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Immediate Jeopardy (IJ) was determined on 2/27/2018 at 3:50 PM regarding the facility failing to ensure all minor patients in adult units are receiving care in a safe environment. Facility policy for "Safety-Security" did not provide safety standards and reassessment of safety needs for all minors on adult units. There were two adolescents on adult forensic units (one on same sex unit and one on a co-ed unit) without 24 hour supervision.

The facility was notified of the IJ on 2/27/2018 at 3:50 PM.

The IJ was removed on 2/28/2018 at 3:00 PM by placing both minors into private rooms with 24 hour one to one supervision by staff on the adult forensic units.

The facility failed to ensure all minor patients on adult units were receiving care in a safe setting. (See tag A-0144)

Based on record review and interview, facility staff failed to asses risk and implement 1:1 to all minors on adult units, enforced 1 of 1 policy (Safety-Security Precautions #202.19) that did not provide the same safety precautions for minor patients that were hospitalized under Chapter 971, and failed to assess minors on adult units for safety and security in 2 of 2 minor patients reviewed (Patient #1 & Patient #2).

Findings include:

Review of facility policy "202.19 Safety-Security Precautions" dated 4/2015 revealed "All patients are entitled to receive treatment in an environment that is safe and secure. At times, some patients require an increased level of supervision and intervention to prevent self-injurious behavior, elopement, behaviors that threaten the safety and security of others, or harm due a patient's vulnerability...Staff have a moral, legal, and professional responsibility to protect patients from physical aggression and assault, and from sexual contact, abuse, assault, harassment, exhibitionism, and exploitation by others...Physicians and treatment team members consider the patient's clinical condition, clinical risks, and the environmental and physical limitations of the unit when selecting the most appropriate Safety-Security Precautions required for safeguarding the patient...D. Requirements for Minors on Adult Units: 1. Minors waived into adult court and admitted under Statute Chapter 971 are admitted and treated adult forensic patients. 2. Minors admitted or transferred to an adult unit under Statutes Chapter 51 or Chapter 938 will have a specific safety-security treatment plan in place until the individual turns 18 years old. A. The Safety-Security Responsibility Log 1. Addresses the special risks involved when a minor is living on an adult unit. The plan should evaluate the risks and state how any physical, mental, and sexual risks are being addressed. 2. Includes assigning a specific staff member to the patient for the purpose of monitoring (1:1) and ensuring safety and security. 3. Requires a one-time Physician's Order describing the purpose of the 1:1 (i.e. , due to the patient being a minor)".

Per medical record review, Patient #1 is a minor residing on an adult co-ed forensic unit at the facility. Patient #1's "Initial Assessment" dated 6/30/17 documented "(Patient #1) will be admitted to WMHI/PHS (Winnebago Mental Health Institute) for evaluation. (Patient #1) is a minor but is being placed in PHS (Petersik Hall) due to the nature of (his/her) crime. (Patient #1) is placed on the adult forensic unit as an adolescent for (his/her) safety, confidentiality, and to prevent propaganda through various sources. Due to (his/her) placement on the adult unit, (he/she) will be placed on 1:1 supervision during waking hours until (he/she) is asleep for 30 minutes. (He/she) will sleep in (his/her) room with (his/her) door closed and monitor per standard unit protocol." At the time of the survey on 2/27/18, Patient #1 was residing on the adult co-ed forensic unit Choices. Patient #1 (age 15) was not on 1:1 supervision by a staff at all times on adult unit. Patient #1's Safety-Security log did not include an assessment of risks involved when a minor is living on an adult unit, and the plan of care did not contain the evaluation of the risks and state how any physical, mental, and sexual risks are being addressed for patient #1.

Per interview on 2/27/18 at 9:29 AM, Chief Operating Officer Q stated "Initially (Patient #1) was on 1:1 was 'weaned off' (1:1)...once (Patient #1) was found guilty NGI (not guilty by reason of insanity) and tried as an adult under Statute Chapter 971...(Patient #1) could not be put on the youth unit."

Per medical record review, Patient #2 is a minor residing on an adult forensic unit at the facility. Patient #2's "Initial Assessment" dated 1/3/18 documented "1. Admit to Petersik Hall South...3. Standard unit precautions will be observed." Review of Patient #2's Safety-Security log did not include an assessment of risks involved when a minor is living on an adult unit, and the plan of care did not contain the evaluation of the risks and state how any physical, mental, and sexual risks are being addressed for Patient #2. Patient #2 was not on 1:1 supervision by staff at all times on adult forensic unit.

When asked about the facility's policy for minors residing on adult units on 2/27/18 at 10:00 AM, Director of Nursing M stated "we keep minors that are on adult units on 1:1 supervision unless they are Chapter 971." Per Staff M both Patients #1 and #2 were admitted under Chapter 971. Staff M was not able to explain why Chapter 971 minor patients were not provided the patient rights for safety and security as all other minors admitted to adult units.

Based on record review, and interview, the facility failed to involve contracted services in their quality assessment and performance improvement program in 2 of 2 contracted services (Radiology and Laundry Services); and failed to maintain an ongoing program for quality improvement in 4 of 16 departments of the facility (Laundry, Radiology, Environmental Services and Organ Procurement).

Finding include:

Per interview on 2/27/18 at 10:00 AM, Staff M (Director of Nursing) was asked to describe quality projects pertaining to organ, tissue, and eye procurement, Staff M stated, "nothing I can think of."

Per interview on 2/27/18 at 11:00 AM with Staff P (Nurse Educator/Quality) there was no cumulative list of all departments in facilities active quality assessment program. Staff P composed and provided a list titled "Departments with Active PI" (Performance Improvement) on 2/27/18 at 1:00 PM that document revealed "X-ray (no, it's a contracted service)" and did not document environmental services, laundry or organ procurement as having an "active" quality program. This was confirmed in interview with Staff P upon receiving the list.

Based on record review and interview, the facility failed to provide preventive equipment for 1 of 1 patient with a pressure ulcer (Patient #28).

Findings include:

Per medical record review, Patient #28 was admitted to the facility on 3/22/06 for mental illness. Patient #28's medical problems include multiple sclerosis with limited mobility, wheels chair use and urinary incontinence. Patient #28 developed 3 pressure ulcers while in the hospital in September 2017, staged I, II, and III. Review of "Progress Note--Wound Assessment" form dated 1/8/18 through 1/31/18 reveal staff were treating one pressure ulcer, stage II, on Patient #28's left buttock. The wound measured 2.3 cm x 1.3 cm on 1/8/18 and 3 cm x 2.5 cm on 1/31/18.

On 2/16/18 Patient #28's physician ordered "Use ROHO (ROHO cushion is to decrease the amount of pressure on the sitting area through a patented technology of interconnected neoprene air cells that increase and decrease in air volume to match an individual's contours) cushion for stage III pressure ulcer" and "Use Mepilex [absorbent dressing] to periwound."

Patient #28's nursing care plan for Impaired Tissue Integrity includes the following active interventions for wound care: "veneflex cream to wound on buttocks QID [4 times daily], Apply aquacel (enough to cover open wound) cover then with gauze, Use Mepilex over butt wound" and the following interventions for positioning: "Pt. may stay up as long as desired in chair, Patient to utilize chair 3x/day for no more than 1 hour at a time, May be up in chair more than 1 hour but propped off right side."

Review of Patient #28's "Progress Note -- Wound Assessment" reveal Aquacel was the only preventive equipment documented as used from 1/8/2018 through 2/26/18. The care plan was updated on 2/16/18 to include "Use ROHO cushion when available."

During an interview on 2/28/18 at 1:40 PM Staff M (Director of Nursing) stated "We are still waiting on a gel mattress for [Patient #28], it's not in yet." Review of wound assessment progress notes dated 2/26/18 reveal "...wound has worsened this month."

Based on record review and interview, the facility failed to ensure care plans accurately reflect patient strengths in 2 of 2 patients reviewed (Patient #19 & Patient #26) and failed to document status of goals for active medical problems for 1 of 1 inpatients reviewed who was discharged within one week (Patient #24).

Findings include:

Review of facility policy "Documentation Guidelines" dated 1/2018 revealed "The plan for nursing care shall be reviewed and updated as patient needs change and must be reviewed with Primary RN progress note."

Per medical record review, Patient #19's Nursing Care Plan, initiated on 12/20/2017 identifies a strength of "access to housing." Review of Patient #19's initial social service assessment revealed "Problems: [Patient #19] does not have a home to return to in the community..."

Per medical record review, Patient #24's Nursing Care Plan, initiated on 2/22/17, includes a goal of "Patient will be able to identify 2 facts regarding the disease process within 1 month" for a nursing diagnosis of risk for impaired liver function. Patient #24 was discharged on 2/26/18. The care plan does not include progress made toward goal or whether or not the goal was met at discharge.

Per review on 2/27/17 at 8:50 AM of Patient #26's medical record revealed an admission date of 9/26/17. Initial assessment dated 9/26/17 revealed the following, "Unable to take care of self. Has to be fed and dressed." The following problem was initiated on the care plan on 10/11/17- "Frail elderly syndrome related to history of falls, malnutrition, age psychiatric disorder, Dementia with Psychosis as evidence by activity intolerance, bathing self-care deficit, dressing self-care deficit, fatigue, feeding self-care deficit, impaired memory, impaired physical mobility, impaired walking, toilet self-care deficit". Findings were shared with Director of Nursing M on 2/28/18 at 1:45 PM. Director of Nursing M, stated, "The care plans need work".

During an interview on 2/27/18 at 11:40 AM Staff H (Nursing Supervisor) stated "nursing care plan goals are what the nurses should be working on with patients while they are here." Per Staff H, "not all patient's stay for a full week, so the nurses work on a short-term goal related to the physician's goal for treatment. The care plan is supposed to complement the physician's goal." Staff H stated "there is no documentation of progress toward nursing care plan goals if the patient is here less than 1 week, we are working to fix that."



29963

Based on record review and interview the facility failed to follow physician orders in 1 of 33 patient (patient #26) medical records reviewed.

Findings include:

Per review on 2/28/18 at 8:50 AM of Patient #26's medical record revealed a physician order dated 9/29/17, "monitor strict I & O" (intake and output). Intake and Output Record dated 10/1/17 revealed, "Refused breakfast, 120 ml of grape juice, 100% of Salisbury steak and 75% of potatoes". There was no output documented. On 10/2/17- oral intake was documented for 3 meals, output for 24 hours revealed, "urinated in toilet with bowel movement" on PM shift. No other documentation. On 10/4/17- no output was documented for 24 hours. On 10/5/17 no intake or output was recorded for PM and night shift. On 10/6/17- no output was documented for AM and PM shift. On 10/7/17- "4 cc of apple juice for breakfast", no other intake was recorded for breakfast and lunch. Output was documented on AM shift, "urine in bed", no documentation for PM and night shift. On 10/8/2017, no output was documented for AM and night shift. On 10/9/17- no output documented for PM and night shift. On 10/10/17- No intake recorded for breakfast and lunch, no output was documented for AM, PM, and night shift. On 10/12/17- no output was documented for AM, PM, and night shift. On 10/13/17- no output was documented for AM, PM, and night shift. On 10/14/17- no output was documented for AM shift. Findings were confirmed with Director of Nursing on 2/28/18 at 1:45 PM.

Per interview on 2/28/18 at 1:45 PM, Staff M (Director of Nursing) stated, "If a patient was on strict intake and output, everything should be documented throughout the 24 hours".

Based on observation, record review and interview, facility staff failed to ensure that hot and cold food were held at safe temperatures in 1 of 3 cafeterias (Gordon Hall Servery); failed to ensure foods were labeled, dated and stored per policy in 3 of 7 nursing unit kitchenettes (Gordon North, Gordon South, Gemini); and failed to ensure cooking equipment was maintained in a sanitary manner in 1 of 1 kitchen and 2 of 7 nursing unit kitchenettes (Gordon North, Gordon South).

Findings include:

Hot/Cold Holding Temperatures:

Review of facility policy "Holding Potentially Hazardous Hot Foods" dated 5/25/16 revealed "3. ...Hold hot foods at 135 degrees Fahrenheit or above. Monitoring: 4. For hot foods held for service: ...Take the internal temperature of food before placing it on a steam table or in a hot holding unit and at least every 2 hours thereafter. ...Hot foods need to be reheated to 165 for 15 seconds if the temperature is found to be below 135 and the last temperature measurement was 135 or higher and taken within the last 2 hours. Discard the food if it cannot be determined how long the food temperature was below 135 degrees."

Review of facility policy "Holding Potentially Hazardous Cold Foods" dated 5/25/16 revealed "3. ...Hold cold foods at 41 degrees Fahrenheit or below. Monitoring: 4. For cold foods held for service: ...Take the internal temperature of the food before placing it onto any salad bar, display cooler, or cold serving line and at least every 2 hours thereafter. ...Cafeteria staff will refrigerate all cold foods that come to their serveries until time of service. ...Discard the food if it cannot be determined how long the food temperature was above 41 degrees."

Per interview on 2/27/18 at 4:45 PM, Staff X (Food Service Supervisor) stated hot and cold foods delivered from the kitchen to the cafeterias and are held in the cafeterias before serving dinner. The Gordon Hall Servery serves 2 dinner shifts at approximately 4:45 PM and 5:00 PM. During an interview on 2/27/18 at 4:50 PM, Staff Y (Food Service Assistant) stated that cold food was delivered to the Gordon Hall Servery from the main kitchen at 2:15 PM and hot food was delivered at 3:00 PM. Per Staff Y, the temperatures of the foods are checked upon arrival from the kitchen and documented. Review of the food temperature log revealed one set of temperatures dinner shifts, not every 2 hours per policy.

On 2/27/18 at 5:00 PM observed Staff Y checked the temperature of fish that was being held for serving. Staff Y stated the fish was "130 degrees, I will turn up the warmer." Mixed vegetables, also held in the hot holding area, were temped at 130 degrees. Staff Y then checked the temperature of a mayonnaise-based pasta salad. Per Staff Y, the temperature of the pasta was "44 degrees." Staff X stated "that's too warm." When asked what happens to the cold food after it was delivered at 2:15 PM, Staff Y didn't state anything. Staff X stated "they are supposed to be keeping it in the refrigerator until serving time."

Food Storage:

Review of facility policy "Food Storage/Preparation/Service in Non-Nutrition Service Areas" dated 12/2016 revealed "IV. Food Storage: Condiments/Shelf stable dry storage items -- use a container to keep them in. Label and date the container with date filled. Throw out any that remain after 6 months."

On 2/26/18 at 12:50 PM observed the Gordon Hall North kitchenette contained unlabeled, undated containers of powdered sugar, granulated sugar, brown sugar, powdered cocoa and flour. A labeled container of baking powder was dated 11/2014.

On 2/26/18 at 1:00 PM observed the Gordon Hall South kitchenette contained 3 open, unsealed and undated bags of dry cereals.

On 2/26/18 at 2:00 PM observed the Gemini kitchenette contained opened, undated containers of rice, flour, sugar, oatmeal, coconut and a package of ice cream cones with an expiration date of 2016.

During an interview on 2/26/18 at 12:50 PM, Staff H (Nursing Supervisor) stated nursing staff was responsible for the food supplies on the kitchenettes in the nursing units.

Cookware and Equipment:

Review of facility policy "Food Storage/Preparation/Service in Non-Nutrition Service Areas" dated 12/2016 revealed "A. Cleaning and Sanitizing: 6. The general area should be kept clean, orderly and free of debris and other garbage."

On 2/26/18 at 12:50 PM observed the Gordon Hall North kitchenette contained an oven/range with a layer of black debris inside. Staff H stated at the time of the observation "it does not appear that it [the oven] is cleaned regularly."

On 2/26/18 at 1:00 PM observed the Gordon Hall South kitchenette's refrigerator had a black substance on the door and pink substance on the shelves in the refrigerator. When asked how frequently the refrigerators are cleaned and by whom, Staff H stated "I believe the nursing staff is responsible to clean them" but was unsure of a schedule or how often they are cleaned.

On 2/27/18 at 4:00 PM observed dust and debris on the oven hoods in the main kitchen. During an interview on 2/28/18 at 10:45 AM, Staff Z (Food Services Manager) stated the hoods in the kitchen are serviced and cleaned annually and that kitchen staff clean the hoods regularly, "every month on the weekends I think." Staff Z was unable to provide evidence of when the hoods were last cleaned or that the schedule was adequate to prevent build up of dust and debris on the hoods.

Based on record review and interview, the facility failed to have a current therapeutic diet manual reviewed and approved by the dietician and medical staff in 1 of 1 nutrition manual reviewed (Therapeutic Diet Manual).

Findings include:

Review of the facility's therapeutic diet manual on 2/27/2018 revealed the diet manual was dated January 2010. The approval signatures were signed in March 2010. During an interview on 2/27/2018 at 4:00 PM, Staff A (Management Services Director) stated "sections of the manual have been updated" but the manual had not gone through a review or approval process since 2010 "that I know of."

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies:

K 131 multiple occupancies
K 223 doors with self closing devices
K 311 vertical openings
K 321 hazardous areas
K 341 fire alarm system installation
K 345 fire alarm system testing and maintenance
K 351 sprinkler system installation
K 353 fire suppression sprinkler maintenance
K 355 portable fire extinguishers
K 363 corridor doors
K 374 subdivision of building spaces
K 781 portable space heaters
K 791 construction repair and improvement operations
K 920 electrical equipment power cords and extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41(b) Standard: Life safety from fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies:

K 131 multiple occupancies
K 223 doors with self closing devices
K 311 vertical openings
K 321 hazardous areas
K 341 fire alarm system installation
K 345 fire alarm system testing and maintenance
K 351 sprinkler system installation
K 353 fire suppression sprinkler maintenance
K 355 portable fire extinguishers
K 363 corridor doors
K 374 subdivision of building spaces
K 781 portable space heaters
K 791 construction repair and improvement operations
K 920 electrical equipment power cords and extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview the facility failed to maintain an environment that was free from potential contamination and/or failed to follow national standards of practice in 4 of 8 observations (Sherman Hall, Facility Clean Linen Storage, Petersik Hall North).

Findings include:

Per "Guidelines for Environmental Infection Control in Health-Care Facilities" from the CDC (Centers for Disease Control) on June 6, 2003 under "Recommendations--Laundry and Bedding" "IV. Laundry Process A. If hot-water laundry cycles are used, wash with detergent in water >160 degrees F for >25 minutes."

Examples on Sherman Hall:

On 2/26/18 on tour of Sherman Hall observed in 8 of 8 laundry rooms that there was no monitoring of water temperatures being completed for the washing machines provided to the patients who choose to do their own laundry. An interview was conducted with Staff G (Nurse Manager of Sherman Building) at the time of discovery. When questioned Staff G as to how it was ensured that water temperature would be high enough to kill any potential organisms (i.e. C Difficle Bacteria for example) Staff G replied "I don't know". Upon request of a facility policy on patient's doing their own laundry and Staff G stated there was not one. An email was provided on 2/26/18 stating that water temperatures for the facility range from "108-110 degrees Fahrenheit. The water temps are checked daily by the maintenance department." An interview was conducted on 2/28/17 at 9:30 AM with Staff M (Director of Nursing) who stated "the water temperatures are checked daily by maintenance at the water source for the facility."

An interview was conducted on 2/28/18 at 2:30 PM with Staff L (Infection Preventionist) revealed that the facility uses CDC for infection control standards.

Examples in clean linen storage:

On 2/26/18 observed in 8 of 8 unit laundry rooms in Sherman Building clean utility rooms all clean linen were stored uncovered. An interview was conducted with Staff G (Nurse Manager Sherman Building) at the time of observations confirmed that linen was left uncovered. There was blue curtains able to be slid across shelves with clean linen to cover them but curtains were pushed to the side on the units (5 of 8) that had them, the other units had no curtain present.

On 2/27/18 at 1:30 PM observed clean linen storage located in the basement of facility revealed all clean linen was stored uncovered.

Per interview on 2/27/28 at 2:15 PM, Staff K (Supervisor of Housekeeping and Linen) stated, "we were not sure if the clean linen needed to be covered while in storage".

Examples in nursing:

Per review on 2/27/18 at 11:45 AM titled, "Blood Glucose Testing Procedure", #3149972, dated 2/2017 revealed under "Specimen Collection and Handling: 6. If the patient is able, the patient should wash his/her hands with warm water prior to testing with capillary samples taken from the fingertip".

On 2/27/18 at 11:10 AM observed Staff J (Registered Nurse) perform a blood glucose check on Patient #27. Patient #27 was not observed or asked to complete hand hygiene prior to procedure. Staff J completed the procedure in the exam room across from the nurse's station, removed gloves and did not perform hand hygiene. Staff J picked up the blood glucose meter and blood glucose supply case and returned the meter and the case to the common area in the nurses station. STaff J then disposed of single use lancet in sharps container in the medication room. Staff J then completed hand hygiene and used a sani-wipe and cleaned the surface of the blood glucose meter. Staff J did not clean the supply case.

Per interview on 2/27/18 at 2:30 PM, Staff L (Infection Preventionist) stated, "The supply case and monitor should be cleaned at the point of use, and hand hygiene should be completed anytime gloves are removed".

Based on record review and interview, facility staff failed to complete discharge forms per policy in 2 of 6 discharged patients reviewed (Patient #20 & Patient #21).

Findings include:

Review of facility policy "Documentation Guidelines" dated 1/2018 revealed "Aftercare Transition Record: An Aftercare Transition Record shall be completed for every patient discharged or transferred from [the facility]. ...The discharging nurse is responsible for the accuracy and completeness of the Aftercare Transition Record... A copy is also provided to the patient and /or patient's guardian, family or caregiver..."

Per medical record review, Patient #20 was discharged from the facility on 1/26/18. Patient #20's Aftercare Transition Record does not include a discharge status and was not signed the patient or discharging nurse.

Per medical record review, Patient #21 was discharged from the facility to home on 2/1/18. Patient #21's Aftercare Transition Record does not include the reason for discharge.

During an interview on 2/28/18 at 9:00 AM, Staff W (Social Services Director) stated all patients are provided an "Aftercare Transition Record" at discharge. Per Staff W, the social worker sends an email near patient discharge to the interdisciplinary team and the nursing staff was responsible to complete the form, have the patient sign and give the form to the patient at discharge. During an interview on 2/28/18 at 1:40 PM with Staff M (Director of Nursing) stated the nursing staff was expected to fill out all portions of the form accurately.

Based on record review and interview, facility staff failed to ensure at risk patients are screened for suicide risk prior to discharge in 1 of 6 discharged patients reviewed (Patient #27).

Findings include:

Review of facility policy "Procedure for Discharge Preparation" dated 1/2018 revealed "F. Final assessment of the patient must include: ...2. Condition upon discharge - as located in the Columbia Suicide Severity Rating Scale."

During an interview on 2/28/2018 at 9:00 AM, Staff W (Social Services Director) stated all staff are trained in the Columbia Risk Screening tool and all patients are screened for risk prior to discharge.

Per medical record review, Patient #27 was admitted to the facility on 1/22/18 with self-harm behaviors. Patient #27 was discharged from the facility on 2/20/18. Review of physician progress notes dated 2/19/18 reveal "Patient states [#27] is confused and worried... Denies suicidal or homicidal ideations." Patient #27's medical record did not include a Columbia Suicide Severity Rating Scale form at the time of discharge. Patient #27 was readmitted to the facility on an emergency detention on 2/23/18, 3 days after discharge, for self-harm behaviors.

During an interview on 2/28/18 at 1:40 PM, Staff M (Director of Nursing) stated patients are expected to have a Columbia screen completed at discharge. Per Staff M, "I was unable to locate a discharge Columbia for [Patient #27]."

Based on record review and interview, facility staff failed to perform analysis of readmission data in an effort to evaluate the efficacy of the discharge planning process in 1 of 1 patients reviewed for readmission (Patient #27).

Findings include:

Review of facility policy "Discharge Planning" dated 1/2016 revealed "11. The discharge planning process is reviewed and reassessed during the Social Services Department Peer Review meeting(s) at least every two years... This will include a review of discharge plans to determine if the plans meet the identified needs of the patients."

During an interview on 2/28/18 at 9:00 AM, Staff W (Social Services Director) stated the facility tracks hospital readmissions. Review of the facility's log of readmitted patients does not included analysis of the reasons for readmission. Per Staff W, the facility has a form titled "Readmission Analysis" that was filled out for readmission patients. Information on the form includes evaluation of the discharge plan, primary reasons for readmission and other possible contributing factors. When asked about readmission goal rates or interventions designed to improve readmission rates, Staff W stated "we worked on a project about 3 or 4 years ago but we're not really doing anything now besides tracking." Per Staff W, "I audit the social worker documentation to make sure it includes all the required components." Staff W stated there was no other evaluation of the discharge services provided at the facility.

Per medical record review, Patient #27 was admitted to the facility on 1/14/18 through 1/18/18 and was readmitted to the facility on 1/22/18 through 2/20/18. Patient #27 was admitted on both 1/14/18 and 1/22/18 for self-harming behaviors. Review of Patient #27's "Readmission Analysis" form on 2/28/18, dated 1/22/18 does not include any information about Patient #27's discharge plan from 1/18/18 or admission information of the current hospitalization of 1/22/18. During an interview on 2/28/18 at 11:35 AM, Staff W stated "we're not really completing them [readmission forms] as we should." Per Staff W Patient #27 was readmitted again to the facility on 2/23/18, 3 days after discharge.

Based on observation, interview, and document review, the facility failed to maintain medical records that provides a basis for purposeful goal-directed treatment.

Specifically, the facility failed to:

I. Develop and document individualized treatment interventions with the specific purpose and focus based on the needs of 11 of 15 active sample patients (Patient 1, A23, B2, B14, C7, D2, D13, E9, E15, F7, and F23). This deficiency results in a failure to provide a basis for accurate implementation, evaluate treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B122)

II. Provide alternative treatment for three (3) of 15 sample patients (A23, C7, and D13) who were unable or unwilling to attend groups. This deficient practice results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125, Section I)

III. Provide age-appropriate treatment for two (2) of two (2) adolescent patients (active sample Patient 1 and non-sample Patient 2 who was added to review active treatment). These adolescent patients were housed and programmed on adult forensic units. This deficiency results in patients not receiving appropriate treatment that considered their age/developmental level and resulted in potentially delaying their improvement. (Refer to B125, Section II)

IV. Provide a cohesive and comprehensive treatment schedule for all units in which patients and staff could readily ascertain what specific groups/activities were available and at what time. As each discipline maintained their schedule independent of other disciplines and only posted on a daily basis without descriptions, patient and staff remained confused as to what therapies were offered when. This lack of a cohesive treatment schedule prevented patients from accessing all therapies available to them and potentially delayed their improvement. (Refer to B125, Section III)

Based on record review and interview, there was a failure to address memory and intellectual functioning or document how memory functioning was tested to establish a baseline for future testing of the individual patient for five (5) of 15 active sample patients (1, B2, B14, C7, and F23). This failure hinders the treatment team's ability to determine stability or change in status in subsequent reassessment.

Findings include:

A. Record Review:

1. Patient 1-A progress note (2/13/18) provided by the facility as a psychiatric evaluation update and written by a nurse practitioner failed to address memory or intellectual functioning.

2. Patient B2-A progress note (11/3/17) provided by the facility as a psychiatric evaluation update and written by a nurse practitioner failed to address memory or intellectual functioning.

3. Patient B14-In the psychiatric evaluation update (5/24/17), the physician documented memory as "Memory is fair." [His/Her] immediate, intermediate, past, and rete [sic] are fair." No additional information was documented.

4. Patient C7-The psychiatric evaluation dated (2/22/18) and written by a nurse practitioner documented "memory could not be deciphered as patient would not engage in conversation." A progress note dated 2/22/18 and written by the doctor did not address memory.

5 Patient F23-In the psychiatric evaluation (1/30/18), the physician documented memory as "Registration and recall intact. Remote memory intact." No additional information was documented.

B. During an interview on 2/28/18 about 10:30 a.m., the Medical Director confirmed
the above-documented findings.

Based on interview and record review, there was a failure to note patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 12 of 15 active sample patients (1, A1, A23, B2, B14, C7, D2, D13, F7, F23, G16, and G26). This deficiency does not permit the facility to create individualized active treatment that builds on the patient's existing strengths.

Findings include:

A. Record Review:

1.Patient 1-A progress note (2/13/18) provided by the facility as a psychiatric evaluation update and written by a nurse practitioner failed to address the patient's assets.

2. Patient A1-The psychiatric evaluation (1/30/18) listed patient's assets as "Access to care." No specific skills or characteristics were listed as patient assets.

3. Patient A23-The psychiatric evaluation (2/13/18) listed patient's assets as "Access to healthcare" and "Cooperative with staff." No specific skills or characteristics were listed as patient assets.

4. Patient B2-A progress note (11/3/17) provided by the facility as a psychiatric evaluation update and failed to address the patient's assets.

5. Patient B14-The psychiatric evaluation update (5/24/17) failed to address the patient's assets.

6. Patient C7-The psychiatric evaluation (2/3/18) listed patient's assets as "Quietly sitting in chair and not a threat to staff at present." No specific skills or characteristics were listed as patient assets.

7. Patient D2-The psychiatric evaluation (2/7/18) listed patient's assets as "Currently cooperative." No specific skills or characteristics were listed as patient assets.

8. Patient D13-A progress note provided by the facility as a psychiatric evaluation dated 11/7/17 failed to address assets.

9. Patient F7-The psychiatric evaluation (2/8/18) listed patient's assets as "No current suicidal/homicidal ideation upon admission," "Cooperative with staff" and "Able to make needs known." No specific skills or characteristics were listed as patient assets.

10. Patient F23-The psychiatric evaluation (1/30/18) listed patient's assets as "Access to care" and "Appears to be physically healthy." No specific skills or characteristics were listed as patient assets.

11. Patient G16-The psychiatric evaluation (2/5/18) listed patient's assets as "No current suicidal/homicidal ideation upon admission," "Cooperative with staff" and "Able to make needs known." No specific skills or characteristics were listed as patient assets.

12. Patient G26-The psychiatric evaluation (12/4/17) listed patient's assets as "Good physical health" and "Access to healthcare." No specific skills or characteristics were listed as patient assets.

B. During an interview, with a review of psychiatric evaluations, on 2/28/18 about 10:30 a.m., the Medical Director confirmed that the information listed was not descriptive statements of the patients' skills and characteristics.

Based on interview and record review, the facility failed to ensure that master treatment plans (MTP) clearly defined the disabilities (problems) to be addressed for four (4) of 15 active sample patients (B2, B14, D13, and E9). For these patients, the problem statements were legal issues, rather than specific problem behaviors related to their psychiatric/biopsychosocial issues to be reduced or resolved. This failure results in a fragmented treatment plan and can prevent the patient from receiving goal-directed treatment for behavioral/psychiatric problems in a timely manner.

Findings include:

A. Patient Findings:

1.Patient B2-Treatment plan dated 10/4/17

The "Justification for Admission" (problem) was a legal issue stated as "Legal 971.17 (1) as evidenced by arson." There was no additional behavioral information documented.

2. Patient B14-Treatment plan revision unclear. Most team members signed the plan on 10/3/17, but some interventions entered in July 2017.

The "Justification for Admission" (problem) was a legal issue stated as "Revocation of NGI (Not Guilty due to Insanity) for first degree murder as evidenced by violation of conditional release criteria." There was no behavioral information documented.

3.Patient D13 - Treatment plan dated 11/7/17

The "Justification for Admission" (problem) was a legal issue stated as "Found NGI for 8th offense OWI (Operating While Intoxicated) and involuntary medication order as evidenced by operating a motor vehicle while intoxicated." There was no additional behavioral information documented.

4. Patient E9 - Treatment plan dated 1/31/18

The "Justification for Admission (problem) was a legal issue stated as "Adjudicated incompetent to proceed as evidenced by inability to participate in [his/her] trial." There was no behavioral information documented.

B. During an interview, with a review of treatment plans for Patient B2 and B14, Physician 1 and RN W11 stated that these documented problems were not behavioral statements for treatment.

Based on record review, interview, and policy review, the facility failed to formulate Master Treatment Plans (MTPs) that included patient-related long and short-term goals stated in observable and measurable terms for 10 of 15 active sample patients (1, A23, B2, B14, C7, D2, E15, F7, F23 and G11) The goals identified on the treatment plans were a mixture of non-measurable goals and treatment compliance statements for the patient. Some goals did not correlate with the stated problem. This failure hinders the ability of treatment team to measure changes in the patient behavior as a result of treatment intervention and may contribute to failure of the team to modify the plan in response to patient improvement or lack of improvement.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan (MTP) dated 10/26/17) listed problem as "Suicidal Ideation ... as evidenced by depressive mood, suicidal thoughts, cuts to arms," the non-measurable long-term goal was stated as "Pt. (Patient will maintain psychiatric stability to facility [his/her] participation in future courtroom proceedings." A short-term non-measurable goal was "Manage the stress of adapting to a minimum security unit."

These goals did not correlate with the patient's stated problem.

2. Patient A23 (MTP dated 2/11/18) listed the problem as "Aggression, attacked staff member and police." The long-term goal stated, "[Patient] will take medications as prescribed and demonstrate appropriate behavior for a lesser [sic] restrictive environment." This goal was a treatment compliance statement and not an individualized goal.

3.Patient B2 (MTP revision date was unclear). Staff signatures dated 1/3/18, but interventions dated as early as 10/4/17. The patient was admitted to the hospital on 11/6/96. This plan had problem stated as "Legal 971.17 (1) as evidenced by arson," the long-term non-measurable goal was stated as "To successfully discharge to the community ..." A short-term goal was stated as "Demonstrate use of coping skills AEB (as evidenced by) minimal use of PRN's (as needed) & (and) absence of outbursts." The first part of this goal was non-measurable.

These goals did not correlate with the stated problem.

4. Patient B14 (MTP dated 10/3/17) had problem stated as "Revocation of NGI (Not Guilty due to Insanity) for first-degree murder as evidenced by violation of conditional release criteria." The long-term non-measurable goal was stated as "Safely discharge into the community." A non-measurable short-term goal was stated as "Show appropriate behavior towards peers and staff."

These goals did not correlate with the patient's stated problem.

5. Patient C7 (MTP dated 2/15/18) had the problem listed as "Psychosis/aggression as evidenced by pt. lives in a group home and was brought to the ER (Emergency Room) by EMS (Emergency medical services) d/t (delirium) labile mood, hallucinating, and responding to internal stimuli. Patient got very upset believing [his/her] father killed the woman who runs the GH (Group Home). [He/she] attempted to leave group home in [his/her] pajamas and no shoes. When parent tried to stop [him/her] from leaving [he/she] became aggressive. Patient has not been taking meds for the last couple of days and was given prn in the emergency room." The non-measurable long-term goal was "Just to be out." The short-term goal was "(Patient name) will consistently take medications as prescribed while demonstrating ability to keep self and others safe 100% of the time." This goal was a treatment compliance statement rather than a patient goal.

The Nursing Care plan attached to the MTP had a problem stated as "Disturbed Personal Identity related to alteration in social role, noncompliance as evidenced by altered thought processes, inability to follow simple directions, inconsistent behavior, ineffective coping strategies, ineffective role performance, and loss of social functioning." The short-term goal was "Pt. will be 100% compliant with scheduled medication within one week." This goal was a treatment compliance statement.

6. Patient D2 (MTP dated 2/22/18) had the problem listed as "drinking and suicidal ideation lead [sic] to revocation as evidenced by drinking and suicidal ideation." The non-measurable goals are "(Patient name) ... will engage in all provided treatment recommendation in order to transfer to a less restrictive environment" and "(Patient name) ...will adhere to all goals identified on [his/her] weekly progress rating sheet (phase II) and will attend 100% of scheduled/offered treatment groups over the next 90 days." Both goals were treatment compliance statements.

7. Patient E15 (MTP dated 1/3/18) had the problem listed as "Violation of commitment order, anger to [his/herself] and others as evidenced by swallowing razor blade, abuse of protruding surgical pin, possible overdose/misuse of Benadryl." The non-measurable Long-term goal was "Pt. will maintain safety and apply coping skills to address frustration/distress.

8. Patient F7 (MTP dated 2/9/18) stated the problem as "Increase in paranoia, extreme rage and agitation in jail; pt. (patient) threaten jail staff; patient was restrained in ER (Emergency Room) as evidenced by 14 day detention; order of involuntary medication and treatment." A non-measurable long-term goal was stated as "To get better. Be clean."

9. Patient F23 (MTP dated 2/2/18) listed the problem as "Paranoid/Delusional as evidenced by Patient has not slept in 5 days. Paranoid. Believes staff are poisoning [his/her] medications. Has been noncompliant with [his/her] medications for past couple months (sic)." The non-measurable long-term goal was stated as "'When can I leave here?' Stabilize and maintain safe behavior to transition back to community placement."

A nursing plan addition to the comprehensive treatment plan was a problem listed as "Disturbed Personal Identity ...as evidenced by altered thought processes." A short-term goal was "Patent will adhere to medication regimen 100% of the time within 30 days." This statement was a treatment compliance requirement, rather than an outcome behavioral goal.

10. Patient G11 (MTP dated 2/7/18) listed the problem as "Threats to harm others/hypersexual behaviors." The long-term goal stated, "To improve behavioral functioning and utilization of appropriate coping skills and reduce suicidal and homicidal ideation prior to discharge." This goal was non-measurable.

B. Policy Review

The facility policy titled, "Individualized Treatment Plan (ITP)" and last revised 9/2017 stated, "Goals should be measurable, achievable, time specific and written in terms that improve patient outcomes." Furthermore, it stated, "The ITP Goal and corresponding methods shall be individualized based on the patient's initial assessment." The facility was not in compliance with their policy.

Based on observation, interview and record review, the facility failed to adequately develop and document individualized treatment interventions with the specific purpose and focus based on the needs of 11 of 15 active sample patients (1, A23, B2, B14, C7, D2, D13, E9, E15, F7 and F23). This deficiency results in a failure to provide a basis for accurate implementation, to evaluate treatment provided, and to plan revisions based on individual patient needs and findings.

Findings include:

A. Record Review

1. Patient 1-Comprehensive treatment plan dated 10/26/17

a. For the problem, "Suicidal Ideation ... as evidenced by depressive mood, suicidal thoughts, cuts to arms," a generic physician intervention was stated as "Will meet with [Patient] to monitor for symptoms of [his/her] Schizophrenia and adjust medication as indicated. Will monitor for side effects and provide supportive psychotherapy."

A generic psychology intervention was stated as "Will offer psychology (illegible word) to provide opportunity to express concerns and to facilitate positive coping."

There were no nursing interventions to address the safety of this patient in the clinical area for suicidal and cutting behaviors.

b. A nursing plan addition to the comprehensive treatment plan was a problem listed as "Disturbed Personal Identity ...as evidenced by altered thought processes, ineffective coping strategies, loss of social functioning." Only one of the nursing interventions chosen for this patient from a "computerized list" was individualized for this patient. The other identified interventions were guidelines for care without additional information based on individual patient findings/needs.

2. Patient A23-Comprehensive treatment plan dated 2/11/18

For the problem of "Chronic Confusion as evidenced by inability to solve problems, reason, purposeful wandering," the nursing interventions were:
"Assigned nursing staff will provide assistance with ADLs [activities of daily living]."
"Assigned nursing staff will encourage participation in social groups."
"All nursing staff will provide a calm living environment by eliminating extraneous noise and stimuli and keeping area free of clutter."

These interventions were generic.

3. Patient B2-Comprehensive treatment plan revision date unclear. Staff signatures dated 1/3/18, but interventions dated as early as 10/4/17. The patient was admitted to the hospital on 11/6/96.

a. For problem, "Legal 971.17 (1) as evidenced by arson," the team interventions did not correlate with the stated problem.

A generic physician intervention was stated as "Meet with patient monthly or per request to discuss mental & physical health, psychopharmacology and cognitive therapy.

b. A nursing plan addition to the comprehensive treatment plan was a problem listed as "Impaired social Interaction ...as evidenced by appearing depressed, anxious, or angry, failure to interact with others nearby." Interventions chosen for this patient from a "computerized list" were guidelines for care without additional information based on individual patient findings/needs.

4. Patient B14-Comprehensive treatment plan dated 10/3/17

a. For problem, "Revocation of NGI (Not Guilty due to Insanity) for first degree murder as evidenced by violation of conditional release criteria," the team interventions did not correlate with the stated problem.

A generic physician intervention was stated as "Stabilization of mental illness /c (with) psychopharmacology & cognitive behavioral treatment."

b. A nursing plan addition to the comprehensive treatment plan was a problem listed as "Impaired social Interaction ...as evidenced by appearing depressed, anxious, or angry, describes a lack of meaningful relationships, expressed feelings of loneliness or rejection, feelings of uselessness, sexually inappropriate behavior." The interventions did not address the specific "sexually inappropriate behavior" the staff should monitor.

5. Patent C7 - Comprehensive treatment plan dated 2/15/18

a. The problem was stated as "Psychosis/aggression as evidenced by pt. lives in a group home and was brought to the ER (Emergency Room) by EMS (Emergency medical services) d/t (delirium) labile mood, hallucinating, and responding to internal stimuli. Patient got very upset believing [his/her] father killed the women who runs [sic] the GH (Group Home). [He/she] attempted to leave group home in [his/her] pajamas and no shoes. When parent tried to stop [him/her] from leaving [he/she] became aggressive. Patient has not been taking meds for the last couple of days and was given prn in the emergency room."

A generic APNP intervention was stated as "Will meet with (patient) a minimum of 1 time within 7 days to assess the need/efficacy of psychotropic medications, evaluate patient's response to medication regimen and monitor for adverse reaction/side effects." This intervention was the clinician required job duties.

b. Nursing care problem was "Disturbed Personal Identity related to alteration is social role, noncompliance as evidenced by altered thought processes, inability to follow simple directions, inconsistent behavior, ineffective coping strategies, ineffective role performance, and loss of social functioning." The generic staff interventions were listed as "Under the direction of Primary RN assigned nursing staff draw [sic] attention to (patient) attention to activities of others and events that are happening in the environment. Primary RN will assess (patient) current level of functioning and ability to identify self as a unique individual."

6. Patient D2 - Comprehensive treatment plan dated 2/22/18

a. For problem, "drinking and suicidal ideation lead [sic] to revocation as evidenced by drinking and suicidal ideation," a patient goal was listed as a psychologist intervention: "(Patient) will cooperate with psychological testing requested by psychiatrist for differential diagnostic purposes."

b. There were no nursing problem or interventions addressing the patient suicidal ideation.

7. Patient D13-Comprehensive treatment plan dated 11/7/17

a. For problem, "Found NGI for 8th offense OWI and involuntary medication order as evidenced by operating vehicle while intoxicated. Past admission for similar charges,"
a generic physician intervention was stated as "Will meet with patient for symptoms, discuss with nurses and staff, and give medication if needed as pt. (patient) presently refusing meds."

b. Nursing care problem was listed as "Ineffective coping related to legal issues, situational crisis as evidenced by AODA issues, inability to control impulses of aggressive behavior." A generic staff intervention was stated as "Under the direction of (RN name), assigned staff will set firm, clear limits without debating, arguing, rationalizing or bargaining with patient."

c. For nursing problem stated as "Impaired mood regulation related to impaired social functioning, psychosis as evidenced by changes in verbal behavior, dysphoria, flight of thoughts, irritability, and psychomotor agitation," a generic staff intervention was listed as "Under the direction of primary RN, assigned nursing staff will encourage patient to engage in group/or independent activities a minimum of______ (left blank) times/shift."

8. Patient E9 - Comprehensive treatment plan dated 1/31/18

a. For problem, "Adjudicated incompetent to proceed as evidenced by inability to participate in [his/her] trial," a generic psychology intervention was "(Clinician name) will provide the court with regular progress reports and once (patient name) has obtained maximum benefit from treatment a summary report of [his/her] progress in treatment and opinion regarding [his/her] competency to proceed."

b. For nursing problem: "Ineffective coping related to legal issues, situational crisis as related to alteration in societal participation, anxiousness, ADOA issues, inability to problem solve, Hx (history) of SI (suicidal ideation), chronic pain," generic staff interventions were "Under the direction of (name of staff) assigned staff will maintain an attitude of 'It's not you, but your behavior that is unacceptable.' Assigned staff will set firm, clear limits without debating, arguing, rationalizing or bargaining with patient."

9. Patient E15- Comprehensive treatment plan dated 1/3/18

a. For problem, "Violation of commitment order, anger to [him/herself] and others as evidenced by swallowing razor blade, abuse of protruding surgical pin, possible overdose/misuse of Benadryl," a generic APNP (Advanced Practice Nurse Practitioner) "Will monitor mood & behavior & work with multidisciplinary team to work on treatment plan and make appropriate referrals to community & within institute for services as needed."

b. A nursing problem was identified as "Ineffective coping related to history of abuse, inadequate support systems, situational crisis as evidenced by destructive behavior toward self and others, inability to control impulses of aggressive behavior, refusal to follow rules and expectations." Staff interventions were "Under the direction of (name of staff) assigned staff will maintain an attitude of 'It's not you, but your behavior that is unacceptable.' Assigned staff will set firm, clear limits without debating, arguing, rationalizing or bargaining with patient." These interventions were not individualized and similar to other patients ' plans in the sample.

10. Patient F7-Comprehensive treatment plan dated 2/9/18

a. For problem, "Increase in paranoia, extreme rage and agitation in jail; pt. (patient) threaten jail staff; patient was restrained in ER (Emergency Room) as evidence by 14 day detention; order of involuntary medication and treatment," a generic physician intervention was stated as "Will evaluate progress towards decreased psychosis and adjust medications accordingly, based on assessment, chart review, and discussion with the treatment team."

A generic social work intervention stated, "Will meet with patient at least one time weekly to provide supportive contacts, legal education, and mental health education. This worker will also continue to communicate with Lincoln County contacts and other involved parties to assist in coordination continued treatment and discharge planning."

11. Patient F23-Comprehensive treatment plan dated 2/2/18

a. For problem, "Paranoid/Delusional as evidenced by Patient has not slept in 5 days. Paranoid. Believes staff are poisoning [his/her] medications. Has been noncompliant with [his/her] medications for past couple months (sic)," a generic physician intervention was stated as "Will evaluate progress towards decreased psychosis and adjust medications accordingly, based on assessment, chart review, and discussion with the treatment team."

A generic social work intervention stated, "Will meet with patient at least once weekly to provide legal/mental health education ..."

b. A nursing plan addition to the comprehensive treatment plan was a problem listed as "Disturbed Personal Identity ...as evidenced by altered thought processes." Only one individualized nursing intervention was identified. All other interventions were selected from a "computerized list" without additional information added based on individual patient findings/needs.

B. Interviews:

1. During an interview on 2/28/18 around 11:15 a.m. Physician 1 confirmed that the physician interventions were generic and not individualized based on patient findings.

2. During an interview on 2/27/18 at 2:30 p.m., the Director of Nursing agreed that interventions were generic and not individualized for each patient."

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

I. Provide alternative treatment for three (3) of 15 sample patients (A23, C7, and D13) who were unable or unwilling to attend groups. This deficient practice results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Patient Findings:

1. Patient A23

a. Record Review

Patient A23 was admitted on 2/11/18 due to aggressive behavior, delusions and cognitive decline according to the Psychiatric Evaluation dated 2/13/18. An Occupational Therapy entry dated 2/22/18, documented that [Patient A23] "attends on unit groups only sporadically. [Patient] is unable to follow the group topic. When it is [patient's] turn to share [he/she] is off topic and not able to follow directions." A progress note, written on 2/23/18 by a counselor stated, "[Patient] attended Here and Now group for 5 minutes total." These two notes were the only documentation of group attendance/ participation. There was no written record of any alternative interventions employed.

b. Observation

On 2/26/18 at 2:20 p.m. and on 2/27/18 at 11:30 p.m., Patient A23 was observed wandering in the unit hall while other patients attended groups. Staff members were not interacting with the patient or providing any individual treatment.

c. Interviews

(1). On 2/26/18 at 2:30 p.m., Patient A23 stated, "I'm bored here and I want to go home to my wife."

(2). On 2/26/18 at 2:45 p.m., RN B4 stated that Patient A23 does not receive any alternative treatment.

(3). On 2/28/18 at 10:00 a.m., Social Worker 3 confirmed that Patient A23 was not provided alternative or individual treatment.

2. Patient C7

a. Record Review

Patient C7 was admitted on 2/3/18 due to hallucinations, aggressive behavior, not taking medication and suicide ideations according to the Psychiatric evaluation dated 2/3/18. A Therapeutic Service progress noted dated 2/13/18, documented "Patient continues to make delusional and paranoid statements, [he/she] presents irritable much of the time, responds to internal stimuli, present labile mood, yells at staff and spends the majority of time isolating in [his/her] room." The Patient Activity Report provided by the facility for 2/18/18 to 2/25/18 documented a total of 28 groups offered to patient of which only 7 groups were attended by the patient.

b. Interviews

(1). On 2/26/18 at 1.45 p.m., Patient C7 stated, "I attend sometimes, I need encouragement to attend."

(2). On 2/26/18 at 2.00 p.m. RN S1 stated, "Some days Patient C7 will go to groups and then walk out." Also confirmed alternative treatment was not provided.

3. Patient D13

a. Record Review

Patient D13 was admitted on 8/13/14 due to being found "Not guilty by reasons of mental disease or defect on operating motor vehicle intoxicated and operating a motor vehicle while revoked" according to the Psychiatric Evaluation dated 8/13/14. The Patient Activity Report provided by the facility documented Patient D13 absent for 15 of 16 groups offered from 2/21/18 - 2/26/18.

b. Observation

On 2/27/18 at 1.30 p.m. Patient D13 was observed in his/her room while other patients were in a group.

c. Interview

(1). On 2/27/18 at 3.30 p.m., Patient D13 stated, "I don't go to group because I don't get anything out of them."

(2). On 2/27/18 at 3.45 p.m., Occupational Therapist 1 stated, "Patient D13 is currently refusing all treatment. There is no alternative provided, but I touch base with [him/her]."

B. Policy Review

The facility policy provided titled "101.07 Plan for Services" and most recently reviewed 12/14 stated, "Inpatient services at Winnebago Mental Health Institute are intended to ensure that each unit provides appropriate treatment for patients to obtain an optimal level of functioning, support them in their recovery, and return them to the community at the earliest possible date." The facility did not demonstrate compliance with this policy.

II. Provide age-appropriate treatment for 2 of 2 adolescent patients (active sample Patient 1 and non-sample Patient 2 who was added to review active treatment). These adolescent patients were housed and programmed on adult forensic units. This deficiency results in patients not receiving appropriate treatment that considered their age/developmental level and resulted in potentially delaying their improvement. (Refer to B125, Section II)

Findings include:

A. Patient Findings:

1.Patient 1 is a 15-year-old patient admitted on 6/3/16. S/he was currently housed and treated on the Adult Choices Unit.

a. According to the psychiatric evaluation (6/4/16), Patient 1 was admitted due to "a legally mandated hospitalization" with a diagnosis of Schizophrenia.

A psychiatric progress note (2/14/18) documented, "Presents as much [sic] more depressed looking and is less engaged in our session today than previously." This note documented the patient's diagnoses as "Schizophrenia and Major Depressive Disorder."

b. A psychological consultation report (performed during an earlier hospitalization (10/10/14) documented "fire-setting incidents ...upwards of twenty fires" and auditory and visual hallucinations. One of the recommendations stated in this report was listed as "Social skills training is recommended. It will be best that this take [sic] place in a highly structured environment with similar-age peers to best enhance the option for positive interaction. This should be designed to be a corrective experience for [him/her], one in which [s/he] can feel accepted and respected by peers. This can assist in developing socially the skills to manage the increasingly complex social milieu as [s/he] grows older."

2. Patient 2 was a 16- year-old patient admitted on 1/3/18. S/he was currently housed and treated on the Adult Petersik Unit.

a. According to psychiatric evaluation (1/3/18) Patient 2 was admitted "after being found NGI (Not Guilty due to Insanity) with a diagnosis of Folie a Deaux/Shared Psychotic Disorder

B. Interview:

The survey team met with the Medical Director, Physician 1 (primary psychiatrist) and the Chief Operating Officer on 2/27/18 at 9:05 a.m. During this interview, they stated that Patients 1 and 2 could not be assigned to the same Unit, nor could they be housed on a child/adolescent Unit due to the nature of their past behaviors. They confirmed that all of treatment and education for Patients 1 and 2 were currently being offered in individual sessions and all other treatment was on the adult wards where they reside. They verified that at this time there was no age-appropriate treatment for either Patient 1 or Patient 2.

III. Provide a cohesive and comprehensive treatment schedule for all units in which patients and staff could readily ascertain what specific groups/activities were available and at what time. As each discipline maintained their schedule independent of other disciplines and only posted on a daily basis without descriptions, patient and staff remained confused as to what therapies were offered when. This lack of a cohesive treatment schedule prevented patients from accessing all therapies available to them and potentially delaying their improvement.

Findings include:

A. Document Review

The "7 Day Activity and Treatment Schedule" posted on each unit merely noted "Treatment Groups" without specifically identifying what these groups addressed. In addition, the treatment mall schedule was a grid without descriptors of groups. Furthermore, Activity Therapy shared a list of activities and times but with an extremely confusing grid of which units were addressed in the list Patients were provided a schedule of their groups on a day-to-day basis, so they were unable to plan appropriately in advance.

B. Interviews

1. On 2/27/18 at 10:00 a.m., Social Worker 1 agreed that the group schedules were confusing and not coordinated.

2. On 2/28/18 at 11:15 a.m., the Medical Director concurred that the schedules were "in pieces" and not cohesive throughout the facility. In addition, the Medical Director acknowledged that there was no central staff or committee in charge of providing comprehensive programming throughout the facility.

Based on document review/medical record review and interviews, the facility failed to ensure adequate numbers of qualified nursing staff to provide on-going active treatment to the patient population. Specifically, the facility failed to:

I. Ensure the availability of a Registered Nurse on each ward on the night tours of duty accounting for breaks and emergencies. Only one RN was scheduled routinely on each locked unit during the night shifts. This staffing pattern results in a lack of on-going professional assessments of patients and the supervision of non-professional nursing personnel in the provision of care. (Refer to B150, Section I).

II. Ensure that necessary nursing personnel was assigned to ensure safety of patients on special precautions. Specifically, 2 non-sample patients (3 and 4) on safety precautions were assigned to 1 staff member and were required to remain in the central day room or across the hallway in the patient group room. These rooms were in direct view of the Psychiatric Care Technician assigned to patient monitoring and stationed in the hallway between the two rooms. These patients could not leave this area due to staff not being assigned 1:1 even though these patients were on safety precautions requiring them to be in constant view of the assigned staff member. This staffing pattern results in a restriction of patients' rights without documented justification. (Refer to B150, Section II).

In addition, the facility failed to ensure that the Medical Director and the Director of Nursing monitored and took corrective action as follows:

I. The Medical Director failed to:

A. Ensure that psychiatric evaluations addressed memory and intellectual functioning for five (5) of 15 active sample patients (1, B2, B14, C7 and F23) and documented patient assets in descriptive, not interpretive, fashion for 12 of 15 active sample patients (1, A1, A23, B2, B14, C7, D2, D13, F7, F23, G16 and G26). These deficiencies hinder ability to determine stability or change in mental status in subsequent reassessment and to create individualized treatment that builds on the patient's existing strengths. (Refer to B144, Section I)

B. Ensure development of individualized comprehensive treatment plans to include behaviorally stated problem, outcome-oriented measurable treatment goals and individualized treatment interventions with specific purpose and focus based on the needs of 11 of 15 active sample patients (1, A23, B2, B14, C7, D2, D13, E9, E15, F7 and F23). This deficiency resulted in a failure to provide a basis for accurate implementation, evaluate treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B144, Section IV)

C. Provide alternative treatment for three (3) of 15 sample patients (A23, C7 and D13) who were unable or unwilling to attend groups. This deficient practice resulted in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B144, Section III)

D. Provide age-appropriate treatment for two (2) of two (2) adolescent patients (active sample Patient 1 and non-sample Patient 2 who was added to review active treatment). These adolescent patients were housed and programmed on adult forensic units. This deficiency results in patients not receiving appropriate treatment that considered their age/developmental level and resulted in potentially delaying their improvement. (Refer to B144, Section IV)

E. Provide a cohesive and comprehensive treatment schedule for all units in which patients and staff could readily ascertain what specific groups/activities were available and at what time. As each discipline maintained their schedule independent of other disciplines and only posted on a daily basis without descriptions, patient and staff remained confused as to what therapies were offered when. This lack of a cohesive treatment schedule prevented patients from accessing all therapies available to them and potentially delaying their improvement. (Refer to B144, Section V)

II. The Director of Nursing failed to ensure that individual nursing treatment interventions were developed and documented with specific purpose and focus based on the needs of 11 of 15 active sample patients (1, A23, B2, B14, C7, D2, D13, E9, F15, F7, and F23).). This deficiency results in a failure to provide a basis for accurate implementation, to evaluation of treatment, and to plan revisions based on individual patient needs and findings. (Refer to B148, Section I)

Based on observations, interview and document review, monitoring, and evaluation by the Medical Director failed to include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. Specifically, the Medical Director failed to:

I. Ensure that psychiatric evaluations addressed memory and intellectual functioning for five (5) of 15 active sample patients (1, B2, B14, C7 and F23) and document patient assets in descriptive, not interpretive, fashion for 12 of 15 active sample patients (1, A1, A23, B2, B14, C7, D2, D13, F7, F23, G16, and G26). These deficiencies hinder the ability to determine stability or change in mental status in subsequent reassessment and to create individualized active treatment that builds on the patient's existing strengths. (Refer to B116 and B117)

II. Ensure development of individualized comprehensive treatment plans to include behaviorally stated problem, outcome-oriented measurable treatment goals and individualized treatment interventions with specific purpose and focus based on the needs of 15 of 15 active sample patients (1, A23, B2, B14, C7, D2, D13, E9, E15, F7, and F23). This deficiency results in a failure to provide a basis for accurate implementation, to evaluate treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B119, B121, and B122)

III. Provide alternative treatment for three (3) of 15 active sample patients (A23, C7, and D13) who were unable or unwilling to attend groups. This deficient practice results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125, Section I)

IV. Provide age-appropriate treatment for two (2) of two (2) adolescent patients (active sample Patient 1 and non-sample Patient 2 who was added for review of active treatment). These adolescent patients were housed and programmed on adult forensic units. This deficiency results in patients not receiving appropriate treatment that considered their age/developmental level and resulted in potentially delaying their improvement. (Refer to B125, Section II)

V. Provide a cohesive and comprehensive treatment schedule for all units in which patients and staff could readily ascertain what specific groups/activities were available and at what time. As each discipline maintained their schedule independent of other disciplines and only posted on a daily basis without descriptions, patient and staff remained confused as to what therapies were offered when. This lack of a cohesive treatment schedule prevented patients from accessing all therapies available to them and potentially delaying their improvement. (Refer to B125, Section III)

Based on record/document review, policy review and interview, the Director of Nursing failed to:

I. Ensure that individual nursing treatment interventions were developed and documented with specific purpose and focus based on the needs of 11 of 15 active sample patients (1, A23, B2, B14, C7, D2, D13, E9, F15, F7, and F23).). This deficiency results in a failure to provide a basis for accurate implementation, to evaluation of treatment, and to plan revisions based on individual patient needs and findings. (Refer to B122)

II. Ensure the availability of a Registered Nurse (RN) on each ward on the night tours of duty accounting for breaks and emergencies. Only one RN was scheduled routinely on each locked unit during the night shifts. This staffing pattern results in the lack of on-going assessments of patients and the supervision of non-professional nursing personnel in the provision of care. (Refer to B150, Section I)

III. Ensure that necessary nursing personnel was assigned to maintain safety of patients on special precautions. Specifically, 2 non-sample patients (3 and 4) on safety precautions were assigned to 1 staff member and were required to remain in the central dayroom or across the hallway in the patient group room. These rooms were in direct view of the Psychiatric Care Technician assigned to patient monitoring and stationed in the hallway between the two rooms. These patients could not leave this area due to staff not being assigned 1:1 even though these patients were on safety precautions requiring them to be in constant view of the assigned staff member. This staffing pattern results in a restriction of patients' rights without documented justification. (Refer to B150, Section II)

Based on interview and document review the facility failed to:

I. Ensure the availability of a Registered Nurse on each unit on the night tours of duty accounting for breaks and emergencies. Only one RN was scheduled for each locked unit during the night shifts. This staffing pattern resulted in a lack of on-going professional assessment of patients and the supervision of non-professional nursing personnel in the provision of care.

Findings include:

A. Document Review

1. The "Direct Nursing Staffing Form" completed by the Director of Nursing for 2/20-2/26 2018 units revealed that for the 8 locked units there were 54 shifts in which there was but 1 RN covering a locked area with at least 2 halls to supervise. There were only 2 shifts (day and evening) in which there were 2 RNs available. The patient census on these units ranged from 23-37.

2. The "Nursing Service Staffing Plan" provided by the Director of Nursing revealed that the routine staffing on night shifts on all locked wards for the facility was 1 RN.

B. Interviews

1. On 2/27/18 at 2:15 p.m., the Director of Nursing (DON) confirmed that there were no Unit Nurse Managers or House Supervisors to provide coverage should the sole RN on a unit during the night shift require assistance in an emergency or cover for a break. The DON revealed that there was only one House Supervisor for the entire facility.

2. On 2/27/18 at 3:00 p.m., the DON related to the surveyor that there were "not enough RN positions allocated" to provide more robust scheduling during the night shifts.

II. Ensure that necessary nursing personnel was assigned to ensure safety of patients on special precautions. Specifically, 2 non-sample patients (3 and 4) on safety precautions were assigned to 1 staff member and were required to remain in the central day room or across the hallway in the patient group room. These rooms were in direct view of the Psychiatric Care Technician assigned to patient monitoring and stationed in the hallway between the two rooms. These patients could not leave this area due to staff not being assigned 1:1 even though these patients were on safety precautions requiring them to be in constant view of the assigned staff member. This staffing pattern resulted in a restriction of patients' rights without documented justification.

Findings include:

A. Interviews:

1. During an interview on 2/26/18 at 1:45 p.m., Patient 4 reported that s/he was admitted due to a suicide attempt. S/he stated that s/he was waiting to see the physician. S/he added, "I have to stay in this room and can't go to my room."

2. During an interview on 2/27/18, PCT W8 (Psychiatric Care Technician) stated that patients who are on safety precautions on the day and evening shifts remain in the dayroom or in the group room across the hall to ensure that they are "in view" of the staff member who is assigned to patient monitoring. When asked about the night shift, PCT W8 reported that patients on safety precautions are assigned 1:1 monitoring on the night shift and are in their assigned room. She reported that Patient 4 is not on safety precautions today and that Patient 3 remains on safety precautions and is currently in the group room (pointing to the room adjacent to the hallway with a viewing window). She reported that Patient 3 has been on safety precautions for some time.

3. During an interview on 2/27/18 at 10:50 a.m., RN W10 verified that patients who are on safety precautions are required to remain in the dayroom or group room in view of an assigned staff member for safety monitoring. She verified that Patient 4 would be able to go to his/her room if assigned to 1:1 monitoring.

B. Medical Record Review:

1. Patient 3

a. According to the psychiatric evaluation (11/1/17), Patient 3 was admitted for "self-injurious behavior."

b. Review of "Safety-Security Responsibility Logs" that documented when patients were on safety precautions revealed that many of these forms were not completed for Patient 3. Dates/times were unclear and the form failed to ensure that the signature for the assigned staff member was on the form.

2. Patient 4

a. According to the psychiatric evaluation (2/27/18), Patient 4 was admitted after a suicide attempt.

b. Review of "Safety-Security Responsibility Log" for Patient 4 revealed that the dates on this form are unclear.