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Based on record review and interview, the facility failed to provide psychiatric evaluations that reported memory functioning in measurable, behavioral terms for eight (8) of 16 sample patients. This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

The Psychiatric Evaluation of the following patients were reviewed (dates of evaluations are in parentheses): B2 (2/28/18); C1 (10/13/17); K1 (7/23/18); K2 (7/11/18); L2 (11/28/18); L15 (2/22/18); N2 (11/20/17) and N3 (10/25/17). This review revealed:

1. Patient B2: "Memory" was recorded as "Memory appears to be grossly intact," There was no evidence of how this determination was made.

2. Patient C1: "Memory" was recorded as "The patient seems to have reasonable and good remote and short-term memory; however, is [sic] very difficult to assess due to [his/her] refusal to give any details." No additional information was added.

3. Patient K1: "Memory" was recorded as "Memory is intact for recent and remote events." There was no evidence of how this determination was made.

4. Patient K2: "Memory" was recorded as "Memory appears to be grossly intact for recent and remote events." There was no evidence of how this determination was made.

5. Patient L2: "Memory" was recorded as "All three types within normal limits." There was no evidence of how this determination was made.

6. Patient L15: "Memory" was recorded as "All three types are within normal limits. Doesn't show any signs of significant memory problems." There was no evidence of how this determination was made.

7. Patient N2: "Memory" was recorded as "All three types within normal limits.

Based on record review and staff interview the facility failed to provide psychiatric evaluations that included an assessment of patients' assets in 10 of 16 active sample patients (B2, C1, C2, G1 I1, I2, K2, L2, L15 and N3). This failure to identify patient strengths impairs the treatment team's ability to identify and choose treatment modalities which best utilize the patient's attributes in treatment.

A. Record Review

1.Patient B2 psychiatric evaluation dated 2/28/18 stated "The patient is able to make [her/his] needs known. [She/he] has a history of positive response to medications." These are not personal assets that can be utilized in the treatment planning process.

2. Patient C1 psychiatric evaluation dated 10/13/17 stated "The patient is in good physical health." This is not a personal asset that can be utilized in the treatment planning process.

3. Patient C2 psychiatric evaluation dated 4/16/18 stated "[He/she] is physically stable, friendly, able to communicate [his/her] needs, and assured treatment team to work on anger issues". These are not personal assets that can be utilized in the treatment planning process.

4. Patient G1 psychiatric evaluation dated 2/12/18 stated "[He/she] is physically stable. [He/she] is able to communicate [his/her] basic needs through writing. Also listed as a patient strength was "[He/she] was provided a hearing aid, but [he/she] sometimes has a problem with the hearing aid and is not using it properly and [He/she] went for three appointments." These last statements are what the treatment team did and are not personal assets.

5. Patient I1 psychiatric evaluation dated 6/27/18 stated assets were "Average intelligence and ability to express [his/her] needs and wants and ability to independently attend to [his/her] ADL needs." These are not persona

Based on interview and record review, the facility failed to ensure that comprehensive treatment plans included nursing interventions to address major behavioral issues in the clinical area (e.g. self-harm, aggression to others) for 10 of 16 active sample patients (B1, C1, C2, G1, I1, I2, K1, K2, L2 and L15). This deficiency resulted in a failure to document guidelines to direct nursing personnel providing individualized care for patients.

Findings include:

A. Record Review:

1. Patient B1 - Comprehensive Treatment Plan revision dated 6/14/18.

Problem: "Delusional ideation grandiose (reported writing a number of books, multiple inventions, owing multiple lands) and paranoid in nature.....auditory hallucinations (reported hearing music and drums); history of medication non-compliance, poor insight and judgement."

Nursing: There were no documented nursing interventions.

2. Patient C1 - Comprehensive Treatment Plan revision dated 6/25/18.

Problem: "Behaviors of religious preoccupation, rambling speech, racing thoughts, argumentative, verbally and physically aggressive, irritable, uncooperative, and delusional and medication non-compliant."

Nursing: "[Name of nurse] RN, (or designee), will meet with [patient] for at least 5 mins [minutes] on Fridays at 9:30am during Healthy Promotions group to encourage and redirect [him/her] to engage in social appropriate conversations with others." This intervention did not specifically address the stated behavior-specific interventions to address these problems in the clinical area and were not identified in the plan of care.

3. Patient C2 - Comprehensive Treatment Plan revision dated 7/17/18.

Problem: "aggressive behavior, suicidal ideations."

Nursing: "[Name of nurse] RN, (or designee), w

Based on interview and document review, the facility failed to ensure that at least one Registered Nurse was present on each ward at all times on 15 of 15 certified wards during each eight hour shift and that a sufficient number of nursing personnel (RNs, LPNs and Aides) were assigned to seven (7) of 15 certified wards to provide safe, adequate care to the patients on all shifts of duty. These staffing failures hinder quality patient care and results in a safety risk for all patients and staff on these certified units. (Refer to B150)

Based on record review and interview, the Medical Director failed to monitor and take corrective action to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. Specifically the Medical Director failed to provide psychiatric evaluations that reported memory functioning in measurable terms for eight (8) of 16 sample patients (B116) and that included an adequate assessment of patients' assets in 10 of 16 active sample patients (B117). These failures compromise the database from which diagnoses are determined and from which changes in response to treatment may be measured and in choosing treatment modalities which best utilize the patient's attributes in treatment.

Based on observation, record review and interview, the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. Active treatment interventions documented by Registered Nurses for 10 of 16 active sample patients (B1, C1, C2, G1, I1, I2, K1, K2, L2 and L15) were linked to specific behavioral issues in the clinical area (e.g. potential self-harm and aggression to others). These failures to develop focused, individualized interventions can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122).

II. Ensure that at least one Registered Nurse was present on each ward at all times on 15 of 15 certified wards during each eight hour shift. This failure results in wards being without professional nurses to assess and monitor patient care and provide supervision and direction for para-professionals (licensed Practical Nurses and aides)." (Refer to B150, Section I)

III. Ensure that a sufficient number of nursing personnel (RNs, LPNs and Aides) were assigned to seven (7) of 15 certified wards to provide safe, adequate care to the patients on all shifts of duty. Due to the high census of acutely ill patients and various off ward duties performed by nursing personnel, many shifts were not sufficiently staffed. This failure hinders quality patient care and results in a safety risk for all patients and staff on these certified wards. (Refer to B150, Section II)

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

I. Ensure that at least one Registered Nurse (RN) was present on all shifts and at all times on 15 of 15 wards (Beistel Building (Bldg.) Wards C1, C2, B3 and B4; Greizman (GM) Bldg. Wards 1, 2, 3, 4; Renner Building Wards 1, 2, and 4; and Wiseman Bldg. Wards North1, North 2, South 1 and South 2). RNs were required to attend several activities that take them off their assigned ward during the course of their shift. This pattern of staffing results in wards being without a professional nurse to assess and monitor patient care and to provide supervision and direction for para-professionals staff (Licensed Practical Nurses and Aides). This staffing pattern also hinders the provision of active psychiatric care.

Findings include:

A. Registered Nurses are assigned tasks/activities such as responding to codes, acting as building supervisor whilst still covering their assigned ward, leaving the ward to provide the oncoming building supervisor with end of shift report, assigning nursing personnel for upcoming shift within their assigned building, and taking their meal breaks. During these absences there was no scheduled RN relief. Instead, RNs were required to make arrangements with a peer in the building to provide coverage when they were off the ward.

B. Document Review

The "Direct Nursing Staffing Form" completed by each building supervisor for a 7 day period, including the first day of the survey (9/10/18), revealed that the following Wards on several occasions had 1 Registered Nurse assigned to the shift. On one occasion (9/10/18) one registered nurse was assigned to two wards.

1. Beistel Building

a. Ward C1

1). 4 of 7 days, the day shifts were staffed wit