to provide follow up appointments at the time of discharge. She noted that that the discharge planners had recently left the adult and adolescent units and the Licensed Professional Counselors were handling the discharge coordination and may have missed some follow up appointments.

C. Policy Review

Hospital policy 304.29.1, dated 09/98; Rev. 01/18/11 was reviewed. On page 2, Item D, the policy reads" "The therapist's discharge/transfer note will be completed on the same day as the patient's discharge/transfer and will include the following: No. 7, Discharge plan, including appointments."

Based on record review and interview, the Medical Director failed to monitor and evaluate the quality and appropriateness of clinical and medical services provided to patients. Specifically, the Medical Director failed to:

I. Ensure that psychiatric evaluations reported intellectual functioning, memory functioning, and orientation in measurable terms for 6 of 8 sample patients (A1, A5, A7, B2, B4 and B12). This compromises the database from which diagnoses are determined and from which improvements in response to treatment are assessed. (Refer to B116).

II. Ensure that psychiatric evaluations included and inventory of patient assets in a descriptive fashion for 6 of 8 active sample patients (A1, A4, A5, A7, B9 and B12). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy. (Refer to B117).

III. Ensure that interventions on the Master Treatment Plans of 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12) were individualized and included a specific focus and purpose. These patients' Master Treatment Plans contained lists of modalities (individual therapy, group therapy, family therapy), or current psychiatric techniques without specifying a focus for treatment. In addition, the plans contained generic nursing tasks written as interventions and interventions assigned to nursing and recreational therapy staff with no focus of treatment. They also failed to specify whether interventions would be delivered in individual or group sessions. These deficiencies result in treatment plans that do not provide guidance to in delivering consistent and effective treatment related to the patients' problems and goals.(Refer to B122)

IV. Ensure that the name and discipline of staff responsible for interventions was listed on the Master Treatment Plans of 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12). The Master Treatment Plans only listed the discipline responsible for each intervention. This practice potentially results in lack of staff accountability for interventions. (Refer to B123)

V. Ensure the proper documentation of a chemical restraint for 1 of 1 non-sample patient (C1) chosen for review of seclusion and restraint procedures. This failure results in a restriction of patients' rights without adequate documented justification.

VI. Ensure that discharge plans which specified the dates and times of follow-up appointments for 5 of 5 discharged patients (D1, D2, D3, D4 and D5). Failure to provide patients specific information needed for follow up requires patients, who may still be compromised in their ability to act for themselves, to negotiate with agencies or offices for follow-up care. This can result in the patients not receiving follow-up care.

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 the Master Treatment Plans of 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12) included generic nursing interventions with no specific focus or stated purpose. The treatment plans for these patients also failed to specify whether the nursing interventions would be delivered in individual or group sessions. These deficiencies result lack of guidance to nursing staff in providing consistent and effective treatment related to patients' problems and goals.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (2/15/11); A4 (2/11/11); A5 (2/12/11); A7 (2/9/11); B2 (2/12/11); B4 (2/11/11); B9 (2/1/11) & B12 (2/14/11). This review revealed that:

1. For "Psych [Psychiatric] Problem #1," patients A1, A4, A5, and A7 all had the following identical or similarly worded nursing interventions listed on the master Treatment Plan with no focus of treatment and/or specified modality (individual or group sessions). Each patient had different "AED" [as evidenced by]" for the problem listed. The RN [Registered Nurse] Intervention listed for Patient A4 and A5 was: "Medication Management." (Individual or group contact not specified.) There were no registered nurse interventions listed for Patient A1 and A7.

2. Patients A4 and A5 also had the following nursing task listed as an intervention under "Psych Problem #1:" MHT Intervention: "Supervision" The modality listed was "Milieu."

3. For "Psych Problem #2," Patients A1 and A7 both had a nursing task listed as an interventions listed on the master treatment plan. Each patient had different "AED" [as evidenced by]" for the problem listed. The MHT [Mental Health Technician] Intervention for Patient A1 was: "Supervision" (staff task). The modality was listed as "milieu."

4. For "Psych Problem #1," Patients B2, B4, B9, and B12 had the following identical or similarly worded nursing interventions listed on the Master Treatment Plans with no focus of treatment or listed modality (individual or group sessions). Patient B4 had these same interventions listed for all three problems on the Master Treatment Plan. Each patient had different "AED" [as evidenced by]" for the problem listed.

MHT Intervention: "Rehabilitation." The modality was listed as "psychoed" [psycho-education]. (Individual or group contact not specified)

RN Intervention: "Medication management." The modality was listed as " Rounds." (Individual or group contact not specified)

5. For the "Medical Problem List," Patient B4 & B12 had the following identical or similarly worded nursing task listed as an intervention: RN/LPN [Licensed Practical Nurse] Intervention: "RN/LPN will administer medications as prescribed by MD/PA." "Administer pain meds as ordered by physician."

B. Staff Interviews

1. During an interview on 2/15/11 at 10:40a.m., RN2 confirmed that there was no focus of treatment for nursing interventions on the treatment plans, and that the plans did not specify whether the nursing intervention would be conducted in individual or group sessions. She stated, "RNs are responsible for the "Preliminary Treatment Plan" but not the other plan - just the medical section."

2. During an interview on 2/15/11 at 1:10p.m., the registered nurse involvement in active treatment and treatment plan was discussed with the Director of Nursing. The Director of Nursing stated that nurses are responsible for the Preliminary Plan and the Medical Problems on the plan developed after admission. She also confirmed there was no focus of treatment specified for nursing interventions recorded on the treatment plan.

II. Ensure that the name of each nursing staff responsible for nursing interventions was listed on the Master Treatment Plans of 8 of 8 active sample patients (A1, A4, A5, A7, B2, B4, B9 and B12). The treatment plans listed "RN" and "MHT" rather than the name of the RN and MHT responsible for the assigned nursing interventions. This practice results in lack of staff accountability for interventions.

Findings Include:

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A1 (2/15/11); A4 (2/11/11); A5 (2/12/11); A7 (2/9/11); B2 (2/12/11); B4 (2/11/11); B9 (2/1/11) and B12 (2/14/11). This review revealed that the name of RN and MHT responsible for the listed nursing interventions were not recorded on the plans.

B. Staff Interviews

1. During an interview on 2/15/11 at 10:40a.m., RN2 confirmed that the names of the RN and MHT responsible for the nursing interventions were not recorded on the Master Treatment Plans.

2. During an interview on 2/15/11 at 1:10p.m., the DON confirmed that the names of nursing staff responsible for nursing interventions were not recorded on patient's Master Treatment Plans.

III. Ensure proper documentation of a chemical restraint for 1 of 1 non-sample patient (C1) chosen for review of seclusion and restraint procedures. This failure results in a restriction of patients' rights without adequate documented justification. (Refer to B125)

IV. Ensure adequate numbers of Registered Nurses (RN) and Licensed Practical Nurses (LPN) to provide nursing care, supervise, and monitor patients. This failed practice can result 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. (Refer to B150)

Based on observation, record review and interview, the facility failed to deploy adequate numbers of Registered Nurses (RN) and Licensed Practical Nurses (LPN) to provide nursing care, supervise, and monitor patients. This failed practice can result 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.

Findings include:

I. Adolescent Unit

A. Observations

1. Observations on the Acute Adolescent/Residential Unit on 2/14/11 from 1:05p.m. to 4:15p.m. and on 2/15/11 from 2:00p.m. to 3:15p.m. revealed that the registered Nurse (RN) duties included discharging patients, stepping down patients to residential care, transferring patients to the Residential Treatment Facility, documenting in CIS [computer record], administering medications, assisting therapists, and answering phones. These duties required the registered nurse (RN) to remain in the nursing stations most of the time. While the RN remained in the nursing station, Mental Health Technicians (MHT) received limited supervisions in providing patient care.

2. During an observation on 2/14/11 at 2:00p.m., the nurse surveyor saw Patient A1 vomiting three times consecutively in the trash barrel located in the dayroom. The MHT in the dayroom was conducting a group and did not observe the patient vomiting. The surveyor notified the RN, and she responded immediately by asking a MHT to assist the patient. Review of Patient A1's records on 2/15/11 at 10:45a.m. (the day after the observation) revealed no documentation of the vomiting episode or an assessment of the patient's condition, (information about the vomit [e.g. color]) or what the RN did to assist the patient. When asked about the missing documentation, RN2 stated that the patient said he was feeling better, and that she did not get a chance to document any information in CIS.

B. Document Review

1. An analysis of staffing data for the Adolescent Unit (which currently included 9 adolescent patients designated as acute care and 3 adolescent patients designated as residential care) revealed the following staffing on 2/14/11:

Day Shift: One RN and 3.25 MHTs. RN worked 7a.m. to 7p.m. One MHT worked 1p.m. to 9p.m.

Evening shift: One RN and 3.75 MHTs. RN worked 7p.m. to 7a.m.

Night Shift: One RN and 2 MHTs.

2. A review of staffing data for the dates2/8/11 to 2/13/11 revealed a similar census and staffing as that above (see #1). The census ranged from 10 to 14 patients (combined acute and residential care patients) with staffing as follows:

Day Shift: One RN and 3.25 MHTs for 4 of 6 shifts. RN worked 7a.m. to 7p.m. One MHT worked 1p.m. to 3p.m. One RN and 3 MHTs for 2 of 6 shifts. RN worked 7 a.m. to 7 p.m.

Evening shift: One RN and 3.75 MHTs for 4 of 6 shifts. RN worked 7p.m. to 7a.m. One MHT worked 3p.m. to 9p.m. One RN and 3 MHTs for 2 of 6 shifts.

Night Shift: One RN and 2 MHAs for 6 of 6 shifts.

3. Review of a "Nursing Needs Assessment" Form completed for the Adolescent/Residential Unit during the survey revealed the following:

a. On 2/14/11, there was one patient who engaged in assaultive behavior within the last 48 hours; 3 patients were potentially assaultive; 2 patients were considered an acute suicidal risk, and 3 patients were classified as having a high potential for self injury and required close observation.

b. The average number of admissions per week was 5 on the evening shift, and 2 on the night shift. The average number of discharges per week was 2 on the day shift and 2 on the evening shift. The average number of transfers per week was 2 on the day shift and 4 on the evening shift. The Director of Nursing stated that these statistics were estimated numbers.

c. Additional data submitted for 2/16/11 showed that the Adolescent Unit (combined acute and residential care) had 77 admissions, 74 discharges, and 31 transfers during January 2011.

4. A review of "Seclusion and Restraint Monthly Tracking Records" for the Adolescent Unit revealed that there were 21 episodes of seclusion or restraint in January 2011. Some of these could have required the RN from the Adult Unit to conduct a face-to-face assessment on the Adolescent Unit.

5. A review of "Seclusion and Restraint Monthly Tracking Records" for TCAT [Tulsa Center for Adolescent Therapy] revealed that there were 41 episodes of seclusion or restraint in January 2011, and 27 S/R episodes in February 2011 that would have potentially required an RN to go across the street to the Residential Care Facility to conduct a face-to-face assessment.

6. The hospital's "Policy #307.2: Seclusion/Restraint - Adolescent & Child Acute" was reviewed. Under section "B. Physician, PA, NP, or RN Assessor Responsibilities," the policy states that the required face-to-face assessments include the following tasks for the assessor... "2. Completes the Assessment Section of the Seclusion and Restraint Form ...3. Work with patient to identify ways to help him/her regain control. 4. Review the event with the treatment team to determine if revisions are required on the treatment plan."

C. Staff Interviews

1. In an interview on 2/14/11 at 10:00a.m., when asked about the "Adolescent Acute Schedule," RN2 stated that there are no RN led groups on the schedule, and that Techs are responsible for the groups [Rehabilitative]. She stated that she does medication education at medication time. She agreed that when she administers medications, there is very limited time to provide patient education.

2. In an interview on 2/15/11 at 9:30a.m., RN3 [assigned to work 7 p.m. to 7 a.m.] stated she had to stay over to complete her assignments because it was so busy.

3. In an interview with RN2 on 2/15/11 at 10:40a.m., RN2 stated that the nursing workload "was very heavy yesterday." RN2, who works 7a.m. to 7p.m., discussed having to work until 12:30p.m. on 2/14/11 in order to complete all of the required duties. She said that these duties included those for 2 admissions [one at 5p.m. and one at 6:30 p.m.]; 2 discharges [one at 3 p.m. and one between 4 and 5p.m.], 2 transfers to the Residential Care Facility, and following up on medication consents that were not done. RN2 stated she also had to do paperwork regarding a physical hold and for two adolescents who were changed from acute care to residential care during the shift. RN2 stated, "We need help. The second floor has a LPN [Licensed Practical Nurse] to help."

During the same interview (above), when discussing the face-to-face assessments for episodes of seclusion or restraint, RN2 stated that the registered nurse from downstairs [Adult Unit] is responsible for the face-to-face assessments on the Adolescent Unit. She stated that the RN on the Adolescent Unit is primarily responsible for completing the face-to-face assessments on "TCAT" [Tulsa Center for Adolescent Therapy]. (This was the Residential Care Facility located in a building across from Parkside Hospital.) RN2 confirmed that there is no licensed nurse on the Adolescent Unit when this occurs. She stated that the RN on the 2nd floor, [Adult Unit] goes to TCAT when she [RN on Adolescent Unit] is busy.

4. During an interview on 2/15/11 at 11:45a.m., the Director of Nursing [DON] confirmed that RNs from the hospital are required to conduct face-to-face assessments of children and adolescents located in the Residential Care Facility. She stated that there is no MD in the hospital in the evening.

5. During an interview on 2/15/11 at 1:10p.m., the treatment plans and RN involvement in patient teaching were discussed. The DON stated that nurses do medication education at med times but do no groups. She confirmed that there are no RN groups on the Unit Schedules. She stated that RNs may do groups on weekends, but that these groups are not included on the schedule or on patients' treatment plans.

II. Adult Unit

A. Document Review

1. An analysis of the staffing data for 2/14/11 revealed the Adult Unit had a census of 13 patients and the following staffing.

Day Shift: One RN, .5 LPN, and 3 MHTs.

Evening shift: One RN and 3 MHTs.

Night Shift: One RN and 2 MHTs.

2. A review of staffing for the dates of 2/8/11 to 2/13/11 for the Adult Unit revealed a similar census and staffing as that above (see #1). The census ranged from 10 to 15 patients with staffing as follows:

Day Shift: One RN, .5 LPN, and 3 MHTs for 3 of 6 shifts. One RN, .25 LPN, and 3 MHTs for 1of 6 shifts. One RN and 3 MHTs for 2 of 6 shifts (weekend).

Evening shift: One RN and 3 MHTs for 5 of 6 shifts. One RN and 2 MHTs for 1 of 6 shifts.

Night Shift: One RN and 2 MHTs for 6 of 6 shifts.

3. A "Nursing Needs Assessment" Form completed during the survey revealed the following:

a. On 2/14/11, there were two patients who were potentially assaultive, two acutely suicidal patients, 3 patients on Detox Protocols, and 1 patient on Diabetic checks.

b. The average number of admissions per week was 3 on the day shift, 3 on the evening shift, and 1 on the night shift. The average number of discharges per week was 4 on the day shift and 2 on the evening shift. The Director of Nursing stated that these statistics were estimated numbers.

c. Additional data provided by the Director of Nursing on 2/16/11 showed that the Adult Unit had 48 admissions and 47 discharges during January 2011.

4. A review of "Seclusion and Restraint Monthly Tracking Records" for the Adult Unit revealed that there were 3 episodes of seclusion or restraint in January that would have potentially required the RN from the Adolescent Unit to conduct a face-to-face assessment on the Adult Unit.

B. Staff Interview

In an interview on 2/16/11 at 8:45a.m., RN1 stated that RN staffing is very "tight." She reported that she works an 8-hour shift but frequently stays 2 to 4 hours after her shift to complete her charting for the day. When asked about break times for meals and time off unit, she replied, "There is not coverage for breaks, so I usually don't take one." When asked about coverage for face-to-face assessment for episodes of seclusion or restraint, she stated that these are usually of short duration. She added "I take the radio so that staff can reach me." When asked about patient teaching, RN1 stated that she occasionally gets a chance to run a group, but that in general, there are not scheduled nursing groups.

Based on document review and interview, the facility failed to provide a Director of Social Work who possessed a master's degree in social work or who assigned a social work staff person with an MSW to fulfill the duties, functions and responsibilities of the Director. This failed practice results in no professionally directed social work services for patients.

Findings include:

A. Document Review

Review of the Curriculum Vita for the Director of Social Services showed that the incumbent Director has a Masters Degree in Counseling Psychology and is a Licensed Professional Counselor.

B. Interview

In an interview on 02/15/11 at 9:30a.m., the Director of Social Services said that one of the part-time social work staff does have an MSW. She added that this person works on weekends and does not undertake any specific tasks related to clinical review or oversight of social services programming. The Director of Social Services stated that there was no one with a Master's degree in social work serving in that capacity at the time of the survey.