HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to inform each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for three of three medicare patients (MR4, MR12, and MR13).

Findings include:

Review of facility policy "Social Service Department Torrance State Hospital Admission Policy / Procedure" dated January 30, 2012, revealed C. Admission Social Services ... 3. The Social worker reviews with the patient the ... an important Message from Medicare"

1) Review of MR4 revealed the patient was admitted on October 5, 2011, and discharged on December 20, 2011. Further review of MR4 revealed no documentation of the Important Message from Medicare (IMM) having been given to the patient.

Interview with EMP4 on April 3, 2012, at approximately 3:30 PM confirmed the above findings and revealed, "I don't see one (IMM)."

2) Review of MR12 revealed the patient was admitted on May 19, 2011, and discharged on January 17, 2012. Further review of MR12 revealed an Important Message from Medicare(IMM) signed by the patient with no documentation of a date of the signature.

3) Review of MR13 revealed the patient was admitted on June 29, 2011, and discharged on March 29, 2012. Further review of MR13 revealed an Important Message from Medicare(IMM) dated June 30, 2011.

Interview with EMP4 on April 5, 2012, at approximately 3:35 PM confirmed the patients were not presented a copy of An Important Message from Medicare (IMM) no more than two calender days of discharge and revealed, "They (patients) receive one IMM on admission. They do not receive a second one. That's how I was educated."

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that nursing staff developed and kept current a plan of care for one of one pain medical record reviewed (MR29).

Findings include:

Review of Torrance State Hospital "Clinical Services Policy/Procedure Comprehensive Individualized Treatment Plan (CITP) Guidelines," reviewed September 2009 revealed, "Policy Statement. Each patient will have a comprehensive Individualized Treatment Plan that incorporates all pertinent information gathered by the Treatment team for the purpose of identifying problems/assets and planning for the individual's active and subsequent aftercare plan."

Review of Torrance State Hospital "Pain Management Guidelines. ... 3. As part of the initial nursing and annual assessment, patients are assessed for pain and pain risk factors. ... The plan of care initiates and multidisciplinary approach to pain management and allows for individualized care. 4. If complaints of pain occur at any time during hospitalization, the nursing pain assessment tool will be and plan of care will be added as part of the CITP."

1. Review of MR29 on April 5, 2012, revealed no documentation of pain on the individualized treatment plan. Review of the pain assessment tool revealed the patient received medication for right foot pain 23 times from March 8, 2012, to April 6, 2012.
Continued review of MR29 revealed the Initial and Comprehensive Nursing Assessment was completed on March 8, 2012. The pain screen on the assessment was not completed. Further review of MR29 revealed a physician order written on March 20, 2012, at 5:10 PM, 1. "Non weight bearing right foot. 2. Keep right foot elevated. 3. Wheelchair for mobility."

Based on interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the active treatment of 16 of 16 sample active patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14, A15 and A16), 4 non-sample patient added for restraint review (C1, C2, C3, C4) and 1 of 5 discharged patients (B5). Specifically, the hospital failed to:

I. Modify or revise the Master Treatment Plans (MTP) following restraint episodes for 3 of 3 active patients (A4, A8 and A12), 1 of 1 discharged patients (B5) and 4 patients that were added to the sample in order to evaluate the use of restraints (C1, C2, C3 and C4). In addition, the facility failed to follow their own policy requiring the treatment team to meet with the CEO and members of the administrative staff following each restraint episode in an effort to eliminate future restraints. This can result in a failure to provide interventions needed to address individual problems of aggression and can potentially lead to additional restrictive episodes. (Refer to B118.)

II. Develop Master Treatment Plans that specified individualized interventions with a specific focus based on the individual needs and abilities of each patient for 14 of 16 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A15 and A16). The treatment plans included a list of interventions which were generic monitoring and routine clinical functions that lacked focus for treatment. (Refer to B122). This results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific modality needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

III. Ensure appropriate use and documentation of seclusion/restraints. The facility failed to correctly document the use of physical restraints in physician orders and staff progress notes for 3 of 3 active patients (A4, A8, A12), 1 of 1 discharged patients (B5), and 4 added sample patients (C1,C2, C3, C4). In addition, the patients' Master Treatment Plans were not modified to reflect new strategies addressing behavior necessitating the physical restraints. This failure results in patients being physically restrained without proper documentation of professional assessment and intervention and without appropriate modifications to their treatment to prevent further incidents and to assist the treatment team in determining progress. (Refer to B125)

Based on record review and interview, the facility failed to ensure that the handwritten Psychosocial Assessments completed for 4 of 4 sample patients on the Forensic Unit (A5, A6, A7, A8) included an integration of factual and historical information and an evaluation of psychosocial issues with recommendations for social work roles in treatment. The form utilized on the forensic unit was titled the "Multidisciplinary Initial Assessment Social History." This was not consistent with hospital policy which requires use of the form titled "Initial Comprehensive Social Work Assessment." This results in a document that does not address patient needs and social work interventions necessary for treatment planning.

Findings include:

A. Record Review

1. The psychosocial assessment for forensic Patient A5 dated 12/7/11 only stated the type of legal commitment in the section of the assessment form that requires "specific behaviors and symptoms that prohibit the patient from being discharged." It did not include an evaluation of psychosocial issues with recommendations for the social work role in treatment.

2. The psychosocial assessment for forensic Patient A6 dated 11/23/11 only stated the type of legal commitment in the section of the assessment form that requires "specific behaviors and symptoms that prohibit the patient from being discharged". There was no information in the Personal History Section for education and employment. There was no evaluation of psychosocial issues and no recommendations for the social work role in treatment.

3. The psychosocial assessment for forensic Patient A7 dated 8/9/11 only stated the type of legal commitment in the section of the assessment form that requires "specific behaviors and symptoms that prohibit the patient from being discharged." There was no evaluation of psychosocial issues and recommendations for the social work role in treatment.

4. The psychosocial assessment for forensic Patient A8 dated 12/19/11 did not include strengths, needs or an evaluation of psychosocial issues and recommendations for the social work role in treatment.

B. Interviews

1. In an interview on 2/7/12 at 2:45PM, after reviewing the social assessments from the forensic program, the Director of Social and Rehabilitation Services stated that the facility is working on making all forms uniform, but that the forensic social work department has insisted the (hospital's) assessment form does not capture what they need and has not implemented its use.

2. In an interview on 2/7/12 at 3PM, the Director of Social Work stated that she requires the psychosocial assessments be completed in accordance with policy, and that they be dictated and complete, including evaluation of psychosocial issues and recommendations for the social work role in treatment, She agreed that the social histories are not adequate.

3. In an interview on 2/7/12 at 4PM, the Chief Forensic Executive stated, "There is a disconnect between operations and clinical application. There are no separate policies for forensic documentation. The policies for psychosocial assessments and documentations for forensic units are the same as on the civil units."

C. Policy Review

Torrance State Hospital, Admission Policy/Procedures, Social Service Department, Policy No.: 125-7, dated 1/30/12, states on page4, #12: "Within 5 working days of admission, the Social Worker completes the Initial Comprehensive Social work Assessment: Section B (Attachment D), #14. "...the social worker provides interventions to address individualized needs of the patient."

Based on document review and interview, the facility failed to modify or revise the Master Treatment Plans (MTP) following restraint episodes for 3 of 3 active patients (A4, A8 and A12), 1 of 1 discharged patients (B5) and 4 patients added to the sample in order to evaluate the use of restraints (C1, C2, C3 and C4). In addition, the facility failed to follow their own policy requiring the treatment team to meet with the CEO and members of the administrative staff following each restraint episode in an effort to eliminate future restraints. This can result in a failure to provide interventions needed to address individual problems of aggression and can potentially lead to additional restrictive episodes.

Findings include:

A. Specific Patient Findings

1. Patient A4

a. The 5/01 facility form, "Initial Documentation for Seclusion, Mechanical or Physical Restraint Intervention" dated 2/6/12 at 5:15PM revealed that Patient A4 was restrained for "10 min x 2." (5:15-5:25PM).

b. A review of the MTP dated 10/5/11 revealed no addition or modification to Patient A4's MTP as of 2/8/12.

2. Patient A8

a. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 12/12/11 at 4:52PM revealed that Patient A8 was restrained from "1655-1701 [military time]."

b. Review of the MTP dated 12/20/11 revealed no mention of patient aggression or the use of restraint as of 2/8/12.

3. Patient A12

a. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 1/4/12 at 6:35 PM revealed that Patient A12 was restrained for "2 minutes."

b. Review of the MTP (annual update 10/6/11) revealed no addition or modification to the plan as a result of the restraint as of 2/8/12.

4. Patient B5

a. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 10/11/11 at 3:59PM, 4:08PM and 4:20PM (3 completed forms) revealed that Patient B5 was restrained during three 10-minute episodes from 3:59-4:08PM, 4:09-4:19PM and 4:20-4:30PM.

b. Review of the MTP (annual update 12/15/11) revealed no addition or modification to the plan as a result of the restraints as of 2/8/12.

5. Patient C1

a. The 5/01 facility form, "Initial Documentation For Seclusion, Mechanical Or Physical Restraint Intervention," dated 1/23/12 and timed 4:20PM, revealed that Patient C1 was physically restrained for "10 min. x 3."

b. A review of the Master Treatment Plan (annual update 5/17/11) revealed no addition or modification to the plan related to aggression or physical restraint as of 2/8/12.

6. Patient C2

a. The 1/07 facility form, "Initial documentation For Mechanical (MR) Or Physical (PR) Restraint Intervention," dated 12/10/11 and timed "2100 [military time]", revealed that Patient C2 was physically restrained for "10 min. x 2" with no indication of the actual time periods.

b. A review of the Master Treatment Plan (annual update 10/06/11) revealed no addition or modification to the plan related to aggression or physical restraint as of 2/8/12.

7. Patient C3

a. The 1/07 facility form, "Initial Documentation For Mechanical (MR) Or Physical (PR) Restraint Intervention," dated 12/2/11 and timed "0900 [military time]", revealed that Patient C3 was physically restrained with "Number of reapplications: 3" with no specific times indicated. The 7/10 facility form, "Initial Documentation For Physical (PR) Restraint Intervention" dated 12/2/ 11 and timed "1530 [military time]" revealed that Patient C3 was physically restrained for "10 min." with no specific times noted.

b. A review of the Master Treatment Plan (annual update 10/20/11) revealed no addition or modification to the plan related to aggression or physical restraint as of 2/8/12.

8. Patient C4

a. The 1/07 facility form, "Initial Documentation For Mechanical (MR) Or Physical (PR) Restraint Intervention", dated 10/29/11 and timed "1505 [military time]", revealed that Patient C4 was physically restrained three times.

b. A review of the Master Treatment Plan (annual update 5/18/11) revealed no addition or modification to the plan related to aggression or physical restraint as of 2/8/12.

B. Policy Review

1. Review of the "Torrance State Hospital Policy/Procedure for Physical and Protective Restraints," Clinical Services Policy No. 25-24, Nursing Policy No 85-113 dated June 3, 2010 revealed the following statements:

a. "The treatment team is required to review and revise the Comprehensive Individualized Treatment Plan (C.I.T.P.) and Crisis Plan within twenty-four (24) hours of the restraint or on the next working day whichever is sooner. Documentation will include changes as well as the specific plan of intervention for inclusion in the C.I.T.P. with the intent to avert future need for restraint."

b. "The treatment team will meet with the CEO and members of the administrative staff the next working day to discuss the restraint incident and their plan to eliminate future need for restraint with the individual, including the individual's feedback."

C. Interview

1. In interview on 2/7/12 at 8:45AM, when asked about the hospital policy requirement that the treatment team meet with the CEO after each restraint incident, the Director of Nursing (DON) stated, "We are not there yet."

2. In an interview on 2/7/12 at 2PM, RN1 stated that the treatment plan is not always modified after restraints. When asked if Patient A4's treatment plan would be modified following restraint, RN1 stated, "Sometimes the doctor, social worker and nurse get together early in the morning and talk about things like that." RN1 was unsure whether Patient A4's plan would be modified.

Based on record review and interviews, the facility failed to provide Master Treatment Plans (MTPs) for14 of 16 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A15 and A16) that included interventions with a specific focus, based on the individual needs and abilities of each patient. The listed interventions were generic monitoring or routine clinical functions with identical or similar wording for patients with different problems and needs. In addition, the treatment plans failed to specify how these generic modalities would be delivered or how often they would be delivered. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient A1 was admitted on 9/08/10. The Master Treatment Plan (MTP) dated 9/22/11 stated the following generic or routine clinical functions for the identified problem of "Altered Thought Process: Dementia": "SNAPMD (Social Work, Nursing, Activities, Psychology, MD, Psychiatrist): Establish rapport by consistent approach; Assess family involvement and include their suggestions to make patient feel safe" and "Provide active treatment programming based on assessment of assets, need, and interest." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

2. Patient A2 was admitted on 12/07/11. The MTP dated 12/14/11 stated the following generic interventions for the identified problem of "Altered Thought Processes": "N (Nursing): Observe present level of functioning and interaction with peers, staff and family; Be alert for signs of increasing fear, anxiety or agitation; Administer psych meds as prescribed by MD and observe for side effects" and "Observe for nonverbal cues and symbolic meanings." The plan failed to state how these generic modalities would be delivered or how often they would be delivered. There were no interventions for other disciplines.

3. Patient A3 was admitted on 1/5/12. The MTP dated 2/8/12 stated the following generic interventions for the identified problem of "Social Isolation (Withdrawal)": "SNAPD (Social Work, Nursing, Activities, Psychology, Psychiatrist): Establish frequent contact on each shift. Give positive feedback for any response and encourage to continue to reach out to others." "NPD(Nursing, Psychology, Psychiatry) : Approach patient in a direct manner." "SND (Social Work, Nursing, Psychiatry): Identify the patient's significant support persons and encourage them to make frequent contacts..." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

4. Patient A4 was admitted on 9/28/11. The MTP dated 10/5/11stated the following generic functions for the identified problem of "Altered Thought Processes": "SNAP (Social Work, Nursing, Activities, Psychology): Observe present level of functioning and interaction with peers, staff, and family." "N: Administer psych meds as prescribed by MD: and observe for side effects...." "S (Social Work): Assist in maintaining community relationships with family and, landlord in a coherent manner through assisted communication, specifically by phone calls" and "Promote family involvement in hospital treatment." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

5. Patient A5 was admitted on 12/7/11. The MTP dated 12/15/11 stated the following generic functions for the identified problem of "Altered Thought Processes manifested by impaired thinking, judgment": "All (staff): Observe present level of functioning and interaction with peers, staff and family." "RN (the treatment plan did not use the hospital's abbreviation "N" for Nursing): Administer psych meds as prescribed by MD: antipsychotics and observe for side effects of...." "FSE (Forensic Security Employee): Remove the patient from the group/dayward (the facility designates some units' dayrooms as a common area - dayward - for patients not in other activities) if behavior becomes increasingly bizarre, disturbing or dangerous." "S (Social Work): Assist in maintaining community relationships with family, friend, placement/landlord, ICM [sic] probation, in a coherent manner through assisted communication, specifically by phone calls." "SNAP (Social Work, Nursing, Activities, Psychology): Encourage to ventilate feelings and support attempts to verbalize anxiety fears directly." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

6. Patient A6 was admitted 11/22/11. The MTP dated 11/23/11 stated the following generic functions for the identified problem of "Altered Thought Processes manifested by delusional ideas": "SNA (Social Work, Nursing, Activities): Observe present level of functioning and interaction with peers, staff and family/significant other." "N (Nurse): Administer psych meds as prescribed by MD: antipsychotics and observe for side effects..." "FSE (Forensic Security Employee): Remove the patient from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous." "SNAP (Social Work, Nursing, Activities, Psychology): Help the patient feel safe by using non-authoritarian approach. Keep to simple concrete topics of conversation." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

7. Patient A7 was admitted 6/29/11. The MTP dated 7/5/11 stated the following interventions for the identified problem of "High Risk Alcohol and Other Drug Abuse/Dependence": "P (Psychology): Assess drinking/drug use history by review of records and talking with patient and family." "SNAP (Social Work, Nursing, Activities, Psychology): Observe for common behaviors or problems...Encourage to express feeling about family difficulties and other problems in life. Redirect attempts to rationalize or explain away difficulties or to blame problems on others or on circumstances beyond the client's control. Encourage to explore alternative ways to deal with stress and difficult situations such as with regular physical exercise." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

8. Patient A8 was admitted on 12/12/11. The MTP dated 12/20/11 stated the following generic interventions for the identified problem of "Altered Thought Processes": "RN will speak with patient daily prior to med pass...Will promote verbalization of feelings if anxious or angry...Will educate to use of relation and/or diversional techniques to help gain/maintain control." "FATSW (Forensic Activities, Social Work): will provide opportunities for patient to attend recreation/leisure sessions in the rec room. Monitor attendance and behavior while engaging him in reality based social interaction." "FSW (Forensic Social Work): will meet with the pt (patient) weekly to provide full range of relevant social services, i.e., phone calls, financial concerns, etc." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

9. Patient A9 was admitted 1/18/12. The MTP dated 1/25/12 stated the following generic interventions for the identified problem of "High Risk for Self-Injurious Behaviors (Self-Abusive)": "NM (Nursing, Medical Physician): Assess for self-injurious behaviors or acts such as: cutting, burning,..." "N (Nursing): Reassure patient that staff will protect and help patient to feel safe by observations and safety restrictions." "SNAP (Social Work, Nursing, Activities, Psychology): Communicate to the patient that you do not blame the patient for the self-abuse, that you know this behavior has become out of control and you are hopeful that this can change." The plan failed to state how the generic interventions would be delivered or how often they would be delivered.

10. Patient A10 was admitted on 9/1/10. The MTP dated 11/9/11 stated the following generic interventions for the identified problem of "Altered Thought Processes": "S (Social Work): Assist in maintaining community relationships with family...in a coherent manner through assisted communication, specifically by phone calls; Explore with patient various ways to express and deal with feelings, including attending Active Treatment groups" and "Promote family involvement in hospital treatment." The plan failed to state how these generic interventions would be delivered or how often they would be delivered. No other staff was identified on the plan for this problem.

11. Patient A11 was admitted on 1/10/06. The MTP dated 1/11/12 stated the following generic functions for the identified problem of "Altered Thought Processes": "SNA (Social Work Nursing, Activities): Observe present level of functioning and interaction with peers, staff and family/significant other." N (Nurse): Administer psych meds as prescribed by MD: antipsychotics and observe for side effects..." "SNA (Social Work Nursing, Activities): Remove the patient from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

12. Patient A12 was admitted 10/11/00. The MTP dated 10/6/11 stated the following generic functions for the identified problem of "High Risk of Self Harm": "SNA (Social Work, Nursing, Activities): Provide a safe milieu in accordance with TSH (Torrance State Hospital) policy...Establish rapport and maintain direct communication...Refer to Anger Groups if appropriate ... Teach recognition of and ways to increase positive self-esteem..." "N (Nurse): Administer psych meds as prescribed by MD and observe for side effects...Observe sleeping habits." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

13. Patient A15. was admitted 7/18/08. The MTP dated 7/19/11 stated the following generic functions for the identified problem of "Altered Thought Processes": "SNAP (Social Work, Nursing, Activities, Psychology): Observe present level of functioning and interaction... Remove the patient from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous...Keep to simple, concrete topics of conversation." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

14. Patient A16 was admitted 3/23/11. The MTP dated 3/24/11 stated the following generic functions for the problem identified as "Altered Thought Processes": "N (Nurse): Administer psych meds as prescribed by MD: Antipsychotics and observe for side effects...Remove from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous." "SNAP (Social Work, Nursing, Activities, Psychology): Redirect, speak calmly, be consistent...Encourage to ventilate feelings and support attempts to verbalize anxiety fears directly...Explore with patient various ways to express and deal with feelings, including attending Active Treatment groups." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

B. Interviews

1. In an interview on 2/7/12 at 8:45AM, the DON stated, "I agree; the interventions stated (on the treatment plans) should be individualized."

2. In an interview on 2/7/12 at 9AM, the Director of Social Work and Rehabilitation Services (SRS) acknowledged the lack of individualized interventions on patient's treatment plans.

Based on record review and interview, the facility failed to ensure that the name and discipline of all staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTP) for 12 of 16 sample patients (A1, A2, A3, A4, A7, A9, A10, A11, A12, A13, A14 and A15). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Patient A1 was admitted 9/8/10 with the diagnoses of "Chronic Paranoid Schizophrenia" and "Dementia, NOS." On the MTP of 9/22/11, the name of the person responsible for Activities interventions was left blank for Problem I, "Altered Thought Processes" and Problem II, "High Risk Sexual Behavior" even though Activities was identified as a therapeutic modality for the problem.

2. Patient A2 was admitted 12/7/11 with the diagnoses of "Recurrent Major Depression"; "Polysubstance Dependence"; and "Factitious Psychological Symptoms." On the MTP of 12/14/11, for Problem I, "Altered Thought Processes" and Problem III, "High Risk Alcohol and Other Drug Abuse/Dependence," nursing was the discipline listed as responsible for all of the interventions, including those not limited to the nursing scope of practice, such as "Help the patient feel safe by using non-authoritarian approach," and "Observe for common behaviors and problems."

3. Patient A3 was admitted 1/5/12 with diagnoses of "Major Depression, Severe, Recurrent;" "Obsessive Compulsive Disorder;" and "Post Traumatic Stress Disorder." On the MTP of 1-5-12, for Problem III, "Alteration in Comfort: Pain" and Problem IV, "High Risk for Self-Harm (Suicide), Potential/Actual" there were only check marks in the spaces to designate the responsible disciplines.

4. Patient A4 was admitted 9/28/11 with diagnoses of "Schizoaffective Disorder, Depressed Type, Polysubstance Abuse." On the MTP of 10/5/11, none of the identified problems ("Altered Thought Processes"; "High Risk for Violence directed at Others"; "High Risk Alcohol and Other Drug Abuse/Dependence"; "Knowledge Deficit: Medications"; and "Alteration in Comfort: Pain") identified the psychiatrist as having a role in any identified interventions.

5. Patient A7 was admitted 6/29/11 with diagnoses of "Major Depression, Recurrent Severe with Psychotic Features" and "Ethanol Dependence in Remission." On the MTP of 7/5/11, for Problem I: "Competency Restoration" only "staff" was listed as being responsible for nursing interventions. The psychiatrist was not designated as having a role in any interventions. For Problem III: "High Risk Alcohol and Other Drug Abuse/Dependence," the space for listing the person responsible for nursing interventions was left blank. The psychiatrist was not designated as having a role in any of the listed interventions.

6. Patient A9 was admitted 1/18/12 with the diagnoses of "PTSD", "Recurrent Major Depression" and "Self Inflicted Abdominal Wound". On the MTP of 1/25/12, for Problem IV: "Potential for skin breakdown, High Risk," there was no assigned discipline for any of the interventions.

7. Patient A10 was admitted 9/1/10 with the diagnosis of "Schizoaffective disorder, depressed type." On the MTP of 11/9/11, Problem I: "Altered Thought Processes", only Social Service was listed as the responsible discipline for all interventions, including those not limited to the social service scope of practice such as "Observe present level of functioning and interaction with peers, staff and family/S.O. [sic]" In addition, the interventions listed for Activities and the Medical Physician had no designated responsible persons. For Problem II: "Knowledge Deficit: Understanding of Diabetes, Hypo/Hyperclycemia [sic], Complications, Medications" and Problem IV: "Impaired tissue integrity, actual," there were no staff names for the listed interventions.

8. Patient A11 was admitted 1/10/06 with the diagnoses of "Schizoaffective Disorder, Depressed," and "Polysubstance Abuse." On the MTP of 1/11/12, for all Problems ("Altered Thought Processes"; "High Risk Sexual Behavior"; "Altered nutrition, more than body requirements"; and "High Risk Alcohol and other Drug Abuse/Dependence"), the psychiatrist was not designated as having a role in any interventions.

9. Patient A12 was admitted 10/11/00 with the diagnoses of "Post Traumatic Stress Disorder" and "Borderline Personality Disorder." On the MTP of 10/6/11, for the only listed problem: "High Risk for Self-Harm (Suicide), Potential/Actual," the psychiatrist was not designated as having a role in any interventions.

10. Patient A13 was admitted 7/1/06 with the diagnoses of "Pedophilia, non-exclusive, Paraphilia NOS [Not Otherwise Specified]" and "Personality Disorder NOS." On the MTP of 11/17/11, for Problem I (identified with a list of diagnoses), the interventions listed groups conducted by various disciplines (Vocation/Education; Recreation, Spiritual Support, Operations), but without responsible persons named.

11. Patient A14 was admitted 3/3/09 for diagnoses of "Paraphilia, NOS [Not Otherwise Specified]"; "Conduct Disorder, Borderline Personality Disorder." On the MTP of 11/21/11, for Problem I (identified with a list of diagnoses), the interventions listed groups conducted by various disciplines (Vocation/Education; Recreation, Spiritual Support, Operations), but without responsible persons named.

12. Patient A15, admitted 7/18/08 for diagnoses of "Schizoaffective Disorder," "Bipolar" and "Borderline Personality Disorder. " On the MTP of 7/19/11, for Problem I: "Altered Thought Processes"; Problem II: "High Risk of Self Injurious Behaviors (Self-Abusive)"; and Problem IV: "Alteration in Comfort: Pain," the responsible persons were not listed for several disciplines (Activities, Medical Physician, Psychology, Psychiatrist).

B. Interview

In an interview on 2/7/12, at 3:30PM, the CMO (Chief Medical Officer) acknowledged that all clinician responsibilities in delivering care should be clearly specified on the patients' treatment plans. He stated, "The psychiatrist's role should be identified as appropriate."

C. Policy Review

Clinical Services Policy #25-6, "Comprehensive Individualized Treatment Plan Guidelines," dated September 8, 2011, states the following on page 8: "Person Responsible - The names of the staff responsible for the intervention will be listed." On the same page, the policy states "Interventions": "Interventions are what the staff will do to help the patient achieve the short-term goal. All appropriate blanks must be completed to individualize the plan. Each discipline is to use the designated code to indicate responsibility for the intervention."

Based on record review, policy review and staff interviews, the facility failed to correctly document the use of physical restraints in physician orders and staff progress notes for 3 of 3 active patients (A4, A8, A12), 1 of 1 discharged patients (B5), and 4 added sample patients (C1,C2, C3, C4). In addition, the patients' Master Treatment Plans were not modified to reflect new strategies addressing behavior necessitating the physical restraints. This failure results in patients being physically restrained without proper documentation of professional assessment and intervention and without appropriate modifications to their treatment to prevent further incidents and to assist the treatment team in determining progress.

Findings include:

A. Specific Patient Findings

1. Patient A4

a. The patient was admitted on 9/28/11. Review of the 5/01 facility form, "Initial Documentation for Seclusion, Mechanical or Physical Restraint Intervention" dated 2/16/12 at 5:15PM, revealed that Patient A4 was physically restrained on 2/6/12 at 5:15PM for 10 minutes. The telephone order written on the Physician's Orders/Progress Notes on 2/6/12 at 5:45PM stated, "10 min hold 1715-1725 [military time]," with no description of the precipitating behavior or criteria for release. According to the same facility form, the patient was restrained a second time on 2/6/12 at 5:25PM for 10 minutes. The telephone order written on 2/6/12 at 5:50PM stated "Hold x 10 min 1725-1735 [military time]" with no description of the precipitating behavior or criteria for release.

b. The 5/01 facility form, "Initial Documentation for Seclusion, Mechanical or Physical Restraint Intervention" dated 2/6/12 at 5:15PM revealed that Patient A4 was restrained for "10 min x 2." There was only one form completed for the two restraint episodes, with no documentation of the patient's condition from restraint episode one to restraint episode two. In addition, there was no documentation on the form or in the medical record to indicate that the physician assessed Patient A4 during or following the restraint episodes.

c. Review of the Master Treatment Plan dated 10/5/11 revealed no modification to Patient A4's MTP as of 2/8/12.

2. Patient A8

a. The patient was admitted on 12/12/11. Review of the 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 12/12/11 revealed that Patient A8 was physically restrained on 12/12/11 at 4:55PM for 6 minutes. The verbal order documented on 12/12/11 at 4:55PM stated, "Physical hold NTE (not to exceed) 10 min 1655-1701 [military time] for (increased) agitation" with no criteria for release.

b. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 12/12/11 at 4:52PM revealed that Patient A8 was restrained from "1655-1701 [military time]." The space for "Time physician examined patient" on the documentation form was not completed. On the "Physician Orders/Progress Notes," the physician wrote "12/12/11 Agitation/Agress [sic]." The physician note was untimed. There was no other documentation in the medical record to show that the physician assessed Patient A8 during or following the restraint episode.

c. Review of the Master Treatment Plan dated 12/20/11 revealed no mention of patient aggression or the need to restrain as of 2/8/12.

3. Patient A12

a. The patient was admitted on 10/11/00 with diagnoses of "PTSD" (Post Traumatic Stress Disorder and "Borderline Personality Disorder." Review of the 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 1/4/12 at 6:45PM revealed that Patient A12 was physically restrained on 1/4/12 at 6:35 PM for 2 minutes. The telephone order written on 1/4/12 6:45PM stated, "Physical hold x 1 up to 10 mins" with no description of the precipitating behavior or any criteria for release.

b. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 1/4/12 at 6:35 PM revealed that Patient A12 was restrained for "2 minutes." The space for "Time physician examined patient" on the documentation form was not completed. There was no documentation on the form or in the medical record to show that the physician assessed Patient A12 during or following the restraint episode.

c. Review of the Master Treatment Plan (annual update 10/6/11) revealed no addition or modification to the plan as a result of the restraint as of 2/8/12.

4. Patient B5

a. The patient was admitted on 12/16/10 with a diagnosis of "Schizoaffective Disorder" and "PTSD." Review of the 1/07 facility forms, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 10/11/11 at 3:59PM and 10/11/11 at 4:20PM revealed that Patient B5 was physically restrained during 2 episodes on 10/11/11 between 3:59PM and 4:19PM (episode one from 3:59-4:08PM and episode two from 4:09-4:19PM). The verbal order documented on 10/11/11 at 4:10PM stated "physical hold up to 10 minutes x 2" with no description of the precipitating behavior or criteria for release. A third facility form dated 10/11/11 at 4:20PM revealed that patient B5 was physically restrained a third time on 10/11/11 from 4:20PM to 4:30PM. The verbal order documented on 10/11/11 at 4:25PM stated "physical hold up to 10 minutes" with no description of the precipitating behavior or criteria for release.

b. The 1/07 facility forms, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 10/11/11 at 3:59PM, 4:08PM and 4:20PM (3 completed forms) revealed missing documentation for "Time physician examined patient." There was no documentation on the forms or in the medical record to show that the physician assessed Patient B5 during or following the restraint episode.

c. Review of the Master Treatment Plan (annual update 12/15/11) revealed no addition or modification to the plan as a result of the restraints as of 2/8/12.

5. Patient C1

a. The patient was admitted on 5/14/02. The5/01 facility form, "Initial Documentation For Seclusion, Mechanical Or Physical Restraint Intervention" dated 1/23/12 and timed "1620 [military time]" stated the patient was physically restrained three times on 1/23/12 between 4:20PM and 4:50PM. The physician order written on 1/23/12 at 4:20PM stated, "Physical hold up to 10 min." with no description of the precipitating behavior or criteria for release. A second physician order written on 1/23/12 at 4:30PM stated, "Physical hold up to 10 min." with no description of precipitating behavior or criteria for release. A third physician order written on 1/23/12 at 4:40PM stated, "Physical hold up to 10 min." with no description of precipitating behavior or criteria for release.

b. The 5/01 facility form, "Initial Documentation For Seclusion, Mechanical Or Physical Restraint Intervention" dated 1/23/12 and timed "1620" listed the following on the line beside "Time": "1620-1630 [military time]", "1630-1640", "1640-1650." There was only one form completed for all three restraint episodes. There was no documentation on the form in the medial record to show that the physician assessed Patient C1 during or following any of the restraint episodes.

c. Review of the Master Treatment Plan (annual update 5/17/11) revealed no addition or modification to the plan as a result of the restraint as of the date of the review during the survey.

6. Patient C2

a, The patient was admitted on 10/05/95 with diagnoses of "Depression, Borderline Personality Disorder." The 1/07 facility form, "Initial Documentation For Mechanical (MR) Or Physical (PR) Restraint Intervention "dated 12/10/11 and timed "2100 [military time]" stated the patient was physically restrained two times on 12/10/11. The physician order on 12/10/11 at "2100 [military time]" stated "Physical hold for up to 10 min." There was no description of precipitating behavior or criteria for release. A second physician order written on 12/10/11 at "2011 [military time]" stated, "Physical hold for up to 10 min." There was no description of precipitating behavior or criteria for release.

b. The 1/07 facility form, "Initial Documentation For Mechanical (MR) Or Physical (PR) Restraint Intervention" dated 12/10/11 and timed "2100 [military time]" was blank beside the line "Time physician examined patient." There was only one form completed for both restraint episodes. There were no physician progress notes related to the restraint episode.
c. Review of the Master Treatment Plan (annual update 10/06/11) revealed no addition or modification to the plan as a result of the restraint as of the date of the review during the survey.

7. Patient C3

a. The patient was admitted on 10/31/06. The 1/07 facility form, "Initial Documentation For mechanical (MR) Or Physical (PR) Restraint Intervention," dated 12/02/11, stated that the patient was physically restrained on 12/02/11. The physician order on 12/02/11 at 9:20 AM stated, "Physical Hold up to 10 mins" with no criteria for release. A second physician order written on 12/02/11 at 9:30AM stated, "Physical Hold up to 10 mins" with no criteria for release.

b. The 1/07 facility form, "Initial Documentation For mechanical (MR) Or Physical (PR) Restraint Intervention," dated 12/02/11, stated, "Number of reapplications 3." There was only one form completed for both of the restraint episodes. The space beside "Time physician examined patient" was left blank.

c. Patient C3 was again restrained on 12/02/11 at 3:30PM. The physician order dated 12/02/11 and timed "1530 [military time]" stated, "Hold up to 10 min" with no criteria for release.

d. The 7/10 facility form, "Initial Documentation for Physical (PR) Restraint Intervention" dated "12/2/11" and timed "1530 [military time]" stated "Time Physician examined patient: 1830 [military time]." There were no physician notes in the medical record documenting the assessment of Patient C3 during or following any of the episodes on 12/02/11.

c. Review of the Master Treatment Plan (annual update 10/20/11) revealed no addition or modification to the plan as a result of the restraint as of the time of the review during the survey.

8. Patient C4

a, The patient was admitted on 05/10/11. The 1/07 facility form dated 10/29/11 and timed "1505 [military time]" stated that the patient was physically restrained 3 times on 10/29/11. The physician order dated "10/29/11" and timed "1505" stated, "Physical Hold up to 10 min." with no description of precipitating behavior or criteria for release. A second physician order dated "10/29" and timed "1517" stated, "Physical Hold up to 10 min" with no description of precipitating behavior or criteria for release. A third physician order dated "10/29" and timed "1530" stated, "Physical Hold up to 10 min" with no description of precipitating behavior or criteria for release.

b. The 1/07 facility form dated 10/29/11 and timed "1505" stated "Number of reapplications: 2. "There was only one form completed for the three restraint episodes.

c. Review of the Master Treatment Plan (annual update 5/18/11) revealed no addition or modification to the plan as a result of the restraint as of the date of the review during the survey.

B. Policy Review

1. Review of the "Torrance State Hospital Policy/Procedure for Physical and Protective Restraints", Clinical Services Policy No. 25-24, Nursing Policy No 85-113 dated June 3, 2010 revealed the following statement:

"The physician involved shall see the consumer within thirty (30) minutes of the initiation of restraint (barring extenuating circumstances), and then shall write/countersign the order for the restraint and document his/her assessment of the consumer in the medical record. Specific behavioral criteria written by the physician shall specify when the physical restraints may be discontinued, to insure minimum usage."

2. Review of the "Physical Restraint Procedure," review date 6/9/10, revealed the following statements:

a. "Physical restraint may not exceed 10 minutes. If the patient has not gained control within this time period, staff is to disengage the hold, reassess the situation and need for further intervention."

b. "A physician shall examine the patient within 30 minutes."

C. Interviews

1. In interview on 2/6/12 at 2PM, when asked the time frame for the physician to assess a restrained patient, RN2 stated, "twenty four hours."

2. In interview on 2/7/12 at 1:45PM, when asked how the patient's condition following each restraint episode could be determined when multiple episodes were documented on one restraint form, RN3 stated, "I see what you mean. We should use one form for each episode."

3. In interview on 2/8/12 at 9:15AM, the DON stated that writing "aggressive" or "agitated" on the "Physician Orders/Progress Notes" sheet did not meet the requirements for a documented physician assessment.

Based on record review, interview and policy review, the Chief Medical Officer failed to:

I. Ensure the Master Treatment Plans (MTP) were modified or revised following restraint episodes for 3 of 3 active patients (A4, A8 and A12), 1 of 1 discharged patients (B5) and 4 patients added to the sample in order to evaluate the use of restraints (C1, C2, C3 and C4). In addition, the facility failed to follow their own policy requiring the treatment team to meet with the CEO and members of the administrative staff following each restraint episode in an effort to eliminate future restraints. This can result in a failure to provide interventions needed to address individual problems of aggression and can potentially lead to additional restrictive episodes. (Refer to B118).

II. Ensure that Master Treatment Plans (MTPs) for14 of 16 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A15 and A16) included interventions with a specific focus, based on the individual needs and abilities of each patient. The listed interventions were generic monitoring or routine clinical functions with identical or similar wording for patients with different problems and needs. In addition, the treatment plans failed to specify how these generic modalities would be delivered or how often they would be delivered. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment. (Refer to B122).

III. Ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTP) for 12 of 16 sample patients (A1, A2, A3, A4, A7, A9, A10, A11, A12, A13, A14 and A15). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123).

IV. Ensure the correct documentation for the use of physical restraints in physician orders and staff progress notes for 3 of 3 active patients (A4, A8, A12), 1 of 1 discharged patients (B5), and 4 added sample patients (C1,C2, C3, C4). In addition, the patients ' Master Treatment Plans were not modified to reflect new strategies addressing behavior necessitating the physical restraints. This failure results in patients being physically restrained without proper documentation of professional assessment and intervention and without appropriate modifications to their treatment to prevent further incidents and to assist the treatment team in determining progress. (Refer to B125).

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

I. Develop treatment plans that identified clearly delineated nursing responsibilities for interventions to address the identified problems for 14 of 16 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A15, A16). This failure results in staff not being provided with guidance regarding the specific modality needed and the purpose for each modality which compromises treatment.

Findings include:

1. Patient A1 was admitted on 9/08/10. The Master Treatment Plan (MTP) dated 9/22/11 stated the following generic or routine clinical functions for the identified problem of "Altered Thought Process: Dementia": "SNAPMD (Social Work, Nursing, Activities, Psychology, MD, Psychiatrist): Establish rapport by consistent approach; Assess family involvement and include their suggestions to make patient feel safe" and "Provide active treatment programming based on assessment of assets, need, and interest." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

2. Patient A2 was admitted on 12/07/11. The Master Treatment Plan (MTP) dated 12/14/11 stated the following generic nursing interventions for the identified problem of "Altered Thought Processes": "Nursing[N]: Observe present level of functioning and interaction with peers, staff and family. Be alert for signs of increasing fear, anxiety or agitation. Administer psych meds as prescribed by MD and observe for side effects. Observe for nonverbal cues and symbolic meanings." The plan failed to state how these generic modalities would be delivered or how often they would be delivered.

3. Patient A3 was admitted on 1/5/12. The MTP dated 2/8/12 stated the following generic interventions for the identified problem of "Social Isolation (Withdrawal)": "SNAPD (Social Work, Nursing, Activities, Psychology, Psychiatrist): Establish frequent contact on each shift. Give positive feedback for any response and encourage to continue to reach out to others." "NPD(Nursing, Psychology, Psychiatry : Approach patient in a direct manner." "SND (Social Work, Nursing, Psychiatry): Identify the patient's significant support persons and encourage them to make frequent contacts..." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

4. Patient A4 was admitted on 9/28/11. The MTP dated 10/5/11 stated the following generic and routine discipline functions for the identified problem of "Altered Thought Processes": "[SNAP]: Observe present level of functioning and interaction with peers, staff, and family." "[N]: Administer psych meds as prescribed by MD: and observe for side effects..." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

5. Patient A5 was admitted on 12/-7/11. The MTP dated 12/15/11 stated the following generic and routine discipline functions for the identified problem of "Altered Thought Processes manifested by impaired thinking, judgment": "All: Observe present level of functioning and interaction with peers, staff and family." "RN: Administer psych meds as prescribed by MD: antipsychotics and observe for side effects of...." "Social Work, Nursing, Activities, Psychology [SNAP]: Encourage to ventilate feelings and support attempts to verbalize anxiety fears directly." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

6. Patient A6 was admitted 11/22/11. The MTP dated 7/11/11 stated the following generic routine discipline functions for the identified problem of "Altered Thought Processes manifested by delusional ideas": "Social Work Nursing, Activities [SNA]: Observe present level of functioning and interaction with peers, staff and family/significant other." "Nurse [N]: Administer psych meds as prescribed by MD: antipsychotics and observe for side effects...." "Social Work, Nursing, Activities, Psychology [SNAP]: Help the patient feel safe by using non-authoritarian approach. Keep to simple concrete topics of conversation." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

7. Patient A7 was admitted 6/29/11. The MTP dated 7/5/11 stated the following for the identified problem of "High Risk Alcohol and Other Drug Abuse/Dependence": "Social Work, Nursing, Activities, Psychology [SNAP]: Observe for common behaviors or problems. Encourage to express feeling about family difficulties and other problems in life. Redirect attempts to rationalize or explain away difficulties or to blame problems on others or on circumstances beyond the client's control. Encourage to explore alternative ways to deal with stress and difficult situations such as with regular physical exercise." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

8. Patient A8 was admitted on 12/12/11. The MTP dated 12/20/11 stated the following generic interventions for the identified problem of "Altered Thought Processes": "RN will speak with patient daily prior to med pass. Will promote verbalization of feelings if anxious or angry. Will educate to use of relation and/or diversional techniques to help gain/maintain control." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

9. Patient A9 was admitted 1/18/12. The MTP dated 1/25/12 stated the following generic interventions for the identified problem of "High Risk for Self-Injurious Behaviors (Self-Abusive)": "Nursing, Medical Physician [NM]: "Assess for self-injurious behaviors or acts such as: cutting, burning,..." "Nursing [N]: Reassure patient that staff will protect and help patient to feel safe by observations and safety restrictions." "Social Work, Nursing, Activities, Psychology [SNAP]: Communicate to the patient that you do not blame the patient for the self-abuse, that you know this behavior has become out of control and you are hopeful that this can change." The plan failed to state how the generic interventions would be delivered or how often they would be delivered.

10. Patient A10 was admitted on 9/1/10. The MTP dated 11/9/11 identified no nursing interventions.

11. Patient A11 was admitted on 1/10/06. The MTP dated 1/11/12 stated the following generic functions for the identified problem of "Altered Thought Processes": "SNA (Social Work Nursing, Activities)": "Observe present level of functioning and interaction with peers, staff and family/significant other." "N (Nurse): Administer psych meds as prescribed by MD: antipsychotics and observe for side effects..." "SNA (Social Work Nursing, Activities): Remove the patient from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

12. Patient A12 was admitted 10/11/00. The MTP dated 10/6/11 stated the following generic functions for the identified problem of "High Risk of Self Harm": "Social Work, Nursing, Activities [SNA]: Provide a safe milieu in accordance with TSH policy. Establish rapport and maintain direct communication. Refer to Anger Groups if appropriate. Teach recognition of and ways to increase positive self-esteem..." "Nurse [N]: Administer psych meds as prescribed by MD and observe for side effects. Observe sleeping habits." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

13. Patient A15 was admitted 7/18/08. The MTP dated 7/19/11 stated the following generic functions for the identified problem of "Altered Thought Processes": "Social Work, Nursing, Activities, Psychology [SNAP]: Observe present level of functioning and interaction. Remove the patient from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous. Keep to simple, concrete topics of conversation." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

14. Patient A16 was admitted 3/23/11. The MTP dated 3/24/11 stated the following generic functions for the problem identified as "Altered Thought Processes": "Nurse [N]: Administer psych meds as prescribed by MD: Antipsychotics and observe for side effects. Remove from the group/dayward if behavior becomes increasingly bizarre, disturbing or dangerous." "Social Work, Nursing, Activities, Psychology [SNAP]: Redirect, speak calmly, be consistent. Encourage to ventilate feelings and support attempts to verbalize anxiety fears directly. Explore with patient various ways to express and deal with feelings, including attending Active Treatment groups." The plan failed to state how these generic interventions would be delivered or how often they would be delivered.

Interview:

In an interview 2/7/12, at 8:45AM, the DON stated, "I agree, the interventions stated (on the treatment plans) should be individualized."

II. Ensure that the name of nursing staff responsible for specific aspects of care were listed on the Master Treatment Plans for 4 of 16 sample patients (A3, A7, A9 and A10). This failure results in an inability to monitor nursing staff accountability for specific treatment modalities.

Findings include:

1. Patient A3 admitted 1/5/12. Plan of Care initiated 1-5-12: Problem III, "Alteration in Comfort: Pain" and Problem IV, "High Risk for Self-Harm (Suicide), Potential/Actual" have check marks rather than staff names in the spaces used to designate the responsible disciplines for the specific interventions.

2. Patient A7, admitted 6/29/11. Plan of Care initiated 7/5/11: Problem I, "Competency Restoration" lists "staff" as the person responsible for nursing interventions. Problem III, "High Risk Alcohol and Other Drug Abuse/Dependence," has the space designating the person responsible for nursing interventions blank.

3. Patient A9, admitted 1/18/12. Plan of Care initiated 1/25/12: Problem IV, "Potential for skin breakdown, High Risk," does not assign nursing to any of the interventions.

4. Patient A10, Admitted 9/1/10. Plan of Care with no date of initiation: Problem II, "Knowledge Deficit: Understanding of Diabetes, Hypo/Hyperglycemia (sic), Complications, Medications" and Problem IV, "Impaired tissue integrity, actual," designates no specific nursing interventions or responsible persons.

Interview:

In an interview on 2/7/2012 at 8:45AM, the Director of Nursing stated, "I see what you mean about the interventions not being specified by discipline and name."

Policy Review:

Clinical Services Policy #25-6, "Comprehensive Individualized Treatment Plan Guidelines," page 8 states: "Person Responsible - The names of the staff responsible for the intervention will be listed." On the same page the policy continues: "Interventions ---Interventions are what the staff will do to help the patient achieve the short-term goal. All appropriate blanks must be completed to individualize the plan. Each discipline is to use the designated code to indicate responsibility for the intervention."

III. Appropriately document physical restraint episodes in nursing forms or progress notes after a physical restraint episode for 3 of 3 active patients (A4, A8, A12), 1 of 1 (B5) discharged patient, and 4 (C1,C2, C3, C4) added sample patients. This failure results in there being no documented professional nursing assessment or intervention during restraint episodes and, potentially, in further restraint episodes for the identified patients.

Findings include:

A. Record/Document Review

1.Patient A4 was admitted on 9/28/11. The patient was physically restrained on 2/6/12 at 5:15PM for 10 minutes and again at 5:25PM on the same date for 10 minutes The 5/01 facility form, "Initial Documentation for Seclusion, Mechanical or Physical Restraint Intervention" dated 2/6/12 at 5:15PM revealed that Patient A4 was restrained for "10 min x 2." There was only one form completed for the two restraint episodes with no documentation of the patient's condition from restraint episode one to restraint episode two.

2. Patient A8 was admitted on 12/12/11. The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 12/12/11 at 4:52PM revealed that Patient A8 was restrained from "1655-1701." The space for "Time physician examined patient" on the documentation form was not completed. (This is a nursing form and nurses are the ones completing it. See interview 3)

3. Patient A12 was admitted on 10/11/00 with a diagnosis of "PTSD" (Post Traumatic Stress Disorder) and "Borderline Personality Disorder." The 1/07 facility form, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 1/4/12 at 6:35PM revealed that Patient A12 was restrained for "2 minutes." The space for "Time physician examined patient" on the documentation form was not completed. (This is a nursing form and nurses are the ones responsible for completing it.)

4. Patient B5 was admitted on 12/16/10 with diagnoses of "Schizoaffective Disorder" and "PTSD." The 1/07 facility forms, "Initial Documentation for Mechanical (MR) or Physical (PR) Restraint Intervention" dated 10/11/11 at 3:59PM, 4:08PM and 4:20PM (3 completed forms) revealed missing documentation for "Time physician examined patient."

5. Patient C1 was admitted on 5/14/02. The 5/01 facility form, "Initial Documentation For Seclusion, Mechanical Or Physical Restraint Intervention" dated 1/23/12 and timed "1620 [military time]" listed on the line beside "Time" "1620-1630", "1630-1640", "1640-1650 " There was only one form completed for all three restraint episodes.

6. Patient C2 was admitted on 10/05/95 with diagnoses of "Depression, Borderline Personality Disorder." The 1/07 facility form, "Initial Documentation For mechanical (MR) Or Physical (PR) Restraint Intervention dated 12/02/11 stated "Number of reapplications 3." There was only one form completed for both of the restraint episodes.

7. Patient C3 was admitted on 10/31/06 with diagnoses of "Pedophilia, Paraphilia, Attention Deficit/Hyperactivity D/O, Conduct Disorder." The 1/07 facility form dated 10/29/11 and timed "1505" stated "Number of reapplications [of S&R]: 2." There was only one form completed for the three restraint episodes.

8. Patient C4 was admitted on 5/10/11. The 1/07 facility form dated 10/29/2011 and timed "1505" stated, "Number of reapplications: 2." There was only one form completed for the three restraint episodes.

B. Policy Review

Review of the "Torrance State Hospital Policy/Procedure for Physical and Protective Restraints", Clinical Services Policy No. 25-24, Nursing Policy No 85-113 dated June 3, 2010 includes the following statement:

"The treatment team will meet with the CEO and members of the administrative staff the next working day to discuss the restraint incident and their plan to eliminate future need for restraint with the individual , including the individual's feedback."

C. Interviews

1. In interview on 2/7/12 at 8:45AM, when asked about the hospital policy requirement that the treatment team meets with the CEO after each restraint incident, the DON stated "We are not there yet."

2. In interview on 2/7/12 at 1:45PM, when asked how the patient's condition following each restraint episode could be determined when multiple episodes were documented on one restraint form, RN3 stated, "I see what you mean. We should use one form for each episode."

Based on record review, staff interview, and policy review, the Social Service Director failed to ensure that patient records included an integration of factual and historical information and an evaluation of psychosocial issues with recommendations for social work roles in treatment for 4 of 16 active sample patients (A5, A6, A7 and A8). This resulted in a document that did not address patient needs and social work interventions necessary for treatment planning. (Refer to B108).