HospitalInspections.org

Based upon a review of records, documents, and interviews with staff and patients, the facility failed to:

I. Include in the Psychosocial Assessments ("Emergency Evaluation") for eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3 and C7) the anticipated social service role in treatment and discharge planning. This failure results in the treatment team not having available documentation of what efforts the social work staff will be attempting. (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 (A11, A12, A13, B1, B7, B10, C3 and C7). Specifically, the MTPs did not include: (1) Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119)

(2) Observable and measurable short-term goals written in behavioral terms (Refer to B121)

(3) 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. Appropriately evaluate and document episodes of restraint for five (5) of five (5) non- sample patients (D1, D2, D3, D4 and D5) whose records were selected to review episodes of restraint. Specifically, the facility failed to:

A. Provide a comprehensive one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements;

B. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed restraint (physical hold); and

C. Provide documented evidence regarding the competency of RN to complete the face-to-face assessment. These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to patients. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients. (Refer to B125-I)

IV. Ensure that two (2) non-sample active patients (D6 and D7) were provided privacy and dignity. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients and poses a safety risk. (Refer to B125-II)

Based on medical record review and staff interview it was determined that the facility failed to include in the Psychosocial Assessments ("Emergency Evaluation") for eight (8) of eight (8) patients the anticipated social service role in treatment and discharge planning. This failure results in the treatment team not having available documentation of what efforts the social work staff will be attempting. (Patients A11, A12, A13, B1, B7, B10, C3 and C7).

Findings include:

A. Medical Record Review

1. Patient A11: The Psychosocial Assessment dated 2/22/16 had no information about what social services would be provided in either treatment or discharge planning.

2. Patient A12: The Psychosocial Assessment dated 2/26/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills. Upon release from the Center the individual should continue with medication management, and counseling to develop a better understanding of his/her mental health issues and to develop better coping skills and employment skills. He/she would benefit from linkage to the Haven for counseling and support." Psychiatric evaluation, medication management and day treatment activities are not descriptive of what efforts social service staff will be pursuing.

3. Patient A13: The Psychosocial Assessment dated 2/29/16 stated "Patient A13 would benefit from continued psychiatric treatment and acute stabilization." There was no description of what social service staff would be pursuing in treatment and discharge planning.

4. Patient B1: The Psychosocial Assessment dated 2/27/16 has no formation about what social service staff will be pursuing in treatment and discharge planning.

5. Patient B7: The Psychosocial Assessment dated 2/24/16 stated "Information retrieved from prior evaluation by this evaluator on 2/11/16." There was no apparent update, nor a description of what efforts the social service staff would be pursuing.

6. Patient B10: The Psychosocial Assessment dated 2/27/16 stated "Individual would benefit from acute inpatient admission for psychiatric evaluation and possible medication management. Intensive trauma informed therapy would be highly beneficial and should continue upon his/her discharge. Follow up appointment within 7 days of discharged [sic]."

7. Patient C3: The Psychosocial Assessment dated 2/07/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills." There was no description of what efforts the social service staff would be pursuing.

8. Patient C7: The Psychosocial Assessment dated 2/22/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills." There was no description of what efforts the social service staff would be pursuing.

B. Staff Interview

On 3/03/16 at 11:30AM the Director of the Department of Social Services (not a Social Worker by degree) and the facility's Master Level Social Worker who works in conjunction with the Director were interviewed. They were shown the findings described in Section I. above. The anticipated role of the social service staff that would be a part of a complete Psychosocial Assessment was discussed. The Director stated "I won't be able to show that, but I think it is implicit." The Master Level Social Worker agreed that there was no explicit statement regarding what efforts the social service staff would be pursuing in treatment and discharge planning.

Based on medical record review and staff interview it was determined that for six (6) of eight (8) patients the Psychiatric Evaluations failed to describe patient assets in descriptive not interpretive fashion. This failure results in the treatment team not being aware of potential strengths that might be utilized in setting up treatment interventions. (Patients A11, A13, B7, B10, C3 and C7).

Findings include:

A. Medical Record Review:

1. Patient A11: The Psychiatric Evaluation dated 2/23/16 had no assessment of patient assets described.

2. Patient A13: The Psychiatric Evaluation dated 2/29/16 had no assessment of patient assets described.

3. Patient B7: The Psychiatric Evaluation dated 2/24/16 had no assessment of patient assets described.

4. Patient B10: The Psychiatric Evaluation dated 2/28/16 had no assessment of patient assets described.

5. Patient C3: The Psychiatric Evaluation dated 2/08/16 had no assessment of patient assets described.

6. Patient C7: The Psychiatric Evaluation dated 2/23/16 had no assessment of patient assets described.

B. Staff Interview

On 3/03/16 at 12:30 p.m. the facility's clinical director was interviewed. He was shown the findings described in Section I. above. After checking his computer to assure himself that these Psychiatric Evaluations lacked an assessment of patient assets, he told the surveyor that the printed Psychiatric Evaluations that had been provided by the facility's Risk Manager were reflective of the absence of this type of assessment.

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) patients the Master Treatment Plan or Review failed to have individualized psychiatric problem statements written in behavioral and descriptive terms. Instead the stated problems included diagnoses and/or generalized and contradictory statements. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in each patient's condition, and revise the treatment plan when needed. (Patients A11, A12, A13, B1, B7, B10, C3 and C7).

Findings include:

A. Medical Record Review

1. Patient A11: The Master Treatment Plan dated 2/22/16 stated for Problem 1 "Psychosis" and provided for the "Baseline: [Patient A11] is mute and unable to express [him/herself ] at time of admission, has a history of hallucinations. For Problem #2 "Violence risk: directed toward self " and provided the "Baseline: [A11] is having suicidal ideation according to [his/her] COP [sic]." The "Treatment Plan Review" dated 2/24/16 had the same Problems and Baseline statements. These statements failed to provide a behavioral description of hallucinations such as hearing voices and how the hallucinations affected her behavior. There was also no description regarding the content of the suicidal ideation.

2. Patient A12: The Master Treatment Plan dated 2/26/16 stated for Problem 1 "Anxiety" and provided for the "Baseline: Patient A12 denies thoughts of self harm at this time, stated he/she had S.I.(suicidal ideation) earlier but denies having a plan, means or availability d/t[sic] he/she has children." For Problem #2 "Ineffective Coping" provided for the "Baseline: Patient A11 denies thoughts of self harm at this time, stated he/she had S.I.(suicidal ideation) earlier but denies having a plan, means or availability d/t[sic] he/she has children." The "Treatment Plan Review" dated 3/01/16 had the same Problems and Baseline statements.

2. Patient A13: The Master Treatment Plan dated 2/29/16 had as Problem #1 "Violence risk: directed toward others." There was no description of what might occur or who the violence might be either individually or generally directed. Also. Problem #2 (the same Problem as Problem#1) lacked any statement as to how this was or would be manifested behaviorally.

3. Patient B1: The Master Treatment Plan dated 2/28/16 had as Problem #1 "Depressed Mood." There was no further description of the manifestations behaviorally of this symptom.

4. Patient B7: The Master Treatment Plan dated 2/24/16 had as Problem #1 "Violence risk: directed toward others." There was no description of the behavioral manifestation of this issue.

5. Patient B10: The Master Treatment Plan dated 2/28/16 had as Problem #1 "Psychosis" and Problem #2 "Psychosis." Neither of these Problems had a description of what this meant behaviorally.

6. Patient C3: The Master Treatment Plan dated 2/23/16 stated as Problem #1 "Alteration in thought process (geriatric)." There was no description behaviorally regarding what this symptom meant.

7. Patient C7: The Master Treatment Plan dated 2/23/16 stated as Problem #1 "Ineffective coping" and "Baseline: Patient C7 denies any S.I. at this time." For Problem #2 "Anxiety" and "Baseline: Patient C7 stated he/she does not have anxiety, 'I am a happy camper'." There was no description behaviorally regarding what this symptom meant and failed to describe "ineffective coping" behaviorally.

B. Staff Interview

On 3/04/16 at 10:00 a.m. the facility's Risk Manager was interviewed by the surveyors. She was shown examples of Problem statements as described in Section I. above. She did not dispute the findings.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3 and C7) that identified individualized patient-oriented short-term goals (called objectives by the facility) stated in observable, measurable, and behavioral terms. Specifically, the facility continued to have objectives that did not include what the patient would do to lessen the severity of problems identified on admission. In addition, the objectives did not define patient outcomes or areas of patient improvement, were not specific, or they described routine hospital functions performed by clinical staff. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings include:

A. Medical Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A11 (2/22/16), A12 (2/26/16), A13 (2/29/16), B1 (2/28/16), B7 (2/24/16), B10 (2/28/16), C3 (2/23/16) and C7 (2/23/16). This review revealed the following deficient objectives for psychiatric problems. Several objective statements were identical despite each patient ' s different problems and presenting symptoms.

1. Patient A11's MTP listed the following deficient objectives for the objectives for the problem # 1: "Psychosis" and problem #2: "Violence risk: directed toward self."

Objective 1:1: "Evaluate need for psychiatric medications/consults/referrals." This objective was actually a routine hospital function performed by licensed nursing staff. It was not written as a patient oriented goal that included the action statement(s) regarding the patient's understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge.

Objective 2.1: "Evaluate need for psychiatric medications/consults/referrals." This was an identical statement for a different problem. This objective was not patient oriented and was a routine hospital function assigned to license nursing staff not an objective for the patient.

2. Patient A12's MTP listed the following deficient objectives for the problems of "Ineffective coping."

Objective 1.1: "Client will function for one entire day without anxiety, agitation, or obsessive doubts." This objective was not measurable and because the problem statement was very global with no behavioral description of anxiety, agitation, etc., it would be difficult for staff to determine whether the patient had achieved the objective.

Objective 2.1: "Evaluate need for psychiatric medications/consults/referrals."

Objective 2.2: "[Patient's name] will attend 90% of scheduled activities for three consecutive days. Although measureable and specific, this objective was actually a staff expectation and it was not related to improving an identified psychiatric problem related to the reason(s) for the patient's admission.

3. Patient A13's MTP listed the following deficient objectives for the problem #1 and #2: "Violence risk: directed toward others."

Objective 1:1: "Identify the relationship between mental illness symptoms and anger control problems. This objective was not measurable and was very broad. Because problems statement contained no behavioral descriptions of symptoms of mental illness and anger, it would be difficult for staff to know when and if the patient achieved this objective.

Objective 2.1: "[Patient's name] will attend psychoeducational groups. This objective was not patient oriented and not related to the patient's presenting psychiatric symptoms.

Objective 2.1: "[Patient's name] will work with the doctor to control paranoid symptoms. This objective was a staff expectation and not a patient outcome related to what the patient would be doing or saying to improve his or her presenting psychiatric symptoms.

4. Patient B1's MTP listed the following deficient objectives for the objectives for the problem # 1: "Depressed Mood" and problem #2: "Stability in living situation."

Objective 1.2: "[Patient's name] will gain knowledge on Depression."

Objective 2.1: "accept and review list of shelters."

Objective 2.2: "make phone calls to see if there are available beds."

Objective 1.1 was very broad and not measureable and behaviorally specific. Objective 2.2 was a clinical function usually performed by social work staff.

5. Patient B7's MTP listed the following deficient objectives for problem # 1: "Violence risk: directed toward self " and problem #2: "Auditory, visual, or tactile hallucinations resulting in impaired functioning."

Objective 1.1: "Evaluate need for psychiatric medications/consults/referrals."

Objective 1.2: "[Patient's name] will practice one specific strategies for managing conflicts without emotional outbursts or physical aggression." This objective was not measurable and failed to identify behavioral descriptive outcomes.

Objective 2.1: "Demonstrate understanding of the medication by taking as prescribed. This objective was not measurable and did describe what the patient would be doing or saying to show understanding of medications. Taking prescribed medications would not necessarily correlate with the patient's understanding his or her medications.

6. Patient B10's MTP listed the following deficient objectives for problems # 1: "Psychosis" and problem #2: "Psychosis." [The same problem was repeated twice].

Objective 1.1. "Modify the environment to decrease the stimuli and the effects of psychotic confusion." This was a staff function not a patient outcome related to the patient's improvement in presenting psychiatric symptoms.

Objective 1.2: [Patient's name] will work with Doctor to control symptoms.

Objective 2.1: [Patient's name] will demonstrate willingness to take medications as prescribed. "

Objective 2.1: [Patient's name] will attend 90% of scheduled activities for three consecutive days.

7. Patient C3's MTP listed the following deficient objectives for problem of "Alteration in thought processes (geriatric)."

Objective 1.1: "Evaluate need for psychiatric medications/consults/referrals."

Objective 1.2: "[Patient's name] will improve in orientation." This objective was not measureable and did not identify descriptive behavioral outcomes the patient would exhibit.

8. Patient C7's MTP listed the following deficient objectives for problem # 1: "Ineffective coping," problem #2: "Anxiety," and problem #3: "Mania/Hypomania."

Objective 1.1: "Evaluate need for psychiatric medications/consults/referrals."

Objective 3.1: "[Patient's name] will demonstrate understanding of need for medication."

Objective 3.2: "[Patient's name] will accept psychoeducational groups."

B. Staff Interviews

1. In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, MTPs were reviewed. She acknowledged that the objectives developed by registered nurses were not specific patient oriented goals and did not dispute that many objectives were staff functions or clinical tasks performed by licensed nurses.

2. In an interview on 3/4/16 at 10:00 a.m. with the Risk Manager, the treatment plans were reviewed. She agreed that objectives were not patient oriented and that several objectives were related to staff expectations and routine clinical tasks instead patient outcome statements. She noted that they were changing their electronic medical record system and these objective statements would be corrected at that time.

Based on observation, record review, document review, and interview, the facility failed to provide eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3, and C7) with Master Treatment Plans (MTPs) that included individualized active treatment interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Specifically, the facility continued to have MTPs that: (a) included routine discipline functions selected from options on the facility's electronic medical record. These options written as treatment interventions were generic, vague, and global statements without an identified method of delivery; (b) included a separate treatment plan to be implemented by the attending psychiatrist. These plans were all identical and contained no active treatment interventions related presenting psychiatric problems identified for eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3 and C7) and (c) failed to include a nurse led group on the treatment plan that was listed on the unit schedule and attended by four (4) of eight (8) active sample patients (A11, A12, A13 and C3). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

I. Failure to include individualized treatment intervention

A. Medical Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A11 (2/22/16), A12 (2/26/16), A13 (2/29/16), B1 (2/28/16), B7 (2/24/16), B10 (2/28/16), C3 (2/23/16), and C7 (2/23/16). This review revealed the following interventions reflecting deficient practice.

1. Patient A11's MTP included the following non-specific interventions for the problems identified below:

Problem #1 - "Psychosis."

RN Interventions: "Approach an acutely psychotic client in a calm, confident, open, direct manner..."

Problem #2 - "Violence risk: directed toward self."

RN Intervention: "Identify behavior of violence towards self and place on precautions."

Rehabilitation (Activity Therapy): "AT/Rehab to help patient develop leisure skills as alternative methods of coping and self expression."

Problem #3 - "Speech, behavior, or reports indicating significant danger to self."

SW [Recovery Specialist (RS)] Intervention: "RS will assess [Patient's name] status on ongoing basis." "[Patient's name] will attend psychoeducational groups."

The RN and SW interventions above were routine discipline staff functions and were not individualized and specific to the patient's improvement related to presenting psychiatric symptoms. The AT intervention failed to include whether the intervention would be delivered in individual or group sessions.

2. Patient A12's MTP included the following non-specific interventions for the problems identified below:

Problem #1 - "Anxiety."

RN Intervention: "Help the client to apply cognitive etiology information to his or her specific symptoms and experiences of anxiety."

SW Interventions [Recovery Specialist (RS)]: "Motivational Interviewing: RS will meet with [Patient's name] daily to discuss her symptoms." "Motivational Enhancement Therapy: RS will meet with [Patient's name] daily to discuss [his/her] progress and explore new coping skills.

Problem #2 - "Ineffective coping."

RN intervention: "Encourage individual to discuss current life situations."

Rehabilitation (Activity Therapy): "Provide daily activity groups, for interpersonal development, social skills building and relaxation."

SW [Recovery Specialist (RS)] Intervention: "Illness Management and Recovery: RS will meet with [Patient's name] to determine appropriate resources and review these with [Patient's name]."

The interventions above were routine staff functions and/or were not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. Most of these intervention statements failed to include whether the intervention would be delivered in individual or group sessions.

3. Patient A13's MTP included the following non-specific interventions for the problems identified below:

Problem # 1: "Violence risk: directed toward others."

RN Intervention: "Maintain and convey a calm attitude."

Problem #2: "Violence risk: directed towards other."

SW [Recovery Specialist (RS)]: "[Patient's name] will obtain written or verbal non-harm contract." This was a patient objective not a staff intervention. "[Patient's name] will attend psychoeducational groups."

Rehabilitation (Activity Therapist): "Encourage [Patient's name] to attend groups for relaxation, exercise, and interpersonal development." "[Patient's name] will attend psychoeducational groups." [Not individualized and specific to the patient's improvement related to presenting psychiatric symptoms.]

4. Patient B1's MTP included the following non-specific interventions for the problems identified below:

Problem # 1: "Depressed Mood."

SW [Recovery Specialist (RS)]: "RS will explore with [Patient's name] obtain written or verbal non-harm contract." "Encourage [Patient's name] to attend groups for exercise and interpersonal development." "[Patient's name] will discuss triggers related to anxiety."

No active treatment interventions were identified to be implemented by RN and AT staff for Patient B1.

5. Patient B7's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Violence risk: directed toward others."

[No clinical staff assigned]: "Illness Management and Recovery." [No focus of treatment and delivery method].

Rehabilitation (Activity Therapist): "Encourage [Patient's name] to attend groups for relaxation and social skills building."

Problem #2: "Auditory, visual, or tactile hallucinations resulting in impaired functioning."

SW [Recovery Specialist (RS)] Intervention: "[Patient's name will take medications daily as prescribed by the doctor." "[Patient's name] will discuss any negative symptoms or side effects with the doctor or staff." [No delivery method].

There were no RN interventions for any of the problems identified on the MTP for this patient.

6. Patient B10's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Psychosis."

MD Intervention: "Jonathan will provide information to Doctor for use in alleviating situation." [This was a patient objective not an intervention to be provided by the MD].

RN Interventions: "Help the client identify specific environmental trigger patters [sic] for acute psychotic episodes based on his/her history." [No delivery method included].

Rehabilitation (Activity Therapist) Intervention: "Encourage [Patient's name] to attend groups for relaxation and social skills building."

Problem #2: "Psychosis."

SW [Recovery Specialist (RS)] Intervention: "[Patient's name will take medications as ordered." [This was not an intervention to be provided by the SW.] "[Patient's name] will attend psychoeducational groups." [This intervention was not individualized and specifically related to the patient's presenting psychiatric symptoms.]

7. Patient C3's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Alteration in thought processes (geriatric)."

RN Interventions: "Promote communication and sensory input." [This intervention statement was very broad and had no delivery method included].

Rehabilitation (Activity Therapist) Intervention: "Encourage [Patient's name] to attend groups for reality orientation, yoga and interpersonal development. relaxation and social skills building." [This intervention was not individualized and failed to include a focus of treatment related to the patient's presenting psychiatric symptoms.]

Problem #2: "Alcohol or drug intoxication or abuse."

SW [Recovery Specialist (RS)] Intervention: "[Patient's name will discuss triggers to substance abuse." [This was a patient objective not an intervention to be provided by the SW to assist the patient to accomplish treatment objective].

8. Patient C7's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Ineffective coping."

RN Interventions: "Encourage individual to discuss current life situations." [This intervention statement was very broad and had no delivery method included].

Rehabilitation (Activity Therapist) Intervention: "Encourage [Patient's name] to attend groups for interpersonal development and exercise." [This intervention was not individualized and failed to include a focus of treatment related to the patient's presenting psychiatric symptoms.]

Problem #2: "Anxiety."

RN Intervention: "Provide the client with specific information re: anxiety disorders and phobias." [This intervention statement was very broad and had no delivery method included].

Problem #3: "Mania/Hypomania."

SW [Recovery Specialist (RS)] Intervention: "[Patient's name will attend psychoeducational groups." [This intervention was not individualized and specifically related to the patient's presenting psychiatric symptoms.]

The interventions cited above in items one (1) through eight (8) revealed that the MTPs included routine and generic statements written as treatment interventions to be delivered by registered nurses (RN) and social workers (SW) [recovery specialists]. Several interventions were written reflecting what the patient will do instead of what the staff will do to assist the patient. Therefore, clinical staff confused staff interventions with patient objectives. In additions, many interventions failed to include all of the components of an active treatment intervention, including the focus of treatment based on each patient's presenting psychiatric problems and the method of delivery (individual or group sessions). Several intervention statements were identical or similarly worded.

B. Staff Interviews

1. In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, MTPs were reviewed. She acknowledged that some interventions were routine nursing tasks and that they were not individualized and specific statements to assist patients to improve presenting psychiatric symptoms.

2. In an interview on 3/4/16 at 10:00 a.m. with the Risk Manager, the treatment plans were reviewed. She did not dispute that interventions were routine clinical tasks and not individualized. She noted that interventions many of the current problems with interventions would be corrected in the modified electronic medical record.

II. Failure to include MD interventions related to psychiatric problems

The separate treatment plans submitted by the facility for the attending psychiatrics were reviewed (dates of plans in parentheses): A11 (2/23/16), A12 (2/26/16), A13 (2/29/16), B1 (2/29/16), B7 (2/24/16), B10 (2/29/16), C3 (2/08/16), and C7 (2/23/16). This review revealed the following deficient practice.

A. Medical Record Review

All of the active sample patients had the following identical plan titled "Treatment Plan - Inpatient Medical Modalities" in their medical record:

"Goal: [Patient's name] will report significant reduction in symptoms and behaviors that impair functioning.

Objective: To assess the consumer's need for medications based on the clinical presentation. Units: 1. Description: Psychiatric Evaluation/IP [Inpatient Patient]
Frequency: One time per admission. Days: 30.

Objective: The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis. Units: 30. Description: Psychiatric Doctor Services/Ongoing evaluation. Frequency: One time per week. Days: 30

Objective: To assess the consumer's physical health and well-being. Units: 1. Description: Initial H&P [History and Physical]. Frequency: One time per admission. Days: 30."

This document was not a treatment plan that met CMS requirements. This was actually a plan regarding routine services that would be provided any patient regardless of their presenting symptoms and needs.

III. Failure to Include a Group Attended by Patients on the Master Treatment Plan

A. Document Review and Observations

1. A review of the facility's "Daily Schedule of Unit Activities" revealed that a "Nurses Group" was schedule daily at 9:45 a.m. and at 6:00 p.m. This group was not included on the MTPs for Patients A11, A12, A13, B1, B7, B10, C3 and C7.

2. During observation on 3/2/16 at 10:00 a.m., active sample patients A11, A12 and A13 were observed in the dayroom attending and participating in a "Nurses Group" conducted by RN1. The topic of the group was "Watching for Medicine Side Effects" and a handout was distributed to patients attending. This group was not included on these patients' MTP.

3. During observation on 3/3/16 at 9:45 a.m., active patient C3 was observed in the dayroom attending a "Nurses Group" conducted by LPN2. The topic of the group was regarding positive thinking and the LPN read to patients attending the group. This group was not included on this patient's MTP. During interview on 3/3/16 at 10:15 a.m., LPN 2 admitted that some patients had cognitive dysfunctions and may have not understood the content. She also agreed that many patients were not listening.

B. Staff Interviews

In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, MTPs were reviewed. She acknowledged that "Nurses Group" listed on the unit schedules and attended by patient was not on the MTP and should be included.

Based upon record and document review, direct observation, and interviews, the facility failed to:

I. Appropriately evaluate and document episodes of restraint for five (5) of five (5) non- sample patients (D1, D2, D3, D4 and D5) whose records were selected to review episodes of restraint. Specifically, the facility failed to:

A. Provide a comprehensive one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements. Four (4) of five (5) face-to-face assessments [DAP Notes] for (D1, D2, D3 and D4) were completed by a Licensed Practical Nurse (LPN) rather than a trained RN. Three (3) of five (5) "Seclusion or Restraint Record" were completed by a LPN instead of a trained RN.

B. Ensure that Master Treatment Plans (MTPs) were revised when five (5) of five (5) non-sample patients (D1, D2, D3, D4 and D5) were placed restraint (physical hold). Specifically, MTPs were not revised to reflect problem statements related to the use of restraint to control aggressive behavior, identification of treatment goals and interventions outlining healthy alternatives and approaches for patients to use to replace aggressive behavior(s).

C. Provide documented evidence regarding the competency of RN to complete the face-to-face assessment.

These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to patients. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients.

II. Ensure that two (2) non-sample active patients (D6 and D7) were provided privacy and dignity. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients and poses a safety risk.

Findings include:

I. Failure to appropriately document after the initiation of restraint

A. Face-to-Face Assessments

1. Record and Document Review - DAP [Data, Assessment, and Plan] notes, incident reports provided by the facility for selected incidents of seclusion and restraint were reviewed for adherence to facility policy and CMS guidelines. There was no comprehensive record containing a linear and organized account of the patient's response to these interventions nor a detailed assessment of an individual's medical needs as required by CMS guidelines and facility policy.

a. Patient D1 experienced the following episodes that required a physical hold:

- on 2/3/16, at 6:00 p.m. the incident reported patient was "Screaming, cursing at staff, throwing things, threatening staff...Team technique was used to escort [Patient's name]... Placed in a prone position and an ETO [Emergency Treatment Order] of Ativan 2 mg., Benadryl 50 mg., Zyprexa 10 mg. The DAP note dated 2/3/16 [submitted by the facility as the face-to-face assessment] was completed by a LPN. The facility's "Seclusion or Restraint Record" dated 2/3/16 was also reported to include information for the required one hour face-to-face assessment. This form, signed by a LPN, documented that the patient was restrained at 6:10 p.m. for 20 minutes and noted that, "4 staff physically restraining on bed." This form also noted the patient's behavior and staff action related to the physical hold using a reprinted checklist. The facility did not provide a comprehensive one-hour face-to-face assessment completed by a physician, physician assistant, or trained RN. There was no order for this physical hold.

- On 2/5/16 at 7:30 a.m., the incident report noted patient, "Screaming obscenities to staff, threatening to harm staff...Dr. Strong [Facility's code alert for aggressive behavior] called... Team technique [Physical hold] used and medication administered..." Another episode occurred at 9:30 a.m. and the patient was reported to be, "Physically & verbally abusive... Dr. Strong called. Physical hold administered while medication was administered." The DAP note dated 2/5/16 [submitted by the facility as the face-to-face assessment] was completed by a LPN. The facility's "Seclusion or Restraint Record" dated 2/5/16 was also reported to include the one hour face-to-face assessment. This form documented that the patient was restrained at 9:30 a.m. The form, signed by a LPN, noted the patient's behavior and staff action related to the physical hold using a preprinted checklist. The facility did not provide a comprehensive one-hour face-to-face assessment completed by a physician, physician assistant, or trained RN.

b. Patient D2 experienced an episode that required a physical hold on 2/3/16 at 7:30 p.m. The incident report noted patient was, "Throwing flip flog at staff, screaming at staff...ripping items off walls...[Patient's name] was placed in a team hold...ETO [Emergency Treatment Order] of Ativan 2mg...was administered." The DAP note dated 2/3/16 [submitted by the facility as the face-to-face assessment] was completed by a LPN. The facility's "Seclusion or Restraint Record" dated 2/3/16 was also reported to include the one hour face-to-face assessment. This form documented that the patient was restrained at 7:45 p.m. This form, completed by a RN, noted the patient's behavior and staff action related to the physical hold using a reprinted checklist. The facility did not provide a comprehensive one face-to-face assessment completed by a physician, physician assistant, or trained RN. There was an order for medications but no order for the physical hold.

c. Patient D3 experienced an episode that required a physical hold on 2/2/16 at 7:40 a.m. The incident report noted, "...consumer behavior began to escalate out of control...got into the shower...walking up and down hallway and refusing to get dryed [sic] off...pushed [his/her] way into the shower again scratching staff...Dr. Strong was called...Benadryl 50 mg., Ativan 2 mg., and Haldol 5 mg. given IM...The DAP note dated 2/3/16 [submitted by the facility as the face-to-face assessment] was completed by a LPN. The facility' "Seclusion or Restraint Record" dated 2/2/16 was also reported to include the one hour face-to-face assessment. This form documented that the patient was restrained and noted, "four (4) staff physically restraining." The form, completed by a RN, noted the patient's behavior and staff action related to the physical hold using a reprinted checklist. The facility did not provide a comprehensive one-hour face-to-face assessment completed by a physician, physician assistant, or trained RN. There was an order for medications but no order for the physical hold.

d. Patient D4 experienced an episode that required a chemical restraint [as defined by the facility] on 2/21/16 at 8:30 p.m. The incident report noted, "[Patient's name] began ripping his pants apart and refused to stop...[S/he] was assisted to [his/her] room to change...[s/he] began [sic] combative [with] staff...ETO ordered." The DAP note dated 2/21/16 [submitted by the facility as the one-hour face-to-face assessment] was completed by a LPN. This note reported, "The staff had to struggle to stop him from hurting himself and getting the gown away from his neck." The facility's "Seclusion or Restraint Record" dated 2/21/16 was also reported to be used to document the one hour face-to-face assessment. This form documented restraint but noted, "3/3/16 per manager, this is an error. [sic[, there is no use of mechanical restraint only chemical." This form, completed by a RN, noted the patient's behavior and staff actions using a reprinted checklist. The facility did not provide a comprehensive one-hour face-to-face assessment completed by a physician, physician assistant, or trained RN.

e. Patient D5 experienced an episode that required a physical hold on 2/16/16 at 7:05 p.m. The incident report noted, "...Consumer became extremely agitated with hallucinations...Screaming inappropriate verbage [sic]...Consumer running at full speed into doors and striking doors and walls with arms and fists..." The DAP note dated 2/16/16 [submitted by the facility as the required one-hour face-to-face assessment] was completed by a RN. This note reported, "Consumer restrained in a 4 point hold using team technique and assisted to room...obtained ETO 2 mg Ativan, 10 mg Haldol, 50 mg Benadryl..." The facility' "Seclusion or Restraint Record" dated 2/16/16 was also reported to represent the one hour face-to-face assessment. This form documented that the patient was restrained at 7:10 p.m. The form, completed by a RN, noted the patient's behavior and staff action related to the physical hold using a reprinted checklist. The facility did not provide a comprehensive one-hour face-to-face assessment completed by a physician, physician assistant, or trained RN. There was an order for medications but no order for the physical hold.

f. There was no appropriate and comprehensive documentation of the restraint episodes experienced by Patients D1, D2, D3, D4 and D5. The documentation submitted failed to report complications if any or pertinent observations which might be helpful in case a similar intervention was needed in the future. In addition, there was no assessment of the patient's medical condition that included a review of systems and no assessment of the patient's behavioral condition by a physician or specially trained registered nurse as required by CMS.

2. Policy Review

The facility failed to include CMS all requirements regarding physical hold in policies. The facility's policy titled: "Special Treatment Procedures-Operational Procedures" signed 2/28/16 indicated, "Special treatment procedures shall be limited to the use of seclusion and three types of restraint: physical hold, chemical and mechanical." The language in the policy did not require a physician order and a one-hour face-to-face assessment for a physical hold. The policy only referenced this requirement for seclusion and mechanical restraint. The facility's policy titled, "Special Treatment Procedures - Physical Hold" also did not contain language requiring a physician order and an one-hour face-to-face assessment when a patient is placed in a physical hold.

3. Interviews

In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, the seclusion and restraint procedures were reviewed. She reported that the one-hour face-to-face assessment was documented on the DAP notes. She stated the she consider the debriefing on the "Seclusion or Restraint Record" to meet the face-to-face assessment requirement.

In an interview on 3/4/16 at 10:00 a.m. with the Risk Management, the DAP containing the face-to-face assessments were reviewed for Patient D1 and D2. She agreed that the one-hour face-to-face assessment was to be done by a LPN instead of a RN.

B. Failure to revised MTP after episodes of restraint

1. Medical Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): D1 (2/3/16), D2 (12/23/15), D3 (2/2/16), D4 (2/18/16), and D5 (2/16/16) This review revealed the Master Treatment Plans were not revised to reflect a problem statement regarding the multiple use of a restraint procedure, treatment goals, and interventions to reflect alternatives to restraint and approaches the patient could use to replace aggressive behavior(s). Patients D2 and D3 contained a goal statement reducing the need for ETOs, however did not include interventions to assist the patient to use alternatives to aggressive behavior.

2. Policy Review

A review of the facility's policy titled "Special Treatment Procedures-Restraints" contained no provisions to revise the Master Treatment Plan (MTP) after an episode of seclusion or restraint in accordance with CMS requirements. There were no provisions to revise the MTP included in the facility's policy titled, "Special Treatment Procedures - Physical Hold."

3. Interview

In an interview on 3/4/16 with the Risk Manager MTPs were reviewed regarding episodes of restraint. She admitted that not all of the plans contained a statement regarding the use of restraint and acknowledged that plans did not contain interventions to assist the patient to use alternative strategies.

C. Failure to demonstrate competence of RN to complete the one-hour face-to-face assessment.

1. Document Review

The facility was not able to show that registered nurses (RN) were competent to complete the one-hour face-to-face assessment. The facility submitted evidence of a sign-in sheet titled, "Staff Development Attendance Report" and "Acknowledgement of Training Procedure" showing that 12 RNs had been trained. The facility had no evidence that these RNs had been given written tests and/or performed return demonstrations to show demonstrated competency to complete the one-hour face-to-face assessment. In addition, there was only a verbal report of what was included in the training for RN to complete the one-hour face-to-face assessment.

2. The facility failed to include staff training requirements regarding use of seclusion and restraint in policy. There were no specific requirements for training and demonstrated competence included in the policy titled: "Special Treatment Procedures-Operational Procedures" signed 1/28/16 and the policy titled "Special Treatment Procedures - Physical Hold" also signed 1/28/16.

3. Interview

In an interview on 3/4/16 at 11:30 a.m., the Director of Nursing admitted that she had no written evidence to show competency of RNs to complete the one-hour face-to-face assessment. She also confirmed that there was no written evidence of the content included in the face-to-face assessment training. She was only able to provide a verbal account of the content.


II. Lack of privacy and potential for harm

A. Observation and Interview

1. On 3/03/16 at 10: 05 a.m. the surveyor observed a non-sample patient (D6) on the male Unit asleep on a mat in the Dayroom covered by a sheet in front of the Nurses' Station. In interview with RN #2, the charge nurse of the Unit, the surveyor was told that this patient was on "C.V.O" (Continuous Visual Observation). She stated that when this has been ordered by the psychiatrist, nursing staff place the patient in front of the Nurses' Station to accomplish this level of "Special Treatment." RN #2 also reported that in the past as many as four (4) patients might be so situated. This report and acknowledgement of having patients sleep on mattresses by the Nurses' Station was confirmed by the facility's Risk Manager on 3/03/16 at approximately 2:00 p.m.

2. On 3/04/16 at 9:15 a.m. on the female Unit LPN #1 reported that patient (D7) had spent the night in front of the Nurses' Station on C.V.O. "We keep them in the hallway in front of the Nurses' Station. We usually pick up the mattresses before breakfast because we consider them a safety hazard."

B. Policy Review

The facility policy regarding patient observation was reviewed and this policy titled
"Special Treatment Checks- Guidelines" stated, "If continuous visual observation is ordered, staff must maintain visual contact at all times (including shower and bathroom)." The policy did not contain language regarding placing patients in front of the Nurses' Station or being placed on a mattress to sleep for safety reasons or provide guidelines for staff using the procedure.

Based on medical record review and staff interview it was determined that the clinical director failed to monitor the quality and appropriateness of the following issues for eight (8) of eight (8) patients (Patients A11, A12, A13, B1, B7, B10, C3 and C7).

Findings include:

I. That Psychosocial Assessments of patients fulfilled the requirement that the proposed efforts of social service staff be included. For details, see B108.

II. That the Psychiatric Evaluations contained an assessment of patient assets in descriptive not interpretive fashion. For details, see B117.

III. That Treatment Plans have Problems expressed behaviorally. For details, see B119.

IV. That Treatment Plans contain both long and short-term goals. For details, see B121.

V. That Treatment Plans described the specific treatment modalities utilized. For details, see B122.

VI. That following restrictive measures such as physical holds and chemical restraint a face-to-face assessment be documented appropriately in the patient's chart. For details, see B125 Part I.

VII. That patient rights such as privacy was pursued and that potentially harmful situations were avoided. For details, see B125 Part II.

Based on observation, record review, and interview, the facility failed to have a Director of Nursing (DON) to provide adequate oversight to ensure quality nursing services. Specifically, the facility failed to monitor to:

I. Provide eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3 and C7) with Master Treatment Plans (MTPs) that included individualized active treatment interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Specifically, the facility continued to have MTPs that included routine nursing functions selected from options on the facility's electronic medical record. These options written as treatment interventions were generic, vague, and global statements and often written as patient outcomes rather than nursing interventions. These intervention statements failed to identify a method of delivery. In addition, MTPs failed to include a nurse led group on the treatment plan that was listed on the unit schedule and attended by four (4) of eight (8) active sample patients (A11, A12, A13, and C3). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

Failure to include individualized treatment intervention

A. Medical Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A11 (2/22/16), A12 (2/26/16), A13 (2/29/16), B1 (2/28/16), B7 (2/24/16), B10 (2/28/16), C3 (2/23/16), and C7 (2/23/16). This review revealed the following interventions reflecting deficient practice.

1. Patient A11's MTP included the following non-specific interventions for the problems identified below:

Problem #1 - "Psychosis."

RN Interventions: "Approach an acutely psychotic client in a calm, confident, open, direct manner..."

Problem #2 - "Violence risk: directed toward self."

RN Intervention: "Identify behavior of violence towards self and place on precautions."

The RN interventions above were routine discipline staff functions and were not individualized and specific to the patient's improvement related to presenting psychiatric symptoms.

2. Patient A12's MTP included the following non-specific interventions for the problems identified below:

Problem #1 - "Anxiety."

RN Intervention: "Help the client to apply cognitive etiology information to his or her specific symptoms and experiences of anxiety."

Problem #2 - "Ineffective coping."

RN intervention: "Encourage individual to discuss current life situations."

The interventions above were routine staff functions and/or were not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. These intervention statements failed to include whether the intervention would be delivered in individual or group sessions.

3. Patient A13's MTP included the following non-specific interventions for the problems identified below:

Problem # 1: "Violence risk: directed toward others."

RN Intervention: "Maintain and convey a calm attitude."

4. Patient B1's MTP included the following non-specific interventions for the problems identified below:

Problem # 1: "Depressed Mood."

No active treatment interventions were identified to be implemented by RN and/or other nursing staff for Patient B1.

5. Patient B7's MTP included the following non-specific interventions for the problems identified below:

There were no RN interventions for any of the problems identified on the MTP for this patient.

6. Patient B10's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Psychosis."

RN Interventions: "Help the client identify specific environmental trigger patters [sic] for acute psychotic episodes based on his/her history." [No delivery method included].

7. Patient C3's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Alteration in thought processes (geriatric)."

RN Interventions: "Promote communication and sensory input." [This intervention statement was very broad and had no delivery method included].

8. Patient C7's MTP included the following non-specific interventions for the problems identified below:

Problem #1: "Ineffective coping."

RN Interventions: "Encourage individual to discuss current life situations." [This intervention statement was very broad and had no delivery method included].

Problem #2: "Anxiety."

RN Intervention: "Provide the client with specific information re: anxiety disorders and phobias." [This intervention statement was very broad and had no delivery method included].

The interventions cited above in items one (1) through eight (8) revealed that the MTPs included routine and generic statements written as treatment interventions to be delivered by registered nurses (RN) and/or other nursing staff. In additions, many interventions failed to include all of the components of an active treatment intervention, including the focus of treatment based on each patient's presenting psychiatric problems and the method of delivery (individual or group sessions). Several intervention statements were identical or similarly worded.

B. Staff Interview

In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, MTPs were reviewed. She acknowledged that some interventions were routine nursing tasks and that they were not individualized and specific statements to assist patients to improve presenting psychiatric symptoms.

Failure to Include a Group Attended by Patients on the Master Treatment Plan

A. Document Review and Observations

1. A review of the facility's "Daily Schedule of Unit Activities" revealed that a "Nurses Group" was schedule daily at 9:45 a.m. and at 6:00 p.m. This group was not included on the MTPs for Patients A11, A12, A13, B1, B7, B10, C3 and C7.

2. During observation on 3/2/16 at 10:00 a.m., active sample patients A11, A12 and A13 were observed in the dayroom attending and participating in a "Nurses Group" conducted by RN1. The topic of the group was "Watching for Medicine Side Effects" and a handout was distributed to patients attending. This group was not included on these patients' MTP.

3. During observation on 3/3/16 at 9:45 a.m., active patient C3 was observed in the dayroom attending a "Nurses Group" conducted by LPN2. The topic of the group was regarding positive thinking and the LPN read to patients attending the group. This group was not included on this patient's MTP. During interview on 3/3/16 at 10:15 a.m., LPN 2 admitted that some patients had cognitive dysfunctions and may have not understood the content. She also agreed that many patients were not listening.

B. Staff Interview

In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, MTPs were reviewed. She acknowledged that "Nurses Group" listed on the unit schedules and attended by patient was not on the MTP and should be included.

II. Appropriately evaluate and document episodes of restraint for five (5) of five (5) non- sample patients (D1, D2, D3, D4 and D5) whose records were selected to review episodes of restraint. Specifically, the facility failed to:

A. Provide a comprehensive one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements;

B. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed restraint (physical hold); and

C. Provide documented evidence regarding the competency of RN to complete the face-to-face assessment. These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to patients. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients. (Refer to B125-I)

III. Ensure that two (2) non-sample active patients (D6 and D7) were provided privacy and dignity. This failure potentially contributes to continued disease symptoms and delays discharge. In addition, it is in violation of their rights as patients and poses a safety risk. (Refer to B125-II)

IV. Deploy sufficient Registered Nurses (RNs) to cover units based on the acuity needs of patients on two high acuity Adult Psychiatric Units and one Geriatric Unit. Specifically, the facility failed to consistently assign a registered nurse (RN) to cover these units. Frequently only Licensed Practical Nurses (LPNs) covered these units with only a RN supervisor and RN Lead who were assigned to cover the entire facility, which included five units and the admission/intake area. This practice results in the lack of ongoing active treatment interventions and psychiatric nursing care provided by registered nurses. In addition, this deficit practice potentially leads to an unsafe patient environment because of the lack of an immediate present of a registered nurse to provide ongoing direction and supervision to paraprofessional nursing staff (LPNs and Behavioral Technicians) in the provision of nursing care. (Refer to B150)

Based on document review, observation, and record review interview, the facility continued to fail to deploy sufficient Registered Nurses (RNs) to cover units based on the acuity needs of patients on two high acuity Adult Psychiatric Units and one Geriatric Unit. Specifically, the facility failed to consistently assign a registered nurse (RN) to cover these units. Frequently only Licensed Practical Nurses (LPNs) covered these units with only a RN supervisor and RN Lead who were assigned to cover the entire facility, which included five units and the admission/intake area. This practice results in the lack of ongoing active treatment interventions and psychiatric nursing care provided by registered nurses. In addition, this deficit practice potentially leads to an unsafe patient environment because of the lack of an immediate present of a registered nurse to provide ongoing direction and supervision to paraprofessional nursing staff (LPNs and Behavioral Technicians) in the provision of nursing care.

Findings include:

A. Document Review

1. Psychiatric Care Unit (PCU) - Female: An analysis of the staffing data collected during the survey (2/14/16 through 2/20/16 revealed that there was no RN assigned to be physically present to cover for seven (7) out of 21 shifts and was staffed with non-professional staff which included one (1) or two (2) LPNs and two (2) or three (3) Behavior Technicians. An analysis of the staffing data from 2/21/16 through 2/27/16 revealed a similar staffing pattern with seven (7) out of 21 shifts having no RN to cover this unit. Therefore, a RN was not immediately available to provide ongoing interactions with patients to provide formal and informal active treatment interventions.

a. A review of the needs assessment document for the Psychiatric Care Unit for female patients revealed a very high patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, and clinical supervision of paraprofessional staff. The Needs Assessment Document completed on the first day of the survey revealed a census of fifteen (15) patients with the following needs:

(1). Physical care needs: Two (2) patients requiring diabetic checks, six (6) patients on seizure precautions, and three (3) patients on a detoxification protocol.

(2). Psychiatric nursing care needs: Nine (9) patients potentially assaultive, nine (9) patients were considered a low suicidal risk, five (5) patients had been admitted within the last 48 hours, nine (9) patients were on assault precaution, two (2) patients were on elopement precautions, two (2) patients were on fall precautions, and four (4) patients constantly demanded staff time. In addition, the Psychiatric Care Unit for female patients reported that the average number of admission per week was ten (10) on the day shifts, six (6) on the evening shift, and one (1) on the night shift. The average number of discharges per week was ten (10) on the day shift, five (5) on the evening shift, and none on the night shift.

2. Psychiatric Care Unit (PCU) - Male: An analysis of the staffing data collected during the survey for the period of 2/14/16 through 2/20/16 revealed that there was no RN assigned to cover this unit six (6) out of 21 shifts. For the period of 2/21/16 through 2/27/16, there was no RN to cover this unit five (5) out of 21 shifts. There was only staffed with paraprofessional staff, which included one (1) or two (2) LPNs and two (2) or three (3) Behavior Technicians on these shifts.

a. A review of the needs assessment document for the Psychiatric Care Unit for male patients revealed a high patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, and provide ongoing clinical supervision of paraprofessional staff (LPNs and Behavioral Technicians). The Needs Assessment Document completed on the first day of the survey revealed a census of fourteen (14) patients with the following needs:

(1). Physical care needs: One patient on diabetic checks, five (5) patients on seizure precautions, one patient on skin care, and four (4) patients on a detoxification protocol.

(2). Psychiatric nursing care needs: Five (5) patients were potentially assaultive, one patient was actively assaultive in the last 48 hours, one (1) patient was a low suicidal risk, and one (1) patient was experiencing active hallucinations/delusions. Five patients had been admitted within the last 48 hours, one patient had been placed in restraint within the last 48 hours, five (5) patients were on assault precaution, one (1) patient was on elopement precautions, and one (1) patient was under constant line of sight supervisions. In addition, the Psychiatric Care Unit for male patients reported that the average number of admission per week was ten (10) on the day shifts, six (6) on the evening shift, and four (4) on the night shift. The average number of discharges per week was ten (10) on the day shift, five (5) on the evening shift, and none on the night shift.

3. Geriatric Unit: An analysis of the staffing data collected during the survey for the period 2/14/16 through 2/10/1 revealed that there was no RN assigned to cover this unit six (6) out of 21 shifts and was staffed with only paraprofessional staff which included 1 LPN and 1 Behavior Technician on these shifts.

A review of the needs assessment document for the Geriatric Unit revealed a patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, document patient treatment and progress, and provide ongoing clinical supervision of paraprofessional staff (LPNs and Behavioral Technicians). The Needs Assessment Document completed on the first day of the survey revealed a census of seven (7) patients with the following needs:

a. Physical care needs: One (1) patient requiring partial assistance with bathing, feeding, hygiene, etc., one (1) requiring assistance with mobility, two (2) patients on diabetic checks, seven (7) patients requiring range of motion exercises, and one (1) patient requiring skin care.

b. Psychiatric nursing care needs: Seven (7) patients potentially assaultive, three (3) patients were actively assaultive, two (2) were a low suicidal risk, four (4) patients were experiencing active hallucinations/delusions and were in potential jeopardy due to these symptoms, seven (7) patients were on assault precaution, one patient (1) was on elopement precautions, five (5) patients were on fall precautions, and two (2) patients were under constant line of sight supervisions. In addition, the Geriatric Unit reported that the average number of admission per week was two (2) on the day shifts, two (2) on the evening shift, and one (1) on the night shift. The average number of discharges per week was two (2) on the day shift and three (3) on the evening shift.

4. The review of the facility's FTE data revealed that there was a high RN vacancy rate. The facility reported 14 direct care RNs positions were allocated to cover the entire facility. Although, the facility had recently hired three (3) RNs, the FTE data showed that there were still four (4) direct care RN vacancies. The facility used agency RNs and overtime RNs to cover for shortages and call outs.

B. Unit Observation

During observation on the Geriatric Unit on 3/2/16 from 2:45 p.m. - 3:15 p.m., there was no RN on the unit to provide nursing care and supervision of staff. When asked who was the RN in charge of the unit, LPN #2 stated, "There is no RN in charge. I am a LPN and I am in charge of the evening shift." At approximately 3:15 p.m. RN #4 arrived on the unit and stated that she was the RN in charge. She noted that she had worked the day shift and would stay over until 7 p.m. LPN #2 become very upset and stated, "I should probably look for another job if RNs are going to cover the unit." RN #4 stated that, "I don't know if the unit is staffed everyday with a RN covering."

C. Medical Record Review

The facility used LPNs to complete tasks that should be or usually performed by RN. This included the required one-hour face-to-face assessment need for patients placed in restraint, the nursing assessment, and the Nurses Group scheduled on the day and evening shifts. Because a RN was not consistently available to provide immediate and ongoing interactions with patients and provide active treatment and nursing care, there could be no documented progress and treatment notes reflecting patients' progress or lack of progress and response to active treatment interventions based on the RN's ongoing direct contacts, interactions, and observations of patients. This was supported by the following findings:

1. Six (6) out eight (8) active samples patients (A12, A13, B1, B7, C3 and C7) had their Nursing Assessments completed by LPNs.

2. Most of the DAP notes during the period from 2/14/16 through 2/27/16 related to the progress or lack of progress for eight (8) of eight (8) active sample patients (A11, A12, A13, B1, B7, B10, C3 and C7) were documented by LPNs.

Four (4) of five (5) non- sample patients (D1, D2, D3, and D4) selected to review episodes of restraint and seclusion had the required one-hour face-to-face assessment completed by LPNs.

D. Interview

In an interview on 3/3/16 at 12:20 p.m., with the Interim Director of Nursing, RN staffing was reviewed. She acknowledged that she did not have enough RNs to cover unit to provide active treatment and nursing care. She stated that she is attempting to have at least 5.2 FTE for RNs for each shift. She admitted that change [to have RNs for unit coverage] was a major shift for the facility.

Based on medical record review and staff interview it was determined that the facility's Director of Social Services failed to evaluate the appropriateness of the social services provided. Specifically, the Director failed to ensure that Psychosocial Assessments for eight (8) of eight (8) patients contained a description of the role of the social service staff in treatment and discharge planning. This failure results in the treatment team not being aware of what services are considered necessary or potential interventions in treatment and discharge planning. (Patients A11, A12, A13, B1, B7, B10, C3 and C7).

Findings include:

A. Medical Record Review

1. Patient A11: The Psychosocial Assessment dated 2/22/16 had no information about what social services would be provided in either treatment or discharge planning.

2. Patient A12: The Psychosocial Assessment dated 2/26/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills. Upon release from the Center the individual should continue with medication management, and counseling to develop a better understanding of his/her mental health issues and to develop better coping skills and employment skills. He/she would benefit from linkage to the Haven for counseling and support." Psychiatric evaluation, medication management and day treatment activities are not descriptive of what efforts social service staff will be pursuing.

3. Patient A13: The Psychosocial Assessment dated 2/29/16 stated "Patient A13 would benefit from continued psychiatric treatment and acute stabilization." There was no description of what social service staff would be pursuing in treatment and discharge planning.

4. Patient B1: The Psychosocial Assessment dated 2/27/16 has no formation about what social service staff will be pursuing in treatment and discharge planning.

5. Patient B7: The Psychosocial Assessment dated 2/24/16 stated "Information retrieved from prior evaluation by this evaluator on 2/11/16." There was no apparent update, nor a description of what efforts the social service staff would be pursuing.

6. Patient B10: The Psychosocial Assessment dated 2/27/16 stated "Individual would benefit from acute inpatient admission for psychiatric evaluation and possible medication management. Intensive trauma informed therapy would be highly beneficial and should continue upon his/her discharge. Follow up appointment within 7 days of discharged [sic]."

7. Patient C3: The Psychosocial Assessment dated 2/07/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills." There was no description of what efforts the social service staff would be pursuing.

8. Patient C7: The Psychosocial Assessment dated 2/22/16 stated "Individual would benefit from a psychiatric evaluation, medication management and day treatment activities to build social skills." There was no description of what efforts the social service staff would be pursuing.

B. Staff Interview

On 3/03/16 at 11:30AM the Director of the Department of Social Services (not a Social Worker by degree) and the facility's Master Level Social Worker who works in conjunction with the Director were interviewed. They were shown the findings described in Section I. above. The anticipated role of the social service staff that would be a part of a complete Psychosocial Assessment was discussed. The Director stated "I won't be able to show that, but I think it is implicit." The Master Level Social Worker agreed that there was no explicit statement regarding what efforts the social service staff would be pursuing in treatment and discharge planning.