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Based on document review, and interview it was determined for 1 (Pt. #11) of 3 clinical records reviewed for restraints, the Hospital failed to ensure timely reporting to CMS (Center of Medicare and Medicaid Services), of a patient's death after restraint removal.

Findings include:

1. On 5/18/17 at approximately 10:00 AM, the clinical record of Pt. #11 was reviewed. Pt. #1 was a 16 year old male admitted on 2/4/17 with diagnosis of Disruptive Mood Dysregulation Disorder. Pt. #1 was autistic, agitated, aggresive and destructive to property.

Pt. #11 was placed on restraints (physical hold) in various occasions during his hospital stay and required medications to decrease his agitation. The last date documented of Pt. #11 in restraint was on 2/12/17, 4 days prior to is death on 2/16/17.

Pt. #11's clinical record contained physicians's order dated 2/12/17 at 2:25 PM for Restraint "Physical" due to patient being at risk to self injure. At 2:30 PM Thorazine (antipsycotic) 100 mg intramuscular one time dose. Pt. #11 was restrained (physical hold) for 2:25 PM to 3:17 PM (52 minutes).

The Progress note dated 2/16/17 at 9:40 PM the nurrse documented " ...as this writer returned to the RN's (nurses) station, a hallway staff stated that the pt's (Pt. #11) 1:1 said pt was 'acting funny'. Before the writer could get to the pt's room, he went unresponsive stopped breathing. At aprrox. (aprroximately) 2020 (8:20 PM) a code blue was initiated...pt was transported to (acute care hospital) ER (emergency room) at approximately 2030 (8:30 PM)"

2. On 5/17/17 at approximately 2:30 PM the Hospital's policy entitled "Restraints/Seclusion" (revised 4/2017) was reviewed and indicated "Definitions "Restraint: Physical/Restraint/Hold: Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body. For example, holding a patient to give a forced psychotropic medication in a manner that restricts his or her movement constitutes a physical restraint. Procedure: ...25. Risk Manager reports any death relating to seclusion/restraint use to...Centers for Medicare and Medicaid as a sentinel event. The Hospital must report the following information to CMS: ...Each death known to the hospital tht occurs within 1 week after retraint or seclusion where it is reasonable to assume that the use of restraint or plaement in seclusion contributed directly or indirectly to patient's death..."

3. On 5/17/17 at aproximately 11:40 AM, theDirector of Risk Management and Performance Improvement (E #1) was interviewed. E #1stated the Hospital did not report this death to CMS or any agency because she had been advisd by thier Corporate office they didn't have to due to patient having died at (acute care hospital).

4. On 5/17/17 at approximately 12:00 PM, the Chief Medical Officer (CMO) was interviewed. The CMO stated he was informed by staff vua telephone that Pt. #1 had died shortly after arriving to the acute care hospital ED. The CMO stated the Hospital is not aware of Pt. #11 cause of death.

Based on document review and interview, it was determined for 1 of 2 (Pt #10) clinical records reviewed on the 1 South Unit (children's unit), the Hospital failed to ensure the prescribed levels of observations were implemented and followed.

Findings include:

1. Hospital policy entitled, "Levels of Observation", (revision date 11/16) required, "Procedure: 1. The physician will order one of three levels of observation at time of admission...q (every) 15 (may order a precaution)...2. The physician will order a specific precaution for...assault...homicide...4. The RN may not decrease the level of observation..."

2. The clinical record of Pt #10 was reviewed on 5/16/17 at approximately 2:00 PM. Pt #10 was a 10 year old male admitted on 4/25/17 with a diagnosis of DMDD (disruptive mood dysregulation disorder). Pt #10's clinical record contained a physician's order dated 4/25/17 that required, "Precautions: Assault, Homicide...Level of Observation: q 15 minutes..." Pt #10's Patient Observation Rounds sheets dated 4/25/17 to 5/15/17 failed to include documentation that Pt #10 was being monitored for homicide precautions.

3. The Nursing Manager of the 2 South Unit (E #5) stated that the chart did not include homicide precautions as ordered and there was not an order to discontinue them.

Based on document review and interview, it was determined, for 1 of 3 (Pt #6) patients on the 4 East Unit (Forensic Boys), the Hospital failed to ensure the Care Plan included precautions ordered by the Physician, as per policy.

Findings include:

1. On 5/16/17 at 12:50 PM, Hospital policy titled, "Multidisciplinary Treatment Plan", revised 12/2014, was reviewed. The policy required, "All precautions order by the Attending Psychiatrist require a problem/ impairment to be initiated on the Master Treatment Plan [Care Plan]."

2. On 5/16/17 at 10:30 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a 13 year old male, admitted on 4/12/17, with a diagnosis of ADHD (attention-deficit/ hyperactivity disorder). Pt. #6's "Initial Nursing Treatment Plan" dated 4/12/17, included, "Sexual Acting Out: None" There were no other nursing care plans or updates.

3. Pt. #6's "Individual Treatment Plan", dated 4/12/17, included two problems: 1. "Unfit to Stand Trial" and 2. "Aggressive Behaviors". There was no problem related to sexually acting out.

4. Pt. #6's "Transdiciplinary Treatment Team Meeting" dated 4/19/17, included, "Patient has been very inappropriate of female staff - touching, verbally inappropriate." This information was not added to Pt. #6's Care Plan

5. Pt. #6's physician's orders dated 4/20/17 at 9:00 AM, required, "SX [sexually acting out] precautions". Safety precaution sheet were revised to include sexually acting out precautions. However, there was no revision to Pt. #6's Care Plan to include sexually acting out goals.

6. On 5/16/17 at 11:00 AM, an interview was conducted with a Psychologist (E #3). E #3 stated sexually acting out precautions do not have to be included in the Treatment Plan, in contradiction to the policy.

6. On 5/16/17 at 1:55 PM, an interview was conducted with a Registered Nurse (E #4) on 4 East. E #4 stated Pt. #6 exposed himself to peers on 5/13/17 and a doctor ordered (dated 5/13/17) Pt. #6 to sleep in the "monitored room" until 5/15/17.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on May 16 and May 17, 2017, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on May 16 and May 17, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

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

I. Develop and document Master Treatment Plans (MTP) based on individual patient needs for one (1) of eight (8) active sample patients (A2). Specifically the MTP did not address the patient's individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of the patient. Failure to address the individualized needs of the patient can prolong progress toward discharge and negatively impact the patient's recovery. (Refer to B118)

II. Ensure that the MTP was based on an inventory of the patient's strengths and disabilities for one (1) of eight (8) active sample patients (A2). The treatment team failed to utilize their assessments to identify which patient individualized disabilities were to be addressed during hospitalization and which strengths were to be utilized to build the MTP. This failure results in treatment that potentially focuses on goals and interventions that do not address specific patient needs. This failure can delay recovery and lead to an increase in the length of hospitalization. (Refer to B119)

III. Failed to provide Master Treatment Plans (MTPs) which included observable, behavioral, and measurable goals that delineated specific outcome behaviors for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions. (Refer to B121)

IV. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for two (2) of eight (8) active sample patients (A2 and A5) who were unable, unwilling or not motivated to attend or participate in active treatment groups. The Master Treatment Plans (MTP) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on record review and interview, the facility failed to develop and document Master Treatment Plans (MTP) based on individual patient needs for one (1) of eight (8) active sample patients (A2). Specifically the MTP did not address the patient's individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of the patient. Failure to address the individualized needs of the patient can prolong progress toward discharge and negatively impact the patient's recovery.

Findings include:

A. Record Review

Patient A2 was admitted on 5/6/17. The Psychiatric Evaluation dated 5/7/17 documented a diagnosis of "Schizophrenia, Paranoid Type". Review of the MTP dated 5/9/17 (received from facility at 3:00 p.m. on 5/16/17) revealed an incomplete form. Although there were signatures for the physician, nurse and expressive therapist the following areas were blank: Psychiatric Problems, Psychosocial and Environmental Problems, Deferred Problems and Rationale for Deferring Problems, Patient Strengths/Assets, Patient Disabilities and Discharge Destination. The surveyor requested additional MTP information on 5/17/17 and was given the same documents along with others. All of the missing information was filled in but the "Date Identified" spaces were all left blank. In addition, a therapist signature had been added to the signature page and was dated 5/8/17. The additional documents indicated that goals and interventions had been established for Patient A2 on 5/9/17.

B. Interview

During interview on 5/18/17 at 9:10 a.m., the Medical Director agreed that the MTP was blank on 5/16/17 and filled in on the copy received on 5/17/17. He acknowledged that the identified dates should have been added and could not explain why the documentation had not been completed during the initial MTP meeting on 5/9/17.

Based on record review and interview, the facility failed to ensure that the MTP was based on an inventory of the patient's strengths and disabilities for one (1) of eight (8) active sample patients. (A2). The treatment team failed to utilize their assessments to identify which patient individualized disabilities were to be addressed during hospitalization and which strengths were to be utilized to build the MTP. This failure results in treatment that potentially focuses on goals and interventions that do not address specific patient needs. This failure can delay recovery and lead to an increase in the length of hospitalization.

Findings include:

A. Record Review

Patient A2 was admitted on 5/6/17. The Psychiatric Evaluation dated 5/7/17 documented a diagnosis of "Schizophrenia, Paranoid Type" and listed the patient's assets as, "The patient is ambulating without support." The patient's liabilities were listed as, "The patient has been acting bizarre." The MTP had no assets or disabilities listed. The areas were left blank on the MTP form until 5/17/17 when "good health, self care [sic] and intelligent" were added. The disabilities section remained blank on 5/17/17.

B. Interview

During interview on 5/18/17 at 9:10 a.m., the Medical Director agreed that there were no assets or disabilities listed on the MTP on 5/16/17 and that assets had been added to the plan on 5/17/17. He also acknowledged that the disabilities section remained blank as of 5/17/17. He could not explain why the assets and disabilities were not documented during the initial MTP meeting on 5/9/17.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) which included observable, behavioral, and measurable goals that delineated specific outcome behaviors for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Document Review

The facility used identical pre-printed treatment plan forms which resulted in the selection of identical and/or similar treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), regardless of individual problems and needs. The listed goals for one (1) of eight (8) active sample patients (A3) had no target date for expected achievement.

I. The facility failed to identify discharge planning goals in the MTP for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8).

II. The facility failed to identify nursing goals in the MTP for three (3) of eight (8) active sample patients (A2, A4 and A5).

B. Record Review

1. Patient A1's Master Treatment Plan (MTP) dated 5/16/17 had the following short term goals for Problem #1: "Suicidal thoughts due to conflict with family. Evidenced by making statements to harm [his/her] self to teacher at school."

a. Short-term goal: "__________[sic] will engage in activities that encourage positive forms of self expression and self validation to address intense emotions." Goal was staff expectation/treatment compliance statement rather than a measurable goal. Not stated in behavioral terms identifying what the patient would be doing or saying to "address intense emotions."

b. Short-term goal: "[Name of patient] will verbalize how taking cymbalta [sic] will help manage depression." Goal was staff expectation and not written in observable, behavioral, and measurable terms about medication.

c. Short-term goal: "_________[sic] will identify and practice skills to manage intense emotions and difficult thoughts safely and effectively." Goal was staff expectation/compliance statement and not stated in behavioral terms identifying what skills the patient would be identifying/doing/ saying "to manage intense emotions and difficult thoughts safely and effectively."

d. Short-term goal: "[Name of patient] will identify 3 [sic] stressors in [his/her] life that [s/he] can work on to improve and or change." Goal was not stated in observable, behavioral, and measurable terms reflecting the method(s) to be utilized for identifying stressors in [his/her] life [s/he] can work on to improve and or change. It failed to reflect how the patient would be identifying stressors (saying and/or doing) to improve and or change [his/her] presenting problem.

e. Short-term goal: "[Name of patient] will verbalize 3 ways to manage [his/her] emotions safely." Goal was staff expectation/treatment compliance goal and failed to identify patient's observable behavior to demonstrate how [patient] would "manage [his/her] emotions safely."

f. Short-term goal: "[Name of patient] will verbalize 2 ways to manage thoughts of self injury." There was no way to determine whether patient will "verbalize (self report) 2 ways to manage thoughts of self injury" to staff, thus not a measurable goal.

2. Patient A2's Master Treatment Plan (MTP) dated 5/9/17 had the following short-term goals for Problem #1: "Paranoid, aggressive, delusional. Evidenced by thinks [sic]people are following [him/her] pulling [his/her] teeth out."

a. Short-term goal: "[Name of patient] will verbalize how taking Risperdal Invega injection will help manage________. [sic]" Goal was staff expectation and not written in observable, behavioral, and measurable terms.

b. Short-term goal: "_________ [sic] will both practice and verbalize skills that allow them to make safe decisions not controlled by troubling thoughts [sic]." Goal was staff expectation/compliance statement and not stated in behavioral terms identifying what skills the patient would be practicing and verbalizing "to make safe decisions not controlled by troubling thoughts."

3. Patient A3's Master Treatment Plan (MTP) dated 5/16/17 had the following short-term goals for Problem #1: "Depression and Suicidal Ideation. Evidenced by Pt (patient) has suicidal ideations with no plans."

a. Short-term goal: "[Name of patient] will engage in activities that allow pt (patient) to accept and express emotions in safe and healthy ways." Goal was not stated in observable, behavioral, and measurable terms identifying the activities to be utilized that would "allow patient to accept and express emotions in safe and healthy ways."

b. Short-term goal: "[Name of patient] will verbalize how taking _________will help [sic]." Goal was staff expectation and not written in observable, behavioral, and measurable terms about medication.

c. Short-term goal: "[Name of patient] will identify 3 techniques to help manage thoughts as it relates to suicidal ideations." Goal was not stated in behavioral terms reflecting what the patient would be doing or saying to "manage thoughts as it relates to suicidal ideations."

For Problem #2: "Psychosis. Evidenced by Pt (patient) having auditory command hallucinations telling [him/her] to kill [him/her] self."

a. Short-term goal: "[Name of patient] will verbalize how taking _________will help [sic]." Goal was staff expectation and not written in observable, behavioral, and measurable terms about medication.

b. Short-term goal: "[Name of patient] will identify 3 techniques to help manage thoughts as it relates to psychosis." Goal was not stated in behavioral terms reflecting what the patient would be doing or saying to "manage thoughts as it relates to psychosis."

c. Short-term goal: "[Name of patient] will practice one skill to manage fear psychotic symptoms cause [sic]." Skill was not identified and how patient will use the skill "to manage fear." Goal not observable, measurable and stated in behavioral terms.

4. Patient A4's Master Treatment Plan (MTP) dated 4/26/17 had the following short-term goal for Problem #1: "Aggression. Evidenced by [Name of Patient] was very aggressive at school, hitting staff and peers. Pt (patient) also has been aggressive at home."

a. Short-term goal: "[Name of patient] will both learn and practice skills needed to manage behaviors and feelings safely [sic]." Goal was staff expectation.

b. Short-term goal: "[Name of patient] will engage in activities that allow them to express difficult emotions safely." Goal was not stated in observable, behavioral, and measurable terms identifying the activities to be utilized that would "allow patient to express difficult emotions safely."

c. Short-term goal: "[Name of patient] will verbalize how taking ________ will help make better choices. [sic]" Goal was staff expectation and not written in observable, behavioral, and measurable terms about medication.

d. Short-term goal: "[Name of patient] will identify and practice skills to manage aggression." Goal was not stated in behavioral terms reflecting what identified skills patient will be utilizing "to manage aggression."

e. Short-term goal: "[Name of patient] will learn communication skills with family and develop safety plan. Parents will work on willingness to implement new parenting practices and follow aftercare." Goal was staff expectation/compliance in treatment. The second part of this goal statement is not a patient goal but a parent goal.

d. Short-term goal:"[Name of patient] will identify coping skills to manage [his/her] intense emotions and behaviors and maintain safe [sic]." Goal was staff expectation/compliance in treatment rather than behavior outcomes, thus not a measurable goal.

5. Three (3) patients A6 ( MTP dated 5/2/17), A7 (MTP dated 5/15/17) and A8 (MTP dated 5/8/17) had the following pre-printed identical short term goals: 1. "[Name of patient] will both verbalize and practice skills to decrease life threatening and quality of life interfering behavior. 2. [Name of patient] will engage in activities that encourage positive forms of self expression and self validation to address intense emotions. 3. [Name of patient] will verbalize how taking meds (medications) haldol, seroquel, zyprexa [sic] will help manage their intense negative emotions. 4. [Name of patient] will identify and practice skills to manage intense emotions safely and effectively."

Short-term goals 1, 2 and 4: These goals were not stated in observable, behavioral and measurable terms reflecting what skills the patient will be utilizing to decrease life threatening and quality of life interfering behavior. There was no identification of what activities patient will be engaging in that will encourage positive forms of self-expression and self validation to address intense emotions. It failed to reflect how the patient would identify and practice (saying and/or doing) to manage intense emotions safely and effectively.

Short-term goal 3: This goal was stated as staff expectation/compliance in treatment. No results found to determine whether patient was verbalizing to staff taking medications will help manage their intense negative emotions.

6. One (1) patient A5 (MTP dated 5/15/17) had the following pre-printed short-term goals. 1. "[Name of patient] will engage in activities that allow [him/her] to express [his/her] frustration and expend energy in prosocial ways. 2. [Name of patient] will verbalize how taking [his/her] psychotropic medications will help manage aggression and reduce suicidal ideation. 3. [Name of patient] will increase and practice [his/her] ability to manage [his/her] anger without destruction of property."

Short-term goal: 1, 2 and 3 were not stated in behavioral terms reflecting what activities the patient will be engaged in to express frustration and expend energy. This goal was stated as staff expectation/compliance in treatment. No results found to determine whether patient was verbalizing to staff how medications helps [him/her] manage aggression and reduce suicidal ideation. It failed to reflect method(s) patient would be utilizing to manage [his/her] anger without destruction of property.

C. Interview

In an interview on 5/17/17 at 11:00 a.m., with the unit Clinical Director and the Nurse Manager, The Master Treatment Plans were reviewed. They both agreed that the goal statements were not written in observable, measurable, behavioral terms.

In an interview with the Director of Nursing on 5/18/19 at 10:00 a.m., regarding treatment goals being individualized, observable, measurable and written in behavioral terms, she stated, "I see what you are saying, I agree."

Based on record review, document review and interview, the facility failed to identify in the Master Treatment Plan the specific team members by their full name and discipline that would be held responsible for seeing that each intervention was carried out. The Master Treatment Plan under the "Discipline Responsible/Name" section reflected names of staff, initials of staff, no identification of the discipline assigned for that specific intervention, discipline assigned with no name (staff responsible) for five (5) of eight (8) active sample patients (A4, A5, A6, A7 and A8). This failure of not properly identifying the staff can result in confusion in deciphering who is primarily responsible for ensuring compliance with aspects of the patient's individualized treatment program.

Findings include:

A. Record Review

1. Patient A4's Master Treatment Plan dated 5/9/17.

For the following interventions:
Group Therapy - Discipline not identified.
Expressive Therapy - Discipline not identified. Staff not identified.
1:1 - Discipline not identified. Staff not identified.
Individual Therapy - Discipline not identified.
Family Therapy - Discipline not identified.

2. Patient A5's Master Treatment Plan dated 5/15/17.

For the following interventions:
Group Therapy - Discipline not identified.
Expressive Therapy - Discipline not identified
Individual Therapy - Discipline not identified. Staff not identified.
Family Therapy - Discipline not identified. Staff not identified.

3. Patient A6's Master Treatment Plan dated 5/2/17.

For the following interventions:
Group Therapy - Discipline not identified.
Expressive Therapy - Discipline not identified.
1:1 - Staff not identified.
Family Therapy - Discipline not identified.

4. Patient A7's Master Treatment Plan dated 5/15/17.

For the following interventions:
Group Therapy - Discipline not identified.
Expressive Therapy - Discipline not identified.
1:1 - Staff not identified.
Family Therapy - Discipline not identified. Staff not identified.

5. Patient A8's Master Treatment Plan dated 5/9/17.

For the following interventions:
Group Therapy - Discipline not identified.
Expressive Therapy - Discipline not identified.
1:1 - Discipline not identified.
Family Therapy - Discipline not identified.

B. Interview

In an interview on 5/18/17 at 10:00 a.m., with the Director of Nursing and the Clinical Service Corporation Director, The Master Treatment Plans were discussed. They concurred with the findings.

Based on record review, observation and interviews, the facility failed to ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for two (2) of eight (8) active sample patients (A2 and A5) who were unable, unwilling or not motivated to attend or participate in active treatment groups. The Master Treatment Plan (MTP) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

Findings include:

A. Patient A2

1. Record Review

Patient A2 was admitted on 5/6/17. The Psychiatric Evaluation dated 5/7/17 documented a diagnosis of "Schizophrenia, Paranoid Type". The Master Treatment Plan (MTP) dated 5/9/17 identified the problems "Paranoid, Aggressive and delusional." The interventions for these problems included "Group Therapy 1.5 hrs (hours) a day", "Expressive Therapy 3-5x per week" and "Individual Therapy 2x week 30 min."

2. Review of Progress Notes from 5/10/17-5/14/17 revealed the following:

5/10/17-Individual Therapy Note: "The patient was not able to meet. [S/He] was nonresponsive to all attempts of this writer."

5/10/17-RN Progress Note for evening shift: "Patient isolative and withdrawn spending most of shift in room. Did not attend groups or participate in treatment."

5/11/17-BHT (Behavioral Health Tech) Group Progress Note listed 11 activities offered and noted that the patient had not attended any of them.

5/11/17-BHT Progress Summary for day shift: "Patient refused to attend groups."

5/11/17-"Acceptance and Commitment" Group Note: "Patient was not present for group."

5/12/17-BHT Group Progress Note listed 11 activities offered and noted that the patient had not attended any of them.

5/12/17-BHT Progress Summary for day shift: "Patient stayed in [his/her] room the entire shift."

5/12/17-RN Progress Note for evening shift: "Refused to attend groups."

5/13/17-RN Progress Note for evening shift: "Patient denies going to groups."

5/13/17-BHT Group Progress Note for day shift "Life Skills" group: "Pt refused all treatment and stayed in room for shift." BHT Group Progress Note for evening groups: "Patient refused to leave room."

5/13/17-BHT Progress Summary for day shift: "Pt. slept for entire shift."

5/14/17-BHT Progress Summary for day shift: "Pt was sleeping all day in assigned room. Refused to go to group."

3. Observations

During an observation on the 3 East Unit on 5/16/17 at 11:15 a.m., Patient A2 was observed in bed with the covers pulled over his/her head. There was an Acceptance and Commitment-Values Exploration group being held at this time.

During an observation on the 3 East Unit on 5/17/17 at 10:45 a.m., Patient A2 was observed in bed. There was Therapy Group and a Skills Group being held during this time.

During an observation on the 3 East Unit on 5/17/17 at 1:30 p.m., Patient A2 was observed in bed. There was a Recovery Action Group being held at this time.

During an observation on 3 East Unit on 5/18/17 at 10:45 a.m., Patient A2 was observed in bed. There was an
Acceptance and Commitment-Opening Up group being held at this time.

4. Interviews

During interview on 5/16/17 at 11:20 a.m., Program Specialist 1 stated that Patient A2 was very psychotic and had recently been sleeping all day long. The Program Specialist further stated that all patients were expected to go to all the unit groups.

During interview on 5/16/17 at 11:45 a.m., RN1 stated that Patient A2 was paranoid and sometimes would walk in and out of groups.

During interview on 5/17/17 at 10:45 a.m., MHT2 stated that Patient A2 was actively psychotic and stayed in bed. Surveyor attempted to interview Patient A2 in his/her room during this time and was unsuccessful in getting patient to communicate.

During interview on 5/18/17 at 9:10 a.m., the Medical Director stated that Patient A2 was psychotic, refused medication and stayed in his/her room most of the time.

B. Patient A5

1. Record Review

Patient A5 was admitted on 2/15/17. The Psychiatric Evaluation dated 2/15/17 documented a diagnosis as "Disruptive Mood Dysfunctional Disorder." The Master Treatment Plan (MTP) dated 2/15/17identified the problems, "Aggression and suicidal ideation." Interventions for these problems were identified as;"Group Therapy 1.5 hours a day", "Expressive Therapy 3-5x per week" and "Individual Therapy 2x/week." Although goals were added to the MTP during reviews, the problems and interventions for group and individual therapy remained.

2. Review of Progress Notes from 5/9/17-5/15/17 revealed the following:

5/9/17-BHT Progress Summary for day shift: "Pt did not attend groups and remained isolated in [his/her] room."

5/9/17-BHT Group Progress Note for "Lagging Skills" group: "Refused to attend", "Slept."

5/10/17-BHT Group Progress Note for "Lagging Skills" group: "Slept in room."

5/11/17-BHT Progress Summary for day shift: "The pt slept until just before lunch."

5/11/17-RN Progress Note for evening shift: "Patient did not participate in group as [s/he] slept most of shift."

5/12/17-BHT Progress Summary for day shift: "Pt did hygene [sic] but [s/he] did not attend group"

5/12/17-BHT Group Progress Note for "Lagging Skills" group: "Pt sleeping during group."

5/14/17-BHT Progress Summary for day shift: "Patient has stayed in patient room for the majority of the day."

5/15/17-BHT Progress Summary for day shift: "The pt slept for the entire morning, [s/he] woke up to eat lunch. After lunch pt went back to sleep."

3. Observations

During an observation on 2 East on 5/16/17 at 11:15 a.m., Patient A5 was observed in bed sleeping with his/her head under the sheet. Patient was called by name with no response. There was a Lagging Skills Managing Emotions group being held during this time.

During an observation on 2 East on 5/16/17 at 12:20 p.m., Patient A5 was observed in bed and was refusing to eat lunch.

During an observation on 2 East on 5/16/17 at 3:45 p.m., Patient A5 was observed in bed with his/her eyes closed. There was a Managing Emotions group being held during this time.

4. Interviews

In an interview with BHT1 on 5/17/17 at 11:20 a.m., the BHT stated that patient A5 "hardly leaves [his/her] room, [s/he] comes sometime for lunch, but that's all. [S/He] does not do groups because [s/he] gets upset with the other patients when they share. Sometimes in the evenings [s/he] might come out of [his/her] room and try a group or so."

In an interview with Patient A5 at 9:20 a.m. on 5/17/17, Patient A5, when asked about not going to groups, stated that s/he does not want to get into fights with the others because s/he gets mad with them.

In an interview with the Medical Director on 5/18/17 at 9:10 a.m., the Medical Director stated that Patient A5 was a "challenging case" and that he was aware that the patient isolated in his/her room.

Based on record review, observation and interview, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Develop and document Master Treatment Plans (MTP) based on individual patient needs for one (1) of eight (8) active sample patients (A2). Specifically the MTP did not address the patient's individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of the patient. Failure to address the individualized needs of the patient can prolong progress toward discharge and negatively impact the patient's recovery. (Refer to B118)

II. Ensure that the MTP was based on an inventory of the patient's strengths and disabilities for one (1) of eight (8) active sample patients. (A2). The treatment team failed to utilize their assessments to identify which patient individualized disabilities were to be addressed during hospitalization and which strengths were to be utilized to build the MTP. This failure results in treatment that potentially focuses on goals and interventions that do not address specific patient needs. This failure can delay recovery and lead to an increase in the length of hospitalization. (Refer to B119)

III. Provide Master Treatment Plans (MTPs) which included observable, behavioral, and measurable goals that delineated specific outcome behaviors for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions. (Refer to B121)

IV.Identify in the Master Treatment Plans the specific team members by their full name and discipline who would be held responsible for seeing that each intervention was carried out for five (5) of eight (8) active sample patients (A4, A5, A6, A7 and A8). This failure of not properly identifying the staff can result in confusion in deciphering who is primarily responsible for ensuring compliance with aspects of the patient's individualized treatment program. (Refer to B123)

V. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for two (2) of eight (8) active sample patients (A2 and A5) who were unable, unwilling or not motivated to attend or participate in active treatment groups. The Master Treatment Plans (MTP) for these patients failed to include alternative interventions for these patients. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

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

1. The identified short term goals in the MTPs for eight (8) of eight (8) active sample patients (a1, A2, A3, A4, A5, A6,A7 and A8) were observable, measurable, and addressed the individual patient presenting problems and needs. (Refer to B121).

A. Interview

In an interview with the Nurse Manager on 5/17/17 at 11:30 a.m., the Treatment Plans were reviewed. She acknowledged that the treatment plan goals were not written in observable and measurable terms.

In an interview with the Director of Nursing on 5/18/17 at 10:00 a.m., the Treatment Plans were reviewed. She stated, "I see what you are saying, I agree with you."