HospitalInspections.org

Based on document review, medical record review, and interview, the facility failed to:

I. Modify the Master Treatment Plans (MTP) for three (3) of three (3) non-sample patients (D1, D2, and D3) after restraint episodes. There were no new problem, goals, or interventions in MTPs to prevent restraint episodes in the future and provide these patients with the skills necessary to replace aggressive behaviors. This deficiency potentially compromises the safety of patients, did not provide appropriate treatment guidelines, and did not provide a method to assess each patient's progress.

II. Ensure that treatment interventions were assigned on the Master Treatment Plan (MTP) to all clinical disciplines involved in active treatment for eight (8) of eight (8) active sample patients (A6, A7, B1, B9, B10, B16, C2 and C3). Specifically, there were no active treatment interventions included to be implemented by attending psychiatrists to address psychiatric problems identified on MTPs. Failure to provide the specific active treatment interventions to be provided by the attending psychiatrist results in insufficient information to guide the treatment team and potentially results in inconsistent and/or ineffective treatment.

Findings include:

I. Failure to modify MTPs after episodes of restraint

A. Document Review

1. The facility policy "Special Treatment Procedures" Policy 190-08 Revised March 2016 contained no provision to revise the Master Treatment Plan after an episode of restraint in accordance with CMS requirements. The facility policy "Special Treatment Procedures-Physical Hold" Policy 190-08 Revised March 2016 contained no provision to revise the Master Treatment Plan after an episode of restraint.

2. The facility form "Seclusion/Restraint Face to Face Assessment" included the prompt, "Treatment Plan specified to address need for reduction in Seclusion/Restraint."

B. Medical Record Review

1. Patient D1 was restrained on 4/11/16. A review of the Master Treatment Plan (dated 4/3/16) revealed no revision/modification in response to the restraint episode.

2. Patient D2 was restrained on 4/16/16. A review of the Master Treatment Plan (dated 4/14/16) revealed no revision/modification in response to the restraint episode.

3. Patient D3 was restrained on 4/18/16. A review of the Master Treatment Plan (dated 4/15/16) revealed no revision/modification in response to the restraint episode.

C. Interview

On 4/26/16 at 4:00 p.m., the Risk Manager stated, "No, the problem of restraint is not mentioned in the treatment plans."

II. Failure to include Attending Psychiatrist interventions

A. Medical Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A6 (4/21/16), A7 (4/22/16), B1 (4/22/16), B9 (4/22/16), B10 (4/20/16), B16 (4/2016), C2 (4/16/16), and C3 (4/21/16). This review revealed that none of MTPs contained interventions to be implemented by attending psychiatrists.

B. Interview

In an interview on 4/26/16 at 5:25 p.m. with Medical Director, MTPs were reviewed. He did not dispute the findings that treatment plans did not include interventions to be implemented by psychiatrist to address the patient problems identified on MTPs. He stated, "I seriously thoughts that this had been addressed."

Based on medical record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for seven (7) of eight (8) active sample patients (A6, A7, B1, B10, B16, C2 and C3) 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 be doing or saying to show a decrease in the severity of problems identified on admission. In addition, many objectives described staff interventions or 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): A6 (4/21/16), A7 (4/22/16), B1 (4/22/16), B9 (4/22/16), B10 (4/20/16), B16 (4/2016), C2 (4/16/16), and C3 (4/21/16). This review revealed the following deficient short-term goals (objectives) for psychiatric problems. Several objective statements were identical despite each patient ' s having different problems and presenting symptoms.

1. Patient A6's MTP listed the following deficient objectives for the problems of "[Patient's name] is having delusions that people have a voodoo curse on [him/her] insides...."

Objective 1.1: "Medication to manage psychiatric symptoms." This objective was a routine hospital function not a patient outcome. It was not written as an observable, measurable, and behavioral statement that included the patient's actions regarding his/her understanding about medications such as benefits, side effects, reasons for compliance and the need for compliance after discharge.

Objective 1.2: "[Patient's name] will participate in at least three (3) consecutive Activity groups during her hospital stay engaging with staff and consumers in a socially conventional manner." This statement was individualized and not related to improving an identified psychiatric problem related to the reason(s) for the patient's admission. The statement failed to include what the patient would be saying and/or doing to show resolution of presenting symptoms.

Objective 1.3: "[Patient's name] will accept medications as needed/prescribed for [his/her] delusion." This objective was not individualized or measurable, and did describe what the patient would be doing or saying to show understanding of medications.

Objective 1.4: "Staff will teach medication regime and need for compliance." This was a staff intervention and not a patient outcome statement that reflected what the patient would be doing and/or saying to show his/her understanding regarding medication compliance.

2. Patient A7's MTP listed the following deficient objectives for problem #1 and #2 - "Medication Management as evidenced by: [Patient's name] stated [s/he] was depressed and bipolar schizophrenic [sic] but had not taken [his/her] meds [medications in two weeks." "Suicidal ideation AEB [Patient's name] statement that [s/he] did not deserve to be alive..."

Objective 1.1: "Take psychotic medications as prescribed." This objective was not individualized or measurable, and did not 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 of his/her symptoms or medications.

Objective 2.1: "[Patient's name] will provide support team information to Recovery Specialist for use in alleviating situation." This objective was a staff expectation. It was not individualized or measurable, and/or stated in behavioral terms. There was no behavioral description of the situation that needed to be alleviated. Therefore, it would be difficult for staff to know to observe to determine the patient's improvement.

Objective 2:2: "[Patient's name] will interact with others and participate in therapeutic groups." This objective statement was not individualized or measurable and was not specifically related to patient's presenting symptoms.

3. Patient B1's MTP listed the following deficient objectives for problem #1 and #2 - "[Patient's name] reports [s/he] is having thoughts of hurting [himself/herself]..." "[Patient's name] reports [s/he] is feeling depressed due to isolation and loneliness..."

Objective 1.2: "[Patient's name] will participate in 80% of scheduled Activity groups as evidenced by [his/her] signature on daily group sign-in sheets." Although measureable, this objective was actually a staff expectation and was not related to improving an identified psychiatric problem regarding the reason(s) for the patient's admission.

Objective 2.1: "[Patient's name] will attend therapeutic groups as offered to assist [his/her] [sic] in alleviating [his/her] depression." This objective was not patient oriented and not related to the patient's presenting psychiatric symptoms. There was no behavioral description of the patient's depression. Therefore, the outcome statement failed to describe what the patient would be saying and/or doing to show improvement in his or her symptoms of depression.

4. Patient B10's MTP listed the following deficient objectives for problem #1 and #4 - "Violence risk: directed towards others evidenced by: [Patient's name] reports [s/he] is having extreme HI [homicidal ideations] agains [sic] [his/her] parent..." "Auditory, visual, or tactile hallucinations resulting in impaired functioning as evidence [sic] by hearing voices that tell [him/her] to kill [his/her] parents..."

Objective 1.1: "[Patient's name] will contract for safety." This objective was not individualized, not measurable, and was very broad.

Objective 1.6: "Staff will help [Patient's name] identify the thoughts and mood that proceed Homicidal ideations agains [sic] [his/her] biological parents..." This objective statement was a staff intervention not a patient outcome.

Objective 4.1: "Modify the environment to decrease auditory hallucinations." This was staff intervention not a patient outcome statement that reflected what the patient would be saying and/or doing to show improvement in specific psychiatric symptoms.

Objective 4.2: "Identify the environmental triggers, or the precipitating events that are related to increased psychotic symptoms." This was objective was not measurable; it was broad and did not spell out specific behavioral actions related to the patient's improvement.

5. Patient B16's MTP listed the following deficient objectives for the problem #1 and #2 - "[Patient's name] reports [s/he] is drinking again and wants to get off of Alcohol. As Evidenced By:... reports [s/he] has been drinking for the last 25 years." "[Patient's name] reports [s/he] is currently depressed due to going through a recent divorce and termination from employment."

Objective 1.2: "[Patient's name] will participate in 80% of scheduled groups offered by the Activity Department as evidenced by [his/her] signature on daily group sign-in sheets." Although measureable, this objective was a staff expectation and was not individualized or behaviorally specific reflecting what the patient would be doing and/or saying to show improvement in his or her symptoms of depression when attending specific groups.

Objective 2:2: "[Patient's name] will attend group as offered to assist [his/her] [sic] in alleviating [his/her] depression. This objective was not individualized, measurable, or written in behavioral actions that reflected what the patient would say or do to show improvement in his/her specific symptoms of depression.

6. Patient C2's MTP listed the following deficient objectives for problems #1 and #2 - "[Patient's name] is experiencing symptoms of confusion/dementia AEB [Patient's name] is a dementia patient and believes [his/her] [spouse] is a total stranger and a priest who is trying to put [him/her] in jail." "[Patient ' s name] is exhibiting aggressive behaviors that [s/he] is unable to control and are [sic] putting [himself/herself] and other patients and staff at risk."

Objective 1.1: "[Patient's name] will exhibit a willingness to discuss [his/her] symptoms of confusion/dementia with staff." This objective was not measurable or written in behavioral terms. Given the patient's symptoms of confusion, this objective may not be realistic or reasonable for this patient to achieve.

Objective 1.3: "[Patient's name] will attend 90% of scheduled activities for three consecutive days." Although measureable, this objective was actually a staff expectation and it was not individualized or behaviorally specific reflecting what the patient would be doing and/or saying to show improvement in his or her confusion and symptoms of dementia.

Objective 2.1: "[Patient's name] will refrain from aggression/violence toward other." This objective was not individualized, measurable or written in behavioral terms. Additionally, the objective failed to describe positive and/or replacement behaviors to reflect what the patient would be doing to show healthy alternatives to aggressive behaviors.

7. Patient C3's MTP listed the following deficient objectives for the problem # 1: "Auditory, visual, or tactile hallucination resulting in impaired functioning as evidenced by COP [sic] reads," "Depression /AMS/Hallucinations/Dementia."

Objective 1:1: "[Patient's name] will accept medication as needed/prescribed for [his/her] hallucinations." This objective was actually a staff expectation. It was not written as a patient oriented goal that included the patient's action(s) regarding his/her understanding about medications such as benefits, side effects, reasons for compliance and the need for compliance during hospitalization and after discharge.

Objective 1.2: "[Patient's name] will be oriented in all spheres and discuss psychosis symptoms with staff." This objective was not individualized, and not stated in measurable, observable, or behavioral terms. It was also a very broad statement making it difficult for staff to know what to observe to determine whether the patient achieved the objective.

B. Interviews

1. In an interview on 4/26/16 at 2:30 p.m. with Recovery Specialist 2, MTPs were reviewed. She did not dispute that treatment plans continued to have objective statements that were not individualized, measureable or written in behavioral terms.

2. In an interview on 4/26/16 at 3:00 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute that the treatment plans continued to have objective statements that were not individualized, measurable, or written in behavioral terms. She also agreed that treatment plans continued have staff interventions written as patient outcome.

C. Policy Review

The facility's policy titled, "Master Treatment Planning, Operational Procedure" and revised February 2016 [Note: This policy was unsigned.] stipulated that, "Completion of the master treatment plan, to include:... 6) Observable and measurable short-term goals written in behavioral terms. 7) Long-term objectives, Individualized goals with measurable goals..."

Based on observation, medical record review, document review, and interview, the facility failed to provide eight (8) of eight (8) active sample patients (A6, A7, B1, B9, B10, B16, C2 and C3) 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 discipline functions selected from options in an electronic medical record. These options written as treatment interventions were generic, vague, and global statements without a focus of treatment. The facility also failed to include a nurse led group on treatment plans. This group was listed on the unit schedule and attended by active sample patients. In addition, for three (3) of eight (8) active sample patients (B1, C2 and C3), there were no registered nurse or nursing staff interventions for problems identified on MTPs. 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): A6 (4/21/16), A7 (4/22/16), B1 (4/22/16), B9 (4/22/16), B10 (4/20/16), B16 (4/2016), C2 (4/16/16), and C3 (4/21/16). This review revealed the following interventions reflecting deficient practice. Many intervention statements were written in terms of what the patient will do instead of what the clinical staff would do to assist the patient to accomplish treatment objectives or improve presenting psychiatric problems. In addition, several interventions listed the modality (group or individual) but failed to include the specific focus of treatment for each patient.

1. Patient A6's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "[Patient's name] is having delusions that people have a voodoo curse on [him/her] insides...."

Rehabilitation (Activity Therapy) Intervention: "[Patient's name] will engage in activity groups that demand orientation to sequential tasks, such as arts and crafts, assembling jigsaw puzzles and word search exercises." This intervention statement did not include what the staff would do to assist the patient's with managing his/her delusions and presenting psychiatric symptoms.

RN Intervention: "Modality: Individual."

SW [Recovery Specialist] Intervention: "Modality: Group."

Problem #2 - Anger management issues as evidence [sic] by [Patient's name] reports [s/he] needs help managing [his/her] anger..."

Rehabilitation (Activity Therapy) Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

2. Patient A7's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "Medication Management as evidenced by: [Patient's name] stated [s/he] was depressed and bipolar schizophrenic [sic] but had not taken [his/her] meds [medications in two weeks."

RN Intervention: "Modality: Individual."

Problem #2 - "Suicidal ideation AEB [Patient's name] statement that [s/he] did not deserve to be alive..."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

3. Patient B1's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "[Patient's name] reports [s/he] is having thoughts of hurting [himself/herself]..."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Rehabilitation (Activity Therapy) Intervention: [Patient's name] will engage in Activity groups that provide relaxation techniques, exercise and short-term art projects to facilitate alleviation of violence towards self. This intervention statement did not include what the staff would do to assist the patient's to improve his/her presenting psychiatric problem (thoughts of hurting himself/herself).

Problem #2 - "[Patient's name] reports [s/he] is feeling depressed due to isolation and loneliness..."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

There were no registered nurse and/or nursing staff interventions for the problems identified for this patient.

4. Patient B9's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "[Patient's name] reports and displays symptoms of anxiety as evidenced by upon meeting with evaluator [Patient's name] was visibly anxious and sweating.
RN Intervention: "Modality: Individual."

Rehabilitation (Activity Therapy) Intervention: [Patient's name] will engage in Activity groups that provide relaxation techniques, yoga, meditation and visualization to facilitate alleviation of anxiety. This intervention statement did not include what the staff would do to assist the patient's managing his/her anxiety and other presenting psychiatric symptoms.

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Problem #2 - "Speech, behavior, or reports indicating significant danger to self as evidenced by Ex Parte reads further testimony under oath confirmed [s/he] is recently under doctor care...[s/he] states having suicidal thoughts."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

5. Patient B10's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "Violence risk: directed towards others evidenced by: [Patient's name] reports [s/he] is having extreme HI [homicidal ideations] agains [sic] [his/her] parent..."

RN Intervention: "Modality: Individual."

Rehabilitation (Activity Therapy) Intervention: Encourage to attend groups for exercise and interpersonal development." "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Problem #2 - "Speech, behavior, or reports indicating significant danger to self. As Evidenced By:...Pt [Patient] indicates [s/he] has been thinking about hurting [himself/herself]...[s/he] also rep. [report] cutting [himself/herself] in prep. [preparation] for the attempt..."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Problem #3 - [Patient's name] injures self physically by cutting, hitting or otherwise causing harm to own person as evidence [sic] by self report..."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual" [This intervention statement was listed for all objectives identified for problem #3.

Problem #4 - "Auditory, visual, or tactile hallucinations resulting in impaired functioning as evidence [sic] by hearing voices that tell [him/her] to kill [his/her] parents..."

Rehabilitation (Activity Therapy) Intervention: "[Patient's name] will actively participate in group activity that provides relation, yoga, journaling and vision boards to facilitate healthy coping skills." This intervention statement did not include what the staff would do to assist the patient to manage presenting psychiatric symptoms (hearing voices).

6. Patient B16's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "[Patient's name] reports [s/he] is drinking again and wants to get off of Alcohol. As Evidenced By:...reports [s/he] has been drinking for the last 25 years."

RN Intervention: "Modality: Individual."

Rehabilitation (Activity Therapy) Intervention: "Modality: group."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

Problem #2 - "[Patient's name] reports [s/he] is currently depressed due to going through a recent divorce and termination from employment."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

7. Patient C2's MTP included the following non-specific interventions with no focus of treatment:

Problem #1 - "[Patient's name] is experiencing symptoms of confusion/dementia AEB [Patient's name] is a dementia patient and believes [his/her] [spouse] is a total stranger and a priest who is trying to put [him/her] in jail."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

Rehabilitation (Activity Therapy) Intervention: "Modality: Group."

Problem #2 - "[Patient's name] is exhibiting aggressive behaviors that [s/he] is unable to control and [himself/herself] and other patients and staff at risk."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

SW [Recovery Specialist (RS)] Intervention: "Modality: Group."

There were no registered nurse and/or nursing staff interventions for the problems identified for this patient.

8. Patient C3's MTP included the following interventions that were non-specific and had no focus of treatment:

Problem #1 - "Auditory, visual, or tactile hallucination resulting in impaired functioning as evidenced by COP [sic] reads," "Depression /AMS/Hallucinations/Dementia."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Problem #2 - "Physical aggression as evidenced by...Patient was very agitated, actively hallucinating, aggressive toward staff."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Rehabilitation (Activity Therapy) Intervention: "[Patient name] will activity engage in Activity groups for relaxation, short-term art projects and exercise to explore alternative responses to anger." This intervention statement did not include what the staff would do to teach the patient how to manage aggressive behaviors and use non-harmful alternatives to angry feelings.

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual."

Problem #3 - "Delusional ideas which interfere with normal functioning as evidenced by [Patient ' s name] making frequent statements about three airplanes flying overhead."

SW [Recovery Specialist (RS)] Intervention: "Modality: Individual" [This intervention statement was listed for all objectives identified for problem #3].

There were no registered nurse and/or nursing staff interventions for the problems identified for this patient.

B. Staff Interviews

1. In an interview on 4/26/16 at 2:30 p.m. with Recovery Specialist 2, MTPs were reviewed. She did not dispute that treatment plans continued to have interventions that were not individualized and specific based on each patient's presenting problems. She acknowledged that intervention statements failed to include a focus of treatment for each patient. She stated, "We misinterpreted what was expected for treatment interventions." She added that she had not read the CMS standards and interpretive guidelines noting that this would be helpful in understanding the requirements for interventions.

2. In an interview on 4/26/16 at 3:00 p.m., with the Interim Director of Nursing, MTPs were reviewed. She did not dispute that the treatment plans continued to have interventions that were not individualized and specific. She acknowledged that many interventions were listed with just the modality and failed to include a specific focus of treatment based on each patient's presenting problems and/or needs.

II. 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 active sample patients A6, A7, B1, B9, B10, B16, C2 and C3.

2. During observation on 4/25/16 at 10:00 a.m. and 4/26/16 at 9:45 a.m., active sample patients A6, A7, C2 and C3 were observed in the dayroom attending and participating in a "Nurses Group" conducted by registered nurses. This group was not included on these patients' MTP.

B. Interview

In an interview on 4/25/16 at 2:30 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. She stated, "We have worked hard to make sure the group is held consistently but need to make sure the nurses group is on the treatment plan."

C. Policy Review

The facility's policy titled, "Master Treatment Planning, Operational Procedure" and revised February 2016 [Note: This policy was unsigned.] stipulated that, "Completion of the master treatment plan, to include:...8) Specific individualized active treatment interventions..."

Based on observations, medical record review, document review, and interview, it was determined that monitoring by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the medical redor. The Medical Director failed to:

I. Ensure that Master Treatment Plans (MTP) were modified for three (3) of three (3) non-sample patients (D1, D2 and D3) after restraint episodes. There were no new problem, goals, or interventions in MTPs to prevent restraint episodes in the future and provide these patients with the skills necessary to replace aggressive behaviors. This deficiency potentially compromises the safety of patients, did not provide appropriate treatment guidelines, and did not provide a method to assess each patient's progress. (Refer to B118-I)

II. Ensure that treatment interventions were assigned on the Master Treatment Plan (MTP) to all clinical disciplines involved in active treatment for eight (8) of eight (8) active sample patients (A6, A7, B1, B9, B10, B16, C2 and C3). Specifically, there were no active treatment interventions included at all for the attending psychiatrist related to the identified psychiatric problem statements on MTPs. Failure to provide the specific active treatment interventions to be implemented by the attending psychiatrist results in insufficient information to guide the treatment team and potentially results in inconsistent and/or ineffective treatment. (Refer to B118-II)

III. Ensure that comprehensive Master Treatment Plans (MTPs) were developed to include all of the necessary elements to provide active treatment for eight (8) of eight (8) active sample patients (A6, A7, B1, B9, B10, B16, C2 and C3). Specifically, MTPs were missing the following components:

A. Individualized, measurable, and behaviorally stated short-term (objectives) for seven (7) of eight (8) active sample patients (A6, A7, B1, B10, B16, C2 and C3). (Refer to B121)

C. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems for eight (8) of eight (8) active sample patients (A6, A7, B1, B9, B10, B16, C2 and C3). (Refer to B122)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' active treatment needs not being met.

Based on observation, document review, and interview the facility failed to have a Director of Nursing or designee to provide adequate oversight to ensure quality nursing services. This deficiency results in a lack of clinical/administrative leadership in the Nursing Department compromising staffing and the clinical care of the patients. Specifically, the facility failed to:

I. Designate a Director of Nursing or designate a RN to fulfill the role until a DON was hired.

A. On the first day of the survey (4/25/16) at 9:30 A.M. the Risk Manager stated, "No, we do not have a Director of Nursing or an Interim Director of Nursing. No one has been delegated."

B. On 4/26/15 at 3:20 PM the surveyors were informed by the Risk Manager that an Interim DON had been selected. The Interim Director of Nursing stated, "Yes, I just found out minutes ago that I am the Interim Director of Nursing."

II. Ensure that Master Treatment Plans were reviewed and modified after an episode of restraint. (Refer to B118-I)

III. Provide five (5) of eight (8) active sample patients (A6, A7, B9, B10 and B16) with Master Treatment Plans (MTPs) that included individualized active treatment nursing 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 in the electronic medical record. These options written as treatment interventions were generic, vague, and global statements without a focus of treatment. The facility also failed to include a nurse led group on the treatment plan that was listed on the unit schedule and attended by active sample patients. In addition, for three (3) of eight (8) active sample patients (B1, C2 and C3), there were no registered nurse or nursing staff interventions for problems identified on the MTP. These deficiencies result in a failure to guide treatment staff regarding specific nursing interventions and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment. (Refer to B122)

IV. Deploy sufficient registered nurses to cover units based on the acuity needs of patients on two high acuity Adult Psychiatric Units and one Geriatric Unit. (Refer to B150)

Based on document review, observation, medical record review, and 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. The hospital admits patients on a 24-hour basis. Specifically, the facility failed to consistently assign a registered nurse (RN) to cover these units on each shift. For 22 of 63 shifts (staffing data 4/19/16-4/25/16) there was no RN assigned to be physically present and only Licensed Practical Nurses (LPNs) covered these units with a RN supervisor and, sometimes, a 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 deficient practice potentially leads to an unsafe patient environment because of the lack of the immediate presence 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 had eight (8) patients on the first day of the survey. An analysis of staffing data collected during the survey (4/19/16-4/25/16) revealed that there was no RN assigned to be physically present to cover for three (3) of 21 shifts. Therefore, a RN was not immediately available to provide ongoing guidance to nonprofessional staff or to provide active treatment interventions to patients.

A review of the needs assessment for the Female PCU revealed a high patient acuity that would require immediate, consistent, and ongoing oversight by a RN. The Needs Assessment document completed on the first day of the survey revealed the following patient needs:

There were five (5) patients on a detox protocol, two (2) patients were actively assaultive, two (2) patients were considered a low suicidal risk, three (3) patients were delusional or hallucinating, two (2) patients had medication issues of non-compliance, two (2) patients had been admitted within the past 48 hours and one (1) patient was on constant/line of sight supervision. In addition, this ward averaged two (2) admissions on day shift, three (3) on evenings and two (2) on nights weekly. There were an average of four (4) discharges on days and three (3) on nights weekly.

2. Psychiatric Care Unit (PCU) Male had 22 patients on the first day of the survey. An analysis of staffing data collected during the survey (4/19/16-4/25/16) revealed that there was no RN assigned to be physically present to cover for 11 of 21 shifts. Therefore, a RN was not immediately available to provide ongoing guidance to nonprofessional staff or to provide active treatment interventions to patients.

A review of the needs assessment for the Male PCU revealed a high patient acuity that would require immediate, consistent, and ongoing oversight by a RN. The Needs Assessment document completed on the first day of the survey revealed the following patient needs:

There were four (4) patients on a detox protocol, two (2) were potentially assaultive, 15 were identified as low suicidal risk, one (1) was designated as an acute suicidal risk, three (3) had medication issues, three (3) exhibited hallucinations/delusions, 11 were on assault precautions, one (1) was on elopement precautions, one (1) was under constant/line of sight supervision and two (2) were admitted within the past 48 hours. In addition, this ward averaged two (2) admissions on days, two (2) on evenings and two (2) on nights weekly. There were an average five (5) discharges on days and five (5) on evenings weekly.

3. Psychiatric Care Unit (PCU) Geriatric had four (4) patients on the first day of the survey. An analysis of staffing data collected during the survey (4/19/16-4/25/16) revealed that there was no RN assigned to be physically present to cover for eight (8) of 21 shifts. Therefore, a RN was not immediately available to provide ongoing guidance to nonprofessional staff or to provide active treatment interventions to patients.

A review of the needs assessment for the Geriatric PCU revealed a high patient acuity that would require immediate, consistent, and ongoing oversight by a RN. The Needs Assessment document completed on the first day of the survey revealed the following patient needs:

There were two (2) patients who had been admitted within the past 48 hours, one (1) required diabetic checks and one (1) had medication problems. In addition, the geriatric ward averaged one (1) admission on days, one (1) on evenings and one (1) on nights weekly. There were an average of one (1) discharge on days and one (1) on evenings.

4. The review of the facility's full time employee data revealed that there were two (2) RN vacancies and that there were only 19 direct care RNs to cover the entire hospital (3) distinct wards and two (2) non-distinct).

B. Unit Observation

During observation on the Male PCU on 4/26/17 at 5:45 p.m., there was no RN on the unit to provide nursing care and supervision of staff. LPN 2 stated that "No, we do not have an RN on the unit for this shift."

C. Medical Record Review

The facility utilized LPNs to complete nursing assessments for six (6) of eight (8) active sample patients (A7, B1, B9, B10, C2 and C3).

1. Patient A7's nursing assessment dated 4/22/16 was completed by a LPN.

2. Patient B1's nursing assessment dated 4/22/16 was completed by a LPN.

3. Patient B9's nursing assessment dated 4/20/16 was completed by a LPN.

4. Patient B10's nursing assessment dated 4/20/16 was completed by a LPN.

5. Patient C2's nursing assessment dated 4/15/16 was completed by a LPN.

6. Patient C3's nursing assessment dated 4/21/16 was completed by a LPN.

D. Interviews

1. On 4/26/16 at 3:35 p.m. the Interim Director of Nursing stated, "I know that we do not have enough RNs to staff all the shifts. That is something we are moving toward."

2. On 4/27/16 at 10:30 a.m. the Chief Executive of the facility stated, "This staffing is unacceptable. We have hired a recruiter to attract more RNs."

3. On 4/26/16 at 5:45 p.m. LPN 2 on the Male PCU stated, "No, we do not have an RN on the unit for this shift. I am scheduled with another LPN."