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Based on document/record reviews, observations and staff and patient interviews the facility failed to provide individualized treatment interventions as directed by the Master Treatment Plans for 6 of 8 active sample patients (A1, A2, A3, A4, A6 and A7) and ensure that these patients were engaged in active treatment interventions rather than remaining in their bedrooms during the day when groups were scheduled. Failure to ensure that patients attend assigned treatment activities or receive alternative treatment when they refuse to go to assigned groups impedes patients' progress toward their individualized treatment goals and potentially increases the length of hospitalization. (Refer to B125)

Based on document and record reviews, observations and interviews, the facility failed to provide individualized treatment as identified in the Master Treatment Plans for 6 of 8 active sample patients (A1, A2, A3, A4, A6 and A7) and ensure that these patients were engaged in active treatment interventions rather than remaining in their bedrooms during the day when their assigned groups were in progress. Failure to ensure that patients attend assigned treatment activities or receive alternative treatment when they refuse to go to assigned groups impedes progress toward individualized treatment goals and potentially increases the length of hospitalization.

Findings include:

A. Observations

1. During an observation of the group "Anger Management" on 6/06/2011 at 10:30AM on the Locust Unit, it was noted that Patients A2, A3 and A4 were not in attendance even though they were assigned to this group. All 3 patients were observed in their beds at 10:45AM on 6/06/2011 (see #2 below).

2. During an observation on the Locust Unit on 6/6/2011 at 10:45AM, the surveyor noted that 6 of 8 active sample patients (A2, A3, A4, A6, A7 and A8) were asleep in their rooms. Three of the active sample patients (A2, A3 and A4) were assigned to groups during this time period but did not attend the groups.

3. During an observation of the group "Recovery Discovery" on 6/06/2011 at 2:45PM on the Locust Unit, it was noted that Patients A2 and A3 were not in attendance, even though they were assigned to this group. Both patients were observed in their beds at 3:00 PM while the group was still in progress.

4. During an observation of the group "Thoughts, Feelings and Behaviors" on 6/07/2011 at 10:30AM on the Locust Unit, it was noted that Patient A4 was not in attendance even though assigned to this group. Patient A4 was observed in his bed at 10:45AM while the group was still in progress.

B. Document Review

Review of the undated document, "Directions on how to complete the patient Engagement Note," revealed instructions on how the Mental Health Technicians (MHTs) were to "...encourage each patient to attend each class they are scheduled for as noted on the Daily Class Schedule." The directions instructed the MHTs to ask a second time if the patient refused to go to group and, "If the patient refuses a second time then wait a few minutes and then try to encourage again and if they continue to refuse, provide the patient with a handout from the instructor, if they refuse that, offer a group discussion worksheet, read a news article with the patients or review a section of the patient handbook or try and engage in an activity. Attempts to engage the patient are to be documented on the Patient Engagement Note." [The Patient Engagement Note is a sheet with prompts for staff to write down groups that patients refuse to attend, and check off boxes to document whether handouts for the missed group were offered or other activities were provided. The notes are placed in patients' medical records].

C. Interviews

1. In an interview on 6/06/2011 at 10:30AM, MHT1 stated that they (MHTs) prompt the patients to attend scheduled activities, but the staff has to be careful because "if the patient doesn't want to go to class they can get irate if you keep asking them."

2. In an interview on June 6, 2011 at 10:45AM, Security Therapy Aide (the facility's title for Mental Health Technicians who work on forensics units), STA2, validated that patients A2, A3, A4 and B1 were asleep in their beds rather than being engaged in their assigned therapeutic activities. In response to the surveyor's query about the reasons for this, STA2 stated that she normally didn't work this unit, but that she thought their [patients'] morning meds made them too sleepy.
3. In an interview on June 6, 2011 at 10:45AM, MHT4 validated that patients A2, A3 and A4 were asleep in their beds rather than being engaged in their assigned therapeutic activities. Upon questioning about reasons for this, MHT4 stated that she had attempted to get people [patients] to go to groups but they had refused. She further stated she had offered them hand outs from the missed group but the patients had refused these.
4. In an interview on June 7, 2011 at 10:15AM, the Clinical Nurse Manager stated that Patient Engagement Sheets were for the purpose of showing "that they (MHTs) are trying to engage the patient." She agreed that most patients refused to participate in any alternative activities and their refusal was noted on the completed Patient Engagement Sheets.
5. In an interview on June 7, 2011 at 10:30AM, the Medical Director confirmed that all patients were expected to attend six hours of groups per day.
D. Specific Patient Findings:
1. Patient A1 was admitted on 4/14/2011. The Master Treatment Plan (MTP) dated 4/26/2011 identified problems as "Mood Instability", "Aggression" and "Discharge Planning/Linkage." For the problem "Mood Instability," the groups assigned on the MTP were: "Avoiding Crisis Situations, Crisis Management", "Knowing Your Medication", "Speak Up", "Understanding Your Illness", "Exercising Your Mind", "Relaxation Skills", "Recovery Express", "Anger Management" and "Symptom Management." For the problem "Aggression," the groups assigned on the MTP were "Avoiding Crisis Situations", "Crisis Management", "Keeping the Unit Safe", "Artistic Expression", "Coping Skills", "Interpersonal Skills", "Problem Solving Skills", "Life Management", "Emotional Regulation," and "Thoughts, Feelings and Behaviors." For the problem "Discharge Planning/Linkage," the groups assigned on the MTP were "Relapse Prevention", "Road to Recovery", "Community Re-Entry", "Leisure Education for the Addicted Person (LEAP)", "Wellness", "Recovery Discovery", "Wellness Recovery Action Plan (WRAP)," and "Discharge Planning."

Review of the Daily Class Schedule Sheets for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A1 ' s attendance for assigned groups as follows: June 1: 9 groups assigned, 1 group attended (Emotion Regulation ); June 2: 6 groups assigned, 2 groups attended (Interpersonal Skills and Understanding Your Illness); June 3: 10 groups assigned, 3 attended (Symptom Management, Wellness, Road to Recovery); June 5: 6 groups assigned, 2 groups attended (Crisis Management and Relaxation Skills) and June 6: 9 groups assigned, 9 groups attended (Anger Management, Relaxation Skills, Living an Active Lifestyle, LEAP, Discharge Planning, Recovery Discovery, Speak-Up, Wellness, Relapse Prevention).

Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A1 agreed to take the hand-outs for the 10:30AM June 2nd missed group "Thoughts, Feelings and Behaviors." Patient A1 did not engage in any alternative treatment during the other 23 missed group times.

Review of the "Daily Face Check Sheets" for June 1-6, 2011 revealed that patient A1 was in his bedroom during the following times: June 1 from 8:30AM-12:30PM, 1:00-3:00PM and 4:00-5:30PM; June 2 from 8:30AM-12:30PM and 1:00-4:00PM; June 3 from 8:30AM-12:30PM and 1:00-5:00PM; June 4 from 8:30AM-12:30PM and 1:00-5:00PM; June 5 from 8-9:30AM and 10:30AM-12:30PM.

2. Patient A2 was admitted on 5/11/2011. The MTP dated 5/13/2011 identified problems as "Discharge Planning/Linkage," "Unfit to Stand Trial" and "Substance Abuse." For the problem "Discharge Planning/Linkage," the groups assigned on the MTP were "Avoiding Crisis Situations", "Crisis Management", "Knowing Your Medication", "Relapse Prevention", "Road to Recovery", "Community Re-Entry", "Coping Skills", "Problem Solving Skills", "Life Management", "Anger Management", "Symptom Management", "Recovery Discovery", "WRAP" and "Discharge Planning." For the problem "Unfit to Stand Trial," the groups assigned on the MTP were "Interpersonal Skills", "You and Your Treatment Team", "Emotional Regulation" and "Unfit to Stand Trial." For the problem "Substance Abuse," the groups assigned on the MTP were "LEAP", "Relaxation Skills" and "Wellness,"

Review of the "Daily Class Schedule Sheets" for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A2's attendance for assigned groups as follows: June 1:10 groups assigned, 0 groups attended; June 2:6 groups assigned, 3 groups attended (Unfit to Stand Trial, Interpersonal Skills, Understanding Your Illness); June 3:10 groups assigned, 4 groups attended (Discharge Planning, Keeping the Unit Safe, Wellness, Road to Recovery); June 5:6 groups assigned, 1 group attended (Community Re-Entry Skills); June 6: 9 groups assigned, 3 groups attended (Speak-Up, Wellness, Relapse Prevention).

Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A2 did not engage in alternative treatment during 30 missed group times.

Review of the "Daily Face Check Sheets" for June 1-6, 2011 revealed that patient A2 was in his bedroom during the following times: June 1 from 9:30 AM-12:30PM and 1:00-5:30PM; June 2 from 8:30AM-12:30PM and 1:00-3:00PM; June 3 from 8:30AM-12:30PM; June 4 from 8:00AM-5:30PM; June 5 from 8:30AM-12:00PM and 1:00-3:00PM; June 6 from 8:00AM-12:30PM and 1:00-4:00PM.

In an interview on 6/08/2011 at 10:00AM, Patient A2 stated that he did not go to groups because they were "a waste of time." As of 6/8/2011, the MTP had not been revised to address Patient A2's negative perceptions of the assigned groups.

3. Patient A3 was admitted on 2/18/2011. The MTP dated 3/02/2011 identified problems as "Aggression Towards Self and Others" and "Psychiatric Symptoms -- disturbed thought processes, irritable mood, auditory hallucinations and negative symptoms." For the problem "Aggression towards Self and Others," the groups assigned on the MTP were "Avoiding Crisis Situations", "Crisis Management", "Keeping the Unit Safe", " Speak-Up", "Artistic Expression", "Coping Skills", "Leisure Education", "Problem Solving Skills", "Relaxation Skills", "Recovery Express", "Life Management", "Skills Building", "Anger Management" and "Thoughts, Feelings and Behaviors." For the problem "Psychiatric Symptoms --disturbed thought processes, irritable mood, auditory hallucinations and negative symptoms," the groups assigned on the MTP were "Knowing Your Medication", "Personal Presentation and Skin Care", "Relapse Prevention", "Road to Recovery", "Speak-Up", "Understanding Your Illness", "Exercising Your Mind", "Interpersonal Skills", "Living An Active Lifestyle", "Wellness", "Recovery Express", "Life Management", "Symptom Management", "Thoughts Feelings and Behaviors" and "Nutritional Education."

Review of the "Daily Class Schedule Sheets" for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A3's attendance for assigned groups as follows: June 1:7 groups assigned, 1 group attended (Knowing Your Medication); June 2:5 groups assigned, 1 group attended (Understanding Your Illness); June 3:9 groups assigned, 1 group attended (Keeping the Unit Safe); June 5:6 groups assigned, 5 groups attended (Artistic Expression, Exercising Your Mind, Relaxation Skills, Goal Achievement Through Motivation, Knowing Your Medications); June 6:8 groups assigned, 3 groups attended (Speak-Up, Wellness , Relapse Prevention).

Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A3 did not engage in any alternative treatment during the 24 missed group times.

Review of the Daily Face Check Sheets for June 1-6, 2011 revealed that patient A3 was in her bedroom during the following times: June 1 from 7:00AM-12:30PM; June 2 from 7:00AM-12:30PM and from 1:30-5:30PM; June 3 from 7:00-11:30AM; June 4 from 7:00-11:30 AM and 2:00-4:00PM; June 5 from 7:00-10:00AM and 10:30-12:30AM; June 6 from 7:00AM-12:30 PM and 1:30-4:30PM.

In an interview on 6/7/2011 at 10:00AM, Recovery Specialist 1 stated that Patient A3 was not a "morning person" and that was why she did not go to the before noon scheduled groups. As of 6/8/2011, the MTP had not been modified to take this into account.

In an interview on 6/7/2011 at 11:15AM, Patient A3 stated that she went to some groups but missed some because "I be [sic] sleeping and when I sleep, I sleep." Patient A3 further stated that she usually "sleep[s] all morning and get[s]up for lunch."

4. Patient A4 was admitted on 12/09/2010. The MTP dated 12/20/2010 identified problems as "Psych Symptoms --psychosis, labile mood", "Aggression" and "Unfit to Stand Trial." For the Problem "Psych Symptoms --psychosis, labile mood," the groups assigned on the MTP were: "Knowing Your Medication", "Personal Presentation and Skin Care", "Relapse Prevention", "Road To Recovery", "Speak-Up", "Understanding Your Illness", "Leisure Education", "Wellness", "Symptom Management" and "Recovery Discovery." For the Problem "Aggression," the groups assigned on the MTP were "Avoiding Crisis Situations", "Crisis Management", "Keeping the Unit Safe", "Artistic Expression", "Coping Skills", "Interpersonal Skills", "Problem Solving Skills", "Relaxation Skills", "Wellness", "Recovery Express", "Anger Management", "WRAP" and "Thoughts, Feelings and Behaviors." For the problem "Unfit to Stand Trial," the groups assigned on the MTP were "Goal Achievement Through Motivation", "Life Management" and "Unfit To Stand Trial."

Review of the "Daily Class Schedule Sheets" for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A2's attendance for assigned groups as follows: June 1:7 groups assigned, 1 group attended (Coping Skills); June 2:8 groups assigned, 3 groups attended (Artistic Expression, Problem Solving and Interpersonal Skills); June 3:8 groups assigned, 2 groups attended (Anger Management and Road to Recovery); June 5:6 groups assigned, 0 groups attended; June 6:7 groups assigned, 2 groups attended (Recovery Discovery and Speak-Up).

Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A4 did not engage in any alternative treatment during 34 missed group times.

Review of the Daily Face Check Sheets for June 1-6, 2011 revealed that patient A4 was in his bedroom during the following times: June 1 from 8:30AM-12:30PM and 1:00-4:00PM; June 2 from 8:30AM-12:30PM; June 3 from 7:00-10:30AM, 11:30AM-12:30PM and 1:00-5:30PM; June 4 from 7:00AM-12:30PM and 1:00-4:00PM; June 5 from 7:00AM-12:30PM and 1:30-3:30PM; June 6 from 8:30AM-12:30PM and 1:00-3:30PM.

In an interview on 6/08/2011 at 10:10, Patient A4 stated that he did not go to groups because the doctor said he was "unfit for trial." Patient A4 further stated that since the hospital was not cooperating with him, "I'm not cooperating with you [hospital]." The patient's stance on going to groups was not addressed in the MTP as of 6/08/2011.

In an interview on 6/08/2011 at 10:15AM, Security Therapy Aide 1 (STA), who was pulled from another unit, stated that Patient A4 had trouble getting up in the mornings and stated "probably should have his groups in the afternoon."

5. Patient A6 was admitted on 2/03/2011. The MTP dated 5/11/2011 (MTP revised with new format) identified problems as "Unfit to Stand Trial", "Psychotic Symptoms" and "Discharge Planning/Linkage." For the problem "Unfit to Stand Trial," the group assigned on the MTP was "You and Your Treatment Team." For the problem "Psychotic Symptoms," the groups assigned on the MTP were "Prescribing Medication", "Keeping the Unit Safe", "Understanding Your Illness", "Artistic Expression", "Goal Achievement Through Motivation", "Interpersonal Skills", "Recovery Express", "Skills Building (Dialectical Behavior Therapy) group" and "Thoughts, Feelings and Behaviors (Cognitive Behavioral Therapy [C.B.T.])." For the problem "Discharge Planning/Linkage," the groups listed on the MTP were "Prescribing Medication; Knowing Your Medication", "Road to Recovery", "Speak Up", "Community Re-Entry", "Coping Skills", "Problem Solving Skills", "Life Management", "Symptom Management", "Recovery Discovery", "WRAP" and "Discharge Planning."

Review of the "Daily Class Schedule Sheets" for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A6's attendance for assigned groups as follows: June 1:6 groups assigned, 1 attended (Goal Achievement through Motivation); June 2:7 groups assigned, 3 attended (Artistic Expression, Problem Solving, Interpersonal Skills); June 3:4 groups assigned, 1 attended (Keep the Unit Safe); June 5:4 groups assigned, 0 attended; June 6:2 groups assigned, 2 attended (Recovery Discovery, Speak Up).

Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A6 did not engage in alternative treatment activities during the 23 missed group times.
Review of the "Daily Face Check Sheets" for June 1-6, 2011 revealed that patient A6 was in his bedroom during the following times: June 1 from 8:30AM-12:30PM, 1:30 -4:00PM; June 2 from 8:30AM-12:30PM, 3:00-4:00PM; June 3 from 7:00AM-12:00PM, 1:00 -5:00PM; June 4 from 8:30AM-12:30PM, 1:30-4:30PM; June 5 from 7:00AM -11:30AM, 1:30-3:30PM, 4:00PM-5:00PM; June 6 from 8:30AM-11:30AM.
In an interview on 6/7/11 at 2:20PM, the patient was found in his bed. When asked about his lack of group attendance, he stated "I have a headache." The surveyor could not get additional information from him.
6. Patient A7 was admitted on 5/27/11. The Master Treatment Plan dated 6/3/2011 identified problems as "Psych-hearing voices/aggression" and "Discharged [sic] linkage." For the problem "Psych-hearing voices/aggression," the assigned group on the MTP was "Recovery Express." For the problem "Discharged linkage," the group assigned on the MTP was "Recovery Express."
Review of the "Daily Class Schedule Sheets" for June 1-3, 2011 and June 5-6, 2011 (June 4th sheet was unavailable) showed patient A7's attendance for assigned groups as follows: June 1: no groups assigned, no groups attended; June 2:1 group assigned, 1 attended (Relaxation Skills); June 3:2 groups assigned, 0 attended; June 5:2 groups assigned, 0 attended; June 6:2 groups assigned, 0 attended. The patient attended 2 unassigned groups (Discharge Planning, Speak Up).
Review of the "Patient Engagement" sheets for June 1-3 and June 5-6, 2011 revealed that Patient A7 did not engage in alternative treatment during the 6 missed group times
Review of the "Daily Face Check Sheets" for June 1-6, 2011 revealed that patient A7 was in his bedroom during the following times: June 1 from 9:30AM-12:30PM, 1:00-2:00PM, 2:30-5:00PM; June 2 from 8:30-11:30AM, 1:30-3:00PM; June 3 from 10:00-11:00AM, 1:00-1:30 M; 4:00-5:00PM; June 5 from 8:30-9:00AM, 1:30-3:30PM, 4:00-5:00PM; June 6 from 10:30AM-11:30AM, 1:30-3:00PM, 4:00-5:30PM.

Based on observation, document review, and interview the Medical Director failed to ensure the provision of individualized treatment identified in the Master Treatment Plans of 6 of 8 active sample patients (A1, A2, A3, A4, A6 and A7) and ensure that these patients engaged in active treatment activities rather than remaining in their bedrooms during the day. Failure to ensure that patients attend assigned treatment activities or receive alternative treatment impedes patient progress toward individualized treatment goals and potentially increases the length of hospitalization. (Refer to B125)

Based on document and record review, observations and interview, the Director of Nursing failed to ensure the provision of individualized treatment as identified in the Master Treatment Plans of 6 of 8 active sample patients (A1, A2, A3, A4, A6 and A7) and ensure that these patients were engaged in active treatment rather than being allowed to stay in their bedrooms during group times. Failure to ensure that patients attend assigned treatment activities or receive alternative treatment hinders patient progress toward individualized treatment goals and can increase the length of hospitalization. (Refer to B125)