HospitalInspections.org

Based on observation, record review, interviews, and other document reviews, the facility failed to:

I. Ensure that social service assessments include both conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). This failure results in a lack of current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems not being described for the treatment teams. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). Specifically, the MTPs did not include the following: 1) observable and measurable short-term goals written in behavioral terms (Refer to B121) and 2) specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5, and B18). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

IV. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement. (Refer to B125, Part1)

V. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery. (Refer to B125, Part II)

VI. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7 and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that required understanding of the English language. This failure potentially contributed to their prolonged emotional and mental suffering and delayed discharge. (Refer to B125, Part III)

VII. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures. (Refer to B125, Part IV).

VIII. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients. (Refer to B125, Part V)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included both a conclusion and specific individualized recommendations for social work services from the assessment data gathered for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

The "Social Work Assessment" for the following patients were reviewed (dates of assessments in parentheses): A1 (2/27/15), A5 (2/19/15), A16 (3/2/15), A18 (12/24/14), B1 (2/20/15), B5 (2/18/15), B6 (2/13/15) B7 (2/11/15) and B18 (1/23/15). This review revealed that none of the social assessments included a conclusion regarding information obtained during the admission assessment process. In addition, the social work assessments did not include specific and individualized recommendations regarding social worker interventions to address each patient's presenting symptoms and/or needs. The section of the social worker assessment titled, "Conclusion and Recommendations" only contained a brief generic statement regarding discharge recommendations and/or a generic statement regarding interventions the patient would benefit from during hospitalization. In addition, it failed to include specific psychosocial issues impacting treatment and discharge, specific community resources or systems to be utilized in discharge planning, aftercare treatment sources, and the social worker's role in treatment planning that included anticipated interventions based on each patient's presenting symptoms that will be addressed by social work.

B. Staff Interview

1. During an interview on 3/10/15 at 11:40 a.m., the Director of Social Work agreed that social work assessments do not include both a summary conclusion and social work recommendations based on clinical data collected regarding patients. She acknowledged that for social assessments the role of the social worker was not formulated with specific and individualized social work interventions based on each patient's presenting symptoms.

Based on record review, policy review and interview, the facility failed to provide master treatment plans that identified individualized short term goals in observable, measurable behavioral terms for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). The goals were not specific and/or described routine hospital functions, which did not define areas of patient improvement. Goal statements failed to give specific focus to treatment, leading to fragmentation of care.

Findings include:

A. Record Review

1. The master treatment plan dated 2/27/15 for Patient A1 had the following short term goals for the problem, "Auditory Hallucinations": "Will be compliant with meds". "Will develop coping skills in managing his stressors and attend therapeutic activity program/group sessions." These goals were not measurable and or specific to this patient.

2. The master treatment plan dated 2/17/15 for Patient A5 had the following short term goals for the problem, "Visual and auditory hallucinations": "Will be compliant with meds." "Will not have any visual/auditory hallucinations." These goals were not measurable or specific to this patient.

3. The master treatment plan dated 2/26/15 for Patient A16 had the following short term goal for the problem, "hearing voices": "Will be compliant with meds and participate in Group." This goal was not measurable or specific to this patient.

4. The master treatment plan dated 12/24/14 for Patient A18 had the following short term goals for the problem, "Mood Disorder": "Patient will remain free from harm or injury throughout hospitalization." "Patient will be compliant with medication as prescribed."
These goals were not measurable or specific to this patient.

5. The master treatment plan dated 2/20/15 for Patient B1 had the following short term goals for the problem, "Altered Thought": "Will build a trust relationship with staff." "Patient will attend morning meeting." These goals were not measurable or specific to this patient.

6. The master treatment plan dated 2/20/15 for Patient B5 had the following short term goals for the problem, "Mood Disorder": "Patient will feel safe on the unit." "Patient will develop a therapeutic relationship with staff members to facilitate therapy." These goals were not measurable or specific to this patient.

7. The master treatment plan dated 2/12/15 for Patient B6 had the following short term goals for the problem, "Altered Thought": "Patient will be in compliance with meds." "Patient will feel safe in structured environment." These goals were not measurable or specific to this patient.

8. The master treatment plan dated 2/13/15 for Patient B7 had the following short term goals for the problem, "Altered Thought": "Patient will feel safe on the unit." "Patient will comply with meds." These goals were not measurable or specific to this patient.

9. The master treatment plan dated 1/23/15 for Patient B18 had the following short term goals for the problem, "Altered Thought": "Patient will feel safe." "Patient will develop a trusting therapeutic relationship." These goals were not measurable or specific to this patient.

B. Policy Review

The facility policy (numbered 213-020 and dated 5/22/08) "Interdisciplinary Treatment Team" stated under "Procedure" number 6: "The treatment plan will contain specific goals for the patient, measurable objectives and discharge planning."

C. Staff Interviews

1. The Director of Nursing was interviewed on 3/10/11 at 2:30 p.m. She stated, "I can see that the goals are not specific or measurable."

2. The Clinical Director was interviewed on 3/11/15 at 10:15 p.m. She stated, "The short term goals can be more appropriate to the individual patient."

Based on record review and interview, the facility failed to develop treatment plan interventions specific to each individual patient based on his/her assessed needs for nine (9) of nine (9) sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). This failure results in patients not being provided individualized, goal directed treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed that MTPs did not include individualized active treatment interventions but contained generic statements which were routine discipline functions (such as "prescribing medications", "administering medications", "encouraging", "monitoring" and "assessing") written as active treatment interventions to be delivered by the physician, registered nurse, activity therapist and occupational therapist. Some short term goals in MTPs had no interventions listed for registered nurses and activity therapists and several intervention statements were identical or similarly worded.

1. Patient A1 had the following physician interventions for the short term goal, "Patient will develop insight": "Prescribe and adjust medication related to response to stabilize [his/her] psychosis and not have somatic preoccupation." This intervention was generic and a routine physician function. "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions.

Patient A1 had the following nursing interventions for the short term goal, "Patient will develop insight": "Encourage attendance at therapeutic group sessions." "Assess and document patient's individual expression of hallucinations/delusions..." "Review medications," "maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Instruct patient on condition and management of [sic] delusional symptoms." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

2. Patient A5 had the following physician intervention for the short term goal, "Patient will be compliant with meds [medications]:" "Supportive therapy 7 x week." This intervention did not identify a focus of treatment and how it would be delivered (individual or group sessions).

Patient A5 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications]:" "Assess and document patient ' s individual expression of hallucinations/delusions..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These interventions were generic and a routine nursing function. "Educate and reinforce the benefits of medication compliance." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

3. Patient A16 had the following physician intervention for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions).

Patient A16 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Encourage attendance at Groups...as scheduled." "Assess and document patient's individual expression of hallucinations..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Medication group reinforce and educate." This intervention did not include a frequency of contact, a focus of treatment, and how the intervention would be delivered (individual or group sessions).

4. Patient A18 had the following physician intervention for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Educate patient regarding being compliant with meds [medications] and enable patient to function in the community." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient A18 had the following nursing interventions for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Administer medication to improve [his/her] mood..." "Assess patient's behavior q [every] Shift..." "Provide safe environment by observing Q [every] 30 min." "Assist and encourage patient to attend to her ADLs [activities of daily living]." These were generic interventions, which were routine nursing functions.

5. Patient B1 had the following physician interventions for the short term goal, "Patient will exhibit logical, organized thinking": "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions). "Educate patient regarding importance of compliance with medications to avoid relapse of symptoms and need for rehospitalization." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B1 had no nursing interventions for the short term goal, "John will accept information given at discharge regarding NA meeting, location and times."

6. Patient B5 had the following physician interventions for the short term goal, "Patient will feel safe on the unit:" "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions. "Educate patient regarding importance of compliance with medications to avoid relapse of symptoms and need for rehospitalization." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B5 had no nursing interventions for the short term goal, "Patient will participate in discharge plans."

7. Patient B6 had the following physician interventions for the short term goal, "Patient will be in compliance with meds [medications]:" "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions. "Educate patient regarding being compliant with meds and prevent relapse of symptoms." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B6 had no nursing interventions for the short term goal, "Patient will agree to recommended aftercare."

8. Patient B7 had the following physician interventions for the short term goal, "Patient will feel safe on the unit": "See patient on individual basis at least daily or more often to monitor medications." This intervention was generic and a routine physician function. "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions).

Patient B7 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

9. Patient B18 had the following physician interventions for the short term goal, "Patient will feel safe in the community:" "See patient on individual basis at least daily or more often to monitor patient's condition and med [medication] management." This intervention was generic and a routine physician function. "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions)..

Patient B18 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

B. Staff Interviews

1. On 3/11/15 at 10:15 a.m., the Clinical Director stated, "I know our interventions need work. We can fix them in one month."

2. In an interview on 3/10/15 at 10:20 a.m. with the Clinical Director, the master treatment plans for Patients A1, A5, A16 and A18 were reviewed. She agreed that the MD interventions did not include all of the required components. She acknowledged that interventions were missing either the modality to be used in treating (individual or group sessions), the frequency of contact, and/or the focus of treatment based on each patient's presenting symptoms.

3. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. She stated, "The interventions are not specific or individual to each patient."

Based on observation, record review, and interview, the facility failed to ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5 and B18). When documented, the treatment notes failed to include, what groups were held, topic(s) discussed, the patients' level of response to the active treatment intervention provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed the following findings regarding documentation of treatment interventions on MTPs for registered nurses (RN), social workers (SW), activity therapy staff (AT), and Occupational Therapist (OT).

1. Patient A1

RN Intervention: "Instruct patient on condition and management of [sic] delusional symptoms." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the RN provided this intervention. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to:... promote peer interaction, formulate coping skills to better manage [his/her] illness." "Wellness & Recovery Group/Discharge Planning:...to process wellness and recovery skills to utilize in the community." "Information Group:...for community resources and linkage upon release from Cornerstone." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the SW provided these group interventions. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to group interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking..." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the OT provided these groups. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed documentation on 3/6/15 regarding the patient's participation in all groups. However, this documentation failed to report what groups the patient participated in, what activities were offered and/or what topics were discussed, and the patient's response to these topics/activities offered.

2. Patient A5

RN Intervention: "Educate & reinforce the benefits of medication compliance." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed no documentation showing that the RN provided this intervention that showed discussions with the patient regarding benefits of medications and medication compliance. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to:...support appropriate peer interaction, formulate coping skills to better manage symptoms." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed no documentation showing that the SW provided this group intervention. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 3 x per week for 45 minutes to: [increase] focus & concentration." "Attend Life Skills group 5 x per week for 45 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] relapse prevention, [increase] insight into illness." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed only one treatment note on 3/6/15 showing the patient non-participation in these groups, however this note contained a generalized statement about group participated but failed to report which groups the patient participated in, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15 regarding the patient's non-attendance in activity therapy groups. A Progress note dated 3/6/15 at 9:30 a.m. stated, "...Came out of room 1x [one time] and looked to see what the group was doing and then returned to [his/her] room during morning exercise program..." This documentation failed to report other groups the patient failed to participate in and/or what activities were offered and refused by the patient.

3. Patient A16

SW Interventions: "Group Therapy 2 x week to:...[Patient's name] will discuss with peers coping strategies to better manage [his/her] illness in the community." "Wellness & Recovery Group/Discharge Planning: [Patient's name] will begin to develop wellness plan to better manage [his/her] illness." "Information Group: Encourage [Patient's name] to attend to obtain information on community resources." A review of the medical record including progress notes from 2/25/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

4. Patient A18

RN Intervention: "Medication Education pt [patient] will be compliance [with] medication & review medication [at] time of discharge." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed no documentation showing that the RN provided medication education, discussed compliance, and reviewed medication(s). There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Wellness & Recovery Group/Discharge Planning: [Patient name] will begin to work on a wellness plan to assist [him/her] in remaining on [sic]." "Information Group: [Patient's name] will be scheduled so [s/he] is aware of resources in the community." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking..." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed documentation on 2/11/15, 2/17/15, 2/23/15, and 3/2/15. However, this documentation contained generalized statements about group participation but failed to report which groups the patient participated in, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed documentation on 2/6/15, 2/13/15, 2/20/15, 2/27/15, 3/6/15 and 3/9/15, however this documentation failed to report which groups the patient participated in, what topics were discussed and/or activities offered, and the patient's response to these topics/the activities offered.

5. Patient B1

RN Intervention: "Instruct patient on condition and management of Schizoaffective Disorder - e.g. [for example] paranoid, hyper [sic], [positive] A/V thinking [sic] - Educate to medication Zyprexia..." "Medication Education review discharge meds [medications] [with] pt [patient], verbalizes understanding including side effects & actions." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed no documentation showing that the RN instructed the patient regarding Schizoaffective Disorder and provided medication education. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: learn about how to behave in the community." "Individual Therapy 2 x per week for 20 minutes to: learn about [sic] of illness, coping skills & [negative] consequences of [non] compliance [with] [sic] medication." "Wellness & Recovery Group/Discharge Planning: to learn how to stay well in the community." "Information Group: to learn about community resources." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] wellness, & healthy living, [increase] ADLS [Activities of Daily Living Skills], [increase] insight into illness." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15, however these notes were generalized statements about group participation but failed to report which groups the patient participated in, level of participation, what activities were offered and/or what topics were discussed, and the patient's response to these topics.

6. Patient B5

RN Intervention: "Educate patient on Schizoaffective D.O., [Disorder], symptoms, medications, and coping skills - i.e. [that is] [increase] sleep, aggression, hyper sexuality." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed no documentation showing that the RN provided patient education regarding Schizoaffective Disorder, medications, or coping skills. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: encourage attendance to learn about how to behave in the community." "Wellness & Recovery Group/Discharge Planning: to learn how to stay well in the community." "Information Group: to learn about available community resources." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] self esteem, [increase] insight into illness." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15, however these notes were generalized statements about number of groups attended but failed to report which groups the patient participated in, level of participation, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: music groups, arts and crafts." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed documentation on 2/23/15 and 3/2/15, however this documentation contained general information regarding the number groups attended but failed to report which groups the patient participated in, level of participation, what activities were offered or what topics were discussed, and the patient's response to these topics/activities.

7. Patient B6

RN Intervention: "Instruct patient on condition and management of: [his/her] delusional symptoms." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed no documentation showing: that the RN provided instruction regarding the patient's "delusional symptoms." There were no notes regarding the patient's participation or non-participation, how instruction was delivered (group or individual sessions), what topics were discussed, level of participation, the patient's response to topics presented, and duration and frequency of contact.

SW Interventions: "Group Therapy 2 x week to: encourage groups to promote appropriate peer interaction; formulate coping skills to better manage [his/her] illness." "Wellness & Recovery Group/Discharge Planning: encourage weekly groups to [sic] wellness & recovery skills to utilize in the community." "Information Group: encourage weekly group for community resources and linkage upon release from Cornerstone." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking, [increase] insight, be able to ask for & receive help." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed documentation on 3/2/15 and 3/9/15, however these notes contained generalized statements regarding minimal attendance and about number of groups attended but failed to report which groups the patient participated in and level of participation, what topics were discussed, and the patient's response to these topics.

8. Patient B7

RN Intervention: "Instruct patient on condition and management of [his/her] delusional symptoms - med [medication] adherence [after] discharge,..." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed no documentation showing: that the RN provided patient any instructions regarding delusional symptoms or medication compliance. There were no notes regarding the patient's participation or non-participation, how instruction was delivered (group or individual sessions), what topics were discussed, level of participation, duration and frequency of contact, and the patient's response to topics discussed.

SW Interventions: "Group Therapy 2 x week to: encourage attendance to learn ways [sic] to cope [with] illness in the community." "Wellness & Recovery Group/Discharge Planning: to learn ways to stay well in the community." "Information Group: to learn about a[sic] aftercare programs in the community." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above, duration and frequency of contact, the patient's participation or non-participation, what topics were discussed and the patient's response to these group interventions.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] more organized reality based thinking & [increase] insight into illness." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed documentation on 2/17/15, 2/25/15, and 3/3/15; however, these notes generalized statements about number of groups attended and the patient's behavior but failed to report which groups the patient participated in and level of participation, what topics were discussed, and the patient's response to these topics.

9. Patient B18

RN Intervention: "Instruct patient on condition and management of Schizophrenia, symptoms, medications, & coping skills education..." "Medication Education Educate to expected effects of Haldol, Depakote, Seroquel, and [sic]..." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed no documentation showing: that the RN provided the patient instruction regarding Schizophrenia, medications, or coping skills education. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: learn how to cope [with] [sic] in the community." "Individual Therapy 2 x per week for 20 minutes to: discuss [sic] of illness & importance of [sic], medication compliance." "Wellness & Recovery Group/Discharge Planning: to learn ways, how to stay well in the community." "Information Group: to learn about community resources." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above, duration and frequency of contact, the patient's participation or non-participation, what topics were discussed and the patient's response to these group interventions.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups [left blank] x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: exercise, music." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed documentation on 2/2/15, 2/9/15, 2/16/15, 2/23/15, and 3/2/15, however this documentation contained general information regarding the patient's behavior, percentage of groups attended but failed to report which groups the patient participated in and level of participation. The treatment notes did not include, which groups were attended, what activities were offered and/or what topics were discussed, and the patient's response to these topics.

B. Staff Interviews

1. During interview on 3/10/15 at 11:40 a.m. with the Director of Social Work, the social work groups listed on the comprehensive treatment for Patient A5 was discussed. She acknowledged that treatment notes regarding groups to be provided social workers were not documented showing the attendance or non-attendance of patient A5. She stated, "We do some groups but very few. We did groups until December [2014] when one of our social workers left."

2. During interview on 3/10/15 at 1:50 p.m., OT2 acknowledged that there was only one documented note regarding Patient A5's participation in active treatment groups provided by occupational therapists.

3. During interview on 3/10/15 at 2:40 p.m., RN1 acknowledged that documentation of the nursing groups on the unit schedule was not found in patients' medical record. RN5 noted that since December 2014, these groups have not been conducted and stated, "This has fallen by the wayside."

4. During interview on 3/11/15 at 9:30 a.m., with RN5, documentation of treatment notes related to the nursing interventions on the treatment plan for Patients A1 and A16 was discussed. RN5 confirmed that there was no documentation regarding whether the patients were provided the nursing interventions identified on the MTP related to patient education.

Based on observation, interviews, record reviews, and other documentation, the facility failed to:

I. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement.

II. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7, and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery.

III. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7, and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that require understanding of the English language. This failure potentially contributes to their prolonged emotional and mental suffering and delayed discharge.

IV. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. The one hour face-to-face assessment documented by the licensed independent practitioner did not include the following information: an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results; and the need to continue or discontinue the seclusion and/or restraint procedure. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures.

V. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients.

Findings include:

I. Failure to provide active treatment

Record Review

1. Patient A5 was admitted to the unit on 2/13/15. The Psychiatric Evaluation dated 2/14/15 noted, "...carries diagnosis of Schizoaffective Disorder... Pt [Patient] has hx [history] of multiple hospitalization." Throughout the survey, the patient was observed to be in his/her room and not interacting with other patients or staff. The patient attended no therapeutic groups and left ate his/her room primarily for meals.

2. The Master Treatment Plan dated 2/17/15 identified one psychiatric problem: "Altered Thought: Hallucinations: Visual and auditory." The interventions identified to decrease hallucinations included medication prescribed and supportive therapy by the psychiatrist and generic functions such as assessing and documenting by the nursing staff. The other interventions to address altered thought processes were group treatment to be provided by social workers, occupational therapists, and activity therapists.

3. Despite documentation that the patient was not attending groups, there were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient isolating in his/her room.

4. In staff interviews, it was confirmed that the patient did not attend groups and that no alternative treatment plan had been developed to identify appropriate interventions for the patient.

B. Staff Interviews

1. During interview on 3/10/15 at 1:50 p.m., OT 2 stated that Patient A5 had not been attending group. When asked about alternative active treatment measures, OT 2 stated, "We don't do individual sessions from the occupational therapy perspective."

2. In an interview on 3/10/15 at 10:30 a.m., RN 5 stated that she was assigned to A5 and confirmed that patient did not attend groups and no alternative treatment sessions had been offered and the MTP had not been developed to identify appropriate interventions for the patient.

3. The Director of Social Worker stated, in an interview on 3/10/15 at 10:50 a.m., that Patient A5 does not attend groups and that the patient refuses to talk to her. She confirmed that the treatment plan had not been revised to identify alternatives to group treatment.

4. The Medical Director stated, in an interview on 3/10/15 at 10:20 a.m., that Patient A5 was not her patient and noted that alternatives should be offered. She stated, "Hypothetically, patients who are isolating like Patient A5 should be assigned a one-to-one nursing staff to interact with the patient."

II. Failure to provide a comprehensive active treatment schedule

A. Observations

On 3/9/15 there were only two groups for the patients on the East wing, a walk and Bingo. An occupational therapy group, which was scheduled at 1:00 p.m., was not done. The groups did not start at the time noted on the schedule. There were no therapeutic groups scheduled after 5:00 p.m. or on Saturday or Sunday. On the West wing, there was a nursing group and Bingo. There were no therapeutic groups scheduled after 5:00 p.m. or on Saturday or Sunday.

B. Document Review

1. The schedule for East wing noted: two (2) activity therapy groups on Monday, 2 activity therapy groups on Tuesday and a nutrition group, an activity therapy group and a nursing group on Wednesday, Thursday and Friday. The East wing schedule showed a social work group scheduled with AT on Monday and Tuesday at 9:45 a.m. There were no groups scheduled for weekends or evenings.

2. The schedule for West wing noted: a nursing group and an activity therapy group on Monday (the occupational therapy group did not occur), an activity therapy group and an occupational therapy group scheduled on Tuesday, 2 activity therapy groups and 2 occupational therapy groups scheduled on Wednesday and Thursday, and a nursing and activity therapy group on Friday. There were no social work groups scheduled. There were no groups scheduled for weekends or evenings.

3. The groups were generic in nature (hand washing, bingo) without an individualized treatment focus. All patients were expected to attend the same groups, which resulted in the groups being large (20-24 patients) and not conducive to learning or processing.

C. Patient Interviews

1. When interviewed on 3/9/15 at 10:15 a.m., Patient B1 stated, "We stay to ourselves here. Not much to do. Especially on weekends."

2. When interviewed on 3/9/15 at 11:45 a.m., Patient B5 stated, "It is very boring here, especially on the weekends."

3. When interviewed on 3/9/15 at 1:30 p.m., Patient B6 stated, "There are not enough classes here. No groups on the weekends."

D. Staff Interviews

1. The Activities Therapy Director was interviewed on 3/10/15 at 1:30 p.m. and stated, "We have no evening or weekend activities." She also listed the groups that her department does as, "Grooming, trivia, bingo, exercise, listening to music and arts and crafts."

2. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. and stated, "We know that we need more groups."

3. The Clinical Director was interviewed on 3/11/15 at 10:15 a.m. and stated, "I understand that we need more therapeutic groups. We need groups on weekends and evenings too."

III. Lack of interpreter services

A. Observations

On 3/9/15 at 10:00 a.m., Patients B5, B7, and B18 were in a Nursing group, which was discussing infection control and hygiene. These patients did not have an interpreter present and were unable to participate in this group.

B. Record Review

1. Patient B5 was admitted on 2/17/15 and the psychiatric assessment dated 2/18/15 noted, "Speaks mostly Spanish." However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 2/20/15.

2. Patient B7 was admitted on 2/10/15 and the psychiatric assessment dated 2/11/15 noted, "Spanish speaking." However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 2/13/15.

3. Patient B18 was admitted on 1/22/15 and the interdisciplinary assessment dated 1/22/15 noted "Spanish" as the primary language spoken. However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 1/23/14. A progress note dated 2/16/15 at 10:25 a.m. reported, "[Patient's name] attends AT [activity therapy] groups 80% of the time...Pt [patient] stated that [s/he] gets frustrated when [s/he] can't understand what is going on during AT groups. Other Spanish speaking pts [patients] have been able to translate during AT groups."

C. Policy Review

The facility policy, "Interpretation Assistance Plan Limited English Proficiency and Hearing Speech Impairment" dated 7/18/12 states, "No person shall be denied equal access to services based solely on his/her ability to communicate in the English language or due to hearing/speech impairment. It is the obligation of Runnells Specialized Hospital to ensure that effective communication assistance shall be provided to Limited English Proficiency and Hearing/Speech Impaired persons so that they have a complete understanding of information regarding medical condition, treatment and payment requirements." The facility did not adhere to this policy.

D. Patient Interviews

1. Patient B18 was interviewed on 3/9/15 at 10:45 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I suffer when I go to groups. I don't understand what they say."

2. Patient B7 was interviewed on 3/9/15 at 11:30 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I don't understand the groups at all. I don't understand English."

3. Patient B5 was interviewed on 3/9/15 at 11:50 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I know some English words but I need help understanding. I don't understand the groups or my diagnosis."

E. Staff Interviews

1. When interviewed on 3/9/15 at 12:15 p.m., SW2 stated that she was bilingual and "I interpret for these patients when they meet with their doctor or in treatment team. I have a full caseload of 12 patients and I work 8:00 a.m. till 4 p.m. Monday through Friday I cannot interpret for the patients in groups and other treatment settings."

2. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. and stated, "No, there are no regular interpreters on the units. We rely on two Spanish speaking aides in the evenings or a language phone line." She acknowledged that the aides were not available at all times and even worked on a different unit than where the Spanish-speaking patients were. She stated, "The aides and the language phone line are not adequate to provide proper treatment for the Spanish speaking patients." When asked why there were no interventions in the treatment plan regarding the language barrier she stated, "We were told not to include that the patients did not speak English in the plans."

3. The Clinical Director was interviewed on 3/11/15 at 10:15 a.m. and she stated, "You have a valid point. We need interpreters. We are not following our policy."

4. The Director of Activities was interviewed on 3/10/15 at 1:30 p.m. She stated that, "The non English speaking patients are not always able to understand what we are doing in activities."

IV. Failure to document one-hour face-to-face assessments

A. Record Review

1. Patient C1, admitted 2/13/15, was placed in 4 points restraints on 2/14/15 at 8:20 a.m. The facility's "Restraints/Seclusion Physician's Order Form and Progress Notes" dated 2/14/15 at 8:20 a.m. stated, "Pt [Patient] became agitated & attempted to strike male peer..." Physician orders were documented but there was no comprehensive one-hour face-to-face assessment found in the medical record that included: an evaluation of the patient's medical condition (review of systems); a review of medications; and recent laboratory results) and behavioral assessment, an evaluation of immediate situation; the patient's reaction to the intervention; and the need to continue or terminate the restraint or seclusion. A review of the Master Treatment Plan for this patient revealed that there was a statement dated 2/14/15 under the "Nursing Interventions" section of the MTP noting, "Patient was placed in 4 pt [points] restraints for aggressive physically threatening behavior to staff and peers." However, the MTP was not updated to reflect specific short-term goals and interventions aimed at the patient developing non-harmful behaviors when feeling agitated.

2. Patient C2, admitted 1/7/15, was placed in 4 points restraints on 2/22/15 at 8:15 a.m.. The facility's "...Restraints/Seclusion Physician's Order Form and Progress Notes" dated 2/22/15 at 8:45 a.m. stated, "Patient placed in 4 pt [points] restraints for safety of self and others after pt [patient] ran from RN [registered nurse] with her medications, delusional, cursing, aggressive. Zyprexia 5mg IM given." Physician orders were documented but there was no comprehensive one-hour face-to-face assessment found in the medical record that included: an evaluation of the patient's medical condition (review of systems); a review of medications; and recent laboratory results), an evaluation of immediate situation; the patient's reaction to the intervention; and the need to continue or terminate the restraint or seclusion. A review of the Master Treatment Plan for this patient revealed that there was no revision to reflect the episode of restraint and no update of short-term goals and interventions aimed at effective strategies the patient could use to develop non-harmful behaviors when feeling aggressive.

B. Policy Review

The facility's policy titled "Restraint/Seclusion For Behavioral Management: Special Treatment Procedures" dated 4/28/14 stipulated that, "The Licensed Independent Practitioner will respond to the bedside within one hour to complete a face to face intervention of the patient and write the order for restraint/seclusion and document the rationale for placement of restraint..." This policy failed to include the following requirements for face-to-face evaluation: The patient's immediate situation; the patient's reaction to the intervention; the patient's medical (review of systems, medications, laboratory results, etc.) and behavioral condition; and the need to continue or terminate the restraint or seclusion.

C. Staff Interview

1. In an interview at 10:20 a.m. on 3/10/15, the Medical Director stated that the physician's progress note written at the time of the face-to-face evaluation is the complete documentation written by the MD or APRN when seclusion or restraint occurs. She acknowledged that there was no information documented regarding the patient's medical condition, labs, or need to continue or terminate the restraint procedure.

V. Violation of Patient Privacy

A. Observation

When touring the 2 units on 3/9/15 it was observed that 4 private rooms (room numbers CSE31, CSE33, CW56, and CW60) had surveillance cameras mounted on the walls of the rooms.

B. Policy/Record Review

1. The facility's policy number 213-053, dated 1/26/05 and titled "Use of Surveillance Camera for Suicide Precautions/Behavioral Monitoring" stated, "The surveillance camera will be used when the patient is in need of constant monitoring for safety reasons." The procedure, in its entirety, stated, "Physician order is needed for the surveillance camera. The patient will be admitted to a room equipped with camera surveillance and will be informed that he/she will be under camera surveillance. When the patient's behavior has improved, the surveillance order will be discontinued and the camera turned off." There were no criteria for when cameras would be utilized or any clarification of "safety reasons."

2. The facility did not have a patient privacy policy. They provided the surveyors with the "Patient's Bill of Rights" which referred to the "Mental Patient's Bill of Rights" of 1975. One of the rights was "to privacy and dignity."

C. Patient Interview

On 3/9/15 at 3:15 p.m. Patient B6 (who was non English speaking) stated through the social worker (who was bilingual) that, "No one told me that I would have the camera in my room but I know that it is there. It makes me nervous."

D. Staff Interview

On 3/9/15 at 2:00 p.m. the Director of Nursing stated, "We do not use the cameras. They are not even turned on. We have not used them since I came to work here. We use one-to-one staffing to monitor suicidal patients. And I can see why it would be disturbing to patients to be under surveillance in their rooms. We will have to talk to the administrator about getting rid of them."

Based on interviews, record reviews, and document reviews, the Medical Director failed to:

I. Ensure that social service assessments include both conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). This failure results in a lack of current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems not being described for the treatment teams. (Refer to B108).

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). Specifically, the MTPs did not include the following: 1) observable and measurable short term goals written in behavioral terms (Refer to B121) and 2) specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5 and B18). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

IV. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement. (Refer to B125, Part1)

V. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery. (Refer to B125, Part II)

VI. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7 and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that required understanding of the English language. This failure potentially contributed to their prolonged emotional and mental suffering and delayed discharge. (Refer to B125, Part III)

VII. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures. (Refer to B125, Part IV)

VIII. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients. (Refer to B125, Part V)

Based on record review, policy review, patient interviews, and staff interviews, the Director of Nursing failed to:

I. Ensure that for nine (9) of nine (9) sample patients an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. (See B125 II)

II. Ensure that three (3) of three (3) Spanish-speaking patients received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that require understanding of the English language. (See B125 III)

III. Ensure that two (2) of nine (9) sample patients were provided privacy and dignity. (See B125 V)

IV. Ensure that nine (9) of nine (9) sample patients had master treatment plans that identified individual short term goals in observable, measurable and behavioral terms. (See B121)

V. Ensure that nine (9) of nine (9) sample patients had treatment plan nursing interventions specific to each individual patient based on his/her assessed needs.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed that MTPs did not include individualized active treatment interventions but contained generic statements which were routine nursing functions (such as "administering medications", "encouraging", "monitoring", and "assessing") written as active treatment interventions to be delivered by registered nurses. Some short term goals in MTPs had no interventions listed for registered nurses and several intervention statements were identical or similarly worded.

1. Patient A1 had the following nursing interventions for the short term goal, "Patient will develop insight": "Encourage attendance at therapeutic group sessions." "Assess and document patient's individual expression of hallucinations/delusions..." "Review medications," "maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Instruct patient on condition and management of [sic] delusional symptoms." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

2. Patient A5 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications]:" "Assess and document patient ' s individual expression of hallucinations/delusions..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These interventions were generic and a routine nursing function. "Educate and reinforce the benefits of medication compliance." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

3. Patient A16 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Encourage attendance at Groups...as scheduled." "Assess and document patient's individual expression of hallucinations..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Medication group reinforce and educate." This intervention did not include a frequency of contact, a focus of treatment, and how the intervention would be delivered (individual or group sessions).

4. Patient A18 had the following nursing interventions for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Administer medication to improve [his/her] mood..." "Assess patient's behavior q [every] Shift..." "Provide safe environment by observing Q [every] 30 min." "Assist and encourage patient to attend to her ADLs [activities of daily living]." These were generic interventions, which were routine nursing functions.

5. Patient B1 had no nursing interventions for the short term goal, "John will accept information given at discharge regarding NA meeting, location and times."

6. Patient B5 had no nursing interventions for the short term goal, "Patient will participate in discharge plans."

7. Patient B6 had no nursing interventions for the short term goal, "Patient will agree to recommended aftercare."

8. Patient B7 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

9. Patient B18 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

B. Staff Interview

The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. She stated, "The interventions are not specific or individual to each patient."

Based on schedule review, record review, patient interview and staff interview, the facility failed to plan and implement structured programming of therapeutic/leisure activities during days, evenings and weekends, failed to complete individual activity assessments for four (4) of nine (9) sample patients (A5, B6, B7 and B18) and failed to develop individualized activity master treatment plan interventions for nine (9) of nine (9) sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). These failures resulted in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities and patients not receiving individualized, goal directed treatment.

Findings include:

A. Review of Unit Schedules

The East Wing had eight (8) activity therapy groups scheduled Monday through Friday during the day and the West Wing had seven (7) activity therapy groups scheduled Monday through Friday during the day. There were no activity groups after 5:00 p.m. or on the weekends for either unit.

B. Record Review

1. Patient A1 had the following sole pre-printed activity intervention, "Provide leisure education group focusing on communication, relationship building and self-preservation skills." This was a generic intervention that did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

2. Patient A5 had no individual activity assessment completed. Patient A5 had the following sole pre-printed activity intervention, "Provide leisure education group focusing on communication, relationship building and self-preservation skills." This intervention did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

3. Patient A16 had no individual activity interventions in the master treatment plan.

4. Patient A18 had the following presented activity intervention, "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." These interventions were generic and were routine discipline functions. These interventions also failed to include a specific and individualized focus of treatment based on this patient's presenting symptoms and/or needs.

5. Patient B1 had no individual activity interventions in the master treatment plan.

6. Patient B5 had the following activity intervention in the master treatment plan, "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: music groups, arts and crafts." These interventions were generic and were routine discipline functions. These interventions also failed to include a specific and individualized focus of treatment based on this patient's presenting symptoms and/or needs.

7. Patient B6 had no individual assessment completed. Patient B6 had no individual activity interventions in the master treatment plan.

8. Patient B7 had no individual activity assessment completed. Patient B7 had no individual activity interventions in the master treatment plan.

9. Patient B18 had no individual activity assessment completed. Patient B18 had the following pre-printed activity interventions in the master treatment plan: "Provide leisure education group focusing on communication, relationship building and self-preservation skills." "Educate on Community resources on individual and group basis." These interventions did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

C. Patient Interviews

1. When interviewed on 3/9/15 at 10:15 a.m., Patient B1 stated, "We stay to ourselves here. Not much to do. Especially on weekends."

2. When interviewed on 3/9/15 at 11:45 a.m., Patient B5 stated, "It is very boring here, especially on the weekends."

3. When interviewed on 3/9/15 at 1:30 p.m., Patient B6 stated, "There are not enough classes here. No groups on the weekends."

D. Staff Interview

The Activities Therapy Director was interviewed on 3/10/15 at 1:30 p.m. and stated, "We have no evening or weekend activities." She also listed the groups that her department does as, "Grooming, trivia, bingo, exercise, listening to music and arts and crafts." She acknowledged that the interventions were either missing or generic. She stated, "I see the assessments are not done but I don't know why they are blank."

Based on observation, record review, interviews, and other document reviews, the facility failed to:

I. Ensure that social service assessments include both conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). This failure results in a lack of current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems not being described for the treatment teams. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). Specifically, the MTPs did not include the following: 1) observable and measurable short-term goals written in behavioral terms (Refer to B121) and 2) specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5, and B18). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

IV. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement. (Refer to B125, Part1)

V. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery. (Refer to B125, Part II)

VI. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7 and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that required understanding of the English language. This failure potentially contributed to their prolonged emotional and mental suffering and delayed discharge. (Refer to B125, Part III)

VII. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures. (Refer to B125, Part IV).

VIII. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients. (Refer to B125, Part V)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included both a conclusion and specific individualized recommendations for social work services from the assessment data gathered for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

The "Social Work Assessment" for the following patients were reviewed (dates of assessments in parentheses): A1 (2/27/15), A5 (2/19/15), A16 (3/2/15), A18 (12/24/14), B1 (2/20/15), B5 (2/18/15), B6 (2/13/15) B7 (2/11/15) and B18 (1/23/15). This review revealed that none of the social assessments included a conclusion regarding information obtained during the admission assessment process. In addition, the social work assessments did not include specific and individualized recommendations regarding social worker interventions to address each patient's presenting symptoms and/or needs. The section of the social worker assessment titled, "Conclusion and Recommendations" only contained a brief generic statement regarding discharge recommendations and/or a generic statement regarding interventions the patient would benefit from during hospitalization. In addition, it failed to include specific psychosocial issues impacting treatment and discharge, specific community resources or systems to be utilized in discharge planning, aftercare treatment sources, and the social worker's role in treatment planning that included anticipated interventions based on each patient's presenting symptoms that will be addressed by social work.

B. Staff Interview

1. During an interview on 3/10/15 at 11:40 a.m., the Director of Social Work agreed that social work assessments do not include both a summary conclusion and social work recommendations based on clinical data collected regarding patients. She acknowledged that for social assessments the role of the social worker was not formulated with specific and individualized social work interventions based on each patient's presenting symptoms.

Based on record review, policy review and interview, the facility failed to provide master treatment plans that identified individualized short term goals in observable, measurable behavioral terms for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). The goals were not specific and/or described routine hospital functions, which did not define areas of patient improvement. Goal statements failed to give specific focus to treatment, leading to fragmentation of care.

Findings include:

A. Record Review

1. The master treatment plan dated 2/27/15 for Patient A1 had the following short term goals for the problem, "Auditory Hallucinations": "Will be compliant with meds". "Will develop coping skills in managing his stressors and attend therapeutic activity program/group sessions." These goals were not measurable and or specific to this patient.

2. The master treatment plan dated 2/17/15 for Patient A5 had the following short term goals for the problem, "Visual and auditory hallucinations": "Will be compliant with meds." "Will not have any visual/auditory hallucinations." These goals were not measurable or specific to this patient.

3. The master treatment plan dated 2/26/15 for Patient A16 had the following short term goal for the problem, "hearing voices": "Will be compliant with meds and participate in Group." This goal was not measurable or specific to this patient.

4. The master treatment plan dated 12/24/14 for Patient A18 had the following short term goals for the problem, "Mood Disorder": "Patient will remain free from harm or injury throughout hospitalization." "Patient will be compliant with medication as prescribed."
These goals were not measurable or specific to this patient.

5. The master treatment plan dated 2/20/15 for Patient B1 had the following short term goals for the problem, "Altered Thought": "Will build a trust relationship with staff." "Patient will attend morning meeting." These goals were not measurable or specific to this patient.

6. The master treatment plan dated 2/20/15 for Patient B5 had the following short term goals for the problem, "Mood Disorder": "Patient will feel safe on the unit." "Patient will develop a therapeutic relationship with staff members to facilitate therapy." These goals were not measurable or specific to this patient.

7. The master treatment plan dated 2/12/15 for Patient B6 had the following short term goals for the problem, "Altered Thought": "Patient will be in compliance with meds." "Patient will feel safe in structured environment." These goals were not measurable or specific to this patient.

8. The master treatment plan dated 2/13/15 for Patient B7 had the following short term goals for the problem, "Altered Thought": "Patient will feel safe on the unit." "Patient will comply with meds." These goals were not measurable or specific to this patient.

9. The master treatment plan dated 1/23/15 for Patient B18 had the following short term goals for the problem, "Altered Thought": "Patient will feel safe." "Patient will develop a trusting therapeutic relationship." These goals were not measurable or specific to this patient.

B. Policy Review

The facility policy (numbered 213-020 and dated 5/22/08) "Interdisciplinary Treatment Team" stated under "Procedure" number 6: "The treatment plan will contain specific goals for the patient, measurable objectives and discharge planning."

C. Staff Interviews

1. The Director of Nursing was interviewed on 3/10/11 at 2:30 p.m. She stated, "I can see that the goals are not specific or measurable."

2. The Clinical Director was interviewed on 3/11/15 at 10:15 p.m. She stated, "The short term goals can be more appropriate to the individual patient."

Based on record review and interview, the facility failed to develop treatment plan interventions specific to each individual patient based on his/her assessed needs for nine (9) of nine (9) sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). This failure results in patients not being provided individualized, goal directed treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed that MTPs did not include individualized active treatment interventions but contained generic statements which were routine discipline functions (such as "prescribing medications", "administering medications", "encouraging", "monitoring" and "assessing") written as active treatment interventions to be delivered by the physician, registered nurse, activity therapist and occupational therapist. Some short term goals in MTPs had no interventions listed for registered nurses and activity therapists and several intervention statements were identical or similarly worded.

1. Patient A1 had the following physician interventions for the short term goal, "Patient will develop insight": "Prescribe and adjust medication related to response to stabilize [his/her] psychosis and not have somatic preoccupation." This intervention was generic and a routine physician function. "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions.

Patient A1 had the following nursing interventions for the short term goal, "Patient will develop insight": "Encourage attendance at therapeutic group sessions." "Assess and document patient's individual expression of hallucinations/delusions..." "Review medications," "maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Instruct patient on condition and management of [sic] delusional symptoms." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

2. Patient A5 had the following physician intervention for the short term goal, "Patient will be compliant with meds [medications]:" "Supportive therapy 7 x week." This intervention did not identify a focus of treatment and how it would be delivered (individual or group sessions).

Patient A5 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications]:" "Assess and document patient ' s individual expression of hallucinations/delusions..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These interventions were generic and a routine nursing function. "Educate and reinforce the benefits of medication compliance." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

3. Patient A16 had the following physician intervention for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions).

Patient A16 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Encourage attendance at Groups...as scheduled." "Assess and document patient's individual expression of hallucinations..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Medication group reinforce and educate." This intervention did not include a frequency of contact, a focus of treatment, and how the intervention would be delivered (individual or group sessions).

4. Patient A18 had the following physician intervention for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Educate patient regarding being compliant with meds [medications] and enable patient to function in the community." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient A18 had the following nursing interventions for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Administer medication to improve [his/her] mood..." "Assess patient's behavior q [every] Shift..." "Provide safe environment by observing Q [every] 30 min." "Assist and encourage patient to attend to her ADLs [activities of daily living]." These were generic interventions, which were routine nursing functions.

5. Patient B1 had the following physician interventions for the short term goal, "Patient will exhibit logical, organized thinking": "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions). "Educate patient regarding importance of compliance with medications to avoid relapse of symptoms and need for rehospitalization." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B1 had no nursing interventions for the short term goal, "John will accept information given at discharge regarding NA meeting, location and times."

6. Patient B5 had the following physician interventions for the short term goal, "Patient will feel safe on the unit:" "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions. "Educate patient regarding importance of compliance with medications to avoid relapse of symptoms and need for rehospitalization." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B5 had no nursing interventions for the short term goal, "Patient will participate in discharge plans."

7. Patient B6 had the following physician interventions for the short term goal, "Patient will be in compliance with meds [medications]:" "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions. "Educate patient regarding being compliant with meds and prevent relapse of symptoms." This intervention did not include a frequency of contact and how the intervention would be delivered (individual or group sessions).

Patient B6 had no nursing interventions for the short term goal, "Patient will agree to recommended aftercare."

8. Patient B7 had the following physician interventions for the short term goal, "Patient will feel safe on the unit": "See patient on individual basis at least daily or more often to monitor medications." This intervention was generic and a routine physician function. "Supportive therapy 5 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions).

Patient B7 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

9. Patient B18 had the following physician interventions for the short term goal, "Patient will feel safe in the community:" "See patient on individual basis at least daily or more often to monitor patient's condition and med [medication] management." This intervention was generic and a routine physician function. "Supportive therapy 7 x week." This intervention did not include a focus of treatment and how it would be delivered (individual or group sessions)..

Patient B18 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

B. Staff Interviews

1. On 3/11/15 at 10:15 a.m., the Clinical Director stated, "I know our interventions need work. We can fix them in one month."

2. In an interview on 3/10/15 at 10:20 a.m. with the Clinical Director, the master treatment plans for Patients A1, A5, A16 and A18 were reviewed. She agreed that the MD interventions did not include all of the required components. She acknowledged that interventions were missing either the modality to be used in treating (individual or group sessions), the frequency of contact, and/or the focus of treatment based on each patient's presenting symptoms.

3. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. She stated, "The interventions are not specific or individual to each patient."

Based on observation, record review, and interview, the facility failed to ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5 and B18). When documented, the treatment notes failed to include, what groups were held, topic(s) discussed, the patients' level of response to the active treatment intervention provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed the following findings regarding documentation of treatment interventions on MTPs for registered nurses (RN), social workers (SW), activity therapy staff (AT), and Occupational Therapist (OT).

1. Patient A1

RN Intervention: "Instruct patient on condition and management of [sic] delusional symptoms." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the RN provided this intervention. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to:... promote peer interaction, formulate coping skills to better manage [his/her] illness." "Wellness & Recovery Group/Discharge Planning:...to process wellness and recovery skills to utilize in the community." "Information Group:...for community resources and linkage upon release from Cornerstone." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the SW provided these group interventions. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to group interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking..." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed no documentation showing that the OT provided these groups. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 2/26/15 through 3/10/15 revealed documentation on 3/6/15 regarding the patient's participation in all groups. However, this documentation failed to report what groups the patient participated in, what activities were offered and/or what topics were discussed, and the patient's response to these topics/activities offered.

2. Patient A5

RN Intervention: "Educate & reinforce the benefits of medication compliance." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed no documentation showing that the RN provided this intervention that showed discussions with the patient regarding benefits of medications and medication compliance. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to:...support appropriate peer interaction, formulate coping skills to better manage symptoms." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed no documentation showing that the SW provided this group intervention. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 3 x per week for 45 minutes to: [increase] focus & concentration." "Attend Life Skills group 5 x per week for 45 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] relapse prevention, [increase] insight into illness." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed only one treatment note on 3/6/15 showing the patient non-participation in these groups, however this note contained a generalized statement about group participated but failed to report which groups the patient participated in, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 2/13/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15 regarding the patient's non-attendance in activity therapy groups. A Progress note dated 3/6/15 at 9:30 a.m. stated, "...Came out of room 1x [one time] and looked to see what the group was doing and then returned to [his/her] room during morning exercise program..." This documentation failed to report other groups the patient failed to participate in and/or what activities were offered and refused by the patient.

3. Patient A16

SW Interventions: "Group Therapy 2 x week to:...[Patient's name] will discuss with peers coping strategies to better manage [his/her] illness in the community." "Wellness & Recovery Group/Discharge Planning: [Patient's name] will begin to develop wellness plan to better manage [his/her] illness." "Information Group: Encourage [Patient's name] to attend to obtain information on community resources." A review of the medical record including progress notes from 2/25/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

4. Patient A18

RN Intervention: "Medication Education pt [patient] will be compliance [with] medication & review medication [at] time of discharge." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed no documentation showing that the RN provided medication education, discussed compliance, and reviewed medication(s). There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Wellness & Recovery Group/Discharge Planning: [Patient name] will begin to work on a wellness plan to assist [him/her] in remaining on [sic]." "Information Group: [Patient's name] will be scheduled so [s/he] is aware of resources in the community." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking..." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed documentation on 2/11/15, 2/17/15, 2/23/15, and 3/2/15. However, this documentation contained generalized statements about group participation but failed to report which groups the patient participated in, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." A review of the medical record including progress notes from 1/29/15 through 3/10/15 revealed documentation on 2/6/15, 2/13/15, 2/20/15, 2/27/15, 3/6/15 and 3/9/15, however this documentation failed to report which groups the patient participated in, what topics were discussed and/or activities offered, and the patient's response to these topics/the activities offered.

5. Patient B1

RN Intervention: "Instruct patient on condition and management of Schizoaffective Disorder - e.g. [for example] paranoid, hyper [sic], [positive] A/V thinking [sic] - Educate to medication Zyprexia..." "Medication Education review discharge meds [medications] [with] pt [patient], verbalizes understanding including side effects & actions." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed no documentation showing that the RN instructed the patient regarding Schizoaffective Disorder and provided medication education. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: learn about how to behave in the community." "Individual Therapy 2 x per week for 20 minutes to: learn about [sic] of illness, coping skills & [negative] consequences of [non] compliance [with] [sic] medication." "Wellness & Recovery Group/Discharge Planning: to learn how to stay well in the community." "Information Group: to learn about community resources." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] wellness, & healthy living, [increase] ADLS [Activities of Daily Living Skills], [increase] insight into illness." A review of the medical record including progress notes from 2/15/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15, however these notes were generalized statements about group participation but failed to report which groups the patient participated in, level of participation, what activities were offered and/or what topics were discussed, and the patient's response to these topics.

6. Patient B5

RN Intervention: "Educate patient on Schizoaffective D.O., [Disorder], symptoms, medications, and coping skills - i.e. [that is] [increase] sleep, aggression, hyper sexuality." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed no documentation showing that the RN provided patient education regarding Schizoaffective Disorder, medications, or coping skills. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: encourage attendance to learn about how to behave in the community." "Wellness & Recovery Group/Discharge Planning: to learn how to stay well in the community." "Information Group: to learn about available community resources." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] self esteem, [increase] insight into illness." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed documentation on 2/27/15 and 3/6/15, however these notes were generalized statements about number of groups attended but failed to report which groups the patient participated in, level of participation, what topics were discussed, and the patient's response to these topics.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: music groups, arts and crafts." A review of the medical record including progress notes from 2/18/15 through 3/10/15 revealed documentation on 2/23/15 and 3/2/15, however this documentation contained general information regarding the number groups attended but failed to report which groups the patient participated in, level of participation, what activities were offered or what topics were discussed, and the patient's response to these topics/activities.

7. Patient B6

RN Intervention: "Instruct patient on condition and management of: [his/her] delusional symptoms." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed no documentation showing: that the RN provided instruction regarding the patient's "delusional symptoms." There were no notes regarding the patient's participation or non-participation, how instruction was delivered (group or individual sessions), what topics were discussed, level of participation, the patient's response to topics presented, and duration and frequency of contact.

SW Interventions: "Group Therapy 2 x week to: encourage groups to promote appropriate peer interaction; formulate coping skills to better manage [his/her] illness." "Wellness & Recovery Group/Discharge Planning: encourage weekly groups to [sic] wellness & recovery skills to utilize in the community." "Information Group: encourage weekly group for community resources and linkage upon release from Cornerstone." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed no documentation showing that the SW provided the group interventions listed above. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] more organized realistic thinking, [increase] insight, be able to ask for & receive help." A review of the medical record including progress notes from 2/11/15 through 3/10/15 revealed documentation on 3/2/15 and 3/9/15, however these notes contained generalized statements regarding minimal attendance and about number of groups attended but failed to report which groups the patient participated in and level of participation, what topics were discussed, and the patient's response to these topics.

8. Patient B7

RN Intervention: "Instruct patient on condition and management of [his/her] delusional symptoms - med [medication] adherence [after] discharge,..." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed no documentation showing: that the RN provided patient any instructions regarding delusional symptoms or medication compliance. There were no notes regarding the patient's participation or non-participation, how instruction was delivered (group or individual sessions), what topics were discussed, level of participation, duration and frequency of contact, and the patient's response to topics discussed.

SW Interventions: "Group Therapy 2 x week to: encourage attendance to learn ways [sic] to cope [with] illness in the community." "Wellness & Recovery Group/Discharge Planning: to learn ways to stay well in the community." "Information Group: to learn about a[sic] aftercare programs in the community." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above, duration and frequency of contact, the patient's participation or non-participation, what topics were discussed and the patient's response to these group interventions.

OT Interventions: "Attend Task Skills groups 2 x per week for 60 minutes to: [increase] focus & concentration." "Attend Life Skills group 3 x per week for 60 minutes to: [increase] ADLS [Activities of Daily Living Skills], [increase] more organized reality based thinking & [increase] insight into illness." A review of the medical record including progress notes from 2/10/15 through 3/10/15 revealed documentation on 2/17/15, 2/25/15, and 3/3/15; however, these notes generalized statements about number of groups attended and the patient's behavior but failed to report which groups the patient participated in and level of participation, what topics were discussed, and the patient's response to these topics.

9. Patient B18

RN Intervention: "Instruct patient on condition and management of Schizophrenia, symptoms, medications, & coping skills education..." "Medication Education Educate to expected effects of Haldol, Depakote, Seroquel, and [sic]..." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed no documentation showing: that the RN provided the patient instruction regarding Schizophrenia, medications, or coping skills education. There were no notes regarding the patient's participation or non-participation, what topics were discussed, the patient's response to interventions, and frequency and duration of contact.

SW Interventions: "Group Therapy 2 x week to: learn how to cope [with] [sic] in the community." "Individual Therapy 2 x per week for 20 minutes to: discuss [sic] of illness & importance of [sic], medication compliance." "Wellness & Recovery Group/Discharge Planning: to learn ways, how to stay well in the community." "Information Group: to learn about community resources." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed no documentation showing: that the SW provided the group interventions listed above, duration and frequency of contact, the patient's participation or non-participation, what topics were discussed and the patient's response to these group interventions.

AT Interventions: "Encourage attendance and participation in all therapeutic/recreational groups [left blank] x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: exercise, music." A review of the medical record including progress notes from 1/31/15 through 3/10/15 revealed documentation on 2/2/15, 2/9/15, 2/16/15, 2/23/15, and 3/2/15, however this documentation contained general information regarding the patient's behavior, percentage of groups attended but failed to report which groups the patient participated in and level of participation. The treatment notes did not include, which groups were attended, what activities were offered and/or what topics were discussed, and the patient's response to these topics.

B. Staff Interviews

1. During interview on 3/10/15 at 11:40 a.m. with the Director of Social Work, the social work groups listed on the comprehensive treatment for Patient A5 was discussed. She acknowledged that treatment notes regarding groups to be provided social workers were not documented showing the attendance or non-attendance of patient A5. She stated, "We do some groups but very few. We did groups until December [2014] when one of our social workers left."

2. During interview on 3/10/15 at 1:50 p.m., OT2 acknowledged that there was only one documented note regarding Patient A5's participation in active treatment groups provided by occupational therapists.

3. During interview on 3/10/15 at 2:40 p.m., RN1 acknowledged that documentation of the nursing groups on the unit schedule was not found in patients' medical record. RN5 noted that since December 2014, these groups have not been conducted and stated, "This has fallen by the wayside."

4. During interview on 3/11/15 at 9:30 a.m., with RN5, documentation of treatment notes related to the nursing interventions on the treatment plan for Patients A1 and A16 was discussed. RN5 confirmed that there was no documentation regarding whether the patients were provided the nursing interventions identified on the MTP related to patient education.

Based on observation, interviews, record reviews, and other documentation, the facility failed to:

I. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement.

II. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7, and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery.

III. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7, and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that require understanding of the English language. This failure potentially contributes to their prolonged emotional and mental suffering and delayed discharge.

IV. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. The one hour face-to-face assessment documented by the licensed independent practitioner did not include the following information: an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results; and the need to continue or discontinue the seclusion and/or restraint procedure. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures.

V. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients.

Findings include:

I. Failure to provide active treatment

Record Review

1. Patient A5 was admitted to the unit on 2/13/15. The Psychiatric Evaluation dated 2/14/15 noted, "...carries diagnosis of Schizoaffective Disorder... Pt [Patient] has hx [history] of multiple hospitalization." Throughout the survey, the patient was observed to be in his/her room and not interacting with other patients or staff. The patient attended no therapeutic groups and left ate his/her room primarily for meals.

2. The Master Treatment Plan dated 2/17/15 identified one psychiatric problem: "Altered Thought: Hallucinations: Visual and auditory." The interventions identified to decrease hallucinations included medication prescribed and supportive therapy by the psychiatrist and generic functions such as assessing and documenting by the nursing staff. The other interventions to address altered thought processes were group treatment to be provided by social workers, occupational therapists, and activity therapists.

3. Despite documentation that the patient was not attending groups, there were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient isolating in his/her room.

4. In staff interviews, it was confirmed that the patient did not attend groups and that no alternative treatment plan had been developed to identify appropriate interventions for the patient.

B. Staff Interviews

1. During interview on 3/10/15 at 1:50 p.m., OT 2 stated that Patient A5 had not been attending group. When asked about alternative active treatment measures, OT 2 stated, "We don't do individual sessions from the occupational therapy perspective."

2. In an interview on 3/10/15 at 10:30 a.m., RN 5 stated that she was assigned to A5 and confirmed that patient did not attend groups and no alternative treatment sessions had been offered and the MTP had not been developed to identify appropriate interventions for the patient.

3. The Director of Social Worker stated, in an interview on 3/10/15 at 10:50 a.m., that Patient A5 does not attend groups and that the patient refuses to talk to her. She confirmed that the treatment plan had not been revised to identify alternatives to group treatment.

4. The Medical Director stated, in an interview on 3/10/15 at 10:20 a.m., that Patient A5 was not her patient and noted that alternatives should be offered. She stated, "Hypothetically, patients who are isolating like Patient A5 should be assigned a one-to-one nursing staff to interact with the patient."

II. Failure to provide a comprehensive active treatment schedule

A. Observations

On 3/9/15 there were only two groups for the patients on the East wing, a walk and Bingo. An occupational therapy group, which was scheduled at 1:00 p.m., was not done. The groups did not start at the time noted on the schedule. There were no therapeutic groups scheduled after 5:00 p.m. or on Saturday or Sunday. On the West wing, there was a nursing group and Bingo. There were no therapeutic groups scheduled after 5:00 p.m. or on Saturday or Sunday.

B. Document Review

1. The schedule for East wing noted: two (2) activity therapy groups on Monday, 2 activity therapy groups on Tuesday and a nutrition group, an activity therapy group and a nursing group on Wednesday, Thursday and Friday. The East wing schedule showed a social work group scheduled with AT on Monday and Tuesday at 9:45 a.m. There were no groups scheduled for weekends or evenings.

2. The schedule for West wing noted: a nursing group and an activity therapy group on Monday (the occupational therapy group did not occur), an activity therapy group and an occupational therapy group scheduled on Tuesday, 2 activity therapy groups and 2 occupational therapy groups scheduled on Wednesday and Thursday, and a nursing and activity therapy group on Friday. There were no social work groups scheduled. There were no groups scheduled for weekends or evenings.

3. The groups were generic in nature (hand washing, bingo) without an individualized treatment focus. All patients were expected to attend the same groups, which resulted in the groups being large (20-24 patients) and not conducive to learning or processing.

C. Patient Interviews

1. When interviewed on 3/9/15 at 10:15 a.m., Patient B1 stated, "We stay to ourselves here. Not much to do. Especially on weekends."

2. When interviewed on 3/9/15 at 11:45 a.m., Patient B5 stated, "It is very boring here, especially on the weekends."

3. When interviewed on 3/9/15 at 1:30 p.m., Patient B6 stated, "There are not enough classes here. No groups on the weekends."

D. Staff Interviews

1. The Activities Therapy Director was interviewed on 3/10/15 at 1:30 p.m. and stated, "We have no evening or weekend activities." She also listed the groups that her department does as, "Grooming, trivia, bingo, exercise, listening to music and arts and crafts."

2. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. and stated, "We know that we need more groups."

3. The Clinical Director was interviewed on 3/11/15 at 10:15 a.m. and stated, "I understand that we need more therapeutic groups. We need groups on weekends and evenings too."

III. Lack of interpreter services

A. Observations

On 3/9/15 at 10:00 a.m., Patients B5, B7, and B18 were in a Nursing group, which was discussing infection control and hygiene. These patients did not have an interpreter present and were unable to participate in this group.

B. Record Review

1. Patient B5 was admitted on 2/17/15 and the psychiatric assessment dated 2/18/15 noted, "Speaks mostly Spanish." However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 2/20/15.

2. Patient B7 was admitted on 2/10/15 and the psychiatric assessment dated 2/11/15 noted, "Spanish speaking." However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 2/13/15.

3. Patient B18 was admitted on 1/22/15 and the interdisciplinary assessment dated 1/22/15 noted "Spanish" as the primary language spoken. However, there was no mention of a language barrier or required interpreter services in the master treatment plan dated 1/23/14. A progress note dated 2/16/15 at 10:25 a.m. reported, "[Patient's name] attends AT [activity therapy] groups 80% of the time...Pt [patient] stated that [s/he] gets frustrated when [s/he] can't understand what is going on during AT groups. Other Spanish speaking pts [patients] have been able to translate during AT groups."

C. Policy Review

The facility policy, "Interpretation Assistance Plan Limited English Proficiency and Hearing Speech Impairment" dated 7/18/12 states, "No person shall be denied equal access to services based solely on his/her ability to communicate in the English language or due to hearing/speech impairment. It is the obligation of Runnells Specialized Hospital to ensure that effective communication assistance shall be provided to Limited English Proficiency and Hearing/Speech Impaired persons so that they have a complete understanding of information regarding medical condition, treatment and payment requirements." The facility did not adhere to this policy.

D. Patient Interviews

1. Patient B18 was interviewed on 3/9/15 at 10:45 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I suffer when I go to groups. I don't understand what they say."

2. Patient B7 was interviewed on 3/9/15 at 11:30 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I don't understand the groups at all. I don't understand English."

3. Patient B5 was interviewed on 3/9/15 at 11:50 a.m. with the social worker (SW2) who spoke Spanish was present. The patient stated, "I know some English words but I need help understanding. I don't understand the groups or my diagnosis."

E. Staff Interviews

1. When interviewed on 3/9/15 at 12:15 p.m., SW2 stated that she was bilingual and "I interpret for these patients when they meet with their doctor or in treatment team. I have a full caseload of 12 patients and I work 8:00 a.m. till 4 p.m. Monday through Friday I cannot interpret for the patients in groups and other treatment settings."

2. The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. and stated, "No, there are no regular interpreters on the units. We rely on two Spanish speaking aides in the evenings or a language phone line." She acknowledged that the aides were not available at all times and even worked on a different unit than where the Spanish-speaking patients were. She stated, "The aides and the language phone line are not adequate to provide proper treatment for the Spanish speaking patients." When asked why there were no interventions in the treatment plan regarding the language barrier she stated, "We were told not to include that the patients did not speak English in the plans."

3. The Clinical Director was interviewed on 3/11/15 at 10:15 a.m. and she stated, "You have a valid point. We need interpreters. We are not following our policy."

4. The Director of Activities was interviewed on 3/10/15 at 1:30 p.m. She stated that, "The non English speaking patients are not always able to understand what we are doing in activities."

IV. Failure to document one-hour face-to-face assessments

A. Record Review

1. Patient C1, admitted 2/13/15, was placed in 4 points restraints on 2/14/15 at 8:20 a.m. The facility's "Restraints/Seclusion Physician's Order Form and Progress Notes" dated 2/14/15 at 8:20 a.m. stated, "Pt [Patient] became agitated & attempted to strike male peer..." Physician orders were documented but there was no comprehensive one-hour face-to-face assessment found in the medical record that included: an evaluation of the patient's medical condition (review of systems); a review of medications; and recent laboratory results) and behavioral assessment, an evaluation of immediate situation; the patient's reaction to the intervention; and the need to continue or terminate the restraint or seclusion. A review of the Master Treatment Plan for this patient revealed that there was a statement dated 2/14/15 under the "Nursing Interventions" section of the MTP noting, "Patient was placed in 4 pt [points] restraints for aggressive physically threatening behavior to staff and peers." However, the MTP was not updated to reflect specific short-term goals and interventions aimed at the patient developing non-harmful behaviors when feeling agitated.

2. Patient C2, admitted 1/7/15, was placed in 4 points restraints on 2/22/15 at 8:15 a.m.. The facility's "...Restraints/Seclusion Physician's Order Form and Progress Notes" dated 2/22/15 at 8:45 a.m. stated, "Patient placed in 4 pt [points] restraints for safety of self and others after pt [patient] ran from RN [registered nurse] with her medications, delusional, cursing, aggressive. Zyprexia 5mg IM given." Physician orders were documented but there was no comprehensive one-hour face-to-face assessment found in the medical record that included: an evaluation of the patient's medical condition (review of systems); a review of medications; and recent laboratory results), an evaluation of immediate situation; the patient's reaction to the intervention; and the need to continue or terminate the restraint or seclusion. A review of the Master Treatment Plan for this patient revealed that there was no revision to reflect the episode of restraint and no update of short-term goals and interventions aimed at effective strategies the patient could use to develop non-harmful behaviors when feeling aggressive.

B. Policy Review

The facility's policy titled "Restraint/Seclusion For Behavioral Management: Special Treatment Procedures" dated 4/28/14 stipulated that, "The Licensed Independent Practitioner will respond to the bedside within one hour to complete a face to face intervention of the patient and write the order for restraint/seclusion and document the rationale for placement of restraint..." This policy failed to include the following requirements for face-to-face evaluation: The patient's immediate situation; the patient's reaction to the intervention; the patient's medical (review of systems, medications, laboratory results, etc.) and behavioral condition; and the need to continue or terminate the restraint or seclusion.

C. Staff Interview

1. In an interview at 10:20 a.m. on 3/10/15, the Medical Director stated that the physician's progress note written at the time of the face-to-face evaluation is the complete documentation written by the MD or APRN when seclusion or restraint occurs. She acknowledged that there was no information documented regarding the patient's medical condition, labs, or need to continue or terminate the restraint procedure.

V. Violation of Patient Privacy

A. Observation

When touring the 2 units on 3/9/15 it was observed that 4 private rooms (room numbers CSE31, CSE33, CW56, and CW60) had surveillance cameras mounted on the walls of the rooms.

B. Policy/Record Review

1. The facility's policy number 213-053, dated 1/26/05 and titled "Use of Surveillance Camera for Suicide Precautions/Behavioral Monitoring" stated, "The surveillance camera will be used when the patient is in need of constant monitoring for safety reasons." The procedure, in its entirety, stated, "Physician order is needed for the surveillance camera. The patient will be admitted to a room equipped with camera surveillance and will be informed that he/she will be under camera surveillance. When the patient's behavior has improved, the surveillance order will be discontinued and the camera turned off." There were no criteria for when cameras would be utilized or any clarification of "safety reasons."

2. The facility did not have a patient privacy policy. They provided the surveyors with the "Patient's Bill of Rights" which referred to the "Mental Patient's Bill of Rights" of 1975. One of the rights was "to privacy and dignity."

C. Patient Interview

On 3/9/15 at 3:15 p.m. Patient B6 (who was non English speaking) stated through the social worker (who was bilingual) that, "No one told me that I would have the camera in my room but I know that it is there. It makes me nervous."

D. Staff Interview

On 3/9/15 at 2:00 p.m. the Director of Nursing stated, "We do not use the cameras. They are not even turned on. We have not used them since I came to work here. We use one-to-one staffing to monitor suicidal patients. And I can see why it would be disturbing to patients to be under surveillance in their rooms. We will have to talk to the administrator about getting rid of them."

Based on interviews, record reviews, and document reviews, the Medical Director failed to:

I. Ensure that social service assessments include both conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for nine (9) of nine (9) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). This failure results in a lack of current baseline social functioning on these patients for establishing treatment goals and interventions and specific social work recommendations regarding treatment of patients' psychosocial problems not being described for the treatment teams. (Refer to B108).

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A5, A17, A18, B1, B5, B6, B7 and B18). Specifically, the MTPs did not include the following: 1) observable and measurable short term goals written in behavioral terms (Refer to B121) and 2) specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that the interventions listed on the Master Treatment Plans (MTPs) were provided and documented by clinical disciplines. Specifically, there was no documentation showing that registered nurses met with patients in group and/or individual sessions to provide active treatment interventions on MTPs of eight (8) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6, B7 and B18) and whether social workers met with patients in group sessions identified on the MTPs of nine (9) of nine (9) active samples patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). In addition, there were inconsistent interventions provided and documented by occupational therapists for seven (7) of nine (9) active sample patients (A1, A5, A18, B1, B5, B6 and B7) and by activity therapy staff for five (5) of nine (9) active sample patients (A1, A5, A18, B5 and B18). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

IV. Ensure that adequate active treatment measures and care were provided to one (1) of nine (9) active sample patients (A5) in order to move the patient to a higher level of functioning. Specifically, the facility failed to provide alternative active treatment measures for this patient, who was unwilling and/or unable to participate in group treatment sessions. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement. (Refer to B125, Part1)

V. Ensure that for nine (9) of nine (9) active sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18) an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their recovery. (Refer to B125, Part II)

VI. Ensure that three (3) out of three (3) Spanish speaking patients (B5, B7 and B18) received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that required understanding of the English language. This failure potentially contributed to their prolonged emotional and mental suffering and delayed discharge. (Refer to B125, Part III)

VII. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of two (2) non-sample patients (C1 and C2) whose records were selected to review episodes of restraint. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures. (Refer to B125, Part IV)

VIII. Ensure that two (2) of nine (9) active sample patients (B7 and B18) were provided privacy and dignity. Specifically, these patients were assigned to bedrooms that contained video cameras that could be turned on and monitored in the nursing station. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients. (Refer to B125, Part V)

Based on record review, policy review, patient interviews, and staff interviews, the Director of Nursing failed to:

I. Ensure that for nine (9) of nine (9) sample patients an active therapeutic program was scheduled and available throughout the days, evenings, and weekends. (See B125 II)

II. Ensure that three (3) of three (3) Spanish-speaking patients received adequate interpreter services in order that they could benefit from individual therapy, group therapy, nursing education or other modalities that require understanding of the English language. (See B125 III)

III. Ensure that two (2) of nine (9) sample patients were provided privacy and dignity. (See B125 V)

IV. Ensure that nine (9) of nine (9) sample patients had master treatment plans that identified individual short term goals in observable, measurable and behavioral terms. (See B121)

V. Ensure that nine (9) of nine (9) sample patients had treatment plan nursing interventions specific to each individual patient based on his/her assessed needs.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (2/27/15), A5 (2/17/15), A16 (2/26/15), A18 (12/23/14), B1 (2/30/15), B5 (2/20/15), B6 (2/12/15), B7 (2/13/15) and B18 (1/23/15). This review revealed that MTPs did not include individualized active treatment interventions but contained generic statements which were routine nursing functions (such as "administering medications", "encouraging", "monitoring", and "assessing") written as active treatment interventions to be delivered by registered nurses. Some short term goals in MTPs had no interventions listed for registered nurses and several intervention statements were identical or similarly worded.

1. Patient A1 had the following nursing interventions for the short term goal, "Patient will develop insight": "Encourage attendance at therapeutic group sessions." "Assess and document patient's individual expression of hallucinations/delusions..." "Review medications," "maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Instruct patient on condition and management of [sic] delusional symptoms." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

2. Patient A5 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications]:" "Assess and document patient ' s individual expression of hallucinations/delusions..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These interventions were generic and a routine nursing function. "Educate and reinforce the benefits of medication compliance." This intervention did not include a frequency of contact and whether the intervention would be delivered in individual or group sessions.

3. Patient A16 had the following nursing interventions for the short term goal, "Patient will be compliant with meds [medications] and participate in group:" "Encourage attendance at Groups...as scheduled." "Assess and document patient's individual expression of hallucinations..." "Maintain q [every 15 min [minutes) [check] for unpredictable behavior." These were generic interventions, which were routine nursing functions. "Medication group reinforce and educate." This intervention did not include a frequency of contact, a focus of treatment, and how the intervention would be delivered (individual or group sessions).

4. Patient A18 had the following nursing interventions for the short term goal, "Patient will remain free from harm or injury throughout hospitalization:" "Administer medication to improve [his/her] mood..." "Assess patient's behavior q [every] Shift..." "Provide safe environment by observing Q [every] 30 min." "Assist and encourage patient to attend to her ADLs [activities of daily living]." These were generic interventions, which were routine nursing functions.

5. Patient B1 had no nursing interventions for the short term goal, "John will accept information given at discharge regarding NA meeting, location and times."

6. Patient B5 had no nursing interventions for the short term goal, "Patient will participate in discharge plans."

7. Patient B6 had no nursing interventions for the short term goal, "Patient will agree to recommended aftercare."

8. Patient B7 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

9. Patient B18 had no nursing interventions for the short term goal, "Patient will actively participate in discharge plans."

B. Staff Interview

The Director of Nursing was interviewed on 3/10/15 at 2:30 p.m. She stated, "The interventions are not specific or individual to each patient."

Based on schedule review, record review, patient interview and staff interview, the facility failed to plan and implement structured programming of therapeutic/leisure activities during days, evenings and weekends, failed to complete individual activity assessments for four (4) of nine (9) sample patients (A5, B6, B7 and B18) and failed to develop individualized activity master treatment plan interventions for nine (9) of nine (9) sample patients (A1, A5, A16, A18, B1, B5, B6, B7 and B18). These failures resulted in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities and patients not receiving individualized, goal directed treatment.

Findings include:

A. Review of Unit Schedules

The East Wing had eight (8) activity therapy groups scheduled Monday through Friday during the day and the West Wing had seven (7) activity therapy groups scheduled Monday through Friday during the day. There were no activity groups after 5:00 p.m. or on the weekends for either unit.

B. Record Review

1. Patient A1 had the following sole pre-printed activity intervention, "Provide leisure education group focusing on communication, relationship building and self-preservation skills." This was a generic intervention that did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

2. Patient A5 had no individual activity assessment completed. Patient A5 had the following sole pre-printed activity intervention, "Provide leisure education group focusing on communication, relationship building and self-preservation skills." This intervention did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

3. Patient A16 had no individual activity interventions in the master treatment plan.

4. Patient A18 had the following presented activity intervention, "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: provide leisure outlet for emotional expression and coping." "Provide opportunity to attend preferred group activity: exercises." These interventions were generic and were routine discipline functions. These interventions also failed to include a specific and individualized focus of treatment based on this patient's presenting symptoms and/or needs.

5. Patient B1 had no individual activity interventions in the master treatment plan.

6. Patient B5 had the following activity intervention in the master treatment plan, "Encourage attendance and participation in all therapeutic/recreational groups 10 x week for 1 hour to: [section left blank]." "Provide opportunity to attend preferred group activity: music groups, arts and crafts." These interventions were generic and were routine discipline functions. These interventions also failed to include a specific and individualized focus of treatment based on this patient's presenting symptoms and/or needs.

7. Patient B6 had no individual assessment completed. Patient B6 had no individual activity interventions in the master treatment plan.

8. Patient B7 had no individual activity assessment completed. Patient B7 had no individual activity interventions in the master treatment plan.

9. Patient B18 had no individual activity assessment completed. Patient B18 had the following pre-printed activity interventions in the master treatment plan: "Provide leisure education group focusing on communication, relationship building and self-preservation skills." "Educate on Community resources on individual and group basis." These interventions did not include a focus of treatment based on the specific symptoms/needs of this patient and a frequency of contact.

C. Patient Interviews

1. When interviewed on 3/9/15 at 10:15 a.m., Patient B1 stated, "We stay to ourselves here. Not much to do. Especially on weekends."

2. When interviewed on 3/9/15 at 11:45 a.m., Patient B5 stated, "It is very boring here, especially on the weekends."

3. When interviewed on 3/9/15 at 1:30 p.m., Patient B6 stated, "There are not enough classes here. No groups on the weekends."

D. Staff Interview

The Activities Therapy Director was interviewed on 3/10/15 at 1:30 p.m. and stated, "We have no evening or weekend activities." She also listed the groups that her department does as, "Grooming, trivia, bingo, exercise, listening to music and arts and crafts." She acknowledged that the interventions were either missing or generic. She stated, "I see the assessments are not done but I don't know why they are blank."