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Based on observation, interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment of 8 of 8 sample active patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10). Specifically, the hospital failed to:

I. Develop and document comprehensive multidisciplinary treatment plans (Master Treatment Plans) formulated from individual assessments of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10). These patients' treatment plans were developed from preprinted forms that included lists of generic goals and interventions for diagnoses. These treatment plans, initiated and completed by registered nurses on the day of the patient's admission to the hospital, failed to list individual patients' problems with related goals and interventions. There was lack of evidence that the plans were discussed and approved by the treatment team. Very short-term stay patients were not seen by the treatment team until the day of discharge, if at all. In addition, there were no revisions of the treatment plans to address patients' changing needs or behaviors. The absence of integrated, comprehensive treatment plans results in lack of coordinated and organized treatment. (Refer to B118)

II. Ensure appropriate physician orders, assessments and related documentations for 2 of 2 discharged patients (E4 and E5) added to the sample for the review of restraint incidents. These patients were placed in physical holds (restraint) without a physician's order or a documented face to face patient assessment within one hour following use of the restraint procedure. The use of restraints without proper physician orders or patient assessment is a safety risk and violates patients' rights to be free from restraints without proper justification. (Refer to B125, Part I)

III. Ensure that active and appropriate treatment modalities were provided for 2 of 8 sample active patients (7 and 10). Patient 7's long term psychosis and minimal socialization skills made it difficult to benefit from the structured groups offered. Patient 10's confusion and impaired memory prevented adequate participation in the current treatment groups provided. There was no documentation that alternative interventions were provided to these patients. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge. (Refer to B125, Part II)

IV. Ensure that structured nursing programming/activities occurred as scheduled. Nursing groups were the only structured treatment scheduled for the patients in this facility other than group therapy (held twice on weekdays and one time on weekend days, and recreational therapy activities only held on weekdays). All groups to be conducted by nursing during the survey dates of 7/25-26/11, and for at least 7 days prior to the survey had been cancelled. During the times that these groups were scheduled during the survey, patients were observed to be watching TV, sitting around, napping in chairs or "milling about" the ward. This failed practice results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge. (Refer to B125, Part III)

V. Ensure that patients were provided needed activity therapy (AT) programming on weekends. A review of the patients' program schedules and an interview with the Director of Nursing revealed that the facility failed to provide any AT programming on Saturdays and Sundays. This failed practice can delay patients' improvement, potentially prolonging hospitalization. (Refer to B125, Part IV)

Based on record review and interview, the facility failed to provide Social Work Assessments that included conclusions and recommendations for the anticipated social work role in treatment and discharge planning for 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10). This can result in lack of social work input for treatment planning and inadequate professional social work treatment services.

Findings include:

A. Record Review

The Psychosocial Assessments (see dates below) for 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10) were reviewed. None of the following assessments included conclusions or treatment recommendations:

1. Patient 1A psychosocial assessment completed on 7/12/11
2. Patient 2B psychosocial assessment completed on 7/21/11
3. Patient 3B psychosocial assessment completed on 7/21/11
4. Patient 4A psychosocial assessment completed on 7/08/11
5. Patient 4B psychosocial assessment completed on 7/18/11
6. Patient 7 psychosocial assessment completed on 7/07/11
7. Patient 9B psychosocial assessment completed on 7/11/11
8. Patient 10 psychosocial assessment completed on 7/23/11

B. Staff Interviews

1. SW Therapist 1 and SW Therapist 2 were interviewed on 7/25/11 at 3:00p.m. at the Nurse's Station on the Unit. Both social work therapists acknowledged that no conclusion or recommendations were documented in the psychosocial evaluations that they completed.

2. In an interview on 7/26/11 at 10a.m., the Director of Social Services stated, "I was not involved regarding development of the psychosocial evaluation document. It has no conclusion or social work recommendations."

Based on record review, observation and interview, the hospital failed to develop and document comprehensive multidisciplinary treatment plans (Master Treatment Plans), formulated from the individual assessments of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10). These patients' treatment plans were developed from preprinted forms that included lists of generic goals and interventions for diagnoses. The treatment plans, initiated and completed by registered nurses on the day of the patient's admission to the hospital failed to list individual patients' problems, with related goals and interventions. There was lack of evidence that the plans were discussed and approved by the treatment team. Very short-term stay patients were not seen by the treatment team until the day of discharge, if at all. There also were no revisions of the treatment plans to reflect the patients' changing needs and behaviors. The absence of integrated, comprehensive treatment plans results in lack of coordinated and organized treatment.

Findings include:

A. Record Review

The treatment plans for the 8 sample patients were as follows:

1. Patient 1A-(plan initiated and completed by nursing on admission date of 7/12/11)
2. Patient 2B-(plan initiated and completed by nursing on admission date of 7/21/11)
3. Patient 3B-(plan initiated and completed by nursing on admission date of 7/20/11)
4. Patient 4A-(plan initiated and completed by nursing on admission date of 7/8/11)
5. Patient 4B-(plan initiated and completed by nursing on admission date of 7/17/11)
6. Patient 7-(plan initiated and completed by nursing on admission date of 7/7/11)
7. Patient 9B-(plan initiated and completed by nursing on admission date of 7/9/11)
8. Patient 10-(plan initiated and completed by nursing on admission date of 7/18/11)

The above treatment plans were initiated and completed on the patient's day of admission by nursing. The first form was labeled "Initial Treatment Plan Nursing Standards of Patient Care." This form had a list of general goals and interventions (all usually checked for each patient) with no individualization for each patient. The "Nursing Standards" form was followed by additional forms with preprinted generic problems, goals and interventions. Examples of the problems were: "Risk for Suicide", "Depressed Mood," "Altered Thought Process, Disturbed Sensory Perception," Risk for Other-Directed Violence" and "Ineffective Denial". Two to three of these forms were used for each patient; most of the goals and interventions were checked with no additional information or changes based on individual patient needs.

B. Observation

A treatment team meeting was attended on 7/26/11 at 8:15a.m. In the meeting, active sample Patients 7, 9B and 10 were interviewed and the current treatment was discussed. During the meeting, each patient's treatment plan that was developed on admission by nursing was briefly presented to the patient. There was no formal team discussion of the plans prior to their presentation to each respective patient. During the meeting with Patient 10, the Medical Director, who was also the attending psychiatrist for this patient, stated that the problem of "confusion" needed to be added to the plan. This was the only noted change in the original treatment plan.

C. Staff Interviews

1. During an interview on 7/25/11 at 11:50a.m., the DON reported that team meetings, with discussion of treatment plans, were only held on Tuesday of each week. S/he added that if the patient is discharged prior to attending the team meeting, a staff member "goes over the plan with the patient and has the patient to sign it [sic]." The DON acknowledged that this may not be timely, given the short stay of some patients.

2. During an interview on 7/25/11 at 2:55p.m., SW Therapists 1 and 2 (social work staff) noted that they did not give input into the treatment plans, and that interventions entered into the treatment plans for social work staff were not entered by social work. Therapist 2 stated that social work should enter their interventions into the patients' treatment plans to ensure documentation of the focus of psychotherapy group discussions for the patients.

3. During an interview on 7/26/11 at 9:55a.m., the Director of Social Work agreed that social work interventions should be entered onto the treatment plan by social work staff and should be individualized, based on patient needs.

4. During an interview on 7/26/11 at 10:55a.m., Patient 10's treatment plan was reviewed with the Medical Director. The only change in the patient treatment plan, developed the day of admission, was that "memory impairment" had been checked in the list of problems; however, goals and interventions for this problem had not been developed. The Medical Director acknowledged that this was not sufficient. The Medical Director also noted that the plan was not adequately revised to address the patient's "confusion."

5. During the same interview as above (7/26/11; 10:55a.m.), the Medical Director acknowledged that the "treatment plans" were "not individualized" for the patients.

6. During an interview on 7/26/11 at 12:00p.m., the DON stated that the "RN develops the entire treatment plan." She acknowledged that the interventions on the plans were not adequately individualized for patients.

7. During a discussion on 7/26/11 at 4:00p.m., the Director of Nursing, reported that she thought the addition of the item "memory impairment" on Patient 10's treatment plan was a sufficient revision of the plan.

Based on record review and interview, the hospital failed to provide Master Treatment Plans for 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10) that identified the name of the treatment team members responsible for the listed interventions. This deficiency hamper's the facility's ability to hold team members accountable for care.

Findings include:

A. Record Review

The treatment plans for the 8 sample patients were as follows:

1. Patient 1A-(plan initiated and completed by nursing on admission date of 7/12/11)
2. Patient 2B-(plan initiated and completed by nursing on admission date of 7/21/11)
3. Patient 3B-(plan initiated and completed by nursing on admission date of 7/20/11)
4. Patient 4A-(plan initiated and completed by nursing on admission date of 7/8/11)
5. Patient 4B-(plan initiated and completed by nursing on admission date of 7/17/11)
6. Patient 7-(plan initiated and completed by nursing on admission date of 7/7/11)
7. Patient 9B-(plan initiated and completed by nursing on admission date of 7/9/11)
8. Patient 10-(plan initiated and completed by nursing on admission date of 7/18/11)

On all of the above treatment plans, discipline groups were assigned responsibility for interventions (MD [Medical Doctor], NSG [Nursing], SS [Social Service] and RT [Recreation Therapy]); for many interventions, 2-4 discipline groups were identified as accountable. No names of staff were listed as being accountable for interventions.

B. Interview

During an interview on 7/26/11 at 10:55a.m., the Medical Director stated that the treatment plans should include the name of the person responsible for the intervention and "exactly what they (staff) would do."

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

I. Ensure that appropriate physician orders, assessments and related documentations were completed for 2 of 2 discharged patients (E4 and E5) added to the sample for the review of restraint incidents. These patients were put in physical holds (restraint) without a physician's order or a documented face to face patient assessment within one hour following use of the restraint procedure. The use of restraints without proper physician orders and patient assessments is a safety risk and violates patients' rights to be free from restraints without proper justification.

II. Ensure that active and appropriate treatment modalities were provided for 2 of 8 sample active patients (7 and 10). Patient 7's long term psychosis and minimal socialization skills made it difficult to benefit from the structured groups offered. Patient 10's confusion and impaired memory prevented adequate participation in the current treatment groups provided. There was no documentation that alternative interventions were provided to these patients. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge.

III. Ensure that structured nursing programming/activities occurred as scheduled. Nursing groups were the only structured treatment scheduled for the patients in this facility other than group therapy (held twice on weekdays and one time on weekend days, and recreational therapy activities only held on weekdays). All groups to be conducted by nursing during the survey dates of 7/25-26/11, and for at least 7 days prior to the survey had been cancelled. During the times that these groups were scheduled during the survey, patients were observed to be watching TV, sitting around, napping in chairs or "milling about" the ward. Failure to provide scheduled programming results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge.

IV. Ensure that patients were provided needed activity therapy (AT) programming on weekends. A review of the patients' program schedules and an interview with the Director of Nursing revealed that the facility failed to provide any AT programming for patients on Saturdays and Sundays. This failed practice can delay patients' improvement, potentially prolonging the hospitalization.

Findings include:

I. Inadequate physician orders and 1 hour face to face assessments for use of restraints

A. Specific Patient Findings

1. Patient E4

a. A nursing note in the "Patient/Visitor Safety Report" dated 1/3/11 stated, "Client [referring to patient E4] combative + [and] attempting to fight staff. Client taken to bed c [with]/CPI [preventive intervention training program] technique..."

b. A nursing note dated 1/3/11 documented the following: "Pt [patient E4] argumentative + [and] oppositional c/ [with] instructions from staff. Client difficult to redirect + [and] easily agitated + hostile. Client escorted to observation room for an opportunity to calm down."

c. In an interview on 7/26/11 at 12:00p.m., the DON acknowledged that physical holds were used for Patient E4.

d. A review of Patient E4's medical record revealed no physician order or face-to-face assessment of the patient within one hour of the use of the above physical holds.

2. Patient E5

a. A nursing note dated 7/5/11 documented "Pt [patient E5] became agitated, demanding to go home, be released...Pt taken to room c/ [with] help of another staff, using proper techniques [refers to CPI training technique]."

b. In an interview on 7/26/11 at 12:00p.m., the DON acknowledged that a physical hold was used for Patient E5.

c. A review of Patient E5's medical record revealed no physician order or face-to-face assessment of the patient within one hour of the use of the above physical hold.

B. Interviews

1. During an interview on 7/25/11 at 11:50a.m., when asked if the hospital uses "physical holds" [restraint] for the patients, the DON reported that staff may "hold" a patient "briefly to give a medication against their will or when a patient is acting out." When asked if these "brief holds" were seen as restraints, the DON stated, "If the medication pertains to the patient's diagnosis, then it is not considered as a restraint."

2. During an interview on 7/26/11 at 10:55a.m., the Medical Director stated that she was "not aware that holding a patient to give a needed medication was a physical restraint."

3. In an interview on 7/26/11 at 12:00p.m., the DON stated that "briefly holding a patient" was not viewed as a restraint in this facility. S/he acknowledged that physical holds were used for Patients E4 and E5. She reported that all nursing personnel received the CPI class that included techniques to hold or escort patients when needed.

C. Policy Review

Review of the facility's policy, "Seclusion and Restraints Use," dated 7/20/10, revealed the following statements: "If the patient is in a physical hold, a second staff person who is trained and competent in the use of restraint and seclusion and who is not involved in the physical hold is assigned to observe the patient." The attached form titled "Seclusion/Restraint Orders" failed to include a "physical hold" in the section named "Method of Restraint" other than listing a category as "Other______________."

II. Failure to provide individualized treatment based on patients ' needs

A. Specific Patient Findings

1. Patient 7

a. The Admission Psychiatric Evaluation dated 7/8/11, stated that Patient 7 was admitted on 7/7/11 due to increased psychotic symptoms. This evaluation documented that Patient 7 had "a long history of schizoaffective disorder, bipolar type." It stated, "[Patient] is reporting auditory hallucinations...Attention and concentration is poor. He is of low-average intelligence."

b. The treatment plan dated 7/7/11 identified Patient 7's psychiatric problem as "Altered Thought Process." The short term goals for treatment were "Demonstrate decreased anxiety level," "Express the delusion and related feelings to staff," Interact on reality-based topics" and "Increase participation in therapeutic activities or positive peer group activities." All interventions on the preprinted form were identified with an "x mark." All interventions were generic without any reference to the patient's assessed needs. One intervention stated, "Provide group therapy for patient to improve his/her social judgment and interpersonal skills." Neither the specific level of group therapy, nor the frequency of the groups was specified. None of the interventions considered the low functional and cognitive levels presented by this patient.

c. A review of the progress notes for group therapy meetings from 7/8/11-7/22/11 revealed the following documented information:

--On 7/8/11 a note stated "Pt [Patient] was cooperative, attentive, confused, c/ [with] loose thought process. Pt [Patient] was in an anxious mood c/ [with] flat affect." Another note stated, "Pt [Patient] was guarded, cooperative, talkative, c/ [with] loose thought process. Pt [Patient] was in content mood c/ [with] content affect."
--On 7/9/11 a note stated, "Pt was impulsive, restless, intrusive, c/ [with] loose thought process. Pt was in an euphoric [sic] mood c/ flat affect."
--On 7/10/11 a note stated, "Pt was noncompliant, disruptive, calm quiet, with bizarre thought process. Pt displayed labile mood with appropriate affect."
--On 7/11/11 a note stated, "Pt was distracted, calm, quiet, with delusional thought process. Pt displayed paranoid mood with flat affect." Another note stated "Pt was guarded, isolative, disoriented, c/ [with] loose thought process. Pt was in paranoid mood c/ flat affect."
--On 7/12/11 a note stated, "Pt was withdrawn, isolative, compliant, quiet, calm with delusional thought process. Pt displayed paranoid mood with flat affect." Another similar note on 7/12/11 was stated as "Pt was cooperative, withdrawn, calm, withdrawn with delusional thought process. Pt displayed paranoid mood with flat affect."
--On 7/13/11 a note stated, "Pt's thought process was bizarre and delusional..."
--On 7/14/11 Patient 7 refused to attend the group.
--On 7/15/11 a note stated, "Pt was withdrawn, guarded, isolating c/ loose thought process..." Another note on this date stated that Patient 7 refused to attend the afternoon therapy group.
--On 7/16/11 a note stated, "Pt was present for group, but refused to participate..."
--On 7/17/11 Patient 7 refused to attend the morning therapy group. A note for the afternoon group stated, "Pt was present for group, but refused to participate c/ group session."
--on 7/18/11, notes stated that Patient 7 attended both group meetings but "refused to participate."
--On 7/19/11 a note stated, "Pt was present for group, but refused to participate..." Another note documented that Patient 7 refused to attend afternoon group therapy."
--On 7/20/11 a note stated, "Pt was compliant, withdrawn, calm, drowsy, quiet witt [sic] delusional thought process and minimal participation requiring prompting..."
--On 7/21/11 a note stated "...Pt minimaly [sic] participated with prompting."
--On 7/22/11 a note stated "Pt was guarded, cooperative, confused, with loose thought process. Pt was in anxious mood c/ flat affect." Another note stated the Patient 7 attended the afternoon group therapy meeting, "but refused to participate."

Even though Patient 7's psychiatric symptoms interfered with his/her attendance and participation in higher functioning process groups, as of 7/26/11, the treatment had not been revised to ensure that interventions/modalities were based on current treatment needs.

2. Patient 10

a. The Admission Psychiatric Evaluation for Patient 10,dated 7/19/11, documented "[Patient] was somewhat confused...did not know the date...was oriented to place and person only...also has been hearing voices and seeing things that are not there." The evaluation documented that Patient 7 had a history of smoking marijuana and "had used LSD, Meclizine, herion [sic], cocaine and other drugs."

b. The psychosocial assessment, dated 7/23/11, documented that Patient 10 stated that s/he was "having trouble c/ [with] my memory."

c. The treatment plan dated 7/18/11 identified Patient 10's psychiatric problem as "Depressed Mood." The short term goals for treatment were as follows: "Demonstrate an increase in energy," "Attend and participate in groups," "Comply with medication regimen," "Identify at least 2 contributing factors to depressed mood," "Identify coping skills to prevent severe regression," "Verbalize feelings, needs, goals and discharge plans throughout treatment," "Identify one leisure activity or hobby they are willing to participate in after discharge," "Agree to approach staff when feeling unsafe" and "Be free from self harm." All interventions on the preprinted form were identified with an "x mark." The interventions were generic without specific interventions based on this patient's findings. Two structured group assignments were stated as "Educate patient in nursing groups x 45 minutes" and "Educate patient in nursing groups about psychotropic medication uses [sic] and side effects." The specific focus for the "nursing groups" was not stated.

d. In an interview on 7/26/11 at 9:30a.m., the DON verified that the nursing groups listed in Patient 10's treatment plan had not been conducted for at least 7 days.

e. A review of the progress notes for group therapy meetings from 7/20/11-7/24/11 revealed the following documented information:

--On 7/19/11 a note stated "Pt [Patient] was impulsive, disruptive, intrusive, confused..."
--On 7/20/11 a note stated "Pts [Patient's] thoughts were embedded in the past..."
--On 7/21/11 a note stated "Pt was compliant, withdrawn, drowsy, calm, quiet...disoriented with impaired thought process...Pt minimaly [sic] participated with prompting. "
--On 7/22/11 a note stated "Pt was withdrawn, guarded, confused, talkative, c/ [with] loose thought process..." Another group note for 7/22/11 stated "Pt was cooperative, confused, disoriented..."
--On 7/23/11 a note stated "Pt was confused, disoriented..."
--On 7/24/11 a note stated "Pt was withdraw [sic], isolative, disoriented, confused, quiet, calm with impaired thought process..."

f. Even though Patient 10's confusion and impaired memory interfered with his attendance and participation in higher functioning process groups, as of 7/26/11 his treatment had not been revised to ensure that interventions/modalities were based on his current needs.

g. A review of the progress notes for recreational activity groups revealed that Patient 10 refused to attend 2 of 5 groups he was assigned to attend on 7/20-21/11.

C. Additional Interviews

1. During an interview on 7/26/11 at 9:55a.m., the Director of Social Work stated that Patients 7 and 10 should be in a different level group (rather than the process oriented group). She reported that the social work therapists offered these different level non-process oriented groups "sometimes."

2. During an interview on 7/26/11 at 10:55a.m., the Medical Director acknowledged that Patients 7 and 10 had difficulty in participating in the current process groups offered to the patients, and stated, "Some patients need individualized treatment, sometimes on an individual basis."

III. Failure to ensure that structured programming occurred as scheduled

A. During an interview on 7/25/11 at 11:25a.m., sample active Patient 9B reported that since his/her admission on 7/9/11, the following nursing groups had not been held:

1. Goal-Setting/Exercise (scheduled daily from 8a.m. to 9a.m.). According to the patient, this group had been conducted one time and that was after his/her asking that it be held.

2. Wrap-up groups (scheduled daily from 8:30p.m. to 9:30p.m.) had not been held on any day.

3. Nursing education groups (scheduled daily from 12:30p.m. to 1:30p.m.) had never been held. Patient 9B added, "They allow us to sleep during that time."

4. Exercise groups (scheduled on Saturdays and Sundays from 1:30p.m. to 2:30p.m.) had never been held. Patient 9B added, "They allow us to sleep during that time."

B. Observation on the adult general psychiatry ward on 7/25/11 from 12:35p.m. to 12:45p.m. revealed that the group, "Nursing Education," scheduled from 12:30-1:30p.m. was not conducted. During this time, 12 of the 17 patients, including sample Patients 3B, 4B, 7, 9B, and 10, were sitting, sleeping or walking about the dayroom area. Four additional non-sample patients were sitting outside in the breezeway. At 12:40p.m., sample Patient 9B stated that a staff member "had some papers in her hands and said the group was going to meet."

C. During an interview on 7/25/11 at 4:20p.m., Health Care Technician (HCT) 5 reported that the nursing education group scheduled at 12:30p.m. was not held. HCT5 added, "They have not been having this meeting."

D. During an interview on 7/25/11 at 4:25p.m., LPN7 stated that scheduled nursing groups are held based on what is "going on as treatment team meetings, patient admissions." She reported that the 12:30p.m. nursing education meetings are usually not held because the "patients like to take a nap after lunch and have a heavy psychotherapy group at 1:30p.m." LPN7 reported that scheduled nursing groups are not held in the evenings due to "everything going on." She could not verify when the last nursing group had been held, adding "It has been over a week." At 4:35p.m., RN3 and the DON joined the meeting. RN3 verified the information given by the LPN. The DON stated that she understood the importance of the nursing groups.

E. In an interview on 7/26/11 at 9:30a.m., the DON reported that she could not verify that any scheduled groups to be conducted by nursing staff had been held for at least the last 7 days.

IV. Failure to provide week-end activity therapy (AT) programming

A. Review of the patients' program schedules revealed that only one hour long psychotherapy group was scheduled for Saturdays and Sundays. There was no activity therapy (AT) programming on the weekend schedule.

B. During an interview on 7/26/11 at 2:00p.m., the DON acknowledged that no treatment groups, besides one psychotherapy group' occurs on the weekends.

C. During an interview on 7/25/11 at 2:30p.m., Patients 1A and 4A complained that they have nothing to do over the weekend.

D. During interview on 7/26/11 at 1:30p.m., the Director of Activity Therapy stated that no groups by activity therapy staff were conducted on Saturdays and Sundays.

Based on interview and document review, the facility failed to assure that the Medical Director, the Director of Nursing and the Director of Social Services monitored active treatment and took corrective actions for deficiencies. Specifically,

I. The Medical Director failed to ensure that: 1) patients had individualized Master Treatment Plans and that appropriate changes were made in the plans to reflect the patients' changing needs; 2) patients placed in physical holds had appropriate physician orders and 1 hour face to face assessments, and 3) all patients received active treatment. (Refer to B144)

II. The Director of Nursing failed to ensure that: 1) nursing interventions included in patients' Master Treatment Plans were based on individual patient needs; 2) physical restraints/holds were based on physician orders and were adequately documented; and 3) structured nursing programming/activities occurred as scheduled. (Refer to B148)

III. The Director of Social Services failed to ensure that: 1) all patients' psychosocial assessments included conclusions and treatment recommendations, and 2) the format for psychosocial evaluation forms had a place for conclusions and recommendations. (Refer to B152)

These failures prevent patients from receiving appropriate care and treatment in a safe environment, enabling them to achieve an optimal level of functioning and discharge in a timely manner.

Based on record review and staff interview, the Medical Director failed to ensure the quality of clinical services to patients. Specifically, the Medical Director failed to:

I. Ensure that comprehensive multidisciplinary treatment plans were formulated based on the individual needs assessments of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, and 10). These patients' treatment plans, initiated and completed by registered nurses on the day of the patient's admission to the hospital, failed to list individual patients' problems, with related goals and interventions. There was lack of evidence that the plans were discussed and approved by the interdisciplinary treatment team. Very short-term stay patients were not seen by the treatment team until the day of their discharge, if at all. In addition, there were no documented revisions of the treatment plans, based on the patients' changing needs/behaviors. The absence of an integrated, comprehensive treatment plans results in lack of coordinated and organized treatment. (Refer to B118)

II. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10) identified the names of treatment team members responsible for the listed interventions. This deficiency hinders the facility ability to hold team members accountable for care. (Refer to B123)

III. Ensure that appropriate physician orders, assessment and related documentations were completed for 2 of 2 discharged patients (E4 and E5) added to the sample for the review of restraint incidents. These patients were placed in physical holds (restraint) without a physician ' s order or a documented face to face patient assessment within one hour following use of the restraint procedure. The use of restraints without proper physician orders and assessments is a safety risk and violates patients' rights to be free from restraints without proper justification. (Refer to B125, Part I)

IV. Ensure that active and appropriate treatment modalities were provided for 2 of 8 sample active patients (7 and 10). Patient 7's long term psychosis and minimal socialization skills made it difficult to benefit from the structured groups offered. Patient 10's confusion and impaired memory prevented adequate participation in the current treatment groups provided. There was no documentation that alternative interventions were provided to these patients. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge. (Refer to B125, Part II)

V. Ensure patients were provided needed activity therapy (AT) programming on the weekends. A review of the patients' program schedules and an interview with the Director of Nursing revealed that the facility failed to provide AT programming for patients on Saturdays and Sundays. This failed practice can result in delay of improvement in patients' condition and prolonged hospitalization. (Refer to B125-IV)

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

I. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10) included nursing interventions that were individualized for patients. The treatment plans included nursing interventions which were routine, generic discipline functions that lacked a specific focus for treatment. The absence of individualized and focused nursing interventions on patients' treatment plans hampers the nursing staff's ability to provide individualized care to patients.

Findings include:

A. Record Review

The treatment plans for the 8 sample patients were as follows:

1. Patient 1A-(plan initiated and completed on admission date of 7/12/11)
2. Patient 2B-(plan initiated and completed on admission date of 7/21/11)
3. Patient 3B-(plan initiated and completed on admission date of 7/20/11)
4. Patient 4A-(plan initiated and completed on admission date of 7/8/11)
5. Patient 4B-(plan initiated and completed on admission date of 7/17/11)
6. Patient 7-(plan initiated and completed on admission date of 7/7/11)
7. Patient 9B-(plan initiated and completed on admission date of 7/9/11)
8. Patient 10-(plan initiated and completed on admission date of 7/18/11)

Review of the above Master Treatment Plans revealed that that plans were developed on the patient's day of admission from preprinted forms. The first form was labeled "Initial Treatment Plan Nursing Standards of Patient Care." This form had a list of general goals and interventions (all usually checked for each patient) with no individualization for each patient. The "Nursing Standards" form was followed by additional preprinted forms for generic problems behavioral/psychiatric problems. On most of these forms, all nursing interventions were checked with no additional information or changes to reflect the patients' individual assessed needs.

The listed nursing interventions were as follows:

1. Patients 1A, 3B, 4A, 4B, 9B and 10. For the problem, "Risk for Suicide," all nursing interventions on the form were checked without individualization for all patients. These were listed on the forms as:

a. "Monitor patient for any adverse reaction, side effects, etc., of medications, and report to M.D."
b. "Reassure patient of their safety, assure a safe therapeutic environment."
c. "Assess the patient or any plan or intent on admission and PRN."
d. "Explain suicidal precautions on admit and PRN."
e. "Search patient and their surroundings for any dangerous items on admit and PRN."
f. "Know the patient's whereabouts at all times."
g. "Stay with the patient while attending to hygiene, (shaving, bathing, cutting nails, etc.)"
h. "Be alert to possibility of patient attempting to save medications after each administration."
i. "Observe, record, and report patient's mood every shift."
j. "Be aware of the relationships patient is forming with other patients at all times."
k. "Confront the patient's acting out behaviors as avoidance of the real conflict involving unmet emotional needs."
l. "Reinforce patient's open expression of underlying feelings of anger, hurt, and disappointment."
m. "Support patient's expression of emotional needs to family members and significant others."
n. "Ask patient to make one positive statement about self daily and record it in a journal."

2. Patients 2B and 7. For the problem, "Altered Thought Process," all nursing interventions on the form were checked without individualization for the patient. These were listed on the forms as:

a. "Monitor patient for any adverse reaction, side effects, etc., of medications, and report to M.D."
b. "Let the patient know that all feelings, ideas, and beliefs are permissible to share with you frequently."
c. "Focus interactions and problem-solving on how the patient can avoid further difficulties when problems occur."
d. "Teach/role model basic communication skills daily."
e. "Foster trust: Follow through on goals/tasks discussed."
f. "Provide group therapy for patient to improve his/her social judgment and interpersonal skills."
g. "Maintain a safe environment for the patient at all times."

3. Patient 10. For the problem, "Depressed Mood," all nursing interventions on the form were checked without individualization for the patient. These were listed on the form as:

a. "Monitor patient's response to psychotropic medications."
b. "Establish therapeutic rapport with patient."
c. "Educate patient in nursing groups x 45 minutes."
d. "Educate patient in nursing groups about psychotropic medications uses [sic] and side effects."
e. "Monitor and record patient's mental status and behavior every shift."
f. "Teach patient coping skills and stress management skills."
g. "Monitor patient's sleep pattern."
h. "Assist patient in reducing 'depression' by involving the patient in activities that will increase feelings of self worth by experiencing successes in activity groups."
i. "Encourage patient to pursue interests, hobbies, and leisure activities."
j. "Monitor changes in patient's behavior and assess pt when in treatment for any evidence of Suicidal Thoughts."
k. "Maintain a safe therapeutic environment for the patient at all times."

B. Staff Interview

During an interview on 7/26/11 at 12:00p.m., the DON acknowledged that the nursing interventions on the sample patients' treatment plans were not individualized.

II. Ensure that the names of nurses responsible for nursing interventions on the Master Treatment Plans of 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10) were identified on the plans. This deficiency results in lack of accountability for nursing care.

Findings include:

A. Record Review

The treatment plans for the 8 sample patients were as follows:

1. Patient 1A-(plan initiated and completed on admission date of 7/12/11)
2. Patient 2B-(plan initiated and completed on admission date of 7/21/11)
3. Patient 3B-(plan initiated and completed on admission date of 7/20/11)
4. Patient 4A-(plan initiated and completed on admission date of 7/8/11)
5. Patient 4B-(plan initiated and completed on admission date of 7/17/11)
6. Patient 7-(plan initiated and completed on admission date of 7/7/11)
7. Patient 9B-(plan initiated and completed on admission date of 7/9/11)
8. Patient 10-(plan initiated and completed on admission date of 7/18/11)

On all of the above treatment plans, the discipline "nursing" was assigned responsibility for interventions such as "NSG [Nursing]". No names of nursing staff were listed as being accountable for interventions.

B. Staff Interview

During an interview on 7/26/11 at 4:00p.m. the DON stated that the plans failed to note the nursing team member responsible for nursing interventions.

III. Ensure that nurses' application of physical holds (restraint) were based on physician orders and were adequately documented for 2 of 2 discharged patients (E4 and E5) added to the sample for the review of restraint incidents. Physical holds were applied without a physician's order. The use of restraints without physician orders is unsafe nursing practice and is a violation of the patient's right to be free from restraints without proper justification.

Findings include:

A. Specific Patient Findings

1. Patient E4

a. A "Patient/Visitor Safety Report" dated 1/3/11 stated, "Client combative + [and] attempting to fight staff. Client taken to bed c/ CPI [with preventive intervention] technique..."

b. A nursing note dated 1/3/11 documented "Pt [patient] argumentative + [and] oppositional c/ [with] instructions from staff. Client difficult to redirect + [and] easily agitated + hostile. Client escorted to observation room for an opportunity to calm down."

c. In an interview on 7/26/11 at 12:00p.m., the DON acknowledged that physical holds were used for Patient E4.

d. A review of Patient E4's medical record revealed no physician order for the use of this physical hold.

2. Patient E5

a. A nursing note dated 7/5/11 documented "Pt [Patient] became agitated, demanding to go home, be released...Pt taken to room c/ [with] help of another staff, using proper techniques."

b. In an interview on 7/26/11 at 12:00p.m., the DON acknowledged that a physical hold was used for Patient E5.

c. A review of Patient E5's medical record revealed no physician order for the use of the physical hold.

B. Interviews

1. During an interview on 7/25/11 at 11:50a.m., when asked if the hospital uses physical holds for the patients, the DON reported that staff may hold a patient "briefly to give a medication against their will or when a patient is acting out." When asked if these were seen as restraints, the DON stated, "If the medication pertains to the patient's diagnosis, then it is not considered as a restraint."

2. In an interview on 7/26/11 at 12:00p.m., the DON stated that "briefly holding a patient" was not viewed as a physical hold in this facility. S/he acknowledged that physical holds were used for Patients E4 and E5. She also reported that all nursing personnel received the CPI class that included techniques to hold or escort patients when needed.

C. Policy Review

Review of the facility's policy, "Seclusion and Restraints Use," dated 7/20/10, revealed the following statement: "If the patient is in a physical hold, a second staff person who is trained and competent in the use of restraint and seclusion and who is not involved in the physical hold is assigned to observe the patient." The attached form titled "Seclusion/Restraint Orders" failed to include a physical hold in the section named "Method of Restraint" other than listing a category as "Other______________."

IV. Ensure that structured nursing programming/activities occurred as scheduled. Nursing groups were the only structured treatment scheduled for the patients in this facility other than group therapy (held twice on weekdays and one time on weekend days, and recreational therapy activities only held on weekdays). All groups to be conducted by nursing during the survey dates of 7/25-26/11, and for at least 7 days prior to the survey had been cancelled. During the times that these groups were scheduled during the survey, patients were observed to be watching TV, sitting around, napping in chairs or "milling about" the ward. Failure to provide structured programming results in patients being hospitalized without all interventions for recovery being provided, delaying improvement and discharge. (Refer to B125, Part III)

Based on record review and staff interview, the Director of Social Services failed to monitor the quality and appropriateness of Social Services. Specifically, the Director of Social Services failed to assure that Social Work Assessments included conclusions and recommendations for the anticipated social work role in treatment and discharge planning for 8 of 8 active sample patients (1A, 2B, 3B, 4A, 4B, 7, 9B and 10). This can result in lack of social work input for treatment planning and inadequate professional social work treatment services. (Refer to B108)