HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure that it protected the patient's right to safe care, on 4 of 5 hospital patient care units (Intensive Treatment Unit, Acute Adult Unit, Women's Treatment Unit and Children's Treatment Unit).

Findings include:

The hospital failed to ensure patients were free from injury due to ligature risks by ensuring that Level 2 and Level 3 SOS (Suicide Observation Status) patients were given protections from self-harm while using their bathroom showers, on 4 of 5 mental health patient care units (Intensive Treatment Unit-43A, Acute Adult Unit-43B, Women's Treatment Unit-43C and Children's Treatment Unit-53B). Failure to identify and mitigate potential ligature risks and devices that could be used for self-harm had the potential to affect 53 admitted in-patients during survey: One Level 2 patient (Patient #31) and twelve Level 3 patients on 43A; Sixteen Level 3 patients on 43B; One Level 2 patient (Patient #16) and fourteen Level 3 patients on 43C; Eight Level 2 patients (Patient #'s 8, 9, 10, 18, 30, 32, 33 and 34) and one Level 3 patient on 53B. There were no patients on the PCS (Patient Crisis Services/Observation unit. (Reference A0144)

The hospital failed to ensure that emergency resuscitation equipment was checked daily per hospital policy, on 1 of 5 patient care units (Children's Treatment Unit-53). (Reference A0144)

The cumulative effect of this patient rights failures resulted in the hospital's inability to promote the health, safety and welfare of the 53 patients on their behavioral health units.

Based on observation, record review and interview the hospital failed to ensure patients were free from injury due to ligature risks by ensuring that Level 2 and Level 3 SOS (Suicide Observation Status) patients were given protections from self-harm while using their bathroom showers, on 4 of 5 mental health patient care units (Intensive Treatment Unit-43A, Acute Adult Unit-43B, Women's Treatment Unit-43C and Children's Treatment Unit-53B). Failure to identify and mitigate potential ligature risks and devices that could be used for self-harm had the potential to affect 53 admitted in-patients during survey: One Level 2 patient (Patient #31) and twelve Level 3 patients on 43A; Sixteen Level 3 patients on 43B; One Level 2 patient (Patient #16) and fourteen Level 3 patients on 43C; Eight Level 2 patients (Patient #'s 8, 9, 10, 18, 30, 32, 33 and 34) and one Level 3 patient on 53B. and lack of available emergency equipment, on 1 of 5 patient care units (Children's Treatment Unit-53B). and lack of available emergency equipment, on 1 of 5 patient care units (Children's Treatment Unit-53B).

Findings include:

Record review of hospital policy ID: 3674060, Suicidal Patient: Management and Precautions, effective 6/19/17" revealed under "3. Interventions: Levels and Precautions. Patients identified as suicidal will be placed on appropriate suicide observation status (SOS):
Level I - 1:1 Continuous Observation
Level II - every 15 minute Suicide Observation Checks
Level III - every 30 minute Suicide Observation Checks... 3.b. Bathroom doors and wardrobes will be locked in room of all patients on all levels of SOS. Staff will unlock bathrooms for SOS patient and remain present during toileting or bathing to relock door."

Patient care unit observations for Psychiatric Crisis Services (PCS) Observation Unit, Intensive Treatment Unit-43A, Acute Adult Unit -43B, Women's Treatment Unit-43C and Children's Treatment Unit-53B were conducted on 3/11/2019 and identified the following patient care safety concerns:

1) Observed at 10:55 AM glass shower doors in the above identified areas had regular hinges on the metal rim surrounding the non-shatter resistant glass shower doors inside the patient bathrooms. The hinges on these doors could support a looped ligature device holding less or greater than 30 pounds. The non-shatter proof glass could be used for self-harm or the injury of others.

At 11:00 AM on the Children's Treatment Unit-53B observations revealed that all patient care rooms have 2 wooden closets that are approximately 6-7 feet tall and protrude approximately 2 feet from the wall. The top surface of these closets are not ligature resistant and could support a looped hanging device holding less or greater than 30 pounds.

During interview with Nurse Manager C on 3/11/19 at 10:55 AM, C revealed that all bathrooms are kept locked except when patients are showering and stated all patient rooms have the same bathroom configuration and all rooms have glass in their shower doors. C stated that that all in-patients are Level's 1, 2 or 3 SOS risk.

During interview with Nurse Manager D on 3/11/2019 at 11:00 AM, D stated, "All patients are on 15 minute checks and if a patient is assessed as a high suicide risk they would be on 1:1 constant observation with a staff member." D stated "not every patient" had staff present in patient rooms or bathrooms when showers occur.

2) Record review on the Children's Treatment Unit-53B revealed a form entitled "Emergency Equipment Checklist Crash Cart Check", located in the medical treatment room with the emergency equipment (Ambu bag, oxygen tank, suction machine, automated defibrillator). Form instructions include "...to be completed daily in inpatient areas". Record review of the February 2019 checklist revealed emergency equipment was not conducted on the following 17 of 28 days (2/2/19, 2/11-20/2019, 2/22/19 and 2/24-28/2019).

During interview with Nurse Manager D on 3/11/2019 at 11:10 AM, D stated "It's supposed to be done every day."

Record review of hospital policy "ID: 5977750, Emergency Equipment Maintenance Check Process, last revised 2/13/2019" revealed "IV.2.1. The Emergency Go kits... will be checked each shift by a registered nurse."

Based on record review and interview, the hospital failed to ensure that it's QI (quality improvement) projects showed measurable progress based on a prescribed timeline/goal, for 2 of 5 quality improvement projects (ligature risks and environmental maintenance).

Findings include:

Record review of the color-coded "General Criteria" lists used for tracking "Mental Health Environment of Care..." concerns (ligature risks and environmental maintenance) revealed no documented evidence of prioritization of tasks based on safety risks and no documented evidence of timelines/goal dates for each environmental improvement area identified.

During interview with Safety Officer H on 3/13/19 at 1 PM, H stated that H had a data listing of what hazards had been identified and accomplished regarding the identification of ligature risks and other safety hazards in the hospital. H stated there was no aggregate QI plan data that revealed documentation of periodic progress reports, no documented evidence of how projects were prioritized based on risk, and no documented evidence of a QI plan with timeline goals for each area that revealed timely accomplishment of interventions/tasks.

Based on record review, observation, and interview, the dietary staff failed to disinfect the thermometer between use in 1 of 1 tray preparation and the staff failed to keep the temperature of cold food items in 1 of 2 cold storage areas (3 compartment refrigerator).

Findings include:

Review of policy titled "Using a Thermometer" FS-UT-03-SB-01, dated 2/5/16 revealed, "Clean and disinfect probe before and after use." Thermometer probe wipes packets revealed, "Single Use Packets".

Observation on 3/12/2019 at 9:55 AM of Food Service Staff L checking the temperatures of the lunch food items. Food Service Staff L used the thermometer to check the temperature of the turkey, roast beef, and gravy; wiping off the probe of the thermometer after each food item using the same wipe.

Interview with Food Service Director K stated, "I saw the staff using the same wipe to clean the thermometer between the different food items, they are single use wipes."

Review of form titled "Refrigerator Temperature Log" FS-RS-06-FM-04, dated 6/13/17 revealed, "3. If temperature of product is above 41 degrees Fahrenheit, it must be discarded.

Observation on 3/12/2019 at 10:04 AM of food items in the 3 compartment refrigerator that were prepared to be used for the day, included the following items: cottage cheese (46 degree Fahrenheit), cheese slices (48 degrees Fahrenheit), and salad dressing (48 degrees Fahrenheit).

Interview with Food Service Director K stated, "These items all need to be tossed in the garbage because the temperatures should all be in the high 30's. Staff cleaned the refrigerator earlier today and left the food out of the refrigerator on the counter during the cleaning process."

Based on observations, record review and interview, the hospital failed to ensure that the physical environment was maintained in a manner to assure the safety and well-being of patients, on 2 of 5 patient care units (Children's treatment Unit-53B and Patient Crisis Services Unit).

Findings include:

1) Observations of Unit 53B conducted on 3/11/19 at 10:50 AM revealed the following: numerous darkly stained stained ceiling tiles, black scuff marks on several walls, Dust and black and gray-colored debris build-up on the floor boards. In the multi-purpose room, there were four large holes in the walls - one measuring over 8 inches in width.

During interview with Nurse Manager D, at time of observations, D confirmed the environmental findings on unit 53B and stated the room was often used for 1:1 interventions with patients and psychologists/psychiatrist, social workers or family meetings. When asked when these holes occurred Manager D stated "several weeks ago", and stated the "request for repairs had recently been escalated but have not been taken care of yet."

2) Observations of the PCS area revealed the following on 3/12/19 at 9:12 AM:
The lower cabinet below the sink adjacent to door number 2113-2 had broken hinges not allowing it to close properly. Observation inside this area below the sink revealed raised brown and black debris and large water stains.
At 9:15 AM it was noted that the patient entrance area had scuffed floors, visible dust and debris along the floorboards, and multiple areas of chipped paint on the walls and around the sliding entrance doors exposing metal framework and crumbling plaster.
Observed at 9:20 AM, there were multiple circular holes and penetrations in the walls exposing plaster to the left of the drinking fountain near the patient holding area, and in the woman's bathroom.

During interview with Nurse Manager E, at time of observation, E confirmed the environmental findings on the PCS unit.

During interview with Environmental Maintenance Staff V on 3/12/19 at 11:18 AM, V stated "I have only been given 2 work orders for the PCS unit since 1/18/18."

Record review of the 2 work orders provided by Staff V revealed one for "large gouge in door and drywall adjacent to door" initiated on 6/28/18 showing no completion date, and one initiated on 1/26/18 for "hole in wall-needs to be patched" completed on 3/19/18.

Based on observations, record review and interview, the hospital failed to ensure that the infection control preventionist maintained a system that controlling the spread of infections and communicable diseases, on 2 of 5 patient care units [PCS (Patient Crisis Services unit) and Children's Treatment Unit-53B)].

Findings include:

1) Record review of hospital policy "ID: 4547930, Cleaning of Washing Machine and Dryer, effective 9/1/16" revealed procedure for weekly cleaning is placing "one measured dose of washer cleaner" directly in the washer tub and running a wash cycle and "Wipe the inside of the washer with a bleach wipe when visibly dirty".

Unit observations of 53B on 3/11/19 at 11:15 AM, with Nurse Manager D, revealed patient laundry room instructions to "Clean after each use with a bleach wipe" and "Weekly cleaning of the machine."

During interview with Nurse Manager D on 3/11/19 at 11:15 AM, D confirmed there were no bleach wipes or "washer cleaner" present in the room, and confirmed there was no documentation present to indicate compliance.

2) Observations of the PCS (Patient Crisis Services) unit, with Nurse Manager E on 3/12/19 at 9:30 AM, revealed the following:
The vinyl padded wooden patient chair in the entrance/triage area had two tears in the vinyl of the seat cushion exposing the cotton batting of the cushion which could not be effectively cleaned.

The plastic shoe box container holding clean patient care items (blood glucose supplies, urine cups and breathalyzer supplies) had black and brown debris covering it's internal surfaces. The lid of this container was placed under the bottom of the container and contained a brown and black smear and dust covering the inside of it's surface. This container was on a wooden ledge between the entrance triage area and the security station. This wooden ledge was dust covered with brown and black debris and dried liquid stains.

During interview with Nurse Manager, on 3/12/19 at 9:30 AM, E stated "I never thought about not co-mingling dirty and clean areas."




09948


During interview with ICP (Infection Control Preventionist) U on 3/11/19 at 11:53 AM, U revealed that U had no documented evidence that infection control environmental rounds issues had been addressed with the contracted cleaning service (Clean Power). ICP U stated that U "had not assessed or approved cleaning or laundry products" that were used for patient's personal clothing in the hospital. ICP U stated that U "had not assessed or approved of laundry products that were used by Milwaukee County House of Corrections", the contracted laundry supplier for all patient linens used in the hospital for it's patients.

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

l. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two (2) sample patients (A4 and A5) and two (2) patients (B1and B2) added to the sample in order to evaluate active treatment. Specifically, all four patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). In addition, the majority of patients on Units 43A (Intensive Treatment Unit) and 43C (Women's Treatment Group) did not attend groups and were either in their rooms or sitting on the unit during group time. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-l)

ll. Provide week-end therapeutic and leisure groups to address the needs of all patients. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

Based on medical record review, policy review, and interview, the facility failed to provide Social Work assessments that met professional social work standards. These assessments failed to include conclusions of the data documented in the assessment and failed to include individualized treatment recommendations that described anticipated social work roles during inpatient treatment for eight of eight randomly sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalizations.

Findings include:

A. Medical Records

Patient A1's Social Work Assessment, dated 3/7/19, Patient A2's Social Work Assessment, dated 3/11/19, Patient A3's Social Work Assessment, dated 3/4/19, Patient A4's Social Work Assessment, dated 3/1/19, Patient A5's Social Work Assessment, dated 2/26/19, Patient A6's Social Work Assessment, dated 2/27/19, Patient A7's Social Work Assessment, dated 3/6/19, and Patient A8's Social Work Assessment, dated 2/18/19, all failed to contain assessments that included conclusions based on data collected and treatment recommendations to be implemented by the Social Worker while the patient is in the hospital. Instead, assessments generally focused on discharge planning tasks.

B. Interview

During an interview on 3/12/19 at 10:30 a.m., the Director of Social Work confirmed the findings that Social Work Assessments did not address conclusions, based on data collected, and recommendations for Social Worker treatment interventions while the patient is in the hospital.

Based on medical record review, policy review, and interview, the facility failed to document a psychiatric evaluation for one (1) of eight (8) randomly chosen sample patients (Patient A4). Therefore, there is no psychiatric information to justify the diagnosis and the planned treatment. In addition, there is no baseline data from which the treatment team can assess patient's changes in status through the course of treatment.

Findings include:

A. Medical Records

Patient A5 was admitted to the hospital on 2/22/19. On the first day of the survey (3/11/19) there was not a Psychiatric Evaluation present on the patient's medical record.

B. Policy Review

There were two conflicting hospital policies regarding completion times for psychiatric evaluations present at the facility at the time of the survey.

1. "MCBHS Medical Staff Organization Rules and Regulations," dated February 2019, stated "A psychiatric evaluation including an initial plan of treatment , mental status examination, diagnosis, and estimated length of stay shall be completed and documented within 24 hours after admission of the patient."

2. Hospital Policy titled, "Recovery Planning and Recovery Conference Guidelines: Treatment Team Assessments and Procedures (Acute Inpatients)", Revised 6/16, stated that the assessment for Psychiatric and Psychologicals " ...must be complete by the attending Medical Staff within 72 hours of admission."

C. Interview

In an interview on 3/13/19 at 10:30 a.m., the Clinical Director concurred with the lack of a Psychiatric Evaluation for Patient A5 and the two conflicting timeframes in the hospital documents.

Based on medical record review, document review, and interview, the facility failed to provide the timely completion of psychiatric evaluations in keeping with the CMS requirement of completion within 60 hours of admission for two (2) of eight (8) randomly sampled patients (A3 and A4). This failure has the potential to result in the treatment team not having the information required to create a treatment plan based on data essential for the psychiatric findings and substantiated diagnosis.

Findings include:

A. Medical Records

1. Patient A3 was admitted on 3/1/19. The psychiatric evaluation for this patient was submitted on 3/5/19.

2. Patient A4 was admitted on 3/1/12. The psychiatric evaluation for this patient was submitted on 3/12/19.

B. Policy Review

"MCBHS Medical Staff Organization Rules and Regulations," dated February 2019, stated, "A psychiatric evaluation including an initial plan of treatment , mental status examination, diagnosis, and estimated length of stay shall be completed and documented within 24 hours after admission of the patient."

C. Interview

During an interview on 3/13/19 at 10:30 a.m., the Clinical Director concurred with the findings regarding psychiatric evaluations not being present on the medical record on a timely basis.

Based on medical record review, policy review, and interview, the facility failed to provide a psychiatric evaluation that included the personal assets on which to base a meaningful treatment plan for three (3) of eight (8) randomly sampled patients (A2, A7, and A8). This failure to identify patients' strengths has the potential to impair the treatment team's ability to choose treatment modalities which best utilizes the patient's attributes in therapy.

Findings include:

A. Medical Records

1. Patient A2's psychiatric evaluation, dated 3/9/19, did not list assets to be utilized in basing meaningful treatment.

2. Patient A7's psychiatric evaluation, dated 3/11/19, did not list assets to be utilized in basing meaningful treatment.

3. Patient A8's psychiatric evaluation dated 2/19/19 did not list assets to be utilized in basing meaningful treatment.

B. Policy Review

"MCBHS Medical Staff Organization Rules and Regulations," dated February 2019, stated "a psychiatric evaluation including an initial plan of treatment , mental status examination, diagnosis, and estimated length of stay shall be completed and documented within 24 hours after admission of the patient" (Policy does not require a listing of patient assets within the psychiatric evaluation.)

C. Interview

During an interview on 2/13/19, the Clinical Director concurred with the finding of the lack of patient assets within the psychiatric evaluations.

Based on medical record review and interview, the facility failed to develop Master Treatment Plans (facility uses the term, "Recovery Plan") that delineated specific measurable, behavioral, observable, individualized, patient-centered, Short-Term Goals (STGs) based on the individual patient needs and/or problem behaviors requiring hospitalization for eight of eight randomly selected active patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to hinder the treatment team's ability to measure change in the patient as a result of these treatment goals and may prolong hospital stays beyond the resolution of the behavior(s) requiring admission.

Findings include:

A. Medical Records

1. Patient A1's Master Treatment Plan (MTP), dated 3/8/19, listed for the Problem, "Threatening Staff," the non-measurable STG, "[Patient] will demonstrate a decrease in threating statements to staff in 7 days."

2. Patient A2's MTP, dated 3/9/19, listed for the Problems, "Sleep, Suicidal Ideation, THC [tetrahydrocannabinol] use," the non-measureable and unrelated to the identified problems, STG goal, "Patient will describe a discharge plan agreeable to self, family PSW [Psychiatric Social Worker] w/in [within] 3 days."

3. Patient A3's MTP, dated 3/5/19, listed for the Problem, "Physical Aggression," the non-measurable STG, "Patient will exhibit the ability to interact with others in a self-non-threatening manner for 7 days."

4. Patient A4's MTP, dated 3/1/19, listed for the Problem, "Delusional," the non-measurable STG that placed responsibility on the patient to self-report, "Patient will report an absence in or decrease in delusions for 7 consecutive days."

5. Patient A5's MTP, dated 3/3/19, listed for the Problem, "Impaired Verbal Communication," the non-measurable STG, "[Patient] will demonstrate the ability to hold a [sic] c [with] staff and peers without evidence of the inability to think clearly and speak logically within 7 days."

6. Patient A6's MTP, dated 3/4/19, listed for the Problem, "Audio [sic] Hallucinations," the non-measurable STG which cannot be realistically assessed, "Patient will demonstrate the ability to hold conversation with staff and peers without evidence of hallucinations for 7 days."

7. Patient A7's MTP, dated 3/5/19, listed for the Problem, "Psychosis (Per PCS) [Psychiatric Social Worker] OPBS [Organic Brain Syndrome] responding to internal stimuli," the non-measurable, non-individualized STG, "[Patient] will demonstrate a decrease in disturbed thought processes AEB [as evidenced by] the ability to express logical goal directed thoughts without delusions within the next 7 days."

8. Patient A8's MTP, dated 2/15/19, listed for the Problem, "Psychosis (Delusional Ideation)" the non-measurable, non-individualized STG, "[Patient] will demonstrate a decrease in disturbed thought processes as evidenced by the ability to express logical goal directed thoughts without delusions with next 7 days."

Interviews

1. During an interview on 3/12/19 at 10:30 a.m., the Director of Social Work confirmed the findings that short-term goals were not observable, behavioral, and measurable.

2. During an interview on 3/12/19 at 3:15 p.m., the Chief Nursing Officer (CNO) concurred that short-term goals were not observable, measurable, and behavioral.

3. In an interview on 3/13/10 at 10:30 a.m., the Clinical Director concurred with the findings that short-term goals were not observable, behavioral, and measurable.

Based on medical record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for seven of eight patients in the sample (A1, A2, A3, A5, A,6, A7, and A8). This deficiency has the potential to result in failure to guide treatment staff to achieve measurable, behavioral outcomes. This failure also has the potential of being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

A. Medical Records

1. Patient A1's Master Treatment Plan (MTP), dated 3/8/19, listed for the STG, "[Patient] will demonstrate a decrease in threating statements to staff in 7 days," the generic, non-individualized nursing intervention, "Primary RN will administer as ordered [sic] document behavior and provide purposeful unit activities on a daily basis."

2. Patient A2's MTP, dated 3/9/19, listed for the STG, "Patient will describe a discharge plan agreeable to self, family PSW [Psychiatric Social Worker] w/in [within] 3 days," the generic non-individualized nursing intervention, "Nursing staff will encourage and provide positive conversation topic within the milieu during working hours."

3. Patient A3's MTP, dated 3/5/1, listed for the STG, "Patient will exhibit the ability to interact with others in a self-non-threatening manner for 7 days," the generic non-individualized nursing intervention, "RN will monitor for symptoms of aggression and redirect each occurrence."

4. Patient A5's MTP, dated 3/3/19, listed for the STG, "[Patient] will demonstrate the ability to hold a [sic] c [with] staff and peers without evidence of the inability to think clearly and speak logically within 7 days," the generic, vague nursing intervention, "Nursing and other staff to use therapeutic techniques to try to understand the patients [sic] concerns during interactions."

5. Patient A6's MTP, dated 3/4/19, listed for the STG, "Patient will demonstrate the ability to hold conversation with staff and peers without evidence of hallucinations for 7 days," the routine, generic, non-therapeutic nursing intervention, "Nursing staff will meet 1:1 with patient at least once per working shift for > [greater than] 5 minutes to explore the content of hallucinations reconnect with reality."

6. Patient A7's MTP dated 3/5/19, listed for the STG, "[Patient] will demonstrate a decrease in disturbed thought processes AEB [as evidenced by] the ability to express logical goal directed thoughts without delusions within the next 7 days." The treatment intervention listed for this STG was, "[Patient] will engage in reality -based conversations with staff without evidence of delusions or hallucination for 7 consecutive days." (This patient goal was listed as a treatment intervention rather than listing a treatment intervention.)

7. Patient A8's MTP, dated 2/15/19, listed for the STG, "[Patient] will demonstrate a decrease in disturbed thought processes as evidenced by the ability to express logical goal directed thoughts without delusions with next 7 days." This generic routine nursing intervention listed for this STG was, "RN /designee will engage [Patient] each shift to assess [his/her] mental status. Encourage reality-based conversation."

B. Interviews

In an interview on 3/12/19 at 3:15 p.m., the Director of Nursing concurred that Nursing interventions were largely routine, generic Nursing duties rather than patient specific interventions.

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

l. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two sample patients (A4 and A5) and two patients (B1and B2) added to the sample in order to evaluate active treatment. Specifically, all four patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). In addition, the majority of patients on Units 43A (Intensive Treatment Unit) and 43C (Women's Treatment Group) did not attend groups and were either in their rooms or sitting on the unit during group time. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

ll. Provide week-end therapeutic and leisure groups to address the needs of all patients. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process.

Findings Include:

l. Failure to Provide Active Treatment

A. Specific Patient Findings

1. Patient A4 was admitted on 3/1/19. The Psychiatric Evaluation, dated 3/12/19 (late), stated the patient was disorganized with delusional thoughts, and paranoid behavior. The patient had stopped taking his/her medications and was threatening family members.

The Master Treatment Plan (MTP), dated 3/1/19, for the problem, "Delusional," listed the Rehab Therapy intervention as, "(Rehab staff) will meet with (patient) daily for approximately 50-60 (minutes) and provide a variety of creative acts (activities), leisure and music to increase [his/her] focus." The "Treatment Team Note" (update), dated 3/8/19, stated that the goals were to remain the same and added, "Team will continue to invite and encourage participation within unit activities to work towards wellness."

Observation on Unit 43C on 3/11/19 from 1:00 p.m.-3:00 p.m., revealed that a Creative Expressions group was being offered from 1:00 p.m.-2:00 p.m. The census on the unit was 15 patients. There were four patients attending the group. Patient A4, was sleeping on a couch in the dining room.

During interview on 3/11/19 at 1:30 p.m., when asked about Patient A4 not going to group, RN2 stated that patients were encouraged but if they didn't want to go, "You can't make them color a card."

During interview on 3/11/19 at 1:45 p.m., Patient A4, when asked about attending groups, stated that s/he had gone to at least one group since being admitted.

Observation on Unit 43C on 3/11/19 at 2:30 p.m., revealed that the Music group, scheduled for 2:15 p.m., had not started. The group was convened at 2:40 p.m. and four patients attended. Patient A4 attended the group for 30 minutes.

Observation on Unit 43C on 3/12/19 at 10:30 a.m., revealed that the scheduled RN group was not being held. Patient A4 was sleeping on the couch in the dining room.

During an interview on 3/12/19 at 10:30 a.m., RN8, when asked why the 10:15 RN group was not being held, stated that s/he did not usually work on this unit (Unit 43C) but did know that the hospital was training Psych Techs to do groups.

Observation on Unit 43C on 3/12/19 at 11:00 a.m., revealed that the scheduled Music Therapy Group was in session with three patients attending. Patient A4 was sleeping on the couch in the dining room.

Observation on Unit 43C on 3/12/19 at 1:15 p.m., revealed that the scheduled Creative Expression Group was in session with three patients attending. Patient A4 was sleeping on the couch in the dining room.

Review of the 3/1/19- 3/11/19 "15 Minute Rounds" sheets for Unit 43C, revealed that Patient A4 had attended only two groups during that time, a 3/9/19 Occupational Therapy Task Group and a Music Group on 3/1/19.

2. Patient A5 was admitted on 2/22/19. The Psychiatric/Psychological Assessment, dated 2/26/19, stated "[S/he] was alleged to turn on the gas generator for the past three weeks in the house and carbon dioxide was in the house. It was reported that the patient had not been sleeping for weeks." The diagnosis listed on the Assessment was "Schizophrenia, rule out Schizoaffective Disorder; Bipolar type."

The patient's MTP, dated 2/25/19, listed for the problem, "Impaired Social Interactions," the STG, "[Patient] will engage in one-two activities with minimal encouragement from nurse staff W/I (within) 7 days." The Treatment Intervention for this STG was, "Nursing staff will spend structured time with [patient] each day for a minimum of five minutes each working shift for brief interactions and activities with [patient] on a one to one basis."

The MTP Update, dated 3/11/19, stated Patient A5, "Did not attain any of [his/her] goals in Domain 1 this week." One of the goals in Domain 1 was, "will engage in one or two activities ...." This update, however, does not address a revision in the treatment plan to address Patient A5's lack of attendance in Unit Group activities. This update also did not indicate alternate activities that could be utilized in the event of group refusals.

B. Document Review

The hospital document, "MULTIDISCIPLINARY RECOVERY EDUCATION Record," provided to the surveyor by RN4, documents that Patient A5 had attended only two groups from 2/22/19 until 3/11/19.

C. Observations

1. During observation on Unit 43A at 1:30 p.m. on 3/11/19, an OT Group was observed in session. Patient A5 was observed in bed and refused to be interviewed. At 2:45 p.m. on 3/11/19 Patient A5 was observed still in bed while a Music Therapy Group was occurring and continued to refuse to be interviewed.

2. During observation on Unit 43A on 3/12/19 at 10:45 a.m., Patient A5 was observed in bed while an Occupational Therapy group was occurring.

Interview:

1. During an interview on 3/12/19 at 10:50 a.m., RN5 indicated that Patient A5 does not go to groups.

2. During an interview on 3 /12/19 on Unit 43A at 11:55 a.m., Social Worker 1 indicated that Patient A5 did not attend groups. S/he further stated that attempts were made to get him/her to groups and that attempts were largely unsuccessful.

3. During an interview with Patient A5, Social Worker 1 and the surveyor, Patient A5 discussed his/her concerns about medication. Immediately following the interview, s/he returned to his/her room despite being invited to remain in the Community Group.

4. During an interview on 3/12/19 at 1:00 p.m., RN4 provided the surveyor with the data that showed Patient A5 did not attend groups. RN4 concurred that group attendance was a problem for this patient and active treatment was an overall problem on Unit 43A.

3. Patient B1was admitted on 3/1/19. The Psychiatric Evaluation, dated 3/1/19, stated that the reason for admission was aggression towards staff at the group home and being, " ...disorganized, delusional (having false, fixed beliefs) and paranoid (extremely fearful and suspicious of others)."

The MTP, dated 3/1/19, had for the problem, "Violence", the Rehab Short-Term Goal (STG), "(Patient) will verbalize 2-3 positive coping skills learned in Rehab groups and practiced on the unit to safely express and manage negative feelings (times) 7 days." The intervention for this STG was "(OT staff) to implement task and/or discussion sessions daily for 45-55 minutes duration." Although Patient B1 had not been attending groups as scheduled, the "Treatment Team Note" for the MTP update, dated 3/12/19, did not change any goals or interventions and did not address the non-attendance.

Observation on Unit 43C on 3/11/19 from 1:00 p.m.-3:00 p.m., revealed that a Creative Expressions group was being offered from 1:00 p.m.-2:00 p.m. The census on the unit was 15 patients. There were four patients attending the group. Patient B1 was watching television.

During interview on 3/11/19 at 1:45 p.m., Psych Tech 4 stated that Patient B1 did not go to groups.

Observation on Unit 43C on 3/11/19 at 2:30 p.m., revealed that the Music group, scheduled for 2:15 p.m., had not started. The group was convened at 2:40 p.m. and four patients attended. Patient B1 was observed sitting in front of the television.

Observation on Unit 43C on 3/12/19 at 10:30 a.m., revealed that the scheduled RN group was not being held.

Patient B1 was sitting in the dining room speaking in Spanish to him/herself. When the surveyor attempted to interview the patient, s/he would not stop talking to self and rocking back and forth.

Observation on Unit 43C on 3/12/19 at 11:00 a.m., revealed that the scheduled Music Therapy Group was in session with three patients attending. Patient B1 was meeting with an interpreter.

Observation on Unit 43C on 3/12/19 at 1:15 p.m., revealed that the scheduled Creative Expression Group was in session with three patients attending. Patient B1 was sitting in the dining room.

Review of the 3/1/19- 3/11/19 "15 Minute Rounds" sheets for Unit 43C, revealed that Patient B1 was not listed as being in any group during this time span.

4. Patient B2 was admitted on 12/24/18. The Psychiatric Evaluation dated 12/26/18 stated the reason for admission as " ...attempted to set fire to (his/her) group home residence in an attempt to kill (him/herself)."

The MTP, dated 12/26/18 identified the problem, "Violence". For this problem, the Rehab Services intervention was, "Rehab Services staff (OT/MT) [Occupational Therapy/Music Therapy] will invite (patient) daily to 50-60 (minutes) groups to promote exploration of healthy coping skills to remain safe. Will provide a variety of media keeping (patient's) interests in mind as indicated, such as creative expression, art, discussion, and music. Will praise all efforts." Although Patient B2 routinely refused groups, there were no changes to the intervention and the STGs related to this intervention were "Extended" on 3/13/19.

Although the Rehab "Individual Progress Notes" (IPN) indicated that 1:1 sessions were offered to patient, there was no indication when those were offered and there was no documentation on the MTP to address the purpose, focus or frequency of the interventions. Review of the Rehab IPN dated 3/8/19 stated that for the period 3/4/19-3/7/19, Patient B2 engaged in a 1:1 Music Therapy session (15 minutes) on 3/5/19 and a 1:1 OT Task session (15 minutes) on 3/6/19. The IPN stated that the patient refused a 1:1 "opportunity" on 3/5/19 and engaged in only two of the 15 offered Rehab sessions (unclear how many were group offerings and how many were offered 1:1.) The therapist documented " ...plan to continue inviting (him/her) to MT and OT sessions and offer 1:1 opportunity as clinically indicated to promote optimum recovery." Review of the Rehab IPN dated 3/12/19 stated that patient attended OT 1:1 session on 3/12/19. This was observed by the surveyor and consisted of the patient and OT staff member playing cards and talking. The note documented that on 3/8/19, the patient refused an OT Task Group, an OT Discussion Group and a Music Therapy Group. The patient on 3/11/19 refused an OT Task Group, a Music Therapy Group, an OT Discussion Group and an OT 1:1 opportunity.

Observation on Unit 43C on 3/11/19 from 1:00 p.m.-3:00 p.m., revealed that a Creative Expressions group was being offered from 1:00 p.m.-2:00 p.m. The census on the unit was 15 patients. There were four patients attending the group. Patient B2 was sitting alone at a table in the dining room.

Observation on Unit 43C on 3/11/19 at 2:30 p.m., revealed that the Music group, scheduled for 2:15 p.m., had not started. The group was convened at 2:40 p.m. and four patients attended. Patient B2 was observed sitting alone at a table in the dining room.

During interview on 3/12/19 at 10:15 a.m., Psych Tech 4 stated that Patient B2 did not go to groups and usually sat at the same table in the dining room hoping that someone would play cards with him/her.

Observation on Unit 43C on 3/12/19 at 10:30 a.m., revealed that the scheduled RN group was not being held. Patient B2 was sitting at a table in the dining room playing cards with a staff member.

Observation on Unit 43C on 3/12/19 at 11:00 a.m., revealed that the scheduled Music Therapy Group was in session with three patients attending. Patient B2 was sitting alone at a table in the dining room.

Observation on Unit 43C on 3/12/19 at 1:15 p.m., revealed that the scheduled Creative Expression Group was in session with three patients attending. Patient B2 was sitting in the dining room.

Review of the 3/1/19- 3/11/19 "15 Minute Rounds" sheets for Unit 43C, revealed that Patient B2 was not listed as being in any group during this time span.

B. Observations

1. During an observation on Unit 43C on 3/11/19 at 1:15 p.m., four patients were observed in the Creative Expressions group. The census on the unit was 15. There was one patient watching television, five patients in bed, four patients walking around the unit and one patient was sleeping on a couch in the dining room.

2. During an observation on Unit 43A on 3/11/19 at 1:30 p.m., an OT group was occurring. The census on the Unit was 15 patients. The group started 15 minutes late with six patients who wandered in and out of group. The surveyor and CNA1 (Certified Nursing Assistant) at 1:30 p.m. on 3/11/19, rounded on the Unit and observed that nine patients were in their rooms resting or asleep in their rooms.

3. During an observation on Unit 43C on 3/11/19 at 2:40 p.m., four patients were observed in the Music group. There were five patients in bed, one patient with a therapist, two patients in the dining room, one patient playing cards in the dining room, and two patients pacing the hallways.

4. During an observation on Unit 43A on 3/11/19 at 2:50 p.m., CNA1 and the surveyor made rounds on the Unit. An OT group was occurring. At that time the census on the Unit was 15 patients. Three patients were in group, one patient was on the phone, five patients were in bed, and six patients were sitting in the day room or roaming the hall.

5. During an observation on Unit 43C on 3/12/19 from 10:00 a.m.-11:00 a.m., it was observed that the Community Meeting group (10:05 a.m.) and the Nursing Group (10:15-11:00 a.m.), both of which were listed on the schedule as RN groups, were not held. When RN8 was asked why the groups were not done stated that the Psych Techs were going to start doing the groups. The census on the unit was 14. Observation on the unit at 10:30 a.m. revealed that there were three patients in bed, eight patients in the dining room, two patients at the nurses' station, and one patient in the group room.

6. During an observation on Unit 43A at 10:45 a.m. on 3/12/19, RN4 and the surveyor confirmed that six patients were in their rooms either resting or asleep; one patient was in OT group and six patients were walking around the unit or sitting in the dayrooms. The unit census was 13.

7. During an observation on Unit 43C on 3/12/19 at 11:00 a.m., it was observed that the scheduled Music Therapy group was being held with three patients in attendance. There were two patients in bed, one patient playing cards with a staff member, three patients in the dining room, one patient with an interpreter, one patient in court, and three patients walking the halls.

8. During an observation on Unit 43C on 3/12/19 at 1:00 p.m., three patients were observed attending the Creative Expression group. The census remained at 14. There were three patients in bed, two patients walking the halls, one patient on the phone, two patients watching television and three patients in the dining room.

9. During an observation on Unit 43A on 3/12/19 at 10:45 a.m., RN4 and the surveyor confirmed that six patients were in their rooms, either resting or asleep; one patient was in OT group and six patients were walking around the unit or sitting in the dayrooms. The unit census was 13.

C. Interviews

1. Review of the Group Schedule for Unit 43C (Women's Treatment Unit) on 3/11/19 revealed that a Task Music Group Therapy and a Recovery Occupational Therapy Group (OT group) were scheduled at 11:00 a.m. During an interview on 3/11/19 at 1:00 p.m., RN1 stated, "We don't have Recovery OT [Occupational Therapy] group at 11:00 a.m. on Mondays because we have team meetings." RN1 was uncertain that any group had been held at 11:00 a.m. that morning. When asked if the 10:00 a.m. scheduled Nursing Group had been held that morning, RN1 stated that it was not held because s/he was dealing with an unsafe patient situation. S/he further stated that it depends on how they are staffed and what is happening on the unit as to whether they were able to do the nursing groups. When asked about the 8:05 p.m. scheduled nursing group, RN2 stated that the RN was usually "pouring hs (at bedtime) meds (medications)" during the time the group was scheduled. RN2 further stated that many variables were taken into account when determining whether the nursing groups occurred and that it was "very hard when you only have two RNs for 15 patients."

2. During an interview on 3/11/19 at 1:10 p.m., RN1 and RN2 were unsure why only one of the two groups scheduled for 1:00 p.m. was being held. In addition, both RNs were unsure which group was in session, but thought it was the Creative Expressions group. RN1 stated that the OT staff just come on the unit and say they are going to do a group but don't really involve the nursing staff.

3. During an interview on 3/11/19 at 1:15 p.m. RN1 was asked about the 1:00 p.m. OT group that was listed on the printed unit schedule. S/he indicated that a Music Group would occur at 1:30 p.m. Upon surveyor questioning him/her about the schedule, s/he asked Certified Nursing Assistant 1 (CNA1) to check the schedule. CNA1 verified that the OT Group was scheduled at 1:00 p.m. and stated that the therapist (OT1) was running late.

4. During an interview on 3/11/19 at 1:30 p.m., CNA2 indicated that six people in group was good for group attendance and indicated usually there were fewer patients in attendance.

5. During an interview on 3/11/19 at 1:50 p.m., Psych Tech 3 stated that patients were expected to go to group but lunch had been "heavy" and it was understandable that patients wanted to nap and not go to group.

6. During an interview on 3/11/19 at 2:00 p.m., OT1 discussed the OT Group with the surveyor. S/he indicated that six patients in the group was good attendance for the group. S/he stated that they try to get people in groups but cannot force them. When questioned about his/her role with the patients not attending the group, OT1 indicated sometimes s/he tried to meet with non-attendees but did not necessarily do so given his/her scheduling requirements.

7. During an interview on 3/12/18 at 9:15 a.m., RN6 stated that patients were encouraged to go to groups but if they didn't want to, they could go their rooms and read or nap.

8. During an interview on 3/12/19 at 2:10 p.m., the Chief Nursing Officer (CNO) acknowledged that the nursing staff were currently not committed to doing groups.

ll. Failure to provide week-end activities

A. Document Review

Review of the group schedules for three of the four units revealed that there were few therapeutic or leisure groups offered on Saturday and Sunday. Specifically, Unit 43A, the Intensive Treatment Unit, had one OT group offered each day and the only other groups being offered were a nursing Community Meeting/Goal group in the morning and evening; Unit 43B, the Acute Treatment Unit, had one OT group offered each day, two nursing groups on Saturday, one nursing group on Sunday and one Community group each day; Unit 43C, the Women's Treatment Unit, had one OT group offered each day, two Community groups and two scheduled nursing groups. The nursing groups on the schedule were dependent on staffing numbers and the acuity of the unit. (Refer to B125 l-Interviews: (1) (8) and (9).

B. Interview

During an interview on 3/11/20 at 2:15 p.m., CNA2 indicated that weekends were "more relaxed" with "less activities."

During an interview on 3/11/20 at 12:50 pm., Patient A6 was asked about weekend schedules and activities. S/he indicated weekends were, "laid back, watch movies, sometimes conversations." S/he further indicated it would be "ok" to "sleep, eat, and go back to bed."

During interview on 3/11/19 at 1:00 p.m., RN1, when asked about week-end activities, stated that the OT staff, "are doing what they can on the week-ends," and indicated that the Rehab Department had one staff member leave recently. RN1 also shared that nursing groups on the schedule were not always held due to staffing and acuity.

During an interview on 3/11/19 at 2:30 p.m., Patient A7 indicated that weekends were less active, and s/he spent his/her time "walking around or watching TV."

During interview on 3/12/19 at 9:15 a.m., RN6, when asked about week-end activities, stated that they were getting the Psych Techs trained to do groups so that they could help out on the week-end since there was not much in the way of programming on the week-ends.

During interview on 3/12/19 at 3:15 p.m., the CNO acknowledged that there were minimal activities on the week-ends and they (management) were working on that.

Based on medical record review, policy review, observation, and interview, the medical director failed to ensure:
I. The documentation of a psychiatric evaluation for one of eight randomly selected sample patients (Patient A4). Therefore, there is no psychiatric information to justify the diagnosis and the planned treatment. In addition, there is no baseline data from which the treatment team can assess patient's changes in status through the course of treatment. (Refer to B 110)

II. The provision of timely completion of psychiatric evaluations in keeping with the CMS requirement of completion within 60 hours of admission for two of eight randomly selected patients (A3 and A4). This failure has the potential to result in the treatment team not having the information required to create a treatment plan based on data essential for the psychiatric findings and substantiated diagnosis. (Refer to B111)

III. The provision of a psychiatric evaluation that included the personal assets on which to base a meaningful treatment plan for three of eight randomly sampled patients (A2, A7, and A8). This failure to identify patients' strengths has the potential to impair the treatment team's ability to choose treatment modalities which best utilizes the patient's attributes in therapy. (Refer to B 117)

IV. That active treatment measures, such as group and/or individual treatment, were provided for two sample patients (A4 and A5) and two patients (B1and B2) added to the sample in order to evaluate active treatment. Specifically, all four patients were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). In addition, the majority of patients on Units 43A (Intensive Treatment Unit) and 43C (Women's Treatment Group) did not attend groups and were either in their rooms or sitting on the unit during group time. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-l)

Provision of week-end therapeutic and leisure groups to address the needs of all patients. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

Interview

In an interview on 3/13/19 at 10:30 a.m. the Clinical Director concurred with the deficiencies found in the psychiatric evaluations, the lack of STG's that were observable and behavioral, and the lack of patient engagement in active treatment on the Units as well as the lack of provision of active treatment on the weekends.

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions were based on the individual needs of six of eight sample patients (A1, A2, A3, A5, A7, and A8). Specifically the nursing interventions were generic and not specific to individual patient needs. This failure has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

1. Patient A1's Master Treatment Plan (MTP), dated 3/8/19, listed for the STG, "[Patient] will demonstrate a decrease in threating statements to staff in 7 days," the generic, non-individualized nursing intervention, "Primary RN will administer as ordered [sic] document behavior and provide purposeful unit activities on a daily basis."

2. Patient A2's MTP, dated 3/9/19, listed for the STG, "Patient will describe a discharge plan agreeable to self, family PSW (Psychiatric Social Worker w/in [within] 3 days," the generic non-individualized nursing intervention, "Nursing staff will encourage and provide positive conversation topic within the milieu during working hours."

3. Patient A3's MTP, dated 3/5/1, listed for the STG, "Patient will exhibit the ability to interact with others in a self-non-threatening manner for 7 days," the generic non-individualized nursing intervention, "RN will monitor for symptoms of aggression and redirect each occurrence."

4. Patient A5's MTP, dated 3/3/19, listed for the STG, "[Patient] will demonstrate the ability to hold a (sic) c [with] staff and peers without evidence of the inability to think clearly and speak logically within 7 days," the generic, vague nursing intervention, "Nursing and other staff to use therapeutic techniques to try to understand the patients [sic] concerns during interactions."

5. Patient A6's MTP, dated 3/4/19, listed for the STG, "Patient will demonstrate the ability to hold conversation with staff and peers without evidence of hallucinations for 7 days," the routine, generic, non-therapeutic nursing intervention, "Nursing staff will meet 1:1 with patient at least once per working shift for > [greater than] 5 minutes to explore the content of hallucinations reconnect with reality."

6. Patient A8's MTP, dated 2/15/19, listed for the STG, "[Patient] will demonstrate a decrease in disturbed thought processes as evidenced by the ability to express logical goal directed thoughts without delusions with next 7 days."

This generic routine nursing intervention listed for this STG was, "RN /designee will engage [Patient] each shift to assess [his/her] mental status. Encourage reality-based conversation."

B. Interviews

In an interview on 3/12/19 at 3:15 p.m., the Director of Nursing concurred that Nursing interventions were largely routine, generic Nursing duties rather than patient specific interventions.