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Based on observation and interview it was determined the hospital failed to ensure the high temperature dishwasher reached manufacturers guidelines for temperature. In addition, the dietary supervisor failed to identify low temperature recordings for the high temperature dishwasher from November 2017 through January 2018 (A0620). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure proper sanitation of dishes.

Based on observation, document review and staff interview it was determined the hospital failed to ensure the high temperature dishwasher temperatures were at or above manufacturer's guidelines. This had the potential to affect all 34 patients in the hospital.


Findings include:


At approximately 4:21 PM on 01/29/18, Staff D provided the manufacturer's manual for the facility's dishwasher, the Lamber model L21-ek-add. The manual, titled "Declaration of Conformity", stated incoming water temperatures for the wash cycle should be 131-140 degrees Fahrenheit and incoming water temperatures for the rinse cycle should be 176-185 degrees Fahrenheit. There was no display temperatures found in the manual.

Staff D stated patient plates, cups and cookware was washed in the dishwasher. Eating utensils are disposable plastic.

Telephone interview with the Lamber Customer Service Representative on 01/30/18 at 10:12 AM revealed for the L21-ek-add model the wash temperature display should read 145 degrees Fahrenheit or above and the rinse temperature display should read 180 degrees Fahrenheit or above and this is what the facility should be monitoring. The Representative stated the incoming water temperatures are lower than the display readings and should be set at 131-140 degrees Fahrenheit for the wash and 176-185 degrees Fahrenheit for the rinse.


Observation of the kitchen on 01/29/18 at approximately 2:01 PM revealed the wash cycle on the high temperature dishwasher was 123 degrees Fahrenheit and the rinse cycle was 176 degrees Fahrenheit. Review of the high temperature log from January 1, 2018 through January 29, 2018 revealed that acceptable wash temperatures were 160-170 degrees and final rinse temperatures were 180-190 degrees Fahrenheit.


Interview on 01/29/18 at approximately 2:02 PM with Staff D revealed the wash temperature should be 140 degrees Fahrenheit (F) or above and the rinse temperature should be 180 degrees F and verified the temperatures were too low.

A request of the high temperature dishwasher policy was requested and Staff D stated there was no policy found. Staff D provided the Daily Dish Room Task Sheet and verified the sheet stated the rinse temperature should be 140 degrees Fahrenheit and 180 degrees Fahrenheit. Staff D offered no explanation as to why the High Temperature Dishwasher Log and the Daily Dish Room Task Sheet had different temperature ranges.


Additional review of the High Temperature Dishwasher Log from January 1, 2018 through January 29, 2018 revealed no temperatures were obtained on 01/27/18.

Further review of the High Temperature Dishwasher Log for the month of January 2018 revealed for breakfast the wash temperature was below 145 degrees Fahrenheit for 27 out of the 28 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 14 out of 28 days.

Review of lunch temperatures for the month of January 2018 revealed the wash temperature was below 145 degrees Fahrenheit for 21 out of the 28 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 7 out of 28 days.

Review of dinner temperatures for the month of January 2018 revealed the wash temperature was below 145 degrees Fahrenheit for 19 out of the 28 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 10 out of 28 days.


Review of the High Temperature Dishwasher Log for the month of December 2017 revealed for breakfast the wash temperature was below 145 degrees Fahrenheit for 27 out of the 31 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 16 out of 31 days.

Review of lunch temperatures for the month of December 2017 revealed the wash temperature was below 145 degrees Fahrenheit for 26 out of the 31 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 11 out of 29 days. Review of dinner temperatures for the month of December 2017 revealed the wash temperature was below 145 degrees Fahrenheit for 23 out of the 31 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 4 out of 31 days.


Review of the High Temperature Dishwasher Log for the month of November 2017 revealed for breakfast the wash temperature was below 145 degrees Fahrenheit for 23 out of the 30 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 16 out of 30 days. Review of lunch temperatures for the month of November 2017 revealed the wash temperature was below 145 degrees Fahrenheit for 14 out of the 30 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 8 out of 30 days. Review of dinner temperatures for the month of November 2017 revealed the wash temperature was below 145 degrees Fahrenheit for 15 out of the 30 days recorded and final rinse temperatures were below 180 degrees Fahrenheit for 6 out of 30 days.


Interview with Staff D on 01/30/18 at 10:42 AM revealed there was no policy for the dishwasher. He/she also stated that if the dishwasher temperatures are not meeting the manufactures' guidelines then staff should use the 3 compartment sink and/or use paper products. Staff D verified that the 3 compartment sink or paper products had been initiated in the past three months.

Staff D stated the temperatures were low in the morning because staff was recording temperatures prior to letting the dishwasher run. When interviewed why this was not detected, he/she stated "I don't know". Staff D also verified that the lunch and dinner temperatures for the past three months had several low recordings as well and offered no explanation. Staff D offered no explanation as to why the temperature ranges were different on the High Temperature Dishwasher Log and the Daily Dish Room Task Sheet.


Interview with the Infection Control Officer 01/29/18 at 4:30 PM stated there has been no foodborne illness with patients.


Interview on 01/30/18 at 11:42 AM with Staff D revealed the dishwashing machine repair person was inspecting the dishwasher at this time. Staff D denied knowledge of or notification of food borne illness of any patients within the past three months.


Interview on 01/30/18 at 2:35 PM with Staff D revealed the dishwasher repairman was in today and informed the dishwasher was working fine but the incoming left belt heat exchanger is ruptured in the boiler room and it is "only pulling in 120 degrees F. The dishwasher temperatures are ok for the first two to three washes but after that the water temperatures drop. Staff has been educated to stop running the dish machine and wait about 20-30 minutes then re-run the dishes.

Interview on 01/31/18 at 12:00 PM with Sanitation Staff revealed if the dishwasher temperatures are not 145 degrees F or above for the wash cycle or 180 degrees F or above for the rinse cycle then he/she would let the supervisor or the dietician know. In addition, the staff member stated that he/she would stop using the dishwasher and begin using the three compartment sink until the temperatures are at the required level.


Observation on 01/31/18 at 12:07 PM revealed the machine had to run three times prior to getting to acceptable standards of 145 degrees F for wash and 180 degrees F for the rinse cycle. Interview with Staff D at that time revealed the facility has someone working on the boiler line now.


Review of the Dietary Director's job description dated 03/01/16 revealed the dietary director is responsible for all food service related activities; including patient care, quality improvement, sanitation, infection control and all hospital-related activities.

Review of the Food Service Supervisors' job description dated 06/19/17 revealed they are required to ensure kitchen staff follow proper sanitation procedures, maintain equipment, including refrigerators, stoves and microwaves.

Based on facility tour, documentation review, observation and staff verification it was determined this facility failed to ensure the life safety measures were following the National Fire Protection Association 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies in regard to the failure to ensure occupancy construction barriers were fire resistant, failure to ensure egress doors closed properly, failure to ensure discharge from exits were safe to a public way, failure to ensure emergency lighting in generator transfer switch room, failure to post exit signs at designated exits, failure to conduct sensitivity testing of smoke detectors and maintain heat detectors, failure to maintain the sprinkler system by performing the five year internal pipe inspection and change gauges, failure to ensure corridor room doors closed properly, failure to ensure there were no penetrations in the smoke barriers, failure to maintain all smoke barrier doors; failed to ensure transmission times of the pull station devices during fire drills, failed to uphold all smoking regulations, failed to document the time it took to transfer the generator load and failed to utilize power cords properly. (A709) The cumulative effect of these systemic practices resulted in the hospital's inability to ensure an environment safe from fire.

Based on observation during facility tour and staff verification it was determined the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA) 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies. This had the potential to affect all patients receiving services at the facility. The census is 34 patients.

Findings include:

Please refer to the following life safety code findings:

K133 Failed to ensure occupancy construction barriers were fire resistant
K222 Failed to ensure egress doors closed properly
K271 Failed to ensure discharge from exits were safe to a public way
K291 Failed to ensure emergency lighting in generator transfer switch room
K293 Failed to post exit signs at designated exits
K345 Failed to conduct sensitivity testing of smoke detectors and maintain heat detectors (buildings #1 and #2)
K353 Failed to maintain the sprinkler system by performing the five year internal pipe inspection (buildings #1 and #2) and change gauges (building #2)
K363 Failed to ensure corridor room doors closed properly
K372 Failed to ensure there were no penetrations in the smoke barriers
K374 Failed to maintain all smoke barrier doors
K712 Failed to ensure transmission times of the pull station devices during fire drills (buildings #1 and #2)
K741 Failed to uphold all smoking regulations
K918 Failed to document the time it took to transfer the generator load (buildings #1 and #2)
K920 Failed to utilize power cords properly.

Based on record review, interview and observation, it was determined that the facility failed to:

1. Ensure that Multidisciplinary Treatment Plans for eight (8) of eight (8)active sample patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) included the following components:

a. Ensure that Problem identification was behaviorally expressed in order to substantiate the diagnoses. See B119 for details.

b. Ensure that treatment goals were described in a behaviorally measurable manner. See B121 for details.

c. Ensure that physician and nursing interventions were not a listing of generic discipline functions and were not repetitive for different clinical Problems that had been selected as a focus for treatment. See B122 for details.
These multiple failures result in Master Treatment Plans that were not comprehensive and not individualized. (Refer to B118)

2. Provide active treatment, including purposeful alternative interventions for 1 of 4 active sample patients (5) on the Grace (Adult Unit). Although the Master Treatment Plan for this patient included a few groups (Leisure Skill Awareness, Life Management, Problem Solving, Decision Making and Coping Skill Development Groups), the patient did not attend most groups held on the unit. As a result, this patient spent many hours without any structured activity. Despite inconsistent attendance, the Master Treatment Plan was not revised to reflect more individual treatment sessions instead of group treatment. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to him/her in a timely fashion, potentially delaying his/her improvement. (Refer to B125)

Based on record review and staff interview it was determined that for six (6) of eight (8) active sample patients (Patients 1, 2, 3, 4, 5 and 6) the Psychosocial Assessments failed to contain a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being made available to other members of the multidisciplinary treatment team about what efforts might be made to ensure appropriate discharge.

Findings include:

A. Record Review:

1. Patient 1: The Psychosocial Assessment, dated 1/7/18, had no description of the anticipated role of the social service staff in discharge planning. The Assessment stated only "Pt. (patient) discharge to home & community." No statements about exploring the appropriateness of the placement of the patient home or what community resources were being considered to meet the patient's needs were present.

2. Patient 2: The Psychosocial Assessment, dated 1/16/18, had no description of the anticipated role of the social service staff in discharge planning. The Assessment stated "Pt wants to discharge to inpatient tx (treatment) services". No statement was made as to what efforts would be made to ensure this outcome if appropriate clinically.

3. Patient 3: The Psychosocial Assessment, dated 12/20/17, stated as the anticipated role of the social service staff, "Return home." No information about what the staff might be doing to ensure this was an appropriate outcome following hospitalization was present.

4. Patient 4: The Psychosocial Assessment, dated 1/14/18, in the Section "Initial Discharge Plan" had no statement.

5. Patient 5: The Psychosocial Assessment, dated 1/18/18, stated as the anticipated role of the social service staff, "Coordinate treatment." No information was provided as to what the "treatment" with respect to discharge planning might be.

6. Patient 6: The Psychosocial Assessment, dated 1/19/17, stated "Coordinate w\ (with) family, Access Ohio." No information about what it means to "coordinate" such as assessing appropriateness of family as a placement site or what "coordinate" with Access Ohio meant in order to ensure this patient's needs upon discharge.

B. Staff Interview:

On 1/23/18 at 9:25a.m. the Director of the Department of Social Work was interviewed. A partial focus of the interview was the anticipated discharge plans of Patients 1, 2, 3 and 4. He agreed that these Psychosocial Assessments did not inform about the anticipated role of the social service staff.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) the Psychiatric Evaluations failed to contain an assessment of the patient's personal assets in descriptive not interpretive fashion. This failure results in no information being available to the other members of the multidisciplinary treatment team in the selection of inherent patient assets such as interests, past achievements, hobbies, etc. that might engage the patient in selected therapies.

Findings include:

A. Record Review:

1. Patient 1: The Psychiatric Evaluation, dated 1/7/18, for this 48 year old with the diagnoses "Depressive D/O (Disorder), Unspecified and Panic D/O, W/O (without) agoraphobia, PTSD (Post Traumatic Stress Disorder), and Childhood trauma" had no description of inherent patient assets such as interests, accomplishments, hobbies, goals, etc.

2. Patient 2: The Psychiatric Evaluation, dated 1/15/18, for this 49 year old with the diagnoses "Major depression, Recurrent and Opioid use disorder and in withdrawal" had no assessment of patient assets.

3. Patient 3: The Psychiatric Evaluation, dated 1/11/18, for this 20 year old with the diagnoses "Major depressive disorder, recurrent, unspecified and Opioid dependence with opioid-induced mood disorder" had no assessment of patient assets.

4. Patient 4: The Psychiatric Evaluation, dated 1/6/18, for this 20 year old with the diagnoses "Opiate Withdrawal, Opiate Use D/O, Depressive D/O, unspecified and Anxiety D/O, Unspecified" had no assessment of patient assets.

5. Patient 5: The Psychiatric Evaluation, dated 1/18/18, for this 51 year old with the diagnoses "Schizophrenic, paranoid" had no assessment of patient assets.

6. Patient 6: The Psychiatric Evaluation, dated 1/18/18, for this 37 year old with the diagnosis "Schizoaffective D/Bipolar type" had no assessment of patient assets.

7. Patient 7: The Psychiatric Evaluation, dated 1/8/2018 had for this 50 year old with the diagnosis "Paranoid Schizophrenia- acute (illegible)" as assets "Stable living environment, clear speech, no use of illicit substances." These are not inherent patient assets (excepting clear speech) that might be utilized in selecting in-patient treatment modalities.

8. Patient 8: The Psychiatric Evaluation dated 1/12/18, for this 78 year old with the diagnoses "Schizoaffective DO-Bipolar, Vascular Dementia with behavioral disturbance" had for the patient's asset "stable living environment". This is not an inherent asset and would not be able to be utilized possibly while an in-patient.

B. Staff Interview:

On 1/23/18 at 11:30a.m. the clinical director was interviewed. A partial focus for the interview was the failure to identify patient assets as described in Section A above. He agreed with the findings.

Based on record review and staff interview it was determined that the facility failed to ensure that Multidisciplinary Treatment Plans for eight (8) of eight (8) active sample patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) included the following components:

1. Ensure that Problem identification was behaviorally expressed in order to substantiate the diagnoses. See B119 for details.

2. Ensure that treatment goals were described in a behaviorally measurable manner. See B121 for details.

3. Ensure that physician and nursing interventions were not a listing of generic discipline functions and were not repetitive for different clinical Problems that had been selected as a focus for treatment. See B122 for details.

These multiple failures result in Master Treatment Plans that were not comprehensive and not individualized.

Based on record review and staff interview it was determined that for four (4) of eight (8) active sample patients (Patients 1, 4, 5 and 6) the Master Treatment Plan (MTP) failed to contain a description behaviorally that would substantiate the patient's diagnoses. This failure results in an inability to measure changes behaviorally that would evaluate patient progress or lack of progress.

Findings include:

A.Record Review:

1. Patient 1: The MTP, dated 1/9/18, contained 4 different Problems as follows--1.Bipolar, 2. SI (Suicidal Ideation), 3. Anxiety and 4. Diabetes. None of these 4 diagnoses were described behaviorally or with other substantiating findings like lab studies. Instead in the Section "Problem Description" there were only blank spaces.

2. Patient 4. The MTP, dated 1/19/18, for the Problem identified as "Depression/Anxiety" the statement was: "Patient 4 continues to need assistance with managing his/her depression and anxiety." No specific examples were given.

3. Patient 5: The MTP, dated 1/19/18, for the Problem identified as "Schizophrenia" has: "Patient 5 is responding to internal stimuli" as the only description of what the patient is doing behaviorally. No specific examples were given.

4. Patient 6: The MTP, dated 1/19/18, for the Problem "Acute Psychosis", the behavioral description was: "Pt has labile loose associations and confusion." No other information was described.

B. Staff Interview:

On 1/22/18 the clinical director was interviewed. The issue of the lack of a substantiated diagnosis rather than simply a Diagnosis on the MTP was discussed. He agreed that only a Diagnosis without behavioral description was inadequate.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (Patients 1,2,3,4,5,6,7 and 8) the Master Treatment Plan (MTP) failed to establish patient goals in a behaviorally measurable manner. This failure results in the inability to determine if the patient is evidencing progress or lack of progress from their treatment.

Findings include:

A. Record Review:

1. Patient 1: The MTP, dated 1/9/18, had as the short-term goal for the Problem "Bipolar", "[Patient 1] will demonstrate more level moods within one week", "[Patient 1] will demonstrate appropriate appearance and behavior by discharge," and "[Patient 1] will remain safe and free from injury throughout hospitalization." For both long and short term goals the "Target date"(s) was the same.

2. Patient 2: The MTP, dated 1/19/18, had as goals for the Problem "Suicidal Ideation", "[Patient2] will be safe and free from injury throughout hospitalization" and "[Patient 2] will demonstrate behavior congruent with increased self-esteem by discharge." For both the long and short term goals the "Target date"(s) was the same.

3. Patient 3: The MTP, dated 12/4/17, had as goals for the Problem "Pain," "[Patient 3] will notify a member of the health care team promptly for pain level greater than the comfort-function goal" and "[Patient 3] will effectively and safely detox from alcohol/drugs within three days" without a descriptive statement such as "as manifested by---." Both the short term and long term goals have the same "Target date"(s).

4. Patient 4: The MTP, dated 1/19/18, had for the Problem "Depression/Anxiety," "[Patient 4] will evaluate personal strengths and establish goals within one week." For the Problem "Substance Abuse," "[Patient 4] will effectively and safely detox from
alcohol/drugs within 3 days." Both the short term and long term goals have the same "Target date(s)."

5. Patient 5: The MTP, dated 1/19/18, had for the Problem "Schizophrenia", "[Patient 5] will verbalize decreased psychotic symptoms" and [Patient 5] will express feelings and interact with others in an appropriate manner." No specific behaviors to evidence these types of changes were described to establish progress or lack thereof. Both the long term and short-term goals have the same "Target date(s)."

6. Patient 6: The MTP, dated 1/19/18, had for the Problem "Psychosis," "[Patient 6] will respond to reality based interactions with staff and peers" and "[Patient 6] will take medications and comply with treatment during hospitalization." Both the short term and long term goals have the same "Target date(s)."

7. Patient 7: The MTP, dated 1/10/18, had for the Problem "Aggression," "[Patient 7] will talk about feelings and express anger appropriately within one week" and "[Patient 7] will demonstrate knowledge of correct role behaviors by discharge." Both the short term and long term goals have the same "Target date(s)."

8. Patient 8: The MTP, dated 1/12/18, had for the Problem "Aggression," "[Patient 8] will demonstrate knowledge of correct role behaviors by discharge" and "[Patient 8] will display a decrease in aggressive behavior and verbal outbursts within one week." Both the short term and long term goals have the same "Target date(s)."

B. Staff Interview:

On 1/23/18 at 11:30 a.m. the clinical director was interviewed. A partial focus of the interview was the lack of measurable goals in the MTPs as described in Section I, above. He agreed with the findings.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (Patients 1,2,3,4,5,6,7 and 8) the interventions by the psychiatrist were identical for all of the Problems identified as a focus for treatment and were generic discipline functions. Nursing interventions were routine discipline functions and not patient specific. This failure to individualize interventions for different patients' problems results in no specific information about exactly what efforts the psychiatrist and nursing staff will be implementing.

Findings include:

A. Record Review:

Psychiatrist interventions:

1. Patient 1: The MTP, dated 1/9/18, had for the Problem "Bipolar," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Suicidal Ideation," and "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Anxiety," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Diabetes," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

2. Patient 2: The MTP, dated 1/19/18, had for the Problem "Suicidal Ideation," "[MD#3] will meet with the patient 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem Depression," "[MD#3] will meet with the patient 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Substance Abuse," "[MD#3] will meet with the patient 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Homelessness," "[MD#3] will meet with the patient 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

3. Patient 3: The MTP, dated 12/4/18, had for the Problem Suicidal Ideation/Depression," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Substance Abuse," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Pain," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Hallucinations," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

4. Patient 4: The MTP, dated 1/19/18, had for the Problem "Depression/Anxiety," "[MD#4] will meet with patient 15-30 minutes daily and monitor effectiveness of medications and side effects, and adjust dosages as needed for this hospitalization." For the Problem "Substance Abuse," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

5. Patient 5: The MTP, dated 1/19/18, had for the Problem "Schizophrenia," "[MD#3] will meet with the patient 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

6. Patient 6: The MTP, dated 1/19/18, had for the Problem "Psychosis," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem Wound/Skin," "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

7. Patient 7: The MTP, dated 1/10/18, had for the Problem "Aggression." "[MD#2] will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Delusions," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Fall Risk/Swallow Risk," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem Seizures," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Hypertension," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Diabetes," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

8. Patient 8: The MTP, dated 1/12/18, had for the Problem "Aggression," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Paranoia," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Dementia," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Fall Risk/Pain," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem Diabetes," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Asthma/COPD," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem Hypertension," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization." For the Problem "Long term use of anticoagulant," "(No MD by name was identified) will meet with patient for 15-30 minutes daily and monitor effectiveness of medications and side effects, adjusting dosages as needed for this hospitalization."

B. Examples of nursing interventions that were routine discipline tasks and not patient specific:

1. Patient 1: The MTP, dated 1/9/18, stated: "Provide a safe and therapeutic environment for patients" and "Set and maintain limits on behavior that is destructive or adversely affects others," and "Q (every) 15 minute safety checks level of observation initiated."

2. Patient 2: The MTP, dated 1/19/18 ,stated: "Determine and provide the proper amount of suicide prevention precautions for the patient," and "Q 15 minute safety checks level of observation initiated."

3. Patient 3: The MTP, dated 12/4/17, stated: "Will encourage the patient to pursue positive therapeutic relationships, activities and interests," and "Q 15 minute safety checks level of observation initiated."

4. Patient 4: The MTP, dated 1/19/18, stated "Will provide support and positive feedback to the patient," and "Q 15 minute safety checks level of observation initiated."

5. Patient 5: The MTP, dated 1/19/18, stated: "Protect patient from harming him/herself and others," and "Q 15 minute safety checks level of observation initiated."

6. Patient 6: The MTP, dated 1/19/18, stated: "Will ensure a safe and therapeutic environment and encourage patient to voice feelings," and "Q 15 minute safety checks level of observation initiated."

7. Patient 7: The MTP, dated 1/10/18, stated "Assess the patient for risk behaviors and signs of anger," and "Q 15 minute safety checks level of observation initiated."

8. Patient 8: The MTP, dated 1/12/18, stated: "Encourage and assist the patient to verbalize feelings appropriately either one-on-one or in a group setting," and "Q 15 minute safety checks level of observation initiated."

B. Staff Interview:

On 1/23/18 at 11:30am the clinical director was interviewed. A partial focus of the interview was the repetitive interventions by psychiatric staff in the Treatment Plans described in Section I, above. He concurred with the findings.

Based on record review, observation and interview, the facility failed to provide active treatment, including purposeful alternative interventions for one (1) of four (4) active sample patients (5) on the Grace (Adult Unit). Although the Master Treatment Plan for this patient included a few groups (Leisure Skill Awareness, Life Management, Problem Solving, Decision Making and Coping Skill Development Groups), the patient did not attend most groups held on the unit. As a result, this patient spent many hours without any structured activity. Despite inconsistent attendance, the Master Treatment Plan was not revised to reflect more individual treatment sessions instead of group treatment. Failure to provide active treatment results in affected patient being hospitalized without all interventions for recovery being delivered to him/her in a timely fashion, potentially delaying his/her improvement.

Findings include:

Patient 5

1. Patient 5 was admitted on 1/18/18. The Psychiatric Evaluation, dated 1/18/18, stated "Admitted on pinkslip [emergency admission] due to disorganized behavior."

2. The treatment modalities/interventions on patient 5's Master Treatment Plan (MTP), dated 1/22/18, were either normal and routine discipline functions or non-specific statements that were not related to assisting this patient to improve presenting psychiatric symptoms or problems. The problem on the plan was "schizophrenia". "[Name of patient] is responding to internal stimuli." The MTP stated: "[Name of patient] will participate in daily Leisure Skill Awareness, Life Management, Problem Solving, Decision Making and Coping Skill Development groups."
The long-term and short-term goals were not measurable or difficult to measure. A long-term goal was: "[Name of patient] will establish and maintain focus on reality by the time of discharge." There was no description of how this goal could be measured.
A short-term difficult to measure goal was: "[Name of patient] will verbalize decreased psychotic symptoms."

3. On 1/22/18 when MHT#1(Mental Health Technician) was asked where patient 5 was around 10:00 a.m., MHT#1 stated s/he was in bed asleep.

4. Patient 5 was observed by the surveyor on 1/22/18 in bed with eyes closed during a Coping Skills Group around 10:00a.m.

5. A review of "Group Participation/Progress Notes" sheets for patient 5 revealed the following:

1/19/18 -"Community Goals Group 9:30 a.m. - 10:15 a.m. - "Not present" [Self-Esteem]
- "Psycho Education" - 11:00 a.m. - 12:00 p.m. - "Not present"
- "Progress Group" - 1:30 p.m. - 2:15 p.m. - "Not present"
- "Leisure Activity Group" - 3:00 p.m. - 4:15 p.m. - "Not present"
- 1/22/18 - "Community Goals Group" - 9:30 a.m. - 10:15 a.m. - "Not present"
- "Psycho Education Group" - 11:00 a.m. - 12:00 noon - "Not present"
- "Journaling - Gratitude Group" - 1:30 p.m. - 2:15 p.m. - "Not present"
- "Leisure Activity Group" - 3:00 p.m. - 4:15 p.m. - "Not Present"

6. In an interview on 1/23/18 around 9:26 a.m. with RN#1, s/he agreed that patient five (5) had not been attending groups and that alternative 1:1 activities had not been documented as having been provided for this patient.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (Patients1, 2, 3, 4, 5, 6, 7and 8) the clinical director failed to ensure:

I Psychiatric Evaluations contained a description of patient assets in descriptive not interpretive fashion. See B117 for details.

II. That Master Treatment Plans were complete and individualized. That they did not simply list the same interventions repetitively without any patient specific information. See B118 for details.

III. Active treatment, including purposeful alternative interventions were provided for one (1) of four (4) active sample patients (5) on the Grace (Adult Unit). Although the Master Treatment Plan for this patient included a few groups (Leisure Skill Awareness, Life Management, Problem Solving, Decision Making and Coping Skill Development Groups), the patient did not attend most groups held on the unit. As a result, this patient spent many hours without any structured activity. Despite inconsistent attendance, the Master Treatment Plan was not revised to reflect more individual treatment sessions instead of group treatment. Failure to provide active treatment results in affected patient being hospitalized without all interventions for recovery being delivered to him/her in a timely fashion, potentially delaying his/her improvement. See B125 for details.

Based on record review and interview, the Nursing Director failed to ensure that nursing staff provided individualized nursing interventions that reflected the specific behaviors described on the MTPs for seven (7) of eight (8) active patients (1, 2, 3, 4, 5, 6 and 7). This failure to individualize nursing interventions for different behavioralproblems results in no specific information about exactly what efforts the psychiatrist and nursing staff will be implementing.

Findings include:

A. Examples of nursing interventions that were routine discipline tasks and not patient specific:

1. Patient 1: The MTP, dated 1/9/18, stated: "Provide a safe and therapeutic environment for patients" and "Set and maintain limits on behavior that is destructive or adversely affects others," and "Q (every) 15 minute safety checks level of observation initiated."

2. Patient 2: The MTP, dated 1/19/18 ,stated: "Determine and provide the proper amount of suicide prevention precautions for the patient," and "Q 15 minute safety checks level of observation initiated."

3. Patient 3: The MTP, dated 12/4/17, stated: "Will encourage the patient to pursue positive therapeutic relationships, activities and interests," and "Q 15 minute safety checks level of observation initiated."

4. Patient 4: The MTP, dated 1/19/18, stated "Will provide support and positive feedback to the patient," and "Q 15 minute safety checks level of observation initiated."

5. Patient 5: The MTP, dated 1/19/18, stated: "Protect patient from harming him/herself and others," and "Q 15 minute safety checks level of observation initiated."

6. Patient 6: The MTP, dated 1/19/18, stated: "Will ensure a safe and therapeutic environment and encourage patient to voice feelings," and "Q 15 minute safety checks level of observation initiated."

7. Patient 7: The MTP, dated 1/10/18, stated "Assess the patient for risk behaviors and signs of anger," and "Q 15 minute safety checks level of observation initiated."

B. Interview

In an interview on 1/23/18 at 10:23 a.m. the routine nursing functions interventions were discussed with the Nursing Director. She stated she was aware of this problem from the previous Joint Commission survey.

Based on record review and interview, the facility failed to ensure that activity therapy assessments were implemented for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). Despite the fact that all patients were expected to participate in all activity groups offered on each unit, no activity assessments were done. In addition no activity groups were provided on evenings and weekends. These failures result in activity therapy staff notproviding groups based on assessed needs of each patient, making it difficult to provide specific individual focus for each patient in the group.

Findings include:

A. Record Review

1. None of the following eight (8) active sample patients (dates in parenthesis) include specific activity interventions on the Master Treatment Plans, Patients 1 (1/9/18), 2 (1/19/18), 3 (12/4/17), 4 (1/19/18), 5 (1/19/18), 6 (1/19/18), 7 (1/10/18), and 8 (1/12/18). The intervention on all 8 patients was: "[Name of patient] will participate in daily Leisure and, Life Management, Problem Solving, Coping Skills Development Groups."

2. There were no OT/RT groups provided on evenings and weekends.

B. Interview

In an interview on 1/23/18 at 11:50 a.m. with OT#1, the lack of assessments and evening and weekend activity groups was discussed. S/he did not dispute the findings.