HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #3) in the sample that required plan of care representation, staff failed to include the parent in the development and implementation of the plan of care. Findings include:

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...The patient and or guardians participation in the treatment planning process and his/her signature must be noted on the initial problem list and the master treatment plan...Master treatment plan will be reviewed and signed by the patient..."

The hospital policy entitled "...Statement of Patient Rights" stated, "...You have a right to be part of planning your care and treatment...If you are under the age of 18, your parents or legal guardian have the right to make decisions for you regarding your treatment..."

Review of Patient #3's medical record revealed:

1. "...Admission Agreement" signed by the patient's mother on 10/13/15 at 10:59 PM

2. "Master Treatment Plan" completed on 10/15/15 included the problems "Diabetes" and "Unsafe Behavior" and the following updated interventions:

a. 11/21/(no year) obtain fasting (before eating) blood sugar test results on Monday and Thursday
b. 12/2/15 at 11:15 PM:
- placed in seclusion
- restraint used: 2 intramuscular injection (IM) medications administered

3. No documented evidence to support that the parent was:
- involved and/or participated in the plan of care for diabetes
- notified of the interventions of seclusion and restraint of Patient #3
- involved and/or participated in the implementation of the updated plan of care interventions

Interview with Chief Nursing Officer A on 12/8/15 at 3:58 PM and on 12/9/15 at 9:26 AM confirmed these findings.

Based on medical record review, policy and staff interview, it was determined that nursing staff failed to report the refusal of treatment to the physician for 1 of 5 patients (Patient #3) in the sample. Findings include:

The hospital policy entitled "Refusal of Treatment" stated, "...In instances in which a patient...wishes to refuse prescribed treatment deemed necessary by the physician...this refusal must be documented in the patient's record...which includes the time and that the treating physician has been notified...In instances in which treatment is being refused, the Charge Nurse of the area will contact the patient's physician and advise him/her of the patient's refusal..."

Review of Patient #3's medical record revealed:

1."Physician's Orders" dated 11/21/15 included an order to obtain fasting (before eating) blood sugar levels on Monday and Thursday.

2. "Medication Administration Record" documentation revealed Patient #3 refused to have the blood sugar level obtained on:
- 11/30, 12/3 and 12/7/15

3. No evidence to support that nursing staff informed the physician of the refusal to have the blood glucose levels obtained as ordered

Interview with Chief Nursing Officer A on 12/8/15 at 4:00 PM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 3 patients in the sample (Patient #'s 3 and 5) with documented changes in their plan of care, staff failed to develop and/or revise the plan of care to reflect current needs. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "...The nurse formulates nursing care problem statements...the nursing care problem statements constitute the nursing plan of care which is part of the interdisciplinary plan of care...The nurse reviews and updates the nursing plan of care on a regular basis..."

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...A treatment plan update will be completed at least every (7) days after the development of the Master Treatment Plan...There will be revision to any active treatment plans...for all patients exhibiting...injuries/falls..."

Medical record review revealed:

A. Patient #3

1. "Consultation Form" dated 11/21/15 at 2:00 PM included the following documentation:
- Medical consultation requested and conducted for increased blood sugars

2. "Physician's Orders" dated 11/21/15 included an order to obtain fasting (before eating) blood sugar level on Monday and Thursday.

3. "Medication Administration Record" documentation revealed refusal to have the blood sugar level performed on the following dates:
- 11/30, 12/3 and 12/7/15

4. Review of the "Master Treatment Plan" and "Master Treatment Plan Update" documentation revealed that nursing staff failed to revise the care plan to include:
- increased blood sugar level
- refusal to have blood sugar level obtained

Interview with Chief Nursing Officer A on 12/8/15 at 3:55 PM confirmed these findings.

B. Patient #5

1. "Physician's Orders" dated 11/10/15 at 10:30 PM included the following orders:
- medical consult for facial injury
- continue neurology checks (assessment of neurological status)
- left facial x-ray stat (immediately)

2. "Consultation Form" dated 11/11/15 included the following Medical Consultation findings and plan:
- patient hit left eye on door handle
- x-ray completed of facial bone
- slight swelling and bruising under left eye
- obtain x-ray report to rule out fracture
- continue to apply ice to left eye every shift for 48 hours

3. Review of the "Master Treatment Plan" and "Master Treatment Plan Update" documentation revealed that nursing staff failed to revise the care plan to include the left eye injury and/or implemented interventions

Interview with Chief Nursing Officer A on 12/8/15 at 4:18 PM confirmed this finding.

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

l. Develop and document comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for three (3) of eight (8) sample patients (A1, A5 and A7). Failure to develop and document treatment plans based on patient needs limits staff ability to address the patients' need for inpatient care and can extend the length of hospitalization. (Refer to B118)

ll. Develop Master Treatment Plans (MTP) that identified patient-centered short-term goals in observable, measurable, behavioral terms for five (5) of eight (8) active patients. (A1, A2, A5, A7 and A8) The lack of measureable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. (Refer to B121)

lll. Identify in the MTP specific treatment interventions/modalities to address the identified patient problems for three (3) of eight (8) active sample patients (A5, A7 and A8). The treatment interventions were either stated in vague terms, or were non-individualized generic discipline functions rather than directed at specific interventions. In addition, on the child and adolescent units there were no physician interventions listed for four (4) of four (4) sample patients (A1, A2, A3 and A4). This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients. (Refer to B122)

lV. Identify by name the team member responsible for the nursing modalities/interventions selected for five (5) of eight (8) active patients (A1, A2, A5, A7 and A8). The treatment plans listed only staff initials and did not identify the specific nursing staff names of staff members responsible for treatment modalities/interventions. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment. (Refer to B123)

V. Ensure that the hospital's Special Precautions policy was followed for one of two sample patients on the Children's Unit (A1) and one Children's Unit patient added to the sample in order to evaluate active treatment (B1). Specifically Patient A1 was not continually monitored as required and Patient A1 and B1 were allowed to interact with adolescent patients off their secure, locked unit without their assigned staff. Failure to provide appropriate monitoring and supervision of patients by assigned staff has the potential to compromise the safety of patients and can lead to adverse outcomes. (Refer to B125)

Based on medical record review, observation, and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for three (3) of eight (8) sample patients (A1, A5 and A7). Failure to develop and document treatment plans based on patient needs limits staff ability to address the patients' need for inpatient care and can extend the length of hospitalization.

Findings include:

A. Specific Patient Findings

1. Patient A1 was readmitted on 11/30/15 after being discharged to the Partial Hospital Program (PHP) the same day, 11/30/15. The Psychiatrist Assessment dated 11/30/15 listed the diagnoses, "Disruptive mood dysregulation disorder" and "Oppositional defiant disorder" and stated the reason for readmission as "[He/She] was in PHP. [His/Her] behavior became out of control. [He/She] was aggressive and destructive." Patient A1 was placed on Special Precautions Level ll and assigned a video monitored room on the Children's Unit.

The only psychiatric problem listed on the Master Treatment Plan (MTP) dated 12/1/15 was, "Suicidal Ideations as evidenced by [patient] was telling others to kill [him/her]. [Patient] was digging into [his/her] arms. [Patient] also tried to stab self with pencils and pens. [Patient] attempted to grab gloves and cover [his/her] mouth." There was no problem with aggression addressed on the MTP.

Review of the Nursing Progress Notes and Nurse Notes revealed the following entries related to aggression:

11/30/15 - "Pt. (Patient) was stepped up from PHP. [He/She] was out of control, kicking, biting and hitting."

12/1/15 - "Patient threatened to attack a peer. 'Shut up before I punch you'."

12/2/15 - "Patient became agitated with a peer and threatened peer. 'I will kill him.' Patient then punched peer." "Pt then attacked staff by kicking and punching staff."

12/4/15 - "Patient became agitated during creative arts group and threatened to attack a peer."

12/5/15 - "Having (negative) interactions with many of [his/her] peers, threatening to hurt them."

12/7/15 - "Pt. out of control @ (at) the beginning of the shift. [He/She] was making verbal threats towards peers and attempting to be physical but staff intervened."

During observation on the Child Unit on 2/7/15 at 2:00 PM, Patient A1 was seen getting physically close to another patient while cursing and threatening to hit the other patient.

During observation in the dayroom on the Stabe Unit (where the Children were programming) on 2/7/15 at 2:10 PM, the surveyor witnessed Patient A1 walk out of the dayroom into the hallway and confront another patient. Patient A1 remained in the hallway, without being observed by staff, until she became loud and disruptive and the assigned staff intervened.

During interview on 12/8/15 at 3:45 PM, RN2 acknowledged that Patient A1 was often verbally aggressive and at times physically aggressive with peers and staff and that this behavior was not addressed on the Master Treatment Plan.

2. Patient A5 was readmitted on 11/29/15. The psychiatric evaluation dated 11/30/15 listed a diagnosis of "Schizophrenia, chronic undifferentiated". The patient's intake assessment dated 11/29/15 noted "has been non-compliant c (with) [his/her] medication and recently attempted SI (suicidal ideation) by overdosing on [his/ her] medications" The Master Treatment Plan (MTP) dated 11/29/15 listed the following problem:

"Psychosis as evidenced by increased disorganized thought process and bizarre speech/behaviors. Pt (Patient) has been noncompliant with medications and reports +SI with attempt to OD (Overdose) on medications. Pt demonstrates increase verbal aggression toward family members, anger, irritability, mood swings, and violent behaviors/throwing things. Pt reports hx (history) of physical, sexual, and emotional abuse."

Patient long and short term goals listed on the MTP included:

"Pt will display decreased psychosis, disorganized thought process, and bizarre speech/behaviors."

"(Patient) will demonstrate 1 or less symptoms of psychosis, disorganized thought process, and bizarre speech/behavior for at least 2 consecutive days prior to DC (Discharge)."

During observation on the Middle Unit on 12/7/15 at 1:00 PM, Patient A5 was observed asleep on a floor on a mattress in the ante room to the seclusion rooms. With some difficulty RN3, with assistance, was able to assist patient to move into an interview room. (He/She) was dressed in paper hospital gowns. (He/She) was essentially unavailable for interview due to recent medication and said "I don't know where my clothes are. I scare other patients. I roam at night."

During an interview on 12/7/15 at 1:45 PM, SW1 indicated that the patient was a difficult management problem and there was difficulty maintaining group participation or boundaries from others. He/she further confirmed that the current treatment goals did not meet the immediate treatment needs of the patient.

During an interview on 12/7/15 at 2:15 PM, RN 3 indicated that the patient was a management problem and the current listed treatment goals did not meet the current needs of the patient.

3. Patient A7 was admitted on 12/03/15. His/her psychiatric evaluation dated 12/04/15 listed a diagnosis of "Psychosis, not otherwise specified, and Dementia, Alzheimer's type." The evaluation further described episode of "increasing paranoia, bizarre aggressive behaviors and noncompliance with medications." The Master Treatment Plan dated 12/3/15, however, listed the patient's problem as "Major Depression with psychosis as evidenced by recent change in mental status."

Long and short term goals listed on the MTP included "[Patient] will display positive mood and healthy communication on the unit as seen through staff and peers." "[Patient] will display mood stability for at least three (3) consecutive days prior to discharge." There were no goals or interventions listed for aggressive behaviors, paranoia, or medication noncompliance.

During an interview on 12/08/15 at 10:30 AM, Patient A5 had difficulty hearing, did not know how old he/she was, and did not want to participate in the Music Therapy activity. He/she wanted to know where his/her son was.

During an interview on 12/08/15 at 10:50 AM, SW2 and RN 4 concurred that the current listed treatment goals did not address the needs of the patient. RN3 noted that when patient refused medications, contacting his/her son on the phone and having him speak to him/her, created better medication compliance but this was not noted on the treatment plan.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals in observable, measurable, behavioral terms for five (5) of eight (8) active patients. (A1, A2, A5, A7 and A8) The lack of measureable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings Include:

A. Specific Patients Findings

1. Patient A1 admitted on 11/30/15 had listed on the MTP dated 12/01/15 for the problem, "suicidal behavior" the following short term goals: "[Patient] will talk to staff and participate in group daily to promote healthy self-expression." "[Patient] will identify positive coping skills that lessen suicidal thoughts."

2. Patient A2 admitted on 11/09/15 had listed on the MTP dated 11/10/15 for the problem, "aggression" the following short term goals: "[Patient] will comply with the rules on the milieu for at least 2 days" and "[Patient] will participate in groups daily to demonstrate healthy self-expression."

3. Patient A5 admitted on 11/29/15 had listed on the MTP dated 11/29/15 for the problem, "Psychosis as evidence by increased disorganized thought process and bizarre speech/behaviors", the following short term goals: "Pt [Patient] will display decreased psychosis, disorganized thought process, and bizarre speech/behaviors" and "[Patient] will demonstrate 1 or less symptoms of psychosis, disorganized thought process, and bizarre speech/behaviors, for at least 2 consecutive days prior to DC (discharge). "

4. Patient A7 admitted on 11/23/15 had listed on the MTP dated 11/24/15 for the problem, "Major Depression with psychosis as evidenced by a recent change in mental status. [Patient] has shown an increase in activity level, anger outbursts, mood swings, and unprovoked physical aggression towards others", the following short term goals: " [Patient] will display mood stability for at least three (3) consecutive days prior to discharge" and "[Patient] will maintain healthy eating and sleeping patterns for at least three (3) days prior to discharge."

5. Patient A8 admitted 11/30/15 had listed on the MTP dated 11/30/15 for the problem, "Psychosis...demonstrating behavioral changes....increase in irritability, mood swings, poor impulse control, verbal outbursts, threatening behaviors, and physical aggression toward staff and peers in nursing home...." the following short term goal: "[Patient] will display non-debilitating symptoms and signs of psychosis for at least three (3) days prior to discharge including eliminating suicidal thoughts."

B. Interview

During an interview on 12/07/15 at 1:45 PM, SW1, RN3, and the Director of Clinical Services concurred that treatment goals did not reflect observable, measurable, behavioral goals.


During an interview on 12/08/15 at 10:45 AM, Social Worker 2 and RN4 confirmed that the short term goals, as written for the geriatric patients, did not reflect observable, measurable goals to meet the treatment needs of the patients.

Based on record review and interviews, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for 3 of 8 active sample patients (A5, A7 and A8). The treatment interventions were either stated in vague terms, or were non-individualized generic discipline functions rather than directed at specific interventions. In addition on the child and adolescent units there were no physician interventions listed for 4 of 4 sample patients. (A1, A2, A3 and A4) This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings include:

A. Specific Patient Findings

1. Patient A1 admitted on 11/30/15 had no physician interventions listed on the MTP dated 12/01/15.

2. Patient A2 admitted on 11/09/15 had no physician interventions listed on the MTP dated 11/10/15.

3. Patient A3 admitted on 11/10/15 had no physician interventions listed on the MTP dated 11/11/15.

4. Patient A4 admitted on 11/23/15 had no physician interventions listed on the MTP dated 11/24/15.

5. Patient A5 admitted on 11/29/15 had listed on the MTP, dated 11/29/15, for the problem, "Psychosis as evidence by increased disorganized thought process and bizarre speech/behaviors", the following short term goals: "Pt [Patient] will display decreased psychosis, disorganized thought process, and bizarre speech/behaviors" and "[Patient] will demonstrate 1 or less symptoms of psychosis, disorganized thought process, and bizarre speech/behaviors, for at least 2 consecutive days prior to DC [discharge]. The following interventions were noted on the MTP: "educate pt on [his/her] meds including side effects" and "educate pt on positive coping skills...."

6. Patient A7 admitted on 11/23/15 had listed on the MTP, dated 11/24/15, for the problem, "Major Depression with psychosis as evidenced by a recent change in mental status. [Patient] has shown an increase in activity level, anger outbursts, mood swings, and unprovoked physical aggression towards others", the following short term goals: "[Patient] will display mood stability for at least three (3) consecutive days prior to discharge" and "[Patient] will maintain healthy eating and sleeping patterns for at least three (3) days prior to discharge." The following interventions were noted on the MTP: "[Patient] will actively engage in group therapy to encourage positive socializations with staff and peers" and "administer resperidol" and "administer remeron".

7. Patient A8 admitted 11/30/15 had listed on the MTP, dated 11/30/15 for the problem, "Psychosis...demonstrating behavioral changes....increase in irritability, mood swings, poor impulse control, verbal outbursts, threatening behaviors, and physical aggression toward staff and peers in nursing home...." the following short term goal: "[Patient] will display non-debilitating symptoms and signs of psychosis for at least three (3) days prior to discharge including eliminating suicidal thoughts". The following interventions were noted on the MTP: "administer zyprexa", "administer ativan", and "[Patient] will display mood stability for at least three (3) consecutive days prior to discharge."


B. Interviews


In an interview on 12/08/15 at 3:45 PM, RN2 acknowledged that the nursing interventions were generic nursing functions and did not address individual nursing needs of patients.
In an interview on 12/09/15 at 10:00 AM, the Medical Director concurred there were no physician treatment interventions on the MTP for the Child and Adolescent records selected.

In an interview on 12/09/15 at 10:30 AM, the Director of Nursing and Clinical Director concurred there were no physician interventions on the Child and Adolescent charts selected.
In addition they concurred that the Adult interventions did not adequately address the needs of the patients.

Based on record review and interview, the hospital failed to identify by name the team member responsible for the nursing modalities/interventions selected for five (5) of eight (8) active patients (A1, A2, A5, A7 and A8). The treatment plans listed only staff initials and did not identify the specific nursing staff names of staff members responsible for treatment modalities/interventions. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment.

Findings Include:

A. Specific Patient Findings

1. Patient A1's MTP dated 12/01/15 listed nursing interventions as "RN/RS." (Registered Nurse/Recovery Specialist)

2. Patient A2's MTP dated 11/10/15 listed nursing interventions as "All Staff/RS."
3. Patient A5's MTP dated 11.29/15 listed nursing interventions as "nursing."

4. Patient A7's MTP dated 11/24/15 listed nursing interventions as "NSG."

5, Patient A8's MTP dated 11/30/15 listed nursing interventions as "Nursing Staff," or "Geri staff," or "NSG."


B. Interview

During an interview on 12/08/15 at 10:45 AM, Social Worker 2 and RN 4 confirmed that specific nursing staff were not listed as responsible for nursing treatment interventions.

During an interview on 12/09/15 at 10:30 AM, the Director of Nursing and the Clinical Director concurred that specific nursing staff were not listed as responsible for nursing treatment interventions.

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

l. Ensure that the hospital's Special Precautions policy was followed for one of two sample patients on the Children's Unit (A1) and one Children's Unit patient added to the sample in order to evaluate active treatment (B1). Specifically Patient A1 was not continually monitored as required and Patient A1 and B1 were allowed to interact with adolescent patients off their secure, locked unit without their assigned staff. Failure to provide appropriate monitoring and supervision of patients by assigned staff has the potential to compromise the safety of patients and can lead to adverse outcomes.

Findings Include:

A. Monitoring Patients on Special Precautions Level ll (SP2)

1. Specific Patient Findings

Patient A1 was readmitted on 11/30/15 after being discharged to the Partial Hospital Program (PHP) the same day, 11/30/15. The Psychiatrist Assessment dated 11/30/15 listed the diagnoses, "Disruptive mood dysregulation disorder" and "Oppositional defiant disorder" and stated the reason for readmission as "[He/She] was in PHP. [His/Her] behavior became out of control. [He/She] was aggressive and destructive." Patient A1 was placed on Special Precautions Level ll (SP2) and assigned a video monitored room on the Children's Unit.

2. Policy Review

Review of the "Special Precautions and Patient Level of Observation" policy (No. RM.051) issued 7/08 and revised 7/15, defined the observation level of Special Precautions Level ll (SP2) as "The patient should be within visual range by assigned staff and within a distance that allows the staff member to take immediate action."

3. Observation

During observation in the dayroom on the Stabe Unit (where the Children were programming) on 2/7/15 at 2:10 PM, the surveyor witnessed Patient A1, who was on SP2, walk out of the dayroom into the hallway and confront another patient. Patient A1 remained in the hallway, without being observed by staff, until she became loud and disruptive and the assigned staff intervened. Patient A1 was not within visual sight of the assigned staff during this time.

4. Interview

During interview on 12/7/15 at 2:15 PM, RN2 stated that patients on SP2 were to be within eye site of the assigned staff at all times. RN2 agreed that Patient A1 had not been within eye site of the assigned staff when he/she was in the hallway.

B. Children Interacting with Adolescents

1. Specific Patient Findings

Patient A1 was readmitted on 11/30/15 after being discharged to the Partial Hospital Program (PHP) on the same day, 11/30/15. The Psychiatrist Assessment dated 11/30/15 listed the diagnoses, "Disruptive mood dysregulation disorder" and "Oppositional defiant disorder" and stated the reason for readmission as "[He/She] was in PHP. [His/Her] behavior became out of control. [He/She] was aggressive and destructive." Patient A1 was placed on Special Precautions Level ll (SP2) and assigned a video monitored room on the Children's Unit.

Patient B1 was admitted on 10/26/15. The Psychiatric Evaluation dated 10/26/15 listed the diagnoses, "Cyclothymic disorder" and "Rule out adjustment disorder with mixed emotional features." The reason for admission was due to "...depressed mood and suicidal feelings." Patient B1 was placed on Special Precautions Level lll.

2. Policy Review

Review of the "Special Precautions and Patient Level of Observation" policy (No. RM.051) issued 7/08 and revised 7/15, defined the observation levels as follows:

SP2 was defined as "The patient should be within visual range by assigned staff and within a distance that allows the staff member to take immediate action."

SP3 was defined as "Observation on an every 15 minute (or greater frequency) basis. The staff shall maintain visual and verbal contact sufficient to the patient's condition."

3. Observation

During observation on the Stabe Unit (Adolescent Unit) on 2/7/15 from 2:15-2:45 PM revealed that the door separating the adolescent females from the dayroom where the Children's Unit patients were programming, was unlocked and open. Children's Unit Patients A1 (7 years old) and B1 (11 years old) were sitting in the hallway of the Stabe Unit. There were two adolescent female patients sitting on the floor with A1 and B1. The four patients were talking and coloring. One of the adolescent patients was reading a story to the two children. Recovery Specialist 2 (RS2) who was assigned to the Stabe Unit was sitting at the nurses' station, watching the four patients interact.

4. Interview

During interview on 12/7/15 at 2:35 PM, RS 2, when asked about having the 2 children on the Stabe Unit, stated, "I'm watching them." When asked if the patients from the Children's Unit were usually on the Adolescent Unit, RS 2 answered, "No but they need to calm down." When asked if she knew anything about the Children and possible precautions assigned to each stated, "I've not worked with them but I've seen them around." RS 2 further stated that the assigned staff member, RS 1, came to check on the children every 15 minutes.

During interview on 12/7/15 at 2:40 PM, RS 1, when asked about having the 2 children on the Stabe Unit, stated that the children were so out of control that he was allowing A1 and B1 to be with the adolescents because they were calmer there.

During interview on 12/7/15 at 2:45 PM, RN 2 acknowledged that the children were not to interact with the adolescent patients. RN 2 further stated that the interactions with the children and adolescents should not occur.

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

l. The development and documentation of comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for three (3) of eight (8) sample patients (A1, A5 and A7). Failure to develop and document treatment plans based on patient needs limits staff ability to address the patients' need for inpatient care and can extend the length of
hospitalization. (Refer to B118)

ll. The development of Master Treatment Plans (MTP) that identified patient-centered short-term goals in observable, measurable, behavioral terms for five (5) of eight (8) active patients (A1, A2, A5, A7 and A8). The lack of measureable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. (Refer to B121)

lll. The identification in the MTP specific treatment interventions/modalities to address the identified patient problems for three (3) of eight (8) active sample patients (A5, A7 and A8). The treatment interventions were either stated in vague terms, or were non-individualized generic discipline functions rather than directed at specific interventions. In addition on the child and adolescent units there were no physician interventions listed for four (4) of four (4) sample patients (A1, A2, A3 and A4). This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients. (Refer to B122)

lV. The identification by name the team member responsible for the nursing modalities/interventions selected for five (5) of eight (8) active patients (A1, A2, A5, A7 and A8). The treatment plans listed only staff initials and did not identify the specific nursing staff names of staff members responsible for treatment modalities/interventions. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment. (Refer to B123)

V. That the hospital's Special Precautions policy was followed for one (1) of two (2) sample patients on the Children's Unit (A1) and one Children's Unit patient added to the sample in order to evaluate active treatment (B1). Specifically Patient A1 was not continually monitored as required and Patient A1 and B1 were allowed to interact with adolescent patients off their secure, locked unit without their assigned staff. Failure to provide appropriate monitoring and supervision of patients by assigned staff has the potential to compromise the safety of patients and can lead to adverse outcomes. (Refer to B125)


In an interview on 12/08/15 at 1:00 PM the physician surveyor discussed with the Medical Director the findings related to short term goals, treatment interventions, and staff responsibilities related to Master Treatment plans. The Medical Director understood the deficiencies and did not dispute the findings.

In an interview on 12/09/15 at 10:00 AM, the Medical Director concurred there were no physician treatment interventions on the MTP for the Child and Adolescent records selected.

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

l. The identification by name of the team member responsible for the nursing modalities/interventions selected for five (5) of eight (8) active patients (A1, A2, A5, A7 and A8).¿ The treatment plans listed only staff initials and did not identify the specific nursing staff names of staff members responsible for treatment modalities/interventions.¿ This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment.¿ (Refer to B123)

ll. Ensure that the hospital's Special Precautions policy was followed for one of two sample patients on the Children's Unit (A1) and one Children's Unit patient added to the sample in order to evaluate active treatment (B1). Specifically Patient A1 was not continually monitored as required and Patient A1 and B1 were allowed to interact with adolescent patients off their secure, locked unit without their assigned staff. Failure to provide appropriate monitoring and supervision of patients by assigned staff has the potential to compromise the safety of patients and can lead to adverse outcomes. (Refer to B125)