HospitalInspections.org

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

I. Ensure that the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (C4, C6, D4, D7, M1, M18, P2, and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 II)

II. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for eight (8) of eight (8) sample patients (C4, C6, D4, D7, M1, M18, P2, and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units who were either unable, unwilling or not motivated to attend assigned active treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, such as one to one intervention with staff. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125 I)

III. Ensure that patients on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on weekdays, evening hours, and on weekends. On evenings and weekends, no therapeutic groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge. (Refer to B125 II)

IV. Appropriately utilize and document restraints as external controls of violence with failure to:

A. Ensure that use of mechanical wrist-to-waist restraints was based on an immediate threat of harm to self/others for all patients in the Regional Forensic Psychiatric Center (RFPC) units. Patients were placed in wrist to waist restraints and escorted by facility nursing staff without documented justification during transportation out of the facility for medical care or legal matters. This practice results in a failure of patients' right to be free of restraint without justification that restraint is used for imminent risk of danger to self and/or others and appropriate assessment and monitoring. (Refer to B125 III A)

B. Ensure comprehensive face-to-face assessments of patients placed in restraints within a hour for 1 of 12 sample patients (C6) and three (3) of three (3) active non-sample patients (J19, L4, and P6) whose records were selected to review episodes of physical restraint. Specifically, the facility failed to ensure documentation of a comprehensive face-to-face assessment of the patient's status that included an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results; and any contributory factors to the patient's aggressive behavior. In addition, the facility failed to revise the Master Treatment plan to include goals and modalities to address aggressive behaviors after episodes of physical restraint. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to revise Master Treatment Plans results in patients being hospitalized without adequate interventions for their recovery being provided to them, potentially delaying their improvement. (Refer to B125 III B)

V. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment in the Regional Forensic Psychiatric Center (RFPC) units. Patient bedrooms contained air vents covered with metal grates. The openings of these grates were sufficiently large to allow materials to be affixed to the grate. These grates would support sufficient weight to pose a hanging hazard. This failed practice results in potential physical harm for all patients on the Regional Forensic Psychiatric Center (RFPC) units. (Refer to B125 IV)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of 12 sample patients (C4, C6, D4, M1, M18, P2, and P7). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include a sufficient social evaluation, conclusions and recommendations, or a description of the social worker's role in treatment and discharge planning: Patient C4 (9/4/15), Patient C6 (9/10/15), Patient D4 (10/2/15), Patient D7 (5/8/15), Patient M1 (9/21/15), Patient M18 (9/15/15), Patient P2 (10/15/15), and Patient P7 (10/6/15).

B. Staff Interview

During an interview with the Director of Social Work on 10/20/15 at 1:30 p.m., she acknowledged that the Psychosocial Assessments for Patients C4, C6, D4, D7, M1, M18, P2, and P7 lacked a sufficient social evaluation and conclusion and recommendations, or a description of the social work role in treatment or discharge planning.

Based on record review, interview, and document review, the facility failed to provide psychiatric evaluations that contained sufficient information to justify psychiatric diagnoses and treatment in a timely manner for two (2) of 12 active sample patients (C4 and D4). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses.

A. Record Review

1. Patient C4 was admitted 9/5/13. The last Annual Psychiatric Assessment for Patient C4 was dated 9/16/14. No Psychiatric Assessment was documented since that time.

2. Patient D4 was admitted 9/29/15. The Psychiatric Assessment (no date) did not include sufficient information to determine and justify the patient's diagnosis and treatment.

B. Interview

During an interview with the Medical Director on 10/21/15 at 9:40 a.m., he acknowledged that a Psychiatric Assessment for Patient C4 had not been completed in over a year. He acknowledged that the Psychiatric Assessment for Patient D4 did not include sufficient information to determine and justify the patient's diagnosis and treatment.

C. Document Review

The policy "Policy/Procedure For Psychiatric Medical Record Documentation," dated 3/12/15, number 80-14, stated "Annual assessments must be completed no later than seven (7) working days...prior to the annual C.I.T.P. [Comprehensive Individualized Treatment Plan) update." "The annual Comprehensive Individual Treatment Plan (C.I.T.P.) is due the month of admission..."

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

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for 12 of 12 active sample patients (C4, C6, D4, D7, J3, J5, L2, L3, M1, M18, P2 and P7). Specifically, the MTPs were missing patient oriented goals written in observable and behavioral terms (See B121). The plans were also missing individualized and specific treatment interventions to address each patient's presenting psychiatric problems (See B122). Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

II. Ensure that the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (C4, C6, D4, D7, M1, M18, P2 and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units were revised when the patients failed to participate in the prescribed treatment. MTPs were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient C4

a. Patient C4 was admitted on 9/5/13. The Annual Psychiatric Assessment dated
9/16/14 included the diagnoses of "Schizo-affective Disorder, " "Post Traumatic Stress Disorder," "Polysubstance Abuse," and "Personality Disorder, Not Otherwise Specified."

b. The "Active Treatment Schedule" dated 10/5/15 for Patient C4 included the following group modalities to be used as treatment interventions: "Poetry & Spirituality," "Grief & Loss, Med [medication] Teaching," "Anger Mgt. [management]," "Health relationships," "DBT [Dialectical Behavior Therapy] Skills." A review of progress notes from 7/1/15 through 10/17/15 did not contain documentation that Patient C4 attended these treatment groups.

c. The Master Treatment Plan for Patient C4 indicated no revision to the interventions to address the needs of Patient C4 despite not participating in group therapy.

2. Patient C6

a. Patient C6 was admitted on 9/9/15. The Psychiatric Evaluation dated 9/9/15 noted a diagnosis of "Schizoaffective Disorder."

b. The "Active Treatment Schedule" dated 10/5/15 for Patient C6 included the following group modalities to be used as treatment interventions: "The Human Mind," "AA," "Dealing w/ Addiction & MH [Mental Health]," "Prayer and Hymn Sing," "Anger Management," "Mind your Manners," "SS [Social Services Contact Group]..." A review of progress notes from 9/9/15 through 10/17/15 did not contain documentation that Patient C6 attended these treatment groups.

c. The Master Treatment Plan for Patient C6 indicated no revision to the interventions to address the needs of Patient C6 despite not participating in group therapy.

3. Patient D4

a. Patient D4 was admitted on 9/29/15. The Psychiatric Assessment (no date) included the diagnosis of "Schizoaff [affective] disorder."

b. The Master Treatment Plan for Patient D4 dated 10/14/15 listed the following group modalities to be used as treatment interventions: "Remember When" Group with rehabilitation staff; and "education on the important of treatment compliance" with nursing staff. A review of progress notes from 9/29/15 through 10/19/15 did not contain documentation that Patient D4 attended this treatment group.

c. The Master Treatment Plan for Patient D4 indicated no revision to the interventions to address the needs of Patient D4 despite not participating in group therapy.

4. Patient D7

a. Patient D7 was admitted on 5/12/12. The Psychiatric Evaluation updated 5/6/15 noted a diagnosis of "Dementia Secondary to Huntington's Disease, Psychosis, Secondary to Huntington's Disease, Impulse Control Disorder, Not otherwise Specified."

b. Patient D7's "Active Treatment Schedule" dated 10/5/15 listed 8 assigned groups. Patient D7 included the following groups listed on his/her individual schedule dated 10/5/15: "Sit & Be Fit, SS [Social Services] Contact Group, Remember When, Know your Medications, Current Events..." A review of progress notes from 7/1/15 through 10/17/15 did not contain documentation that Patient D7 attended these treatment groups.

c. The Master Treatment Plan for Patient D7 indicated no revision to the interventions to address the needs of Patient D7 despite not participating in group therapy.

5. Patient M1

a. Patient M1 was admitted on 10/18/10. The Psychiatric Assessment dated 10/16/15 included the diagnoses of "Delusional Disorder, Persecutory Type" and "Paranoid Personality Disorder."

b. The Master Treatment Plan for Patient M1 dated 11/24/14, reviewed 10/2/15, listed the following group modalities to be used as treatment interventions: "Social Work: [staff name] will conduct a Unit Processing group on Tuesdays at 11:00 a.m. for forty minutes and encourage [Patient M1] to attend and participate," "Activities: [staff name] will conduct 'What's On Your Mind?' group weekly on Wednesdays at 7:45 a.m. for forty-five minutes and encourage [Patient M1] to attend and participate to process the symptoms he's experiencing," and "Psychology: [staff name] will conduct Legal Issues group on Fridays at 2:30 p.m. and encourage [Patient M1] to attend and participate during the group." A review of progress notes from 7/1/15 through 10/19/15 did not contain documentation that Patient M1 attended these treatment groups.

c. The Master Treatment Plan for Patient M1 indicated no revision to the interventions to address the needs of Patient M1 despite not participating in group therapy

6. Patient M18

a. Patient M18 was admitted on 9/9/15. The Psychiatric Assessment dated 9/9/15 included the diagnosis of "Schizophrenia, Chronic, Paranoid Type with Acute Exacerbation. "

b. The Master Treatment Plan for Patient M18 dated 9/17/15, reviewed 10/16/15 listed the following group modalities to be used as treatment interventions: "Activities: [staff name] will conduct Anger Management group on Tuesdays at 2:15 p.m. for one hour and encourage [Patient M18] to attend and participate actively with at least one comment per group" and "Social Work: [staff name] will meet with ward patients for a contact group on Thursdays at 2:15 p.m. for forty-five minutes and encourage [Patient M18] to express [his/her] wants and needs appropriately and model appropriate coping skills and communication techniques." A review of progress notes from 7/1/15 through 10/19/15 did not contain documentation that Patient M18 attended these treatment groups.

c. The Master Treatment Plan for Patient M18 indicated no revision to the interventions to address the needs of Patient M18 despite not participating in group therapy.

7. Patient P2

a. Patient P2 was admitted on 10/8/15. The Psychiatric Assessment dated 10/16/15 included the diagnoses of "Schizophrenia, Paranoid Type, Chronic" and "Polysubstance Abuse."

b. The Master Treatment Plan for Patient P2 dated 10/15/15 listed the following group modalities to be used as treatment interventions: "Psychology [staff name] will meet with [Patient P2] 1x per week at 1:30 p.m. for 45 min during legal issues group and utilize group discussion, education videos, and worksheets to facilitate insight into legal charges of burglary and discuss possible outcomes various pleas," "Activities [staff name] will role model reality based speech and utilize verbal redirection when [Patient P2] makes delusional statements for Mondays @ 9:45 a.m. (1hr) during anger management group, Tues. 2:45 p.m. (1hr) during music therapy group and 1 hr Thurs. @ 2:20 p.m. during relaxation group," "Social Work [staff name] will meet with patient for 10 min on Fridays to assist with maintaining community supports," "DATS [Drug and Alcohol Treatment] [staff name] will meet with [Patient P2] Mondays at 10:30 for 1 hr during Drug and Alcohol group and utilize group discussion to increase insight and awareness into the triggers of substance abuse." A review of progress notes from 10/8/15 through 10/19/15 did not contain documentation that Patient P2 attended these treatment groups.

c. The Master Treatment Plan for Patient P2 indicated no revision to the interventions to address the needs of Patient P2 despite not participating in group therapy.

8. Patient P7

a. Patient P7 was admitted on 10/8/15. The Psychiatric Assessment dated
10/16/15 included the diagnoses of "Schizophrenia, Paranoid Type, Chronic" and "Polysubstance Abuse."

b. The Master Treatment Plan for Patient P7 dated 10/5/15 listed the following group modalities to be used as treatment interventions: "Psychology [staff name] will meet with [Patient P7] 1x per week at 10:30 p.m. for 45 min during legal issues group and utilize group discussion, education videos, and worksheets to facilitate insight into legal charges of Terroristic Threats and discuss possible outcomes various pleas," and "Activities [staff name] will role model reality based speech and utilize verbal redirection when [Patient P7] makes delusional statements for Mondays @ 9:45 (1hr) during anger management group, Tues. 2:45 pm (1hr) during music therapy group and 1 hr Thurs. @ 2:20 pm during relaxation group." A review of progress notes from 9/30/15 through 10/19/15 did not contain documentation that Patient P7 attended these treatment groups.

c. The Master Treatment Plan for Patient P7 indicated no revision to the interventions to address the needs of Patient P7 despite not participating in group therapy.

Based on record review, interview, and document review, the facility failed to provide Master Treatment Plans (MTPs), referred to as "Comprehensive Individualized Treatment Plans" (CIPTs) by the facility, that identified patient-related short term goals (STGs) in observable, measurable, and behavioral terms for 12 of 12 active sample patients (C4, C6, D4, D7, J3, J5, L2, L3, M1, M18, P2 and P7). Specifically, MTPs failed to contain short-term goal (STG) statements that reflected what the patient would do to lessen the severity of the identified psychiatric problem(s). Several STGs were identical or similarly worded. The absence of individualized goals that reflect behavioral change and functional improvement needed prevents the team from being able to determine the expected outcome to be observed, if the plan is effective, and actions needed to be taken to revise the treatment plan.

Findings include:

The MTPs for the following patients were reviewed (dates of plans in parentheses): C4 (updated 9/23/15), C6 (9/16/15), D4 (10/14/15), D7 (9/30/15), J3 (7/30/25), J5 (9/25/15), L2 (9/18/15), L3 (8/25/15), M1 (9/3/15), M18 (9/17/15), P2 (10/15/14), and P7 (10/5/15). This review revealed the following deficiencies for psychiatric problems.

1. Patients C4 had the following short-term goal (STG) that was not behaviorally specific for the problems of "...poor impulse control, ADL compliance, mood regulation...unmotivated in treatment...sexually acted out with peers."

"[Patient name] will comply 100% of rules and directives of staff in a 30 day period as evidence by obtaining/maintaining Level 5." This STG was a staff expectation and was not written as a patient oriented goal that included action statement(s) related to his/her psychiatric problems. There were no STGs included on the treatment plan related to the identified psychiatric problems.

2. Patients C6 had the following short-term goal (STG) that was not behaviorally specific for the problems of "...substance abuse, mental health issues, and non-compliance with treatment in the community...ongoing self-injurious behavior..."

"[Patient name] will comply [with] treatment by taking 100% of [his/her] prescribed medications < 30 day period." This STG was a staff expectation and was not written as a patient oriented goal that included the action statement(s) regarding his/her understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge. There were no other STGs included on the treatment plan related to the identified psychiatric problems.

3. Patients D4 had the following short-term goal (STG) that was not behaviorally specific for the problems of "...was alleged to have been found by police naked in [his/her] front yard, screaming...was described as combative and unkempt...was non-compliant with medication and outpatient treatments...paranoid thoughts...disorganized thoughts, limited insight into [his/her] mental health concerns..."

"[Patient name] will evidence improved insight into [his/her] need for mental health treatment by being 100% compliance with psychotropic medication regime and by attending a minimum of 50% of active treatment groups." This STG statement contained staff expectations (taking medications and attending groups). The statement did not include a patient oriented action and behavioral outcome regarding his/her understanding about medications (benefits, side effects), reasons for compliance, and the need for compliance during hospitalization and after discharge. Additionally, there was no goal statement(s) regarding the patient's psychotic symptoms (paranoid, disorganized thoughts, etc.) with behavioral descriptions to ensure that staff knew specific behaviors to observe in order to determine if the goal was achieved or not.

4. Patients D7 had the following short-term goal (STG) that was not behaviorally specific for the problems of "...has experienced ongoing cognitive deficits, such as difficult with memory, executive functioning, and motor functioning including physical impulse control...[s/he] struggles at times to effectively communicate [his/her] needs before resorting to aggressive behavior..."

"[Patient's name] will increase compliance by reducing physical aggression from one time per week to one time per month." This short-term goal statement did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or reduce the aggressive behaviors such as verbalizing what s/he will do instead of engaging in aggressive behavior and/or actually demonstrating non-harmful behavior when becoming angry. Additionally, the goal statement failed to include behavioral descriptions of "physical aggression" so that staff would know the specific behaviors to observe in order to determine if the goal was achieved or not.

5. Patient J3 had the following short-term goal (STG) that was not behaviorally specific for the problem of "...managing the thoughts and emotions related to [his/her] cycle of sexually offending...[his/her] capacity to re-integrate into the community is primarily dependent on the management of deviant sexuality." [Note: Patients J3, J5, L2 and L3 had identical or similarly worded problem statements that were not behaviorally descriptive of the patient's psychiatric problem(s).]

"[Patient's name] will explore at least one challenging emotional state per day, including discussing the underlying thought process and the ways in which [his/her] behavioral issues stem from [his/her] emotional suppression." This short-term goal statement was global, broad, and not behaviorally descriptive of what the patient would be saying and doing so that staff could observe and determine goal attainment. Additionally, the STG was not written in terms that were easily understood by the patient.

6. Patient J5 had the following short-term goal (STG) that was not behaviorally specific for the problem of "...managing the thoughts and emotions related to [his/her] cycle of sexually offending...has a number of secondary goals of importance. However, it is important to first manage the primary goal to a certain extent prior to engaging [him/her] in treatment for other issues."

"[Patient's name] will challenge at 75 percent of [his/her] distorted thinking underlying [his/her] desire to communicate / groom peers to whom [s/he] is attracted." This short-term goal statement was global, broad, and not behaviorally descriptive of what the patient would be saying and doing so that staff could observe and determine goal attainment.

7. Patient L2 had the following short-term goal (STG) that was not behaviorally specific for problem #1: "...managing the thoughts and emotions related to [his/her] cycle of sexually offending...has a number of secondary goals of importance. However, it is important to first manage the primary goal to a certain extent prior to engaging [him/her] in treatment for other issues."

"[Patient's name] will challenging [sic] 'what if ' thinking by journaling daily [his/her] distorted thoughts and challenging all anxiety provoking thoughts using cognitive reframes." This STG was global, broad, and did not reflect what the patient would be saying or doing to show reduction in his/her presenting and/or current psychiatric symptoms. Because the problem statement on the MTP contained no behavioral descriptions of the patient's psychiatric symptoms and behaviors, it was difficult to discern specific behaviors staff would observe to determine if the goal was attained or not.

8. Patient L3 had the following short-term goal (STG) that was not behaviorally specific for problem #1: "...managing the thoughts and emotions related to [his/her] cycle of sexually offending...[his/her] capacity to re-integrate into the community is primarily dependent on the management of deviant sexuality."

"[Patient's name] will identify and process, at least 3 times per week, in either groups or on therapeutic paperwork, emotional/feelings associated with advancement in the program and steps [s/he] is taking to progress." This short-term goal statement was global, broad, and not behaviorally descriptive of what the patient would be saying and doing so that staff could observe in order to determine if the goal was achieved or not.

9. Patient M1 had the following short-term goals (STG) that were not behaviorally specific for problem #1: "...suffers from paranoid delusions regarding [his/her] [spouse] as well as criminal charges."

a. "[Patient's name] will avoid delusional scripting one [sic] per wk [week] per staff report." [Note: This was the updated STG on the treatment plan.] The STG was not stated in behavioral and specific terms with positive alternative or replacement behaviors that would show the patient's increased level of functioning. Additionally, the MTP had no behavioral specific information documented regarding how Patient M1 specifically manifested "delusional scripting." Therefore, there was no behavioral description regarding the content of the patient's delusion and [his/her] response to them so that staff would know what specific behaviors to observe to determine if the goal was achieved or not.

b. "[Patient's name] will attend at least 25% of scheduled therapeutic activities groups per month and make one pertinent comment during each." This STG was a staff expectation and was not written as a patient oriented goal related that included the patient's action statement(s) related to his/her psychiatric problems.

10. Patients M18 had the following short-term goal (STG) that was not behaviorally specific for the problems of "...legal issues and suffers from bizarre, persecutory and grandiose delusion...easily angered or annoyed."

"[Patient name] will accept directives from staff members without aggressive behaviors or emotional outbursts at least once per day." This short-term goal statement also had no behaviorally descriptive of "aggressive behaviors and emotional outbursts" so that staff could know what to observe in order to determine if the goal was achieved or not.

11. Patient P2 had the following short-term goals (STG) that were not behaviorally specific for problem of "...history of auditory hallucinations, paranoia, bizarre beliefs. These issues are further exacerbated by poor medication compliance..."

"[Patient's name] will attend at 25% of therapeutic groups for the duration of an entire treatment period (28 days)." This STG was a staff expectation and was not written as a patient oriented goal that included the patient's action statement(s) related to his/her psychiatric problems. There were no goals included on the treatment plan related to the identified psychiatric problems.

12. Patient P7 had the following short-term goals (STG) that were not behaviorally specific for problem of "...history of paranoia (believing that [his/her] neighbors had accessed [his/her] thoughts...experiencing auditory hallucinations, and mood inconsistencies, all of which causes [him] to struggle with accurately understanding [his/her] experiences...directly impeding [his/her] legal competency and ability to work with [his/her] attorney..."

"[Patient's name] will attend at 25% of therapeutic groups for the duration of an entire treatment period (28 days)." This STG was a staff expectation and was not written as a patient oriented goal that included the patient's action and behavioral outcome statement(s) related to his/her psychiatric problems. There were no goals included on the treatment plan related to the identified psychiatric problems with behavioral descriptions to ensure that staff knew specific behaviors to observe in order to determine if the goal was achieved or not.

B. Staff Interview

During interview on 10/20/15 at 10:15 a.m., MTPs were reviewed with Psychology Services Associate (PSA) 1. He acknowledged that goals for Patients C4 and C6 were staff expectations and were not directly related to their psychiatric problems. However, explained that these goals were aimed at waiting until the patient made improvements before other goals were identified.

C. Document Review

The facility's policy titled, "Clinical Services Policy 25-6, Comprehensive Individualized Treatment Plan (CITP)," stipulated that, "Problem should be written in specific, behavioral terms to avoid the use of generic terms such as delusions, paranoid, depressed, confused..." The policy also stipulated, "The short-term goal is the short-term behavioral outcome...Short-term goals must be written in specific, measurable and achievable terms...Progress note documentation must support changes to these goals."

Based on record review, document review, and interviews, the facility failed to provide Master Treatment Plans (MTPs) for 12 of 12 sample patients (C4, C6, D4, D7, J3, J5, L2, L3, M1, M18, P2 and P7) that included interventions with a specific focus, based on the individual needs and abilities of each patient. The listed interventions were generic monitoring or routine clinical functions with identical or similar wording for patients with problems or different needs. Master treatments plans listed intervention statements that failed to include sufficient frequency of treatment to ensure intensive active treatment and to facilitate each patient ' s improvement. Instead, interventions included only monthly contacts with newly admitted patient improvement for four (4) of 12 active sample patients ( C6, D4, M18 and P2). In addition, the treatment plans failed to specify how modalities would be delivered or how often they would be delivered. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized, approach to multidisciplinary treatment. Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient C4 was admitted on 9/05/13. The Master Treatment Plan (MTP) dated 9/23/15 stated the following generic or routine clinical functions for the identified problem of "Poor impulse control, ADL compliance, mood regulation, and interpersonal skills: " "Social Worker will work with [patient name] with discharge planning when appropriate," "Activities staff [staff name] will encourage [patient name] to attend [his/her] scheduled groups," and "MD, Psychiatry, will assist [patient name] in alleviating psychiatric symptoms by prescribing medications and monitoring for response, side effects, and adverse reactions through regular psychotropic interviews (occurring as needed, at minimum monthly)."

2. Patient C6 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/16/15 stated the following generic or routine clinical functions for the identified problem of "extensive history of incarceration, substance abuse, mental health issues, and non-compliance with treatment in the community:" "Activities staff [staff name] will encourage [patient name] to be compliant with ward routine to decrease aggression, to gain appropriate level to attend groups," "MD, Psychiatry, will assist [patient name] in alleviating psychiatric symptoms by prescribing medications and monitoring for response, side effects, and adverse reactions through regular psychotropic interviews (occurring as needed, at minimum monthly)," "Nursing staff will monitor [patient name] closely at medication times to ensure [his/her] med compliance daily, to include mouth checks and random room checks to look for medication" and "Psychology [staff name] will assess [patient name] mental status and progress in treatment through informal contact on the ward a minimum of 15 minutes one time [sic] between 8 a.m.-12 p.m. Monday through Friday [sic]."

3. Patient D4 was admitted on 9/29/15. The Master Treatment Plan (MTP) dated 9/29/15 stated the following generic or routine clinical functions for the identified problem of "maintaining focus, emotional lability [sic] poor hygiene, paranoid thought [sic], limited insight into [his/her] mental health concerns, and poor judgement [sic]:" "Psychiatry [staff name] will monitor [patient name] medication regimen and engage [him/her] in monthly interviews to allow [him/her] to express any concerns or discuss any side effects [s/he] may be experiencing," "Nursing [staff name] will maintain daily contact with patient [sic] in order to monitor mental status and assist with activities of daily living," and "Social worker [staff name] will work with [patient name] to develop an appropriate plan for discharge when deemed appropriate by treatment team."

4. Patient D7 was admitted on 5/17/12. The Master Treatment Plan (MTP) dated 9/30/15 stated the following generic or routine clinical functions for the identified problem of "Huntington's Disease, cognitive deficits such as difficulty with memory, executive functioning, and motor functioning including physical impulse control:" "Ward psychologist [staff name] or designee will monitor mental status via informal check-ins as needed," "Social worker [sic] will work with [patient name] to develop an appropriate plan when discharge is appropriate and recommended by the treatment team," "Nursing [staff name] will encourage [patient name] to participate in physical therapy once per week. In addition, nursing staff will offer assistance in ambulating in the hallways in order to improve physical well-being and/or engage in positive interactions," and "Psychiatry [staff name] will monitor [patient name] medication regimen and engage [him/her] in monthly interviews to allow [him/her] to express any concerns or discuss any side effects [s/he] may be experiencing."

5. Patient J3 was admitted on 8/29/08. The Master Treatment Plan (MTP) dated 7/30/15 stated the following generic or routine clinical functions for the identified problem of "Issues with deviant sexuality:" "[Patient name] will meet with psychiatry [staff name] on the day of [patient name] treatment team review for further medication review" and "[Patient name] will meet with nursing [staff name] at least once per week to review patient's [sic] medications and ensure [patient name] finds them helpful."

6. Patient J5 was admitted on 4/02/15. The Master Treatment Plan (MTP) dated 9/24/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to cycle of sexually offending:" "During treatment team (monthly) psychiatry [staff name] will review [patient name] medication and address any issues regarding side effects of medication or sexual issues," "Nursing [staff name] will assist [patient name] in reviewing [his/her] medications at least once per week during medication pass in order to verify that [patient name] continues to find medications [sic] helpful in managing [patient name] psychiatric symptoms," and "Social worker [staff name] will meet monthly with [patient name] to help assist [patient name] in learning the program rules and adjusting to the facility [sic]."

7. Patient L2 was admitted on 11/03/14. The Master Treatment Plan (MTP) dated 9/18/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to patient's [sic] cycle of sexually offending:" "[Patient name] will meet with psychiatry [staff name] on the day of [patient name] treatment team review for further medication review," "[Patient name] will meet with nursing [staff name] at least once per week to review [patient name] medications and ensure [patient name] finds them helpful," "Nursing [staff name] will meet with [patient name] at least once per week to discuss [patient name] medication regime and assess if medication [sic][ patient name] is taking is effective in assisting with [patient name] anxiety," "During treatment team (monthly) psychiatry [staff name] will review [patient name] progress and assess if the medication [sic] continues to be an effective medication regime for the management of anxiety," and "Social worker [staff name] will meet monthly with [patient name] to help [patient name] in identifying coping skills to manage [patient name] emotions and triggers."

8. Patient L3 was admitted on 7/01/06. The Master Treatment Plan (MTP) dated 8/25/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to [patient name] cycle of sexually offending:" "Nursing [staff name] will assist [patient name] in reviewing [his/her] medications at least once per week during medication pass in order to verify that [patient name] finds them helpful," "Psychiatry [staff name] will review [patient name] medications at least monthly during [patient name] treatment team and assess continuation of current medications or the need to address new issues," and "Social worker [staff name] will meet with [patient name] monthly in order to discuss needs related to discharge planning, including the role that effort in treatment will play in moving him closer to target."

9. Patient M1 was admitted on 10/18/10. The Master Treatment Plan (MTP) dated 11/24/14 stated the following generic or routine clinical functions for the identified problem of "paranoid delusions regarding patient's [sic] ex-wife as well as criminal charges:" "Nursing [staff name] will administer medications as ordered during medication pass every day for five minutes during which time [patient name] will be encouraged to attend daily treatment" and "Psychiatry [staff name] will meet with [patient name] monthly for treatment team reviews and medication assessment during for at least twenty minutes and individually as needed for at least fifteen minutes to discuss treatment issues and symptomatology."

10. Patient M18 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions for the identified problem of "legal issues and suffers from bizarre, persecutory, and grandiose delusions pertaining to being unaware of where [s/he] is, disorganization and distractibility. In addition, [patient name] has poor affect regulation and becomes easily angered and annoyed:" "Nursing [staff name] will monitor for side effects every day for five minutes following medication pass and report as needed to psychiatrist [staff name] in addition to prompting [patient name] to follow appropriate medication pass procedures and accept directives and rules" and "Psychiatry [staff name] will meet with [patient name] monthly for treatment team reviews and medication assessment during for at least twenty minutes and individually as needed for at least fifteen minutes to encourage patient to use appropriate coping skills and role play appropriate behaviors."

11. Patient P2 was admitted on 10/08/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions for the identified problem of "history of auditory hallucinations, paranoia, and bizarre beliefs:" "Nursing [staff name] will educate with [patient name] for five minutes during medication [sic] pass to explain the benefits of medication compliance" and "Psychiatry [staff name] will meet with the patient every two weeks for ten minutes to continue to monitor [patient name] response to medication [sic]."

12. Patient P7 was admitted on 10/05/14. The Master Treatment Plan (MTP) dated 10/05/14 stated the following generic or routine clinical functions for the identified problem of "history of paranoia [sic] as well as experiencing auditory hallucinations and mood inconsistencies...:" "Nursing [staff name] will educate with [patient name] for five minutes during daily medication [sic] pass about the benefits of medication compliance," "Psychiatry [staff name] will meet with the patient at least every two weeks for ten minutes to continue to monitor [patient name] response to psychotropic medications and make necessary adjustments," and "Social work [staff name] will meet with patient on Fridays for ten minutes to assist with maintaining community supports."

B. Document Review

Clinical Services Policy 25-6, titled Comprehensive Individualized Treatment Plan, dated 3/12/15 states, "These are the actions staff will perform....to increase, decrease or alter behavior and assist the patient to achieve the short-term goal. The staff methods/interventions should state the name and discipline of the staff doing the intervention, the frequency and duration of the intervention (specific for day/time) as well as the intervention utilized...."

C. Interviews

1. During an interview on 10/20/15 at 1:00 p.m., the Activities Director acknowledged the lack of active treatment interventions on patients' treatment plans.

2. During an interview on 10/20/15 at 1:30 p.m., the Social Work Director acknowledged that active treatment interventions on patients' treatment plans were generic and general.

3. During an interview with the Medical Director on 10/20/15 at 2:10 p.m., he acknowledged that interventions for nursing and medical staff were generic and not specific to the needs of the patients.

I. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for eight (8) of eight (8) active sample patients (C4, C6, D4, D7, M1, M18, P2 and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units who were either unable, unwilling or not motivated to attend assigned active treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, such as one to one intervention with staff. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement.

II. Ensure that patients on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on weekdays, evening hours, and on weekends. On evenings and weekends, no therapeutic groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge.

III. Appropriately utilize and document restraints as external controls of violence with failure to:

A. Ensure that use of mechanical wrist-to-waist restraints was based on an immediate threat of harm to self/others for all patients in the Regional Forensic Psychiatric Center (RFPC) units. Patients were placed in wrist to waist restraints and escorted by facility nursing staff without documented justification during transportation out of the facility for medical care or legal matters. This practice results in a failure of patients' right to be free of restraint without justification that restraint is used for imminent risk of danger to self and/or others and appropriate assessment and monitoring.

B. Ensure comprehensive face-to-face assessments of patients placed in restraints within a hour for one (1) of 12 sample patients (C6) and three (3) of three (3) active non-sample patients (J19, L4, and P6) whose records were selected to review episodes of physical restraint. Specifically, the facility failed to ensure documentation of a comprehensive face-to-face assessment of the patient's status that included an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results; and any contributory factors to the patient's aggressive behavior. In addition, the facility failed to revise the Master Treatment plan to include goals and modalities to address aggressive behaviors after episodes of physical restraint. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to revise Master Treatment Plans results in patients being hospitalized without adequate interventions for their recovery being provided to them, potentially delaying their improvement.

IV. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment in the Regional Forensic Psychiatric Center (RFPC) units. Patient bedrooms contained air vents covered with metal grates. The openings of these grates were sufficiently large to allow materials to be affixed to the grate. These grates would support sufficient weight to pose a hanging hazard. This failed practice results in potential physical harm for all patients on the Regional Forensic Psychiatric Center (RFPC) units.)

I. Failure to provide individualized active treatment measures

A. Patient C4

1. Observation

a. During observation on 10/19/15 at 10:40, the patient was scheduled for a "Poetry and Spirituality" Group. The patient became aggressive and had to be physically restrained. During observation on 10/20/15 at 9:30 a.m., the patient was scheduled to attend a "Grief & Loss" Group. S/he was found in bed.

b. Throughout the survey, the patient was observed to be in his/her room and not interacting with other patients or staff. The patient attended no therapeutic groups and left ate his/her room primarily for meals.

2. Record Review

a. Patient C4 was admitted on 9/5/13. The Annual Psychiatric Assessment dated 9/16/14 included the diagnoses of "Schizo-affective Disorder," Post Traumatic Stress Disorder," "Polysubstance Abuse," and Personality Disorder, Not Otherwise Specified." The Master Treatment Plan dated 9/23/15 identified the psychiatric problem as: "...demonstrates poor impulse control, ADL compliance, mood regulation, and interpersonal skills. He frequently requests STAT medications in lieu of utilizing learned coping skills. He appears to be unmotivated in treatment...has also sexually acted out with peers..."

b. Patient C4's "Active Treatment Schedule" dated 10/5/15 listed 12 assigned groups. Active treatment groups included but were not limited to the following groups: "Poetry & Spirituality, Grief & Loss, Med [medication] Teaching, Anger Mgt. [management], Health relationships, DBT [Dialectical Behavior Therapy] Skills."

c. A review of progress notes from 7/1/15 through 10/17/15 revealed the following information about group treatment:

Nursing Treatment Notes: In progress note dated 7/26/15 noted, "attends groups approx. [approximately] 60% of the time..." There was no supporting evidence to verify the number and name of groups attended. On 7/31/15, the "Group Documentation Form" showed that the patient attend two (2) of four (4) Grief & Loss Groups. On 8/23/15, the progress note contained a note on the "Group Documentation Form" that showed the patient only attended two (2) of four (4) Grief & Loss Groups. On 9/28/15, the "Group Documentation Form" showed that the patient attend four (4) of four (4) Grief & Loss Groups. Progress note dated 10/17/15 documented, "...[Patient's name] attends select active treatment groups participation varies...10/14 Requested to be removed from group."

Therapeutic Activities Progress Notes: A note dated 7/17/15 documented, "[Patient's name] attended wellness x1 [with] 2 unexcused..." On 9/7/15 noted, "[Patient's name] has poor attendance at activities groups. He attended wellness x1 with 2 unexcused..."

Psychology Progress Notes: A note dated 10/14/15 documented, "[Patient's name] attended 10 minutes of Healthy Relationships Group...he stated, 'who do I need to talk to get out of this group.'..."

d. There was no documentation regarding attendance or non-attendance found in the medical record for most of the groups listed above including, "Med [Medication] teaching," "Anger Management," and "Poetry and Spirituality which had been assigned since 2/9/15."

e. Despite the patient's inconsistent group attendance was not attending groups, there were no provisions made in the Master Treatment Plan to reflect alternatives such as 1:1 contact to provide information given during the assigned group sessions.

3. Staff Interviews

a. In an interview on 10/20/15 at 10:30 a.m., RN 1 stated that Patient C4 had not been attending groups. RN 1 stated, "[S/he] has a history of doing this [not attending group] after [s/he] achieves a level 6." RN 1 noted that the patient does not want to be discharged.

b. The Medical Director in an interview on 10/20/15 at 2:10 p.m. stated that Patient C4 had decompensated. When asked about alternative one to one sessions, he acknowledged that alternatives should be offered.

B. Patient C6

1. Observation

a. During observation on 10/19/15 at 1:30 p.m., Patient C6 was scheduled for a group titled "The Human Mind." The patient attended the group but did not look at the video showing on the television. Patient C6 left the group after 15 minutes and walked up and down the hallway. The staff did not encourage the patient to return to the group session.

b. During observation on 10/20/15 at 10:45 a.m., Patient C6 was scheduled to attend a group titled, "Dealing [with]/ Addiction & MH [mental health]. The patient refused to attend and stated "I don't need any education about addiction." The patient remained in his/her room most of the day.

2. Record Review

a. Patient C6 was admitted on 9/9/15. The Psychiatric Evaluation dated 9/9/15 noted a diagnosis of "Schizoaffective Disorder."

b. The Master Treatment Plan dated 9/15/15 identified the psychiatric problem as: "...an extensive history of incarceration, substance abuse, mental health issues, and non-compliance with treatment in the community...admitted due to ongoing self-injurious behavior and sporadic compliance with medication management."

c. Patient C6's "Active Treatment Schedule" dated 10/5/15 listed 13 assigned groups. Active treatment groups included but were not limited to the following groups: "The Human Mind, AA, Dealing w/ Addiction & MH [Mental Health], Prayer and Hymn Sing, Anger Management, Mind your Manners, SS [Social Services Contact Group]..."

d. A review of progress notes from 9/9/15 through 10/17/15 revealed the following information about group treatment:

Nursing Treatment Notes: In progress note dated 10/3/15 documented, "...Has not attended active treatment groups..." A progress note dated 10/9/15 documented, "...He attends evening wrap up group but [his/her] participation is limited."

e. There was no documentation regarding attendance or non-attendance found in the medical regarding any of the active treatment groups. Despite the patient's non-attendance in assigned groups, there were no provisions made in the Master Treatment Plan to reflect alternatives such as 1:1 contact to provide information given during the assigned group sessions. Although, the patient was often on a 1:1 and 2:1 protocol during September 2015, clinical staff did not ensure that the assigned 1:1 staff implemented alternative active treatment measures.

3. Staff Interview

In an interview on 10/20/15 at 12:23 p.m., when asked about Patient C6's non-attendance in groups, the Chief Social Rehabilitation Executive explained that Patient C6 was on a "1:1 & 2:1 protocol" because of aggressive behavior. She noted that there was a delay in getting assessments completed. She also stated, "[Patient's name] wasn't comfortable coming out of [his/her] room." "She agreed that the MTP had not been revised to reflect one to one sessions and noted that the plan was revised only for a crisis plan."

C. Patient D4

1. Observation

a. During observation on 10/20/15 at 9:40 a.m., a group titled "Remember When" was scheduled. Patient D4's MTP showed that the patient was assigned to attend this group. This group was not held as scheduled. The patient was just sitting in the dayroom doing nothing.

b. During rounds on the unit at 9:45 a.m., the surveyor found that six (6) patients were found sitting in the hallway; eight (8) patients were found and there was no activities being held; (3) patients had signed off the unit - 2 patients to smoke and 1 patient for group in the multiple purpose room. [Note: Most patients' bedroom doors were locked to encourage patients to attend active treatment groups.]

2. Record Review

a. Patient D4 was admitted on 9/29/15. The Psychiatric Assessment (no date) included the diagnosis of "Schizoaff [affective] disorder."

b. The Master Treatment Plan dated 10/14/15 identified the psychiatric problem as: "...was alleged to have been found by police naked in [his/her] front yard, screaming...was described as combative and unkempt...was paranoid and non-compliant with medication and outpatient treatments..."

c. Patient D4 did not have a master treatment plan available in [his/her] medical record until the surveyor requested it. Additional as 10/20/15, there was no "Active Treatment Schedule with group assigned for this patient." The MTP documented the following interventions: "Individual therapy with psychology; "Remember When" Group with rehabilitation staff; and education on the important of treatment compliance" with nursing staff. [Note: the MTP was not completed in accordance with the facility's required timeline of "within 7 business days after admission."]

d. As of 10/19/15, the patient's assigned active treatment group schedule was not found in the medical record.

3. Staff Interview

In an interview on 10/20/15 at 12:23 p.m., when asked about Patient D4's not having a MTP in the medical record and no group schedule available for the patient. The Chief Social Rehabilitation Executive explained that Patient D4's Plan of care was initiated on 10/7/15, however was waiting on placement in available groups. She stated, "That is not the expectation."

D. Patient D7

1. Observation

During observation on 10/20/15 at 9:40 a.m., Patient D7 was scheduled for a group titled "Remember When." This group was not held as scheduled. The patient was found in [his/her] bedroom sleeping.

2. Record Review

a. Patient D7 was admitted on 5/12/12. The Psychiatric Evaluation updated 5/6/15 noted a diagnosis of "Dementia Secondary to Huntington's Disease, Psychosis, Secondary to Huntington's Disease, Impulse Control Disorder, Not otherwise Specified."

b. The Master Treatment Plan dated 10/14/15 identified the psychiatric problem as: "...has experienced ongoing cognitive deficits, such as difficult with memory, executive functioning, and motor functioning including physical impulse control...[s/he] struggles at times to effectively communicate [his/her] needs before resorting to aggressive behavior..."

c. Patient D7's "Active Treatment Schedule" dated 10/5/15 listed 8 assigned groups. Patient D7 included the following groups listed on his/her individual schedule dated 10/5/15: "Sit & Be Fit, SS [Social Services] Contact Group, Remember When, Know your Medications, Current Events..."

d. A review of progress notes from 7/1/15 through 10/17/15 revealed that very few were documented regarding attendance and/or non-attendance in assigned active treatment groups. A noted by Activity staff dated 8/27/15 documented, "... Unable to attend off ward groups will attend on ward groups at times."

e. The "Treatment Review" Forms dated 7/8/15, 8/3/15, 9/2/15, and 9/30/15, noted that Patient D7 spent the majority of time in her room.

There was no documentation regarding attendance or non-attendance found for most of the groups listed above. Despite documentation that the patient was staying in his/her room, there were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient isolating in his/her room. There were no provisions made in the Master Treatment Plan to reflect alternatives such as 1:1 contact to provide information given during the assigned group sessions. Although, the patient was on a 1:1 and 2:1 protocol, clinical staff did not ensure that the assigned 1:1 staff implemented alternative active treatment measures.

3. Staff Interviews

a. In an interview on 10/20/15 at 10:15 a.m., PA 1 stated, "[Patient's name] don't attend a lot of groups because [s/he] strikes out and is very aggressive."

b. During a discussion with two of these assigned staff on 10/20/15 at 10:00, PA2, and PA3 stated that they were not aware of the groups that the patient was to attend. The patient was assigned to have two staff at all times.

E. Patient M1

1. Observation

During an observation at the time of the scheduled "Legal Issues Group" on 10/19/15 at 2:30 p.m., Patient M1 was observed sitting in the group, facing away from the group leader, with his/her head down asleep.

2. Patient Interview

During an interview with Patient M1 on 10/19/15 at 12:10 p.m., Patient M1 stated that s/he did not hear well. When asked about group treatments, Patient M1 stated that s/he did not usually attend groups. [S/he] stated "it's hard for me, I can't hardly hear."

3. Record Review

a. Patient M1 was admitted on 10/18/10. The Psychiatric Assessment dated 10/16/15 included the diagnoses of "Delusional Disorder, Persecutory Type" and "Paranoid Personality Disorder."

b. The Master Treatment Plan for Patient M1 dated 11/24/14, reviewed 10/2/15, identified the psychiatric problem as: "[Patient M1] suffers from paranoid delusions regarding [his/her] ex-[wife/husband] as well as criminal charges." The Master Treatment Plan listed the following group modalities to be used as treatment interventions: "Social Work: [staff name] will conduct a Unit Processing group on Tuesdays at 11:00 a.m. for forty minutes and encourage [Patient M1] to attend and participate," "Activities: [staff name] will conduct 'What's On Your Mind?' group weekly on Wednesdays at 7:45 a.m. for forty-five minutes and encourage [Patient M1] to attend and participate to process the symptoms he's experiencing," and "Psychology: [staff name] will conduct Legal Issues group on Fridays at 2:30 p.m. and encourage [Patient M1] to attend and participate during the group."

c. The Progress Notes from 7/1/15 to 10/19/15 contained no documentation that Patient M1 attended any active treatment groups.

4. Staff Interviews

During an interview with the Director of Psychology on 10/20/15 at 1:50 p.m., she stated that psychology conducted legal competency groups and individual interventions. She acknowledged that Patient M1 might require a modality other than group therapy to address competency issues due to being hard of hearing.

F. Patient M18

1. Observation

During an observation of the "Legal Issues" group on 10/19/15 at 3:30 p.m., Patient M18 was observed in the dayroom with other patients not engaged in any activity.

2. Patient Interview

During an interview with Patient M18 on 10/19/15 at 2:25 p.m., Patient M18 estimated that s/he had attended "about 4" groups since admission on 9/9/15. Patient M18 stated that on weekends, s/he would "sleep in" and "watch TV more or less." Patient M18 stated that s/he was provided no 1:1 treatments since admission.

3. Record Review

a. Patient M18 was admitted on 9/9/15. The Psychiatric Assessment dated 9/9/15 included the diagnosis of "Schizophrenia, Chronic, Paranoid Type with Acute Exacerbation."

b. The Master Treatment Plan for Patient M18 dated 9/17/15, reviewed 10/16/15 identified the psychiatric problem as: "[Patient M18] has legal issues and suffers from bizarre, persecutory and grandiose delusions pertaining to being unaware of where he is, disorganization and distractibility. In addition, he has poor affect regulation and becomes easily angered or annoyed." The Master Treatment Plan listed the following group modalities to be used as treatment interventions: "Activities: [staff name] will conduct Anger Management group on Tuesdays at 2:15 p.m. for one hour and encourage [Patient M18] to attend and participate actively with at least one comment per group" and "Social Work: [staff name] will meet with ward patients for a contact group on Thursdays at 2:15 p.m. for forty-five minutes and encourage [Patient M18] to express [his wants and needs appropriately and model appropriate coping skills and communication techniques."

c. The Progress Notes from 9/9/15 to 10/19/15 contained no documentation that Patient M18 attended any active treatment groups.

G. Patient P2

1. Observation

During an observation at the time of the scheduled "Drug and Alcohol" group on 10/19/15 at 11:15 a.m., Patient P2 was observed sitting in the dayroom with other patients not engaged in any activity.

2. Record Review

a. Patient P2 was admitted on 10/8/15. The Psychiatric Assessment dated
10/16/15 included the diagnoses of "Schizophrenia, Paranoid Type, Chronic" and "Polysubstance Abuse."

b. The Master Treatment Plan for Patient P2 dated 10/15/15 identified the psychiatric problem as: "[Patient P2] has a history of auditory hallucinations, paranoia, and bizarre beliefs. These issues are further exacerbated by poor medication compliance and drug and alcohol abuse, all of which are directly impeding [his/her] legal competency and ability to work with [his/her] attorney and participate in [his/her] own defense." The Master Treatment Plan listed the following group modalities to be used as treatment interventions: "Psychology [staff name] will meet with [Patient P2] 1x per week at 1:30 pm for 45 min during legal issues group and utilize group discussion, education videos, and worksheets to facilitate insight into legal charges of burglary and discuss possible outcomes various pleas," "Activities [staff name] will role model reality based speech and utilize verbal redirection when [Patient P2] makes delusional statements for Mondays @ 9:45 a.m. (1 hr) during anger management group, Tues. 2:45 p.m. (1 hr) during music therapy group and 1 hr Thurs. @ 2:20 p.m. during relaxation group," "Social Work [staff name] will meet with patient for 10 min on Fridays to assist with maintaining community supports," "DATS [Drug and Alcohol Treatment] [staff name] will meet with [Patient P2] Mondays at 10:30 for 1 hr during Drug and Alcohol group and utilize group discussion to increase insight and awareness into the triggers of substance abuse."

c. The Progress Notes from 10/8/15 to 10/19/15 contained no documentation that Patient P2 attended any active treatment groups.

H. Patient P7

1. Observation

During an observation at the time of the scheduled "Music Therapy" group on 10/19/15 at 2:40 p.m., Patient P7 was observed sitting in the dayroom with other patients not engaged in any activity.

2. Patient Interview

During an interview with Patient P7 on 10/19/15 at 2:15 p.m., Patient P7 stated that s/he spent his/her time "trying to work out and do push-ups and watch movies and TV." Patient P7 stated that s/he spent his/her time "watching TV and snacks and hygiene." Patient P7 stated that s/he was provided no 1:1 treatments since admission.

3. Record Review

a. Patient P7 was admitted on 10/8/15. The Psychiatric Assessment dated
10/16/15 included the diagnoses of "Schizophrenia, Paranoid Type, Chronic" and "Polysubstance Abuse."

b. The Master Treatment Plan for Patient P7 dated 10/5/15 15 identified the psychiatric problem as: "[Patient P7] has a history of paranoia (believing that [his/her] neighbors had accessed [his/her] thoughts and broadcasted them over the T.V. and internet) as well as experiencing auditory hallucinations, and mood inconsistencies all of which causes him to struggle with accurately understanding [his/her] experiences. This issue is directly impeding [his/her] legal competency and ability to work with [his/her] attorney and participate in [his/her] own defense." The Master Treatment Plan listed the following group modalities to be used as treatment interventions: "Psychology [staff name] will meet with [Patient P7] 1x per week at 10:30 pm for 45 min during legal issues group and utilize group discussion, education videos, and worksheets to facilitate insight into legal charges of Terroristic Threats and discuss possible outcomes various pleas," and "Activities [staff name] will role model reality based speech and utilize verbal redirection when [Patient P7] makes delusional statements for Mondays @ 9:45 (1hr) during anger management group, Tues. 2:45 pm (1hr) during music therapy group and 1 hr Thurs. @ 2:20 pm during relaxation group."

c. The Progress Notes from 9/30/15 to 10/19/15 contained no documentation that Patient P2 attended any active treatment groups.

I. Other Staff Interviews

During an interview with the Medical Director on 10/20/15 at 2:10 p.m., he acknowledged that many patients did not attend group therapies and no alternative interventions were provided to patients who refused to addend or participate in group therapies.

II. Failure to provide sufficient therapeutic modalities including evenings and weekends.

A. Observations

1. During an observation on the C2 RFPC Unit at the time of the scheduled "Drug and Alcohol" group on 10/19/15 at 11:15 a.m., 19 patients were observed sitting in the dayroom or walking in the hallway not engaged in any activity.


2. During an observation on the C2 RFPC Unit at the time of the scheduled "Spiritual Support Group" on 10/19/15 at 1:55 p.m., 22 patients were observed sitting in the dayroom or walking in the hallway not engaged in any activity.

3. During an observation on the C2 RFPC Unit during the time of the scheduled "Music Therapy" group on 10/19/15 at 2:40 p.m., no group was being conducted. All 27 patients on the unit were observed sitting in the dayroom or walking in the hallway not engaged in any activity.

B. Patient Interview

During an interview with Patient M18 on 10/19/15 at 2:25 p.m., Patient M18 stated that on weekends, s/he would "sleep in" and "watch TV more or less."

During an interview with Patient P7 on 10/19/15 at 2:15 p.m., Patient P7 stated that s/he would "sleep in and watch sports [on TV]" on weekends. Patient P7 stated no group therapies were provided on evenings or weekends. Patient P7 stated that s/he was provided no 1:1 treatments since admission.

C. Document Review

A review of the unit schedules for C1, C2, B3, and B4 RFPC units, listed between five (5) and 12 active treatment groups were available each weekday for all 4 units with a total census of 99 patients. No treatment groups were listed for nights or weekends.

D. Staff Interviews

1. During an interview with the Chief Forensic Executive on 10/19/15, she stated that the RFPC units "have church in the morning and visits in the afternoon. It's just a lighter schedule [on the weekends]."

2. During an interview with the DON on 10/20/15 at 2:45 p.m., she stated there was only one treatment group per week, "Med [medication] Teaching" for 30 minutes, that was provided by nursing staff for the 99 patients on the RFPC units.

3. During an interview with the Director of Activities Therapy on 10/20/15 at 1:00 p.m. he stated that a treatment schedule was "activated" 7 days after the admission of a patient. He stated that patients were not enrolled in therapeutic groups until the Master Treatment Plan was completed at 7 days.

4. During an interview with the Chief Social Rehabilitation Executive on 10/20/15 at 12:23 p.m., she acknowledged that the available groups were not sufficient to provide treatment to the 99 patients in the RFPC units.

5. During an interview with the Medical Director on 10/20/15 at 2:10 p.m., he acknowledged that the available groups were not sufficient to provide treatment to the 99 patients in the RFPC units.

III. Failure to appropriately utilize and document restraints

A. Use of mechanical wrist-to-waist restraints

Findings include:

1. Patient M1

a. Patient M1 was a 93 year old admitted 10/18/10 with diagnoses including "Delusional Disorder, Persecutory Type," "Coronary Artery Disease/Status Post Myocardial Infarction with Angina," "Vertigo," and "Hypertension." A review of the medical record for Patient M1 indicated that Patient M1 was transferred to an outside medical facility for admission on 8/24/15 at 11:30 p.m. until 9/1/15 at 3:20 p.m. and on 9/2/15 at 6:15 p.m. until 9/4/15 at 2:30 p.m. A review of the medical record indicated no physician order for restraints, assessments by nurses and physicians, or monitoring of the patient was documented.

b. During an interview with the Day Shift Nursing Supervisor on 10/20/15 at 10:40 a.m., she acknowledged that Patient M1 was transferred to an outside facility for medical care in mechanical restraints on 8/24/15 and on 9/1/15. She stated that Patient M1 was in restraints during these periods of hospitalization at the other facility and supervised by facility nursing staff. She acknowledged that no physician order was present except "transport per forensic policy." She acknowledged that no documentation was present to indicate that the patient was assessed or monitored during the time that Patient P25 was in mechanical restraints. .

2. Patient P25

a. Patient P25 was a 22 year old admitted 4/23/15 with diagnoses including "Schizo-Affective disorder" and "Polysubstance Abuse." A review of the medical record for Patient P25 indicated that Patient P25 was transferred to an outside medical facility for admission on 4/25/15 at 8:10 a.m. until 4/28/15 at 1:45 p.m. The nursing progress note on 4/27/15 (no time) stated "Sat with patient at [outside medical facility] for 11-7:30 shift...Restless, tugging at cuffs...A review of the medical record indicated no physician order for restraints, assessments by nurses and physicians, or monitoring of the patient was documented.

b. During an interview with the Day Shift Nursing Supervisor on 10/20/15 at 10:30 a.m., she acknowledged that Patient P25 was transferred to an outside facility for medical care in mechanical restraints on 4/25/15. She acknowledged that no physician order was present except "transport per forensic policy." She acknowledged that no documentation was present to indicate that the patient was assessed or monitored during the time that Patient P25 was in mechanical restraints.

3. Staff interview

a. During an interview with the Day Shift Nursing Supervisor and Chief Forensic Executive on 10/20/15 at 10:10 a.m., they acknowledged that mechanical restraints (cuffs or flexi-ties) were placed on every forensic patient leaving the facility by facility policy. These patients were escorted and supervised by facility nursing staff. They stated that the only exceptions were made in consultation with the CEO, Chief Forensic Executive, and physician. They could only remember one patient who had not been placed in restraints prior to leaving the facility. They acknowledged that no physician order was required other than "transport according to forensic policy." They stated that no assessment of the patient before, during, or after the restraints by a physician or nurse was required. They stated that no documentation of monitoring during the restraint was required.

b. During an interview with the DON on 10/20/15 at 2:45 p.m., she acknowledged that mechanical restraints were applied to all patients in the RFPC Units who were transported out of the facility. She acknowledged that no specific physician orders, assessments or monitoring by nursing or physician staff were documented for these patients in mechanical restraints.

c. During an interview with the Medical Director on 10/20/15 at 2:10 p.m., he acknowledged that forensic patients were placed in mechanical restraints when taken out of the facility by policy without a specific physician order, behavioral justification, or documented monitoring and assessment by nursing or physician staff.

4. Document Review

The policy "Escort and Transport of Forensic Patients and Use of Restraints For Custody Purposes For Medical Procedures Outside The Secure Perimeter," number 165-10, dated 8/18/15 presented by the facility as the current policy, stated the following: "Mechanical Restraints for custody purposes are always to be used whenever a forensic patient is to be transported by Forensic Security staff outside the Forensic Security perimeter," "The RFPC will always use wrist and ankle restraints will always [sic] be used during transport. Exceptions will be determined by the Chief Forensic Executive for medical reasons, in conjunction with the clinical director," and "Restraints are to be metal or leather connected by metal cables or leather. Metal restraints will be used unless otherwise instructed by the Chief Forensic Executive." The policy stated that the patient could be left unsupervised by facility staff as follows: "If a specific diagnostic, surgical or treatment procedure precludes FSE [forensic security staff] from maintaining line of sight observation of the patient...Whenever possible, prior to FSE staff leaving the patient, the patient will be in a minimum of two point restraints..."

B. Face to face assessment

1. Record Review

a. Patient C4 was restrained on 10/19/15 at 10:45 until 11:00 p.m. The only documented found was the time of the assessment and a statement written by the psychiatrist, noting, "Pt. [Patient] had no complaints of pain. [S/he] is alert & [sic]. No acute distress. Patient examined. (See progress notes.) No sign of injury to patient." A review of the progress note dated 10/19/15 [no time] reported the patient's behavior but failed to discuss, the patient's

Based on observations, interview and record review, it was determined that monitoring and evaluation 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 facility. The Medical Director failed to:

I. Ensure psychiatric evaluations that contained sufficient information to justify psychiatric diagnoses and treatment in a timely manner for two (2) of 12 active sample patients (C4 and D4). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses. (Refer to B110)

II. Ensure Master Treatment Plans (MTPs), referred to as "Comprehensive Individualized Treatment Plans" (CIPTs) by the facility, that identified patient-related short term goals (STGs) in observable, measurable, and behavioral terms for 12 of 12 active sample patients (C4, C6, D4, D7, J3, J5, L2, L3, M1, M18, P2 and P7). Specifically, MTPs failed to contain short-term goal (STG) statements that reflected what the patient would do to lessen the severity of the identified psychiatric problem(s). Several STGs were identical or similarly worded. The absence of individualized goals that reflect behavioral change and functional improvement needed prevents the team from being able to determine the expected outcome to be observed, if the plan is effective, and actions needed to be taken to revise the treatment plan. (See B121)

III. Ensure Master Treatment Plans (MTPs) for 12 of 12 sample patients (C4, C6, D4, D7, J3, J5, L2, L3, M1, M18, P2 and P7) that included interventions to be provided by physicians with a specific focus, based on the individual needs and abilities of each patient. The listed interventions were generic monitoring or routine clinical functions with identical or similar wording for patients with problems or different needs. Master treatments plans listed intervention statements that failed to include sufficient frequency of treatment to ensure intensive active treatment and to facilitate each patient's improvement. Instead, interventions included only monthly contacts with newly admitted patient improvement for five (5) of 12 active sample patients. In addition, the treatment plans failed to specify how these generic modalities would be delivered or how often they would be delivered. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized, approach to multidisciplinary treatment. Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient C4 was admitted on 9/05/13. The Master Treatment Plan (MTP) dated 9/23/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Poor impulse control, ADL compliance, mood regulation, and interpersonal skills:" "MD, Psychiatry, will assist [patient name] in alleviating psychiatric symptoms by prescribing medications and monitoring for response, side effects, and adverse reactions through regular psychotropic interviews (occurring as needed, at minimum monthly)."

2. Patient C6 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/16/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "extensive history of incarceration, substance abuse, mental health issues, and non-compliance with treatment in the community:" "MD, Psychiatry, will assist [patient name] in alleviating psychiatric symptoms by prescribing medications and monitoring for response, side effects, and adverse reactions through regular psychotropic interviews (occurring as needed, at minimum monthly)."

3. Patient D4 was admitted on 9/29/15. The Master Treatment Plan (MTP) dated 9/29/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "maintaining focus, emotional lability [sic] poor hygiene, paranoid thought [sic], limited insight into his/her] mental health concerns, and poor judgement [sic]:" "Psychiatry [staff name] will monitor [patient name] medication regimen and engage [him/her] in monthly interviews to allow [him/her] to express any concerns or discuss any side effects [s/he] may be experiencing."

4. Patient D7 was admitted on 5/17/12. The Master Treatment Plan (MTP) dated 9/30/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Huntington's Disease, cognitive deficits such as difficulty with memory, executive functioning, and motor functioning including physical impulse control:" "Ward psychologist [staff name] or designee will monitor mental status via informal check-ins as needed."

5. Patient J3 was admitted on 8/29/08. The Master Treatment Plan (MTP) dated 7/30/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Issues with deviant sexuality:" "[Patient name] will meet with psychiatry [staff name] on the day of [patient name] treatment team review for further medication review."

6. Patient J5 was admitted on 4/02/15. The Master Treatment Plan (MTP) dated 9/24/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Thoughts and emotions related to cycle of sexually offending:" "During treatment team (monthly) psychiatry [staff name] will review [patient name] medication and address any issues regarding side effects of medication or sexual issues."

7. Patient L2 was admitted on 11/03/14. The Master Treatment Plan (MTP) dated 9/18/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Thoughts and emotions related to patient's [sic] cycle of sexually offending:" "[Patient name] will meet with psychiatry [staff name] on the day of [patient name] treatment team review for further medication review" and "During treatment team (monthly) psychiatry [staff name] will review [patient name] progress and assess if the medication [sic] continues to be an effective medication regime for the management of anxiety."

8. Patient L3 was admitted on 7/01/06. The Master Treatment Plan (MTP) dated 8/25/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "Thoughts and emotions related to [patient name] cycle of sexually offending:" "Psychiatry [staff name] will review [patient name] medications at least monthly during [patient name] treatment team and assess continuation of current medications or the need to address new issues."

9. Patient M1 was admitted on 10/18/10. The Master Treatment Plan (MTP) dated 11/24/14 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "paranoid delusions regarding patient's [sic] ex-wife as well as criminal charges:" "Psychiatry [staff name] will meet with [patient name] monthly for treatment team reviews and medication assessment during for at least twenty minutes and individually as needed for at least fifteen minutes to discuss treatment issues and symptomatology."

10. Patient M18 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "legal issues and suffers from bizarre, persecutory, and grandiose delusions pertaining to being unaware of where [s/he] is, disorganization and distractibility. In addition, [patient name] has poor affect regulation and becomes easily angered and annoyed:" "Psychiatry [staff name] will meet with [patient name] monthly for treatment team reviews and medication assessment during for at least twenty minutes and individually as needed for at least fifteen minutes to encourage patient to use appropriate coping skills and role play appropriate behaviors."

11. Patient P2 was admitted on 10/08/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "history of auditory hallucinations, paranoia, and bizarre beliefs:" "Psychiatry [staff name] will meet with the patient every two weeks for ten minutes to continue to monitor [patient name] response to medication [sic]."

12. Patient P7 was admitted on 10/05/14. The Master Treatment Plan (MTP) dated 10/05/14 stated the following generic or routine clinical functions to be provided by the physician for the identified problem of "history of paranoia [sic] as well as experiencing auditory hallucinations and mood inconsistencies...:" "Psychiatry [staff name] will meet with the patient at least every two weeks for ten minutes to continue to monitor [patient name] response to psychotropic medications and make necessary adjustments."

B. Document Review

Clinical Services Policy 25-6, titled Comprehensive Individualized Treatment Plan, dated 3/12/15 states, "These are the actions staff will perform....to increase, decrease or alter behavior and assist the patient to achieve the short-term goal. The staff methods/interventions should state the name and discipline of the staff doing the intervention, the frequency and duration of the intervention (specific for day/time) as well as the intervention utilized...."

C. Interviews

During an interview with the Medical Director on 10/20/15 at 2:10 p.m., he acknowledged that interventions for the medical staff were generic and not specific to the needs of the patients.

IV. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for eight (8) of eight (8) active sample patients (C4, C6, D4, D7, M1, M18, P2 and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units who were either unable, unwilling or not motivated to attend assigned active treatment groups on each individual activity schedule. Although Master Treatment Plans and activity schedules included multiple group therapies, the patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, such as one to one intervention with staff. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (See B125I)

V. Ensure that patients on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on weekdays, evening hours, and on weekends. On evenings and weekends, no therapeutic groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge. (See B125 II)

VI. Appropriately utilize and document restraints as external controls of violence with failure to:

A. Ensure that use of mechanical wrist-to-waist restraints was based on an immediate threat of harm to self/others for all patients in the Regional Forensic Psychiatric Center (RFPC) units. Patients were placed in wrist to waist restraints and escorted by facility nursing staff without documented justification during transportation out of the facility for medical care or legal matters. This practice results in a failure of patients' right to be free of restraint without justification that restraint is used for imminent risk of danger to self and/or others and appropriate assessment and monitoring. (See B125 III A)

B. Ensure comprehensive face-to-face assessments of patients placed in restraints within a hour for one (1) of 12 sample patients (C6) and three (3) of three (3) active non-sample patients (J19, L4, and P6) whose records were selected to review episodes of physical restraint. Specifically, the facility failed to ensure documentation of a comprehensive face-to-face assessment of the patient's status that included an evaluation of the patient's medical condition with a review of systems; a behavioral assessment; a review of medications and recent laboratory results; and any contributory factors to the patient's aggressive behavior. In addition, the facility failed to revise the Master Treatment plan to include goals and modalities to address aggressive behaviors after episodes of physical restraint. Failure to conduct a comprehensive face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to revise Master Treatment Plans results in patients being hospitalized without adequate interventions for their recovery being provided to them, potentially delaying their improvement. (See B125 III B)

VII. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment in the Regional Forensic Psychiatric Center (RFPC) units. Patient bedrooms contained air vents covered with metal grates. The openings of these grates were sufficiently large to allow materials to be affixed to the grate. These grates would support sufficient weight to pose a hanging hazard. This failed practice results in potential physical harm for all patients on the Regional Forensic Psychiatric Center (RFPC) units. (See B125 IV)

Based on record review, interview, and document review, the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that individualized treatment plans were develop to clearly delineated active treatment oriented nursing interventions to address specific patient problems and assist patients to accomplishment treatment goals for 12 of 12 sample patients (C4, C6, D3, D7, J3, J5, L2, L3, M1, M18, P2 and P7).

Specifically MTPs included nursing functions written as interventions instead of individualized specific active treatment interventions to assist patients to replace problem behaviors and to improve (reduce and/or eliminate) presenting symptoms. These MTPs:

1. Listed nursing interventions that were generic monitoring or routine clinical functions with identical or similar wording for patients with problems or different needs.

2. Failed to specify how these generic modalities would be delivered or how often they would be delivered (group or individual treatment).

These deficiencies potentially result in nursing staff being unable to provide consistent and focus active treatment.

Findings include:

A. Record Review

1. Patient C4 was admitted on 9/05/13. The Master Treatment Plan (MTP) dated 9/23/15 stated the following generic or routine clinical functions for the identified problem of "Poor impulse control, ADL compliance, mood regulation, and interpersonal skills:"

"[Patient's name] will attend and participate in the following nursing groups: Med [medication] Teaching...with [Staff's name], Anger Management...with [Staff's name],
Mind Your Manner...with [Staff's name], Walk & Talk...with [Staff's name]."

These nursing groups were treatment interventions but failed to include a statement regarding the specific focus of treatment in during group sessions based on the patient's presenting or current psychiatric problems and needs.

2. Patient C6 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/16/15 stated the following generic or routine clinical functions for the identified problem of "extensive history of incarceration, substance abuse, mental health issues, and non-compliance with treatment in the community:"

"Nursing staff will monitor [patient name] closely at medication times to ensure [his/her] med compliance daily, to include mouth checks and random room checks to look for medication."

3. Patient D4 was admitted on 9/29/15. The Master Treatment Plan (MTP) dated 9/29/15 stated the following generic or routine clinical functions for the identified problem of "maintaining focus, emotional lability [sic] poor hygiene, paranoid thought [sic], limited insight into [his/]her mental health concerns, and poor judgement [sic]:"

"Nursing [staff name] will maintain daily contact with patient [sic] in order to monitor mental status and assist with activities of daily living."

4. Patient D7 was admitted on 5/17/12. The Master Treatment Plan (MTP) dated 9/30/15 stated the following generic or routine clinical functions for the identified problem of "Huntington's Disease, cognitive deficits such as difficulty with memory, executive functioning, and motor functioning including physical impulse control:"

"Nursing [staff name] will encourage [patient name] to participate in physical therapy once per week. In addition, nursing staff will offer assistance in ambulating in the hallways in order to improve physical well-being and/or engage in positive interactions."

5. Patient J3 was admitted on 8/29/08. The Master Treatment Plan (MTP) dated 7/30/15 stated the following generic or routine clinical functions for the identified problem of "Issues with deviant sexuality:"

"[Patient name] will meet with nursing [staff name] at least once per week to review patient's [sic] medications and ensure [patient name] finds them helpful."

This intervention statement did not include how the intervention would be delivered (group or individual sessions) and what information/teaching the nurse would provide during meeting with the patient.

6. Patient J5 was admitted on 4/02/15. The Master Treatment Plan (MTP) dated 9/24/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to cycle of sexually offending:"

"Nursing [staff name] will assist [patient name] in reviewing [his/her] medications at least once per week during medication pass in order to verify that [patient name] continues to find medications [sic] helpful in managing [patient name] psychiatric symptoms."

This intervention was really a nursing task to reinforce the patient's learning during medication administration. This intervention failed to include meeting with the patient for specific period of time (e.g. 10 to 15 minutes) to provide information about his or her specific medications such as benefits, side effects, and compliance. [Note: The facility's treatment plan form required the duration of intervention to be included.]

7. Patient L2 was admitted on 11/03/14. The Master Treatment Plan (MTP) dated 9/18/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to patient's [sic] cycle of sexually offending:"

"Nursing [staff name] will meet with [patient name] at least once per week to discuss [patient name] medication regime and assess if medication [sic][ patient name] is taking is effective in assisting with [patient name] anxiety."

8. Patient L3 was admitted on 7/01/06. The Master Treatment Plan (MTP) dated 8/25/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to [patient name] cycle of sexually offending:"

"Nursing [staff name] will assist [patient name] in reviewing [his/her] medications at least once per week during medication pass in order to verify that [patient name] finds them helpful."

9. Patient M1 was admitted on 10/18/10. The Master Treatment Plan (MTP) dated 11/24/14 stated the following generic or routine clinical functions for the identified problem of "paranoid delusions regarding patient's [sic] ex-[spouse] as well as criminal charges:"

"Nursing [staff name] will administer medications as ordered during medication pass every day for five minutes during which time [patient name] will be encouraged to attend daily treatment."10. Patient M18 was admitted on 9/09/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions for the identified problem of "legal issues and suffers from bizarre, persecutory, and grandiose delusions pertaining to being unaware of where he is, disorganization and distractibility. In addition, [patient name] has poor affect regulation and becomes easily angered and annoyed:" "Nursing [staff name] will monitor for side effects every day for five minutes following medication pass and report as needed to psychiatrist [staff name] in addition to prompting [patient name] to follow appropriate medication pass procedures and accept directives and rules."

11. Patient P2 was admitted on 10/08/15. The Master Treatment Plan (MTP) dated 9/17/15 stated the following generic or routine clinical functions for the identified problem of "history of auditory hallucinations, paranoia, and bizarre beliefs:"

"Nursing [staff name] will educate with [patient name] for five minutes during medication [sic] pass to explain the benefits of medication compliance."

12. Patient P7 was admitted on 10/05/14. The Master Treatment Plan (MTP) dated 10/05/14 stated the following generic or routine clinical functions for the identified problem of "history of paranoia [sic] as well as experiencing auditory hallucinations and mood inconsistencies...:"

"Nursing [staff name] will educate with [patient name] for five minutes during daily medication [sic] pass about the benefits of medication compliance."

These were generic nursing interventions that were not individualized and specific for these patients' presenting clinical problems. They were not written as treatment interventions that included a modality (individual or group sessions) the focus treatment based on the patient's presenting and/or current psychiatric symptoms. Statements regarding monitoring sign effects or mental status, assessing, reviewing medications, administering medications etc. written as treatment interventions but were actually nursing tasks that would be provided for any patient regarding of his or her presenting or current psychiatric problems or needs.

B. Document Review

Clinical Services Policy 25-6, titled Comprehensive Individualized Treatment Plan, dated 3/12/15 stated, "These are the actions staff will perform....to increase, decrease or alter behavior and assist the patient to achieve the short-term goal. The staff methods/interventions should state the name and discipline of the staff doing the intervention, the frequency and duration of the intervention (specific for day/time) as well as the intervention utilized...."

C. Interview

In an interview on 10/20/15 at 2:45 p.m., with the Director of Nursing, Master Treatment Plans were reviewed. She acknowledged that nursing intervention statements such as administering medications and monitoring sign effects of medications were nursing tasks and not specific interventions to assist patients to improve their level of functioning.

II. Ensure that active treatment measures, such as group and individual nursing interventions were provided for 8 of 8 active sample patients (C4, C6, D4, D7, M1, M18, P2 and P7) on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units who were either unable, unwilling or not motivated to attend assigned active treatment groups on each individual activity schedule. Treatment plans for these patients failed to include alternative nursing modalities, such as one to one intervention with staff. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125 I)

III. Ensure that use of mechanical wrist-to-waist restraints was based on an immediate threat of harm to self/others for all patients in the Regional Forensic Psychiatric Center (RFPC) units. Patients were placed in wrist to waist restraints and escorted by facility nursing staff without documented justification during transportation out of the facility for medical care or legal matters. This practice results in a failure of patients' right to be free of restraint without justification that restraint is used for imminent risk of danger to self and/or others and appropriate assessment and monitoring. (Refer to B125 III A)

Based on record review and interviews, the Director of Social Services failed to:

A. Ensure social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of 12 sample patients (C4, C6, D4, M1, M18, P2 and P7). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (See B108)

B. Ensure Master Treatment Plans (MTPs) for seven (7) of 12 sample patients (C4, D4, D7, J5, L2, L3 and P7) that included interventions to be provided by the social worker with a specific focus, based on the individual needs and abilities of each patient. The listed interventions were generic monitoring or routine clinical functions with identical or similar wording for patients with problems or different needs. In addition, the treatment plans failed to specify how these generic modalities would be delivered or how often they would be delivered. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized, approach to multidisciplinary treatment. Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient C4 was admitted on 9/05/13. The Master Treatment Plan (MTP) dated 9/23/15 stated the following generic or routine clinical functions for the identified problem of "Poor impulse control, ADL compliance, mood regulation, and interpersonal skills:" "Social Worker will work with [patient name] with discharge planning when appropriate."

2. Patient D4 was admitted on 9/29/15. The Master Treatment Plan (MTP) dated 9/29/15 stated the following generic or routine clinical functions for the identified problem of "maintaining focus, emotional lability [sic] poor hygiene, paranoid thought [sic], limited insight into [his/her] mental health concerns, and poor judgement [sic]:" "Social worker [staff name] will work with [patient name] to develop an appropriate plan for discharge when deemed appropriate by treatment team."

3. Patient D7 was admitted on 5/17/12. The Master Treatment Plan (MTP) dated 9/30/15 stated the following generic or routine clinical functions for the identified problem of "Huntington's Disease, cognitive deficits such as difficulty with memory, executive functioning, and motor functioning including physical impulse control:" "Social worker [sic] will work with [patient name] to develop an appropriate plan when discharge is appropriate and recommended by the treatment team."

4. Patient J5 was admitted on 4/02/15. The Master Treatment Plan (MTP) dated 9/24/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to cycle of sexually offending:" "Social worker [staff name] will meet monthly with [patient name] to help assist [patient name] in learning the program rules and adjusting to the facility [sic]."

5. Patient L2 was admitted on 11/03/14. The Master Treatment Plan (MTP) dated 9/18/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to patient's [sic] cycle of sexually offending:" "Social worker [staff name] will meet monthly with [patient name] to help [patient name] in identifying coping skills to manage [patient name] emotions and triggers."

6. Patient L3 was admitted on 7/01/06. The Master Treatment Plan (MTP) dated 8/25/15 stated the following generic or routine clinical functions for the identified problem of "Thoughts and emotions related to [patient name] cycle of sexually offending:" "Social worker [staff name] will meet with [patient name] monthly in order to discuss needs related to discharge planning, including the role that effort in treatment will play in moving him closer to target."

7. Patient P7 was admitted on 10/05/14. The Master Treatment Plan (MTP) dated 10/05/14 stated the following generic or routine clinical functions for the identified problem of "history of paranoia [sic] as well as experiencing auditory hallucinations and mood inconsistencies...:" "Social work [staff name] will meet with patient on Fridays for ten minutes to assist with maintaining community supports. "

B. Document Review

Clinical Services Policy 25-6, titled Comprehensive Individualized Treatment Plan, dated 3/12/15 states, "These are the actions staff will perform....to increase, decrease or alter behavior and assist the patient to achieve the short-term goal. The staff methods/interventions should state the name and discipline of the staff doing the intervention, the frequency and duration of the intervention (specific for day/time) as well as the intervention utilized...."

C. Interviews

During an interview on 10/20/15 at 1:30 p.m., the Social Work Director acknowledged that active treatment interventions on patients ' treatment plans were generic and general.