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Based on record review and interview, the facility failed to develop master treatment plans that identified physician, nursing, and activities therapy interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (1, 2, 5, 8, 9, 10, 12, and 13). Instead, master treatment plans included a checklist of interventions which were routine, generic discipline functions that lacked focus for treatment. This failure results in master treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

A review of medical records revealed that the pre-printed master treatment plans only listed routine, generic discipline functions as interventions rather than individualized interventions to assist patients accomplish their treatment goals. The interventions for several patients were identical except for medications.


1. Patient 1 (Master Treatment Plan (MTP) dated 9/23/11)

For the problem of "Paranoia," the following generic interventions were checked:
Nursing: "Assess for paranoid behaviors every shift/PRN [as needed] & document daily," "Monitor and assist with ADL's [activities of daily living] daily/PRN," "Provide less stimulating environment when patient is actively Hallucinating," "Provide Reality Orientation q. [every] shift," "Encourage social interaction and participation with peers,"

"Monitor medication compliance daily," and "Provide Reality Orientation q. [every] shift." Activities Therapy: no interventions were listed for the activities therapist.

For the problem of "Depressed Mood," the following generic interventions were checked:
MD: no interventions were listed for the psychiatrist. Nursing: "Provide patient with a safe therapeutic environment," "Assess for destructive behavior toward self and others," "Provide support to help patient feel secure," and "Monitor medication compliance daily." Activities Therapy: no interventions were listed for the activities therapist.

2. Patient 2 (MTP dated 9/2/11)

For the problem of "Mood Lability," the following generic interventions were checked:
Nursing: "Provide patient with a safe therapeutic environment," "Assess patient's speech pattern every shift or as needed," "Administer medications as ordered by MD," "Observe and document effects of medications," "Monitor medication compliance daily," "Monitor percentage of all meals consumed," "Monitor # of sleep hours throughout hospitalization," "Provide Nursing education groups on a daily basis," "Monitor and assist with ADL's daily/PRN," and "Encourage spontaneous fun during activities and leisure skills groups." Activities Therapy: no interventions were listed for the activities therapist.

For the problem of "Depressed Mood," the following generic interventions were checked:
Nursing: "Establish therapeutic rapport with patient," "Reinforce patient's positive goals and changes," "Encourage patient to pursue interests, hobbies, and leisure activities," and " Maintain a safe environment for the patient at all times."
Nursing only: "Monitor patient's response to psychotropic medications,"

"Educate patient in nursing groups x 45 minutes," "Educate patient in nursing groups about psychotropic medications uses and side effects," "Monitor and record patient's mental status and behavior every shift," "Monitor patient's sleep pattern," and "Monitor changes in patient's behavior and assess pt (patient) when in treatment for any evidence of Suicidal Thoughts." Activities Therapy only: "Provide art/leisure activities for 45 minutes, 5 times weekly to decrease stress/anxiety," and "Assist patient in reducing 'depression' by involving the patient in activities that will increase feelings of self worth by experiencing successes in activity groups."

3. Patient 5 (MTP dated 9/23/11)

For the problem of "Auditory Hallucinations," the following generic interventions were checked: MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: "Assess for hallucinations every shift/PRN [as needed] & document daily," "Monitor and assist with ADL's [activities of daily living] daily/PRN," "Administer medications as ordered by MD, " "Encourage social interaction and participation with peers," "Monitor percentage of all meals consumed," "Monitor # of sleep hours throughout hospitalization," and "Provide nursing education groups on a daily basis." Activities therapy: "Encourage participation in activities that will increase comfort and ability to trust others."

For the problem of "Suicidal Ideation," the following generic interventions were checked:
MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: "Assess and document suicidal ideation and behaviors," "Provide patient with a safe therapeutic environment," "Monitor and prevent destructive behavior toward self and others," "Monitor for physical and safety needs at all times," "Administer medications as ordered by MD," "Monitor medication compliance daily," "Observe and document effects of medications," "Monitor percentage of all meals consumed," "Monitor # of sleep hours throughout hospitalization," and "Provide nursing education groups on a daily basis." Activities therapy: "Provide group activities to increase patient's feelings of self-worth and or self confidence."

For the problem of "Depressed Mood," the following generic interventions were checked:
MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: identical to the interventions identified for Patient 1 for "Depressed Mood," with the addition of the following generic interventions: "Assess and document suicidal ideation and behaviors every shift or as needed," "Monitor for physical and safety needs at all times," "Administer medications as ordered by MD," "Observe and document effects of medications," and "Provide nursing education groups on a daily basis." Therapeutic activities: "Encourage spontaneous fun during activities and leisure skills groups."

4. Patient 8 (MTP dated 9/13/11)

For the problem of "Suicidal Ideation," the following generic interventions were checked:
Nursing: identical to the interventions for Patient 5 for "Suicidal Ideation," with the addition of the following generic intervention: "Provide support to help patient feel secure." Activities therapy: identical to the intervention for Patient 2 for the problem of "Mood Lability."

For the problem of "Depressed Mood," the following generic interventions were checked:
Nursing: "Monitor for physical and safety needs at all times," "Administer medications as ordered by MD," "Provide patient with a safe therapeutic environment," and "Monitor # of sleep hours throughout hospitalization." Activities therapy: "Provide group activities to increase patient's feelings of self-worth and or self confidence," and "Encourage spontaneous fun during activities and leisure skills groups."

For the problem of "Auditory Hallucinations," the following generic interventions were checked: Nursing: identical to the interventions identified for Patient 5 for "Auditory Hallucinations" with the addition of the following generic interventions: "Assess for aggressive/assaultive behavior as needed," "Provide less stimulating environment when patient is actively Hallucinating," and "Provide Reality Orientation q. [every] shift," and "Provide activities with clear, concise directions." Activity therapy: identical to the intervention identified for Patient 5 for the problem of "Auditory Hallucinations."

5. Patient 9 (MTP dated 9/16/11)

For the problem of "Suicidal Ideation," the following generic interventions were checked:
Nursing: identical to the interventions identified for Patient 5 for "Suicidal Ideation."
Activities Therapy: identical to the interventions identified for Patient 5 for "Suicidal Ideation."

For the problem of "Depressed Mood," the following generic interventions were checked:
Nursing: "Assess and document suicidal ideation and behaviors every shift or as needed." Activity therapy: identical to the interventions identified for Patient 5 for the problem of "Suicidal Ideation."

For the problem of "Substance Abuse," the following generic interventions were checked: MD: no interventions were listed for the psychiatrist. Nursing: "Monitor patient for physical and safety needs at all times," "Assess the patient for any signs & symptoms of withdrawals, dependency needs, and expression of emotions daily," "Provide Nursing education groups on a daily basis," "Provide group activities to increase patient's feelings of self-worth and or self-confidence," and "Encourage spontaneous fun during activities and leisure skills groups." Activities Therapy: no interventions were listed for the activities therapist.

6. Patient 10 (MTP dated 9/13/11)

For the problem of "Depressed Mood." the following generic interventions were checked:
Nursing and Activities Therapy: identical to the interventions identified for Patient 2 for "Depressive Mood."

For the problem of "Thought Process, Altered" the following generic interventions were checked: Nursing and Activities Therapy: "Foster trust: - Follow through on goals/tasks discussed" and "Maintain a safe environment for the patient at all times." Nursing only: "Monitor patient for any adverse reaction, side effects, etc, of medications, and report to M.D." and "Let the patient know that all feelings, ideas, and beliefs are permissible to share with you frequently." Activities Therapy only: "Assess for use of gross motor activity to release anxiousness while in art/leisure groups 5 times weekly for 45 minutes."

7. Patient 12 (MTP dated 9/20/11)

For the problem of "Mood Lability," no Nursing or Activities Therapy interventions were checked.

8. Patient 13 (MTP dated 9/20/11)

For the problem of "Suicidal Ideation," the following generic interventions were checked:
MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: identical to the interventions identified for Patient 5 for "Suicidal Ideation." Activities Therapy: no interventions were listed for the activities therapist.

For the problem of "Mood Lability," the following generic interventions were checked: MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: identical to the interventions identified for Patient 2 for the problem of "Mood Lability." Activities Therapy: identical to the interventions identified for Patient 5 for the problem of "Suicidal Ideation."

For the problem of "Depressed Mood," the following generic interventions were checked:
MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications." Nursing: identical to the interventions identified for Patient 5 for "Depressed Mood." Activities Therapy: identical to the interventions identified for Patient 5 for "Suicidal Ideation."

B. Staff Interviews

1. During an interview on 9/27/11 at 10:00a.m. with the treatment team for Patients 1, 2, 5, 8, 9, 10, 12, and 13 including MD1, RN2, SW1, RT1, LPC1, LPC2, and the Director of Nursing (DON), they all agreed that the interventions on the master treatment plans for these patients were generic discipline functions.

2. During an interview on 9/27/11 at 11:30a.m. with the Clinical Director, also attending physician for Patients 1, 2, 5, 8, 9, 10, 12, and 13, s/he agreed that the interventions on the master treatment plans for these patients were generic discipline functions.

Based on interview and document review, the Clinical Director failed to ensure the development of Master Treatment Plans that identified physician interventions for 4 of 8 sample patients (1, 5, 9, and 13). The master treatment plans included a list of interventions that could be chosen by checkmarks. The psychiatrist interventions listed on these Master Treatment Plans were routine, generic discipline functions. This failure results in master treatment plans that do not provide guidance to staff in the care of patients.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan (MTP) dated 923/11)

For the problem of "Depressed Mood," no interventions were listed for the psychiatrist.

2. Patient 5 (MTP dated 9/23/11)

For the problems of "Auditory Hallucinations," "Suicidal Ideation," and "Depressed Mood," and the following generic interventions were checked for the psychiatrist: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications."

3. Patient 9 (MTP dated 9/16/11)

For the problem of "Substance Abuse," no interventions were listed for the psychiatrist.

4. Patient 13 (MTP dated 9/20/11)

For the problems of "Suicidal Ideation," "Mood Lability," "Depressed Mood," the following generic interventions were checked for the psychiatrist for each problem: MD: "Prescribe medication(s): specify [4 blank spaces]" and "Physician will monitor patient for any adverse reaction, side effects, etc., of medications."

B. Staff Interview

During an interview on 9/27/11 at 11:30a.m. with the Clinical Director, also attending physician for Patients 1, 5, 8, 9, and 13, s/he agreed that the physician interventions on the master treatment plans for these patients were generic discipline functions.

Based on record and staff review, it was determined that the Director of Nursing does not have sufficient education and experience for her current administrative position as the Executive Nurse in the facility. This deficiency can result in the lack of quality nursing care for the patients.

Findings include:

A. Document Review

Review of the Director of Nursing's resume in the employee's Human Resource file provided by the Chief Executive Officer revealed that the Director of Nursing had a Associate Degree in Nursing (obtained in 1997), and administrative experience is limited to the Director of Nursing in a skilled nursing home for one year, Acting Director of Nursing for a Behavioral Health Unit for two years. She was hired at the facility on 09/20/11.

B. Staff Interview

During an interview on 09/27/11 at 1:00p.m., the Director of Nursing stated that s/he has an Associate Degree in nursing obtained in 1997. She stated that she had attempted to get a psychiatric nurse certification in the past and was denied because she did not have a Bachelor of Nursing Degree, but now the rules had changed and s/he intended to get certified. She also said that s/he did not have a contract established for consultation with a psychiatric advanced practice nurse.