HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure medical records were protected from water damage. This has the potential to affect all patients seen in this facility for the past ten years. The facility census was 114.

Findings include:

During tour of the medical records department on 03/08/17 at 9:10 AM, mobile file units with open shelving holding paper medical records were observed directly under sprinkler heads. The mobile file units were completely open at each end and when rolled together left approximately an inch of space/gap between each shelving unit. An additional room on the third floor held open shelves and card board boxes of paper medical records as well under sprinkler heads.

Staff F stated that in addition to the current patient's medical records, the medical records for every patient seen at this facility for the last ten years were stored in these two areas. In addition some current patients also have medical records older than the ten years here as well. Staff F verified that any hand-written form, such as orders, progress notes, and consents, were originals and were not backed up anywhere at this time.

Based on medical record review and staff interview the facility failed to ensure a discharge summary was included in the closed medical record for one (Patient #1) of five discharge records reviewed. The total census at the time of survey was 114.

Findings included:

The record review for Patient #1 was completed on 3/06/17. Patient #1 was admitted to the facility on 10/15/02. At the time of discharge the patient's current diagnosis was sexual sadism. Nurses notes in the medical record revealed Patient #1 was transferred and admitted to a medical hospital on 7/05/16 with symptoms of bowel obstruction. Progress notes in the medical record revealed the patient expired on 7/23/16 while a patient at the medical hospital. No discharge summary was found during review of the medical record.

Staff A confirmed there was no discharge summary completed for Patient #1 during interview on 3/06/17 at 2:15 PM.

Based on observation, interview, and record review, the facility failed to ensure the two hour barrier of the annex was free of penetrations, to ensure each hazardous area had self-closing doors and the stated protection rating of the barriers to said areas were maintained, to ensure all pull stations and fire alarm visual signal devices were tested annually, to ensure its fire drills included transmission of a fire signal, to ensure its fire drills included transmission of a fire signal, to maintain the stated rating of its smoke and fire barriers, to ensure each door in a smoke barrier self-closed, to maintain its sprinkler system in accordance with NFPA 25, 2011 edition, to test its fire dampers in accordance with 9.2 NFPA 101, and to determine by a formal and documented risk assessment procedure what risk category each of its building systems were (A709). This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

K131 Failed to ensure two hour barrier of annex was free of penetrations.
K321 Failed to ensure each hazardous area had self-closing doors and the stated protection rating of the barriers to said areas were maintained.
K345 Failed to ensure all pull stations and fire alarm visual signal devices were tested annually.
K353 Failed to maintain sprinkler system in accordance with NFPA 25, 2011 edition.
K372 Failed to maintain the stated rating of its smoke and fire barriers.
K374 Failed to ensure each door in a smoke barrier self-closed.
K521 Failed to test dampers in accordance with 9.2, NFPA 101, NFPA 90A, and NFPA 80
K711 Failed to ensure its fire drills included transmission of a fire signal.
K712 Failed to ensure its fire drills included transmission of a fire signal.
K901 Failed to determine by a formal and documented risk assessment procedure what risk category each of its building systems were.

Based on observation, staff interview, and policy review it was determined the facility failed to ensure all direct care staff wore a personal protection alarm while on duty. This affected six staff members out of eleven on two inpatient psychiatric units. The active census was 114.

Findings include:

Review of the "Policy and Procedure for Personal Alarms" 02.65 ( effective 12/13/16) states "the safety of staff will be enhanced by establishing a policy that requires all direct care staff to utilize a personal protection clip-on alarm while performing their duties at Northwest Ohio Psychiatric Hospital (NOPH). All direct contact staff shall wear the alarm for the duration of their shift, it is mandatory; failure to do so may result in formal discipline proceedings."

1. A tour of unit 500 ( Forensic Unit) was conducted on 03/06/17 at 9:45 AM and an interview was conducted with Staff E with regard to personal protection alarms being worn by all direct care staff as per policy. Assigned to the unit were two Registered Nurses, one Licensed Practical Nurses, and one Therapeutic Worker. Observation confirmed no staff were wearing personal protective equipment. When Staff E was asked about the personal protective alarms he/she stated we know these patients and feel comfortable not wearing them. Staff E then proceeded to provide alarms to three employees, however did not have enough to cover all staff on the unit.

2. A tour of unit 100 (Civil Unit) was conducted on 03/06/17 at 2:30 PM and an interview was conducted with Staff D with regard to personal protection alarms being worn by all direct care staff as per policy. Assigned to the unit was two Registered Nurses, two Licensed Practical Nurses, and three Therapeutic Program Workers. Observation confirmed all direct care staff were not wearing personal protective equipment. Staff D reported only having two personal protective alarms on the unit for the staff. Further, he/she reported this to upper management and no additional personal alarms were supplied to the unit.

This Condition is not met as evidenced by:

Based on medical record review, staff and patient interview, observation and facility policy review it was determined that for 10 of 10 patients (Patients A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2) there occurred-

1. Psychiatric Evaluations that did not contain an assessment of patient assets in descriptive, not interpretive fashion. (See, B117 for details)

2. Comprehensive Treatment Plans that contained interventions that were generic discipline functions, goals that were not relevant to the patient's psychiatric condition and responsible staff not consistently identified on the Treatment Plans. (See, B121, B122 and B123 for details)

3. No active treatment as reflected in Unit group or individual therapies. Also, that physician-patient contacts did not reflect care in an intensive psychiatric milieu. (See, B125 for details)

4. No discharge summary for a patient who had expired (Patient K6) and who had been considered by a morbidity/mortality conference. (See, B133 for details)

Based on medical record review and staff interview it was determined that for seven (7) of 10 patients (Patients B1, B2, C1, C2, D1, E1 and E2) the Psychiatric Evaluations failed to include a description of patient assets in descriptive, not interpretive fashion. This failure results in the multidisciplinary team not being made aware of what inherent patient skills, personal interests, talents, etc. might be utilized in developing treatment modalities for the patients.

The findings include----

I. Medical Record Review:

1. Patient B1: The Psychiatric Evaluation dated 1/13/2017 stated for the assessment of assets "Unknown at this time."

2. Patient B2: The Psychiatric Evaluation dated 11/16/2016 had no statement for the assessment of assets.

3. Patient C1: The Psychiatric Evaluation dated 1/04/2017 stated for the assessment of assets "family support, agreeable to treatment."

4. Patient C2: The Psychiatric Evaluation dated 2/18/2017 stated for the assessment of assets "agreeable to treatment."

5. Patient D1: The Psychiatric Evaluation dated 10/19/2016 had no statement for the assessment of assets.

6. Patient E1: The Psychiatric Evaluation dated 5/11/20162016 had no statement for the assessment of assets.

7. Patient E2: The Psychiatric Evaluation dated 12/09/2016 had no statement for the assessment of assets.

II. Staff interview:

On 3/07/2017 the clinical director was interviewed at 1:30 p.m. The clinical director was told of the findings described in Section I, above. The clinical director, also, looked at several of the Psychiatric Evaluations and agreed that they failed to include an assessment of patient assets.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric conditions for nine (9) of 10 active sample patients (A1, A2, B1, C1, C2, D1, D2, E1 and E2). Many of the goals were either not measurable or were staff goals (what the staff want the patient to achieve) rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Facility policy No. 02.21A, titled Individual Recovery Plan Admitting and Comprehensive, last reviewed 2/16/17, stated "An interdisciplinary treatment team shall evaluate each patient and develop an electronic prioritized plan for service delivery. This plan shall be individualized, detailing observable, measureable behaviors to be achieved to obtain the treatment goal. In addition, the treatment plan shall be a plan developed in terms of long and short term goals and objectives outlined in sequential steps to reach the expected outcome." Many of the goals and objectives on the active sample patients' treatment plans were not measureable.

2. In Patient A1's Master Treatment Plan (MTP), dated 1/27/17, the staff goal (known as long-term in this facility) for the problem of "[Name of patient] was unwilling to cooperate with treatment plan process" was "[Name of patient] will participate in the treatment plan process." The staff objective (known as short-term goal in this facility) was "[Name of patient] will meet with treatment team including psychiatrist, social worker, psychologist, and nursing staff."

For the problem of "[Name of patient] is at risk for harm to self and others to[sic] auditory hallucinations secondary to psychosis as evidenced by collateral reports that s/he wants to kill the male/female voice s/he hears, bizarre comments about mermaids and devils, and expressing the desire to harm staff because they annoy him/her. His/her admitting diagnosis is schizoaffective disorder, bipolar type." The non-measureable and staff goal was "[Name of patient] will commit to treatment and a therapeutic regiment of medications within the next 14 days." The staff objective was "[Name of patient] will take his/her medications with 100% compliance and verbalize name, dose and indication within the next 7 days."

3. In patient A2's MTP, dated 1/17/17, the non-measurable goal for the problem "Disturbed sensory perception AEB (as evidenced by) [name of patient] has verbalized that s/he 'hears bad thoughts'" was "[Name of patient] is able to recognize auditory hallucinations are an exacerbation of his/her disease process over the next three days or by time of discharge. The non-measurable short-term goal was "[name of patient] is able to recognize precipitating factors or signs that result in exacerbation of symptoms and employ learned techniques and prescribed medication to interrupt the response over the next 7 days."

4. In B1's MTP, dated 2/28/17, the non-measurable goal for the problem of "[Name of patient] is incompetent to stand trial," was "[Name of patient] will become competent to stand trial." The staff objective was "[Name of patient] will receive an evaluation of his/her competence to stand trial."

5. In patient C1's MTP, dated 1/31/17, the non-measureable goal for the problem of "[Name of patient] presents symptoms that include disorganized thought process, elevated mood, and insomnia. S/he was sleeping in a tent outside a store with only a thin blanket and speaking in circles" was "[Name of patient] will be able to verbalize insight regarding his/her diagnosis and events that led to symptom exacerbation within the next 21days." The non-measurable long-term goal was "[Name of patient] will be able to participate in milieu activities without interference from his/her presenting symptoms within the next 7 days." The non-measurable long-term objective was "[Name of patient] will reflect reality-based thinking over the next 30 days or by time of discharge."

The non-measurable short-term objective was "[Name of patient] will be able to hold an organized, meaningful conversation during the next 7 days."

6. In patient C2's MTP, dated 2/20/17, the non-measurable long-term goal for the problem "Disturbed thought process AEB [name of patient] holds false belief that wife/husband is deceased" was "[Name of patient] is able to refrain from responding to delusional thoughts should they occur and verbalizations reflect thinking process oriented in reality over the next 30 days or by time of discharge." Non-measurable short-term goal was "[Name of patient] is able to maintain activities of daily living [ADLs] to their maximal ability over the next 7 days."

The non-measurable long-term objective was "[Name of patient] will be able to differentiate between delusional thinking and reality. The client's speech will reflect reality-based thinking over the next 30 days or by time of discharge."

7. In patient D1's MTP, dated 1/5/17, the non-measurable long-term goal for the problem "[Name of patient] is experiencing symptoms of psychosis related to non-compliance with treatment as evidenced by aggressive behaviors, suicidal ideation and mood swings. His/her admitting diagnosis is schizoaffective disorder, bipolar type" was "[Name of patient] will experience resolution of paranoid ideations and commit to both inpatient and outpatient treatment prior to discharge." The non-measurable short-term goal was "[Name of patient] will experience improvement or resolution of delusion, disorganized thinking and paranoia within the next 14 days."

8. In patient D2's MTP, dated 2/11/17, the staff goal for the problem "[Name of patient] transferred to unit 500 on 12/23/16 to continue to work on earning levels and advances in forensic movement. Pt currently has levels II and IV and will continue to work on maintaining appropriate behaviors while complying with hospital rules moving toward level III movement" was "[Name of patient] will work to comply with unit rules and continue with active participation in treatment including groups and safe activities groups." The non-measurable short-term goal was "Pt to continue exhibiting appropriate behaviors and comply w/ unit rules and active treatment in order to obtain recommendation for level II w/ unit rules and active treatment in order to obtain recommendation for level III movement."

9. In patient E1's MTP, dated 2/26/17, the non-measureable long-term objective for the problem "[Name of patient] is diagnosed with schizophrenia, paranoid type with symptoms including paranoia that required hospitalization. [Name of patient] psychotic disorder ended in the death of an 11-week-old baby. S/he was found NGRI [Not Guilty by Reason of Insanity] in March 2015" was "[Name of patient] able to progress to the next movement level within the next 6 months."

Non-measureable short-term objective was "[Name of patient] will be able to follow all unit rules for the next 4 weeks."

10. In patient E2's MTP, dated 2/19/17, the non-measureable long-term goal for the problem "[Name of patient] has been diagnosis with schizoaffective disorder, bipolar type AEB acute psychosis, auditory hallucinations, and delusional beliefs that s/he is 'God/sun god'" was "[Name of patient] will have absence of signs of internal stimuli through discharge."

The non-measureable long-term objective was "[Name of patient] will be able to verbalize five signs or symptoms of schizoaffective disorder bipolar type weekly through discharge." The non-measureable short-term objective was "[Name of patient] will be able to verbalize two reasons s/he will remain compliant with his/her medication and treatment weekly for the next 4 weeks."

B. Interview

In an interview on 3/7/17 at 1:07 p.m., the staff and/or non-measureable goals and objectives were discussed with the Nursing Director. She stated "We have been working on improvement of these plans."

Based on medical record review, staff interview and hospital policy review it was determined that the Master Treatment Plans for 10 of 10 patients (Patients A1, A2,B1,B2,C1,C2,D1,D2,E1 and E2) failed to describe staff interventions that were patient specific and not simply a listing of routine generic discipline functions. This failure results in no individualization for each patient by attending psychiatrists and/or nursing staff in their approach to treatment.

The findings include----

A. Medical Record Review:

1. Patient A1: The Master Treatment Plan dated 1/27/2017 stated as the psychiatrist intervention for Problem 1 (Risk for harm to self or others) "Dr. X/ alternate will meet with Patient A1 for 30 minutes weekly to assess treatment progress, discuss internal and external stressors, assess for altered thought content, provide disease education and discuss treatment options. Problem 2 (has refused his/her admission history and physical) " Dr. X/alternate will meet with Patient A1 for 30 minutes weekly to assess treatment progress, discuss internal and external stressors, asses for altered thought content, provide disease education and discuss treatment options." It should be noted that the 30 minutes of endeavor would both occur at the same treatment team meeting.

The nursing interventions for these 2 Problems was "RN X/alternate will meet with Patient A1 for 30 minutes weekly to asses treatment progress, discuss internal and external stressors, assess for altered thought content, provide disease education and discuss treatment options. RN X/alternate will meet with Patient A1 weekly for 10-20 minutes for focused conversation to asses perceptual distortions discuss barriers to treatment and provide therapeutic encouragement to participate in recovery." Both Problems had these identical statements as nursing interventions.

2. Patient A2: The Master Treatment Plan dated 1/20/2017 stated for Problem 1(Disturbed sensory perception) as the psychiatrist intervention "Dr. X or alternate will prescribe medication and meet with Patient A2 for 10-15 minutes weekly in treatment team or as needed to provide education on benefits of medication management, obtain consent for treatment, evaluate for effectiveness, assess mood & behavior, make changes as needed to facilitate recovery, and discharge planning. For Problem 2 (Risk for self directed/other directed violence) "Dr. X or alternate will prescribe medication and meet with Patient A2 for 10-15 minutes weekly in treatment team or as needed to provide education on benefits of medication management, obtain consent for treatment, evaluate for effectiveness, assess mood & behavior, make changes as needed to facilitate recovery, and discharge planning.

The nursing interventions for these 2 different Problems were alike and stated "RN X or alternate will engage client in 1:1 therapeutic communication for a minimum of 3-5 minutes daily to assess thought process and content, and provide encouragement to participate in treatment. Assess mental status, mood, and behavior and report any new findings to physician and treatment team."

3. Patient B1: The Master Treatment Plan dated 2/28/2017 stated for the Problem (risk for other directed violence) "Dr. Y or alternate will prescribe medication and meet with Patient B1 for 10-15 minutes weekly in treatment team or as needed to provide education on the benefits of medication management, obtain consent for treatment, evaluate effectiveness, asses mood & behavior, make changes as needed to facilitate recovery, and discharge planning.
The nursing intervention for this Problem was" Assigned RN Y or alternate will engage Patient B1 in 1:1 therapeutic communication for a minimum of 3-5 minutes to asses thought process and content, and provide encouragement to participate in treatment. Assess mental status, mood, and behavior and report any new findings to physician and treatment team as needed."

4. Patient B2: The Master Treatment Plan dated 2/13/2017 stated as the psychiatrist intervention for the Problem (requires Court/Administrative approval to advance to less restrictive movement) "Dr.Y or alternative will meet with patient for 10-30 minutes monthly during informal unit contacts and/or in Treatment Team setting to assess signs and symptoms of his/her disorder, assess for changes in privileges, prescribe medications as needed, and provide education regarding symptoms and treatment in order to assist him/her with being able to recognize that symptoms are part of his/her mental illness.:

The nursing intervention for this Problem was "RN B will meet with PatientB2 weekly to discuss triggers to behaviors, provide medication education and encourage patient to journal moods daily to assist in identification of patterns to behavior that relate to the increased use of medication to assist in coping to reduce use of non-routine medication."

5. Patient C1: The Master Treatment Plan dated 1/03/2017 stated as the intervention by the psychiatrist for the Problem (disorganized thought process, elevated mood, and insomnia) "Dr. Z or alternate will prescribe medication and meet with client for 10-15 minutes weekly in treatment team and 1:1 as needed to provide education on the benefits of medication management, obtain consent for treatment, evaluate for effectiveness, asses mood &behavior, make changes as needed to facilitate recovery, and discharge planning."

The nursing intervention for this Problem was "LPN X or alternate will administer medication as prescribed, monitor for efficacy, monitor for noted or reported side effects, and will notify physician of any adverse reactions."

6. Patient C2: The Master Treatment Plan dated 2/20/2017 for the Problem (disturbed thought process) stated as the psychiatrist intervention "Dr. Z or alternate will prescribe medication and meet Patient C2 for 10-15 minutes weekly in treatment team or as needed to provide education on the benefits of medication management, obtain consent for treatment, evaluate for effectiveness, asses mood & behavior, make changes as needed to facilitate recovery, and discharge planning."

The nursing intervention for this Problem was "LPN X or alternate will administer medication as prescribed, monitor for efficacy, monitor for noted or reported side effects, and will notify physician of any adverse reactions."

7. Patient D1: The Master Treatment Plan dated 1/05/2017 for the Problem (symptoms of psychosis) stated as the psychiatrist intervention "MD/ALT will meet with Patient D1 weekly for 30 minutes during treatment team to assess treatment progress, discuss treatment options, provide disease and medication education, prescribe meds and refer for clinical services as needed."

The nursing intervention for this Problem was "RN/ALT will meet with Patient D1 daily for 3-5 minutes to provide therapeutic encouragement to participate in treatment and inform him/her of scheduled active treatment groups. RN/ALT will report clinically significant information to the unit psychiatrist as needed."

8. Patient D2: The Master Treatment Plan dated 2/23/2017 stated for the Problem (Competency Restoration) the psychiatrist intervention "MD/ALT will prescribe medication and meet with the client 10-15 minutes weekly in treatment team or as needed to provide education on the benefits of medication management, obtain consent for treatment, evaluate effectiveness, assess mood & behavior, make changes as needed to facilitate recovery, and discharge planning'"

The nursing intervention for this Problem was "RN/ alternate will engage client in 1:1 therapeutic communication for a minimum of 3-5 minutes to assess thought process, content, mood, provide encouragement to participate in treatment, and report any new findings to physician and treatment team as needed."

9. Patient E1: The Master Treatment Plan dated 2/26/2017 stated as the psychiatrist intervention for the Problem (Psychosis) "Dr. T, psychiatrist or alternative will meet with the patient for a minimum of 10 minutes monthly during informal unit contacts and/or in Treatment Team setting to assess for signs and symptoms of his/her disorder, assess for changes in privileges, prescribe medications as needed, and provide education regarding symptoms and treatment in order to assist him/her with being able to recognize that symptoms are part of his/her mental illness."
The nursing intervention for this Problem was "LPN/alt will encourage the patient to actively participate in the following groups as scheduled..."

10. Patient E2: The Master Treatment Plan dated 2/19/2017 for the Problem (Schizoaffective Disorder, Bipolar Type) stated as the psychiatrist intervention "Dr. T, psychiatrist or alternative will meet with Patient E2 for a minimum of 10 minutes monthly during informal unit contacts and/or in Treatment Team setting to assess for signs and symptoms of his/her disorder, assess for changes in privileges, prescribe medications as needed, and provide education regarding symptoms and treatment in order to assist him/her with being able to recognize that symptoms are part of his/her mental illness."

The nursing intervention for this Problem was "RN or alternative will engage patient in 1:1 interaction for a minimum of 10 minutes a week to educate and assess for signs and symptoms of Schizoaffective disorder, bipolar type including but not limited to previous symptoms and assess for self monitoring of symptoms...RN will also educate him/her of medications and their side effects. RN will assess for effectiveness and side effects he/she may experience while taking medication."

B. Staff Interview:

On 3/7/2017 at 1:30pm the clinical director was interviewed. The findings described in Section I, above were a partial focus for this interview. The clinical director agreed that the interventions by psychiatrists were generic discipline functions and not individualized patient specific modalities.

C: Hospital Policy Review:

The facility's "Individual Recovery Plan" Policy 02.21A last reviewed 2/16/2017 states in Section 2 "Comprehensive Recovery Service Plan, Section 2 Part E" that "Each problem chosen for inclusion in the patient's CRP shall be individualized."

Based on record review and interview, the facility failed to ensure that the first and last names of staff persons responsible for specific aspects of care were consistently listed on the multidisciplinary treatment plans (MTPs) of 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). This practice results in difficulty to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. A review of the following multidisciplinary treatment plans (dates of plans in parentheses) revealed that they did not consistently list the first and last names of the person(s) responsible for seeing that the interventions are carried out: (A1 (1/27/17), A2 (1/17/17), B1 (2/28/17), B2 (2/23/17), C1 (1/3/17), C2 (2/20/17), D1 (1/5/17), D2 (2/11/17), E1 (2/26/17) and E2 (2/19/17)). Some interventions had first initial and last name. Some had first name and last initial.

B. Interview

In an interview with the Nursing Director on 3/7/17 at 1:07 p.m., the irregularity of the staff's identification on the treatment plans was discussed. She did not dispute the variances.

Based on record review, observation and interview, the facility failed to provide active treatment, including alternative interventions for four (4) of 10 active sample patients (A1, A2, C1 and C2). Although the treatment plans for these patients included a few groups (such as therapeutic community group, coping skills group, anger management group, and recovery group), all patients were expected to attend all groups on the unit's activity schedule. The four patients regularly and repeatedly did not attend most groups held on the unit. As a result, they spent many hours without structured activity and occupied their time by lying/sleeping in their rooms or wandering around the hallways or dayroom. Despite inconsistent or lack of regular attendance in groups, Master Treatment Plans were not revised to reflect more individual treatment sessions instead of group treatment for these patients. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.


Findings include:

I. Patients uninvolved in therapeutic endeavors:

A. Patient A1 was admitted on 1/24/17. The Psychiatric Evaluation, dated 1/24/17, documented a diagnosis of "Schizoaffective disorder bipolar type." Reason for admission: "A relapse of psychotic symptoms disorganized thinking, unpredictable behavior that makes him/her a danger to others"--- "Patient is a 36-year-old caucasian male/female who was admitted to NOPH (Northwest Ohio Psychiatric Hospital) for relapse of psychiatric symptoms. S/he was referred by [name of health center] after [name of county jail] asked to prescreen him/her. Patient was incarcerated in [name of county jail] for one night for the theft and presented to a judge January 21, 2017. However, due to his/her psychotic behavior in court, such as laughing out uncontrollably, shouting out comments that s/he wants to 'beat the shit out of cops' because they annoy him/her, throwing papers, yelling, the hearing was continued at a later time. Reportedly in jail, the patient was experiencing auditory hallucinations in the form of female/male voices and s/he stated s/he was going to 'kill them for speaking to me.' When patient was transported to [name of emergency room] for medical clearance, s/he became threatening and agitated so Haldol 10 mg [milligrams] and Ativan 2 mg intramuscularly were given as emergency medications to help patient regain control over his/her behavior. On admission, patient was superficially engaging but easily distracted, appearing drowsy, was not able to concentrate, and provide scattered information. S/he is not reliable as a historian. S/he was laughing inappropriately. When asked about auditory or visual hallucinations, s/he said s/he hears mermaids and devils. 'Everything is annoying,' s/he said. S/he denied feeling suicidal. S/he said s/he never attempted suicide. S/he said 'I am a peaceful person.' S/he denied history of violence. Patient rated his/her mood today as 9 on a scale 1to 10 with 10 being the best mood. Denies problems with sleep, energy, concentration, and, appetite. S/he, in fact, consumed a large amount of food that was offered to him/her in admission area. S/he does not believe s/he was mental illness [sic] but verbalizes agreement to restart his/her medications Seroquel and Depakote."

Patient A1 was observed in his/her room on 3/6/17 around 12:04 p.m. while a group was being conducted by a recreation therapist in the dayroom of the unit. "Five (5) patients out of a census of 20 patients were in attendance. Patient A1 was asked why s/he was not in the group. A1 stated 'I had schizophrenia, homeless, in one jail and out the other. Figure I need a lot of sleep. I have done groups everywhere else'."

A review of group notes with RN1 on 3/7/17 at 9:14a.m. showed that between the periods of 2/22/17 to 3/6/17, patient A1 had only participated in two groups out of 54 groups offered on the unit (dietary 2/28/17 at 1:45p.m. and SAMI (substance abuse and mental illness) from 1:00p.m. to 2:00p.m. on 3/1/17).

4. In an interview on 3/7/17 at 2:09p.m. with MD1, the failure of patient A1 attending groups was discussed. MD1 stated "[Name of patient] spends a lot of time in his/her room. S/he hallucinates a lot. I'm trying to get him/her stabilized on medications, but I think s/he has been doing a lot better lately."


B. Patient A2

Patient A2 was admitted on 1/17/17. The Psychiatric Evaluation, dated 1/22/17, stated "This is a 28-year-old African-American male/female. All available records were reviewed and the patient interviewed. The patient accepted earlier today for admission by writer. I concluded following a review of the referring hospital notes and labs that this patient had no known acute medical issues contraindicating admission to our facility."---"[Name of patient] presented with application for emergency admission for his/her NOPH admission referred by [name of county jail] because of worsening depressed mood, competency restoration. My evaluation represents a review of all available medical and psychiatric records discussions with staff. S/he was incarcerated at [name of county jail] for burglary and disorderly conduct. On admission, patient presents disheveled. S/he denies any suicidal or homicidal thoughts at this time. S/he denies having any difficulties with mood, appetite, concentration, of energy. S/he has very poor insights, but agrees to sign the consent for medications reluctantly."

Patient A2 was observed wandering the hallway on 3/17/17 around 2:18 p.m. S/he was asked why s/he had not attended the Recreational Therapist Group held in the dayroom around noon. Patient A2 stated "I don't have any activities unless my doctor comes in."

A review of patient A2's group notes with RN1 on 3/7/17 around 10:00 a.m. showed that between 2/27/17 to 3/6/17, patient A2 had attended only four groups out of a possible 54 groups offered that period. They were 2/28/17 - Pharmacy Group from 9:30 a.m. to 10:00 a.m., 3/1/17 - SAMI Group from 1:00 p.m. to 2:00 p.m., 3/2/17 - "Therapeutic Community Meeting from 9:00 a.m. to 9:30 a.m."

During the review of the records of A1 and A2 with RN1, a group (focus unknown) was being conducted by a mental health technician, called TPW(Therapeutic Program Worker) in this facility), in the dayroom. Only seven (7) out of a census of 20 patients attended. This lower attendance at groups by most patients on the unit was quite evident on all units except 400 (A Chemical Dependency Unit).

In an interview on 3/7/17 around 1:00 p.m. with MD1 the lack of attendance at groups by patient A2 was discussed. He stated "[Name of patient] went to a lot of groups one month ago."


C. Patient C1

1. Patient C1 was admitted on 1/1/17. The Psychiatric Evaluation, dated 1/4/17, stated "This patient was referred for psychosis and not caring for him/herself adequately. This is a 22-year-old single African-American male/female with a history of schizophrenia. S/he was last discharged from [name of health-care facility] on 1/29/16 on Prolixin/Decanoate. S/he has been noncompliant with treatment. The patient was found by police sleeping in a tent in a strip mall parking lot. S/he had only a thin blanket, and was not dressed for the weather. The patient was disorganized. No reported suicidal, self-harm, or homicidal behavior other than the danger to self from poor decision making. The patient was medically cleared by [name of facility]. His/her toxicology screen was negative. The patient was cooperative with s NOPH intake. S/he had staccato speech with latency and thought blocking, stilted speech 'I decided Columbus was best for appropriating stability for myself. A camping trip was in mind.' The patient was otherwise a poor historian. S/he appeared to be responding to internal stimuli at the time of admission. S/he'd denied depression or mania. S/he denied suicidal, self-harm, or violent thoughts. The patient was agreeable to treatment and signed the informed consent to start Risperdal."

Patient C1 was observed on 3/6/17 at 1:13 p.m. awake in his/her room. "When asked why s/he had not been attending groups, patient C1 stated "I've been to other facilities and they had better groups." When asked how s/he spent his/her time on the unit, patient C1 stated "I look at TV. I like music. I keep myself occupied."

During this time period a social work group was being conducted in the dayroom. Only four (4) patients out of a census of 20 patients were in attendance. Two more came in just before the group ended around 2:30 p.m. One sat in a chair next to the surveyor, but said nothing. The other sat on the floor next to the wall and appeared to be listening to the group, but did not verbally participate.

On 3/7/17 at 10:00 a.m., a review of group notes from 2/27/17 to 3/6/17 was searched for with RN1. None were found for this patient during this period for the 54 groups scheduled for this unit.

During the time of the review above, a Pharmacy Group was being held in a group room on the unit. Only three (3) of a census of 20 patients were in attendance.

In an interview on 3/7/17 at 10:31 a.m., the lack of attendance at groups was discussed with MD2. He stated that patient C1 had residual symptoms from apparent withdrawal "I don't think s/he would be too involved (in groups) based the nature of his/her illness." MD2 agreed that this fact should have been included on Master Treatment Plan.


D. Patient C2

Patient C2 was admitted on 2/18/17. The Psychiatric Evaluation, dated 2/18/17, stated "57 yo male/female with reported listing of Bipolar D/O [disorder]. Client arrested driving erratically when pulled over. S/he and his/her son were found to have self-inflicted wounds on their arms. Client said s/he was travelling to see relatives, was despondent over the death of his/her wife/husband 2 days earlier. (Police never tell us they have contacted wife/husband who is alive at family home in Illinois.) Son gave statement that patient cut his/her arm. However son also says he voluntarily laid down in motel room with him/her overnight 2/14/17 expecting to bleed to death with him/her. Client's arm was [illegible word], & [and] client medically cleared at [name of emergency room]. Client unable to clarify to this confusing situation. At time of intake, client appeared to be responding to internal stimuli, s/he had significant thought blocking, speech latency & tangential response. S/he says his/her husband/wife died approx [sic] 2/16/17, & s/he and 20 yo son left home in Illinois on 2/17/17 to see relatives. S/he's saying s/he was depressed"...." but not suicidal ideation. S/he said his/her son cut himself for the same reason. S/he denies current SI/AH/HI [Suicidal Ideations/Auditory Hallucination/Homicidal Ideations]. S/he was agreeable to [illegible word] medications."

Patient C2 was observed walking around unit 300 on 3/6/17 at 1:20 p.m. When asked why s/he was not attending groups, s/he stated "I don't have any groups unless my doctor comes in."

In an interview on 3/7/17 at 2:00 p.m., the lack of patient C2 going to groups was discussed with MD2. He stated "Patient C2 is very depressed and has a hypothyroid condition. S/he probably can't take too many groups at present." He was told information like this should be included on the Master Treatment Plan.


II. Frequency of physician-patient contacts:


A. Patient Interviews:

Reports by patients for the frequency of contacts with their psychiatrist was as follows-----five (5) of 10 patients (Patients A1, B2, D1, D2 and E2) described to the surveyors that they had seen their psychiatrist on a frequency of----

1. Patient A1 on 3/06/2017 at 12:55 p.m. said "Every month or two."

2. Patient B2 on 3/06/2017 at 10:55 a. m. said "Haven't seen him/her in months."

3. Patient D1 on 3/06/2017 at 12:05 p.m. said "See rarely. Only during treatment team, say, once a month."

4. Patient D2 on 3/06/2017 at 12:30 p.m. said "Not often, once a month."

5. Patient E2 on 3/06/2017 at 1:10 p.m. said "once a month."


B. Staff Interview:

On 3/06/2017 at 2:30 p.m. the clinical director was interviewed with the focus being the reports by patients of contact with the psychiatric staff in this hospital setting. The clinical director stated "At this point we cannot do it" i.e. meet with patients more often. A period 2/06/-2017-----3/06/2017 was examined by the clinical director with the surveyor on 3/07/2017 at approx 11:30 a.m. The agreed conclusion was that the patient recounts were overall correct.

Based on medical record review and staff interview it was determined that Patient K6 who had expired lacked a discharge summary. The findings include----

I. Medical Record Review:

Patient K6 had been admitted 10/15/2002. On 7/05/2017 he/she was transferred to a nearby hospital as a medical emergency. While hospitalized the patient died post-surgery. Both State and Federal surveyors had requested the discharge summary, however, the facility's administrative staff failed to provide it. Surveyors were shown documentation that there had occurred a mortality/morbidity conference where a discharge summary recapitulating the stay, the condition at discharge/ transfer was not available as it was determined that it did not exist.

II. Staff Interview:

On 3/06/2017 at 2:15 p.m. the facility's C.E.O. told the surveyors that it did not exist. "It was an oversight."

Based on medical record review, patient and staff interview, observation and hospital policy review it was determined that the clinical director failed to ensure the following for 10 of 10 patients (Patients A1,A2,B1,B2,C1,C2,D1,D2,E1 and E5).-------

1. Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. (See, B117 for details)

2. Treatment Plans were individualized, set appropriate goals, and listed responsible staff. (See B121, B122 and B123 for details)

3. Active treatment for hospitalized persons was provided. (See, B125 for details)

4. Discharge Summary was prepared following death of Patient K6. (See, B133 for details)

Based on record review and interview, the Nursing Director failed to ensure that nursing interventions selected on the Master Treatment Plans were more than generic discipline tasks for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, D1, D2, E1 and E2). This failure results in treatment plans that fail to individualize patient approaches in treatment. (Refer to B121)