HospitalInspections.org

Based on record review, observation and staff interviews, the facility failed to ensure that: a) Treatment Plans were completed in manner that provided staff with the guidance necessary to provide active treatment; b) patients unable or unwilling to attend group activities and therapy were provided alternative individualized treatment; c) patients received active treatment during the weekday evenings and during weekends, and d) patients remained free of self-harm. Specifically, the facility failed to:

1. Include a substantiated diagnosis that served as the primary treatment plan focus for 9 of 16 active sample patients (A1-1, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20, G1-7).This practice compromises the staff's ability to deliver clinically focused treatment. (Refer to B120)

2. Ensure that the treatment plans of 10 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D2-6, D3-11, E1-21, E3-23 and F2-20) defined short and long-term goals as specific, measurable patient behaviors to be achieved. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans. (Refer to B121)

3. Provide 11 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20, and G1-7) with treatment plans that delineated individualized treatment modalities. Instead, treatment plan interventions were routine generic discipline functions. This failure resulted in staff being unable to provide direction and focused treatment for patients identified problems. (Refer to B122)

4. Identify the responsible team members for treatment modalities listed in the Master Treatment plans of 14 of 16 active sample patients (A1-1, A2-23, A3-22, B2-13, D1-6, D2-6, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7, and G2-4). This results in the inability to determine what staff member was responsible for ensuring compliance with various aspects of treatment. (Refer to B123)

5. Protect 1 of 16 active sample patients (E2-3) from continued self-harm. The patient had repeated episodes of swallowing foreign objects while on 1:1 observation, necessitating transfer to an emergency room and emergency removal three times in the month prior to the survey. The facility failed to follow through with a safety plan put into place on 04/19/10 by the treatment team to prevent further harm to the patient. On 05/05/10, the patient ingested a disposable razor, and then on 05/08/10, ingested a wire while on 1:1 observation. Both incidents necessitated emergency surgical procedures to remove the objects. The patient reported that the staff person responsible for the one-to-one observation on 05/08/10 was asleep at the time of the most recent swallowing incident. These failures continued to place patient E2-3 at risk for further serious harm.

On 05/11/10 at 4:00 PM, the facility was notified that a situation of IMMEDIATE JEOPARDY to patient safety existed. The facility provided a Plan of Correction that was accepted by the regional office on 05/13/10 at 10:00 am, The IMMEDIATE JEOPARDY was removed at that time with the Deficient Practice remaining. (Refer to B125-I)

6. Provide sufficient active treatment measures for 9 of 16 active patients (A1-1, A2-23, B1-15, B2-13, D2-6, E2-3, E3-23, F2-20, and G2-4) for significant periods of time during their hospital stay. Lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125-II)

7. Ensure that 16 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D1-6, D2-6, D3-11, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7, G2-4) received sufficient hours of therapeutic measures, particularly during evening hours and on weekends, which focused on restoring and/or developing optimal levels of mental and psychosocial functioning. This deficiency results in patient inactivity, and can prevent patients from achieving their optimal level of functioning. (Refer to B125-III)

Based on record review and interview, it was determined that for 2 of 16 active sample patients (D1-6 and E1-19), the facility failed to perform and document a complete annual physical examination update, including a descriptive neurological examination, indicating what tests were performed to assess neurological functioning. The absence of this patient information limits the clinician's ability to accurately provide a comparison measure of functioning relative to the patient's initial physical examination, potentially adversely affecting patient care.

Findings are:

A. Record Review

1. Patient D1-6. On a Physical Examination and Assessment form dated 8/28/09, under the section for Neurological Examination, there were handwritten statements within each of 15 sections. The word "Uncooperative" was entered for all of the Cranial nerve examination, the sensory system exam, and the reflex exam. The statement "appears grossly intact" was entered for coordination, station and gait, motor system and facial examinations. There was no follow-up examination found in the patient's record.

2. Patient E1-19. On a Physical Examination and Assessment form dated 3/30/10, under the section for Neurological Examination, there were handwritten statements within each of 15 sections. The word "Refused" was entered in each section. There was no follow-up evaluation noted in the patient's record. The Annual Psychiatric Evaluation dated 03/03/10, noted an Axis III diagnosis of "Rule out Parkinson's Disease."

B. Observation

During observation of Patient E1-19 on 05/12/10 at 12:00 p.m. the patient presented with a masked facial appearance, soft low volume voice, reduced eye blinking, and severe resting tremor in both hands and upper extremities. The patient also had difficulty arising from bed without assistance. These are all signs of Parkinson's disease.

C. Interview

In an interview on 05/11/10 at 4:15 PM, the Medical Director agreed with the above findings.

Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 13 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, D1-6, D2-6, D3-11, E1-19, E3-21, E3-23, F1-19, G1-7 and G2-4). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Record Review

1. Patient A1-1. In a Psychiatric Assessment dated 4/16/10, the preprinted section for "Mental Status Examination, i. Cognitive" noted: (handwritten) "uncooperative - not answering." There was no evidence in the patient record of a follow-up examination since that date.

2. Patient A2-23. In a Psychiatric Assessment annual update, dated 02/24/10, the section "Mental Status Examination" noted: "His memory is impaired to most of the remote events of his life, recent and past. His intellectual functioning is below average." No information as to how these conclusions were reached was included.

3. Patient A3-22. In a Psychiatric Assessment dated 03/04/10, under the section "Mental Status Examination," no information related to memory testing or estimation of intellectual functioning was present.

4. Patient B1-15. In a Psychiatric Assessment dated 3/10/10, under the preprinted section titled "Mental Status Examination, i. Cognitive," was the note: (handwritten) "would not cooperate." There was no evidence in the patient's record that a follow-up examination had been performed since that date.

5. Patient D1-6. In a Psychiatric Assessment dated 08/20/09, the section "Mental Status Examination" noted: "He is not able to cooperate with the formal tests for attention, concentration and memory." There was no evidence of a follow-up examination in the patient's record.

6. Patient D2-6. In a Psychiatric Assessment dated 08/31/09, the section "Mental Status Examination" noted no information related to memory testing or estimation of intellectual functioning.

7. Patient D3-11. In a Psychiatric Assessment dated 4/9/10, a preprinted form under the section titled "Mental Status Examination, i. Cognitive" included handwritten checks in the boxes adjacent to "Recent Memory" and "Remote Memory" to indicate "Intact." No further details related to specific and measurable indicators were noted.

8. Patient E1-19. In a Psychiatric Assessment dated 03/03/10, under the section "Mental Status Examination" it was noted: "Other components of the cognitive functioning cannot be done because of the patient's poor concentration and inability to express coherently to the staff." There was no evidence that a follow-up evaluation had been performed since that date.

9. Patient E3-21. In a Psychiatric Assessment dated 2/4/10, a preprinted section titled "Mental Status Examination, i. Cognitive" had no documentation that memory testing or estimation of intellectual functioning had been performed.

10. Patient E3-23. In a Psychiatric Assessment dated 09/16/09, the section "Mental Status Examination" noted: "The patient's memory for remote memory is very poor. His immediate retention is somewhat acceptable and adequate but recent memory is impaired. The patient's intelligence is below average and may be in the level of being mentally retarded." No further details related to specific and measurable indicators were noted.

11. Patient F1-19. In a Psychiatric Assessment dated 04/14/10, the section "Mental Status Examination" noted: "From a cognitive perspective, her overall intellectual range is in the average category. Her memory is intact for past and immediate recall. She has mild deficits with recent memory recall." No specific and measurable information was provided.

12. Patient G1-7. In a Psychiatric Assessment dated 2/23/10, a preprinted form under the section titled "Mental Status Examination, i. Cognitive" included handwritten checks in the boxes adjacent to "Immediate Retention and Recall", "Recent Memory" and "Remote Memory" to indicate "Intact." No further details related to specific and measurable indicators were noted.

13. Patient G2-4. In a Psychiatric Assessment dated 09/16/09, the section "Mental Status Examination" included no information related to memory testing or estimation of intellectual functioning.

B. Interviews

In an interview on 05/12/10 at 4:15 PM, the Medical Director agreed with the findings noted above.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets that could be used to design treatment for 11 of 16 active sample patients (A1-1, A2-23, B1-15, B2-13, D1-6, E1-19, E2-3, E3-21, E3-23, G1-7 and G2-4). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings are:

A. Record Review

1. Patient A1-1. A Psychiatric Evaluation dated 4/16/10 noted under the section titled "Assets/Strenghts [sic]": (handwritten on a preprinted form) "unable to evaluate."

2. Patient A2-23. A Psychiatric Evaluation annual update, dated 2/24/10, noted under the section "Assets/Strengths": "a) the patient appears to be in fairly good physical health. b) He has fairly good ADL's (activities of daily living). c) Most of the time he is redirectable."

3. Patient B1-15. A Psychiatric Evaluation dated 3/10/10 had noted under the section titled "Assets/Strenghts [sic]": (handwritten on a preprinted form) "would not cooperate."

4. Patient B2-13. A Psychiatric Evaluation dated 10/7/09 noted under the section titled "Assets/Strenghts [sic]" handwritten "x" marks on a preprinted form indicating "Yes" for the following: "c) Is there Cultural/Spiritual/religious and community involvement."; "h) Does the patient attempt to realize his/her potential."; "j: Can the patient exercise self direction."

5. Patient D1-6 A Psychiatric Evaluation dated 8/20/09 noted under the section "Assets/Strengths": "1. The patient has a supportive family, mainly the brother. 2. The patient has been physically healthy. 3. The patient has been incident-free in terms of assault and/or aggressive behavior." These assets are not personal attributes that help guide a patient's treatment in the facility.

6. Patient E1-19. A Psychiatric Evaluation dated 3/03/10 noted under the section "Assets/Strengths": "a) The patient, for a significant period of time, has not exhibited any aggressive behavior towards himself or others nor being destructive to property. b) The patient has not shown any evidence of suicidal behavior. c) Even with the patient's consistent refusal with his medical evaluation and treatment, it appeared that the patient has no acute medical problems." These assets are not personal attributes that help guide a patient's treatment in the facility.

7. Patient E2-3. In a Psychiatric Evaluation dated 10/30/08 (no other more recent evaluation was available), under the section titled "Assets/Strenghts [sic]" (handwritten on a preprinted form), all available choices for assets were marked "No"; there were no assets noted in the affirmative or additionally included.

8. Patient E3-21. In a Psychiatric Evaluation dated 2/4/10, under the section titled "Assets/Strenghts [sic]" there were no assets marked as affirmative on the form.

9. Patient E3-23. A Psychiatric Evaluation dated 9/16/09 noted under the section titled "Assets/Strengths": "a) the patient is able to verbalize his needs. b) The patient has a supportive family." These assets are not personal attributes that help guide a patient's treatment in the facility.

10. Patient G1-7. A Psychiatric Evaluation dated 2/23/10 noted on a preprinted form for "Assets/Strenghts [sic]" a handwritten straight line going down the page through all of the "No" boxes for choices "A" through "J." No assets were marked in the affirmative.

11. Patient G2-4. A Psychiatric Evaluation dated 9/16/09 noted the following under the section for "Assets/Strengths": "a) the patient participates in some therapeutic activities. b) The patient has a fair amount of family support." These assets are not personal attributes that help guide a patient's treatment in the facility.

B. Interview

In an interview on 05/12/10 at 4:15 PM, the Medical Director agreed with the findings above and stated "We need to do a better job."

Based on record review and staff interview, the facility failed to include a substantiated diagnosis that served as the primary treatment plan focus for 9 of 16 active sample patients (A1-1, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20 and G1-7). This practice compromises the staff's ability to deliver clinically focus treatment.

Findings are:

A. Record Review (Dates of Treatment Plans or Updates in parentheses)

There were no diagnoses listed for the following patient records: A1-1 (4/27/10); B1-15 (3/23/10); B2-13(4/27/10); D3-11 (4/19/10); E2-3 (2/3/10); E3-21(4/26/10); E3-23 (3/08/10); F2-20 (4/06/10); G1-7 (4/07/10).

B. Staff interview

In an interview on 5/12/10 at 9:15AM, psychology staff member H1 reported that they do not include a diagnosis in the treatment plan because Joint Commission stated that "a diagnosis on the treatment plan is redundant and they do not have to do it."

Based on record review and interview, the facility failed to ensure that the treatment plans of 10 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D2-6, D3-11, E3-21, E3-23, and F2-20) defined short and long-term goals as specific, measurable patient behaviors to be achieved. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans.

A. Record Review

1. Patient A1-1's presenting problem was "Mood Lability: Agitated, made a suicide threat." The long-term goal of the treatment plan dated 4/27/10 was: "Pt has a stable mood appropriate to context." The short-term objectives were: 1) "Everyday [sic] take my medication to help me emotionally slow down and think realistically." 2) "Have a realistic understanding of how I was acting that led to hospitalization" and 3) "Show better emotional control by not overreacting to situations, keep my thoughts focused and on track, stay cool and respond calmly." The stated goal/objectives were not measurable behaviors.

2. Patient A2-23's presenting problems were: 1) "Self Injurious Behavior" - no long term goal was listed on this treatment plan updated 4/19/10. The short term objective was, "I will talk to staff when feeling angry and I will accept redirection to a safe activity." 2) "Aggression-Physical when perceived needs are not immediately met." The long term goal was "Patient is not aggressive towards people or property." The short term objective was, "I will be compliant with medication. I will accept prns [sic] if I am agitated and not be aggressive or break anything." The goal/objectives were not measurable behaviors.

3. Patient A3-22's presenting problems were "disorganize thinking and speech, hallucinations and delusional ideation, impaired insight and judgment, and disoriented to date." The long-term goal on the treatment plan dated 3/8/10 was, "organized thinking and speech, absence of hallucinations delusions, improved insight and judgment, and oriented x [times]" 3. The short-term objective was, "absence of hallucinations and delusions, as evidence by psychiatric assessments..." The goal/objectives were not measureable behaviors.

4. Patient B1-15's presenting problem was "Auditory Hallucinations with Suicide Attempt and Aggression." The long term goal on the treatment plan updated 3/23/10 was "Pt will display increased desire for self-preservation and be free of suicidal ideation, plans and gestures/attempts, will also display realistic thinking and safe behavior." The short term objectives were: "Take all medications as prescribed, do not have suicidal ideas, and Demonstrate coping skills to manage frustrations of daily living." The goal/objectives were not measurable behaviors.

5. Patient B2-13's presenting problem was "Depression: unable to care for self, threatens suicide." The long term goal on the treatment plan updated 4/27/10 was "Pt will experience stable mood." The long term goal was not a measurable patient behavior.

6. Patient D2-6's presenting problem was "Poor Frustration Tolerance and Decision Making." The long term goal of this treatment plan updated 4/20/10 was "Pt will display appropriate frustration tolerance and improved decision- making when upset." The short term objectives were, "Take medication every day as prescribed, verbalize an understanding of how her behavior is related to consequences and demonstrate coping skills to manage frustrations and express anger appropriately." The goals/objectives were not measurable.

7. Patient D3-11's presenting problem was "bizarre behavior with aggression: pt [patient] overdressed on a hot day and was picked up by police, telling them he needed water." The long-term goal of his treatment plan updated 4/19/10 was "[name of patient] will refrain from specified bizarre behavior, and will exhibit realistic thinking and safe behavior." A short-term goal was "make an effort to communicate ideas that others find sensible, realistic, and understandable." The long and short term goals were not measureable.

8. Patient E3-21's presenting problem was "mood lability with dangerous behaviors: pt has pattern of self harm including - cutting wrist, trying to gas herself, hanging, suffocating, thinking about jumping in front of a train/car" --- The long-term goal on her treatment plan updated 4/26/10 was, "[name of patient] has a stable mood so she is not dangerous to self or others." A short-term goal was, "every day take my medication which helps me control my intense emotions and think more clearly about how I can be more effective in my life." The long and short term goals were not measureable.

9. Patient E3-23's presenting problem was, "paranoid ideations with agitation and verbal aggression." The long-term goal on the Master Treatment plan updated 3/8/10 was, "[name of patient] will no longer experience paranoid ideations." A short-term goal was, "expresses anger and upset feelings in a non-threatening and socially appropriate manner." The long and short term goals were not measureable.

10. Patient F2-20's presenting problem was, "Psychotic Thinking: Hallucinations and Delusions." The long term goal on this treatment plan updated 4/06/10 was "Patient displays rational beliefs." The short term objectives were "Everyday takes my medication so I have realistic thinking and sensible behavior, Hallucinations go away, do not see things or hear voices. Everyday practice safe behavior by not following what the voices tell me to do." The goal/objectives were not measurable behaviors.

B. Interviews

1. In an interview at 1:00 PM on 5/12/10, the Nurse Administrator stated that he was aware that "treatment plans are a problem."

2. In an interview on 5/12/10 at 2:06 PM, RN W5 agreed that many of the long and short term goals on the Master Treatment Plans were not measureable.

Based on record review and staff interview, the facility failed to provide treatment plans that delineated individualized treatment modalities for 11 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20, and G1-7). Instead, treatment plan interventions were routine generic discipline functions. This failure results in staff being unable to provide direction and focused treatment for patients' identified problems.

Findings are:

A. Record Review

1. Patient A1-1 was admitted 4/16/10. The treatment plan, dated 4/27/10 noted the following routine, generic discipline functions: Nursing intervention: "If needed, nursing to assist patient with personal care needs and provide reality orientation." Psychiatrist intervention: "To evaluate and prescribe medications as needed." Rehabilitation services intervention: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

2. Patient A2-23 was admitted 12/14/95. The treatment plan, updated 4/19/10, noted the following routine, generic discipline functions: Nursing interventions: "Nursing to establish firm and consistent limits on behavior, provide appropriate outlets for tension and agitation, encourage verbalization of feelings, encourage appropriate expressions of anger and hostility, provide positive feedback for acceptable behavior and provide reality orientation." Psychiatrist intervention: "Psychiatrist to evaluate and prescribe medications as needed." Rehabilitation services intervention: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

3. Patient A3-22 was admitted 3/7/07. The Master Treatment plan updated 3/8/10 noted the following routine, generic discipline functions: Psychiatric Intervention and Monitoring: "To evaluate and prescribe psych [psychiatric] meds [medications] --- monitor med side effects, and evaluate meds." Nursing intervention: "Oversight and supervision of direct care staff for patient care and resolution of related problems."

4. Patient B1-15 was admitted on 3/10/10. The treatment plan of 3/23/10 noted the following routine generic discipline functions: "To provide an opportunity for all members of the community to participate in the functioning of the ward and to encourage appropriate social interaction skills by attending life management, (community meeting)." Psychiatrist: "Evaluate and prescribe medication as needed." Rehabilitation Services staff: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

5. Patient B2-13 was admitted on 10/07/09. The treatment plan update of 4/27/10 noted the following routine generic discipline functions: "Nursing intervention: Nursing, if needed, to assist patient with personal care/needs." Psychiatrist intervention: "To evaluate and prescribe medications as needed." Rehabilitation services staff: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

6. Patient D3-11 was admitted 4/9/10. The Master Treatment plan dated 4/19/10 noted the following routine, generic discipline functions: Physician intervention: "Provide medication and evaluate progress and effectiveness of medication." Nursing intervention: "Life management to provide an opportunity for all members of the community to participate in the functioning of the ward and to encourage appropriate social intervention skills." Rehabilitation Services staff: "To develop, maintain, and improve task skill and related social interactional skills by improving selected activity experience."

7. Patient E2-3 was admitted on 10/30/08. The treatment plan, updated 2/3/10, noted the following routine generic discipline functions: Nursing intervention: "1:1 with nursing if needed to assist patient with personal care/needs and provide support and reality orientation." Psychiatrist intervention: "To provide medication and evaluate progress and effectiveness of medication." Rehabilitation services staff: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

8. Patient E3-21 was admitted 2/4/10. The Master Treatment plan update of 4/26/10 noted the following routine, generic discipline functions: Physician: "Evaluate and prescribe medications as needed." Nursing interventions: "Provide instruction and insight into the common effect of mental illness." Nutritionist intervention: "Patients will be introduced to different diets and dietary problems so they can better understand their nutritional needs."

9. Patient E3-23 was admitted 9/8/08. The Master Treatment plan updated 3/8/10 noted the following routine, generic discipline functions: Nursing intervention: "Provide a supportive environment, encourage appropriate socialization between group members, reinforce reality orientation, teach skill building for recovery." Nutritionist intervention: "Patients will be introduced to different diets and dietary problems so they can better understand their nutritional needs." Rehabilitation Services intervention "To assist each patient in achieving computer skills."

10. Patient F2-20 was admitted on 9/17/09. The treatment plan update of 4/6/10 noted the following routine generic discipline functions: Nursing intervention: "If needed, nursing to assist patient with personal care/needs and provide support and reality orientation." Psychiatrist intervention: "To provide medication and evaluate progress and effectiveness of medication." Rehabilitation services intervention: "To develop, maintain, and improve task skill and related social interactional skills by providing selected activity experience."

11. Patient G1-7 was admitted 2/23/10. The Master Treatment plan update of 4/7/10 noted the following routine, generic discipline functions: Physician intervention: "Provide medication and evaluate progress and effectiveness of medication." Nursing interventions: "Observe [name of patient] in a variety of situations; identify treatment progress; identify emerging problem areas; administer medication." Rehabilitation Staff intervention: "Open recreational programming cafe, patient library, art studio, music studio, movies. See unit schedule for access times." Nutritional Staff intervention: "Provide pt [patient] with information on healing foods and eating habits in group and as needed."

B. Interview

In an interview on 5/12/10 at 1:00 PM, the Nurse Administrator acknowledged that the Nursing Treatment interventions described generic functions of the discipline.

Based on record review and staff interview, it was determined that the facility failed to identify the responsible team members for the treatment modalities listed in the Master Treatment plans of 14 of 16 active sample patients (A1-1, A2-23, A3-22, B2-13, D1-6, D2-6, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7 and G2-4). This resulted in the inability to determine what staff member was responsible for ensuring compliance with various aspects of treatment.

Findings are:

A. Record review

1. Patient A1-1's treatment plan update of 4/27/10 listed interventions to be implemented by "nursing staff" rather than a responsible individual.

2. Patient A2-23's treatment plan update of 4/19/10 listed interventions to be implemented by Psychology Department as "different staff on a rotating basis." Rehab Services' listed treatment modalities with the responsible person were identified as "Department of Rehab, staff."

3. Patient A3-22's Master Treatment plan update of 3/8/10 contained treatment modalities with responsible staff members listed as "Department of Nursing staff", "Department of Rehabilitation staff" and "Department of Social Work staff."

4. Patient B2-13's treatment plan, updated 4/27/10, listed a nursing intervention with the responsible person listed as "Department of nursing staff". "Rehabilitation services listed treatment modalities with the responsible person identified as "Department of Rehabilitation services staff," not a particular individual.

5. D1-6's Master Treatment plan dated 2/18/10 contained treatment modalities with responsible staff members listed as "Department of Nursing staff" and "Department of Rehabilitation staff."

6. Patient D2-6's treatment plan updated 4/20/10 listed nursing interventions on the treatment plan, however the responsible person listed was "Department of Nursing staff." Rehabilitation services listed the responsible person as "Department of Rehabilitation staff."

7. E1-19's Master Treatment plan updated 4/28/10 contained treatment modalities with responsible staff members listed as "Department of Nursing staff;" "Department of Rehabilitation staff;" and for the "Life Management Group" - "Different staff on a rotating basis".

8. Patient E2-3's treatment plan update of 2/03/10 listed treatment modalities with responsible staff member listed as "Nursing staff", "Rehabilitation staff", "Psychiatrist", and "Department of Nutrition Staff" rather than listing the names of individual staff members.

9. E3-21's Master Treatment plan, updated 4/26/10, contained treatment modalities with responsible staff members listed as "Department of Nursing staff" and "Department of Rehabilitation staff."

10. E3-23's Master Treatment Plan, updated 3/8/10, contained treatment modalities with responsible staff members listed as "Department of Nursing staff" and "Department of Rehabilitation staff."

11. F1-19's Master Treatment Plan dated 4/15/10 contained treatment modalities with responsible staff listed as "Department of Nursing staff." For the "Life Management Group meeting," staff was listed as "Different staff on a rotating basis."

12. Patient F2-20's treatment Plan, updated 4/06/10, contained treatment modalities with responsible staff listed as "Nursing staff" rather than the name of a responsible staff member.

13. G1-7's Master Treatment Plan, updated 4/7/10, contained treatment modalities with responsible staff members listed as "Department of Nursing staff" and "Department of Rehabilitation staff."

14. Patient G2-4's Treatment Plan, updated 5/04/10, contained treatment modalities with responsible staff listed as "Department of Psychiatry staff," "Department of Nursing staff", "Department of Rehabilitation staff," rather than listing the names of individual staff members.

B. Interview

In an interview with RN W5 on 5/12/10 at 2:06 p.m., she agreed that specific names of nurses were not used on the Master Treatment Plans to identify staff accountable for nursing interventions.

I. Based on record review, observation and interview, the facility failed to protect 1 of 16 active sample patients (E2-3) from continued self-harm. The patient had repeated episodes of swallowing foreign objects, even while on 1:1 observation, necessitating transfer to a general hospital and emergency removal of the objects ten times since admission to the facility last fall, including three episodes in the month prior to the survey. The facility failed to follow through effectively with a safety plan for the patient developed 04/19/10 by the treatment team to prevent further harm to the patient. On 05/05/10, the patient ingested a disposable razor, and on 05/08/10, the patient ingested a wire while on 1:1 observation. Both incidents necessitated emergency surgical procedures to remove the objects. The patient reported that the staff person responsible for the one-to-one observation on 05/08/10 was asleep at the time of that incident. These failures continued to place patient E2-3 at risk for further serious harm. The facility was notified of the situation of an IMMEDIATE JEOPARDY to patient safety on 05/11/10 at 4:00 PM. Subsequently, the facility provided a Plan of Correction that was accepted by the regional office on 05/13/10 at 10:00 am. The IMMEDIATE JEOPARDY was removed at that time. However, the facility did not include in the plan the manner in which the patient's rights to privacy and freedom of movement would be restored over time, so that a Deficient Practice remained at the conclusion of the survey.

Findings are:

A. On 5/11/10 at 8:00 AM, the facility's CEO (Chief Executive Officer) and Medical Director informed the surveyors that active sample Patient E2-3 had obtained "a staff petition" that was signed by nineteen staff members of Unit E2. The petition, dated 05/09/10, noted that the staff was concerned that Patient E2-3 was "at extreme risk of harm" from self-harm behaviors. Staff asked for a change in the patient's treatment plan in order to protect the patient. The Medical Director stated that the facility's response was to "transfer the patient immediately to another unit and not have any of these staff members care for this patient." The surveyors asked the Medical Director if there was a safety plan in place to help protect this patient and he responded "not that I know of."

B. An interview was conducted on 5/11/10 at 9:00 AM with hospital staff member RN M1 to discuss recent events related to patient E2-3 and the nursing staff concerns for this patient's safety, which had led to the development of the petition by staff members on the unit.

RN M1 reported that patient E2-3 had a long history of swallowing items and was on and off 1:1 observation. Recent swallowing incidents had occurred both when the patient was on and off of 1:1. On 4/18/10 , while the patient was on 1:1, he swallowed a radio antenna after breaking it into four pieces. Another incident occurred on 5/5/10 when the patient swallowed a razor obtained from another patient on the unit (patient was not on 1:1 at that time.) The most recent incident occurred on Saturday 5/8/10 at 11:30 PM when the patient swallowed a wire while on 1:1. Staff members were not aware of that incident until the patient reported it on 5/9/10 at 9:15 AM. Staff member M1 related that these recent incidents led to the development of the petition.

Staff member RN M1 reported that the petition was started by several HSTs (Health Services Technicians) during the day shift of 5/9/10, following the swallowing episode on 5/8/10. The petition was written "to make clear that we feel there is an extreme safety risk that has not been properly addressed up to this point." The Unit Program Manager and Unit Psychologist signed the petition the next day.

RN M1 was a signer of the petition. RN M1 stated that the purpose of the petition was for the staff to present their concerns and recommendations at the unit treatment team meeting on 5/10/10 hoping that some action would be taken to ensure the safety of this patient. The petition listed safety precautions that the staff felt needed to occur in order for the patient to be safe. RN M1 further stated that they were aware that the patient had obtained a copy of this petition but RN M1 was not sure how this occurred as the patient was on 1:1 observation around the clock. RN M1 further stated that the patient was "angry and felt rejected by the staff" after reading this petition.

C. An interview was conducted on 5/11/10 at 10:00 AM with hospital staff members HST M2 and HST M3 to discuss recent events related to patient E2-3 and the nursing staff concerns for this patient's safety which had led to the development of the petition by staff members on the unit. Both HST M2 and HST M3 said they felt Patient E2-3 was unsafe with his current treatment plan. HST M2 stated "something really bad is going to happen soon."

D. The surveyors observed a treatment team meeting on Unit E2 on 05/11/10 at 11:15 AM related to the proposed transfer of care for Patient E2-3 to Unit G1. During the meeting, the Medical Director said that Patient E2-3 was being transferred to Unit G1 because he (the Medical Director) felt the milieu there was less intense. Patient E2-3 noted to the treatment team during the meeting that "a trigger for me is loud noises and angry behaviors of others on the unit." The attending physician from Unit G1, who was also present, noted that her unit was "just as loud and aggressive as this unit (E2)." The treating psychologist stated that "we have no warning that he (E2-3) is about to ingest an object. Our hands are tied."

E. The surveyors interviewed the Unit E2 attending physician on 05/11/10 immediately after the treatment team meeting (see D. above). The attending physician stated "The staff had become panicky and things were out of control" in reference to E2-3's self-harm behaviors escalating over the last two weeks.

F. Patient E2-3 was interviewed on 05/11/10 at 2:00 PM regarding the incident that occurred on May 8, 2010 at 11:30 P.M. in which the patient swallowed a wire from the transformer of his tape player while on one-on-one observation. Patient E2-3 stated "[Staff member G1] gave me an alarm this past weekend to use if I felt I was going to swallow something." To demonstrate, patient E2-3 pulled the pin of the alarm which emitted a loud high pitch squealing sound. Patient E2-3 stated "I pulled the alarm (the night of swallowing the wire) and nobody came...the tech doing the one to one was fast asleep and didn't awaken with the alarm and then no one else came to check on me so I swallowed the wire."

Patient E2-3 went on to state "This wasn't the first time a staff member was asleep while watching me." When asked how many times this had occurred, Patient E2-3 stated "many times." E2-3 reported "I told the tech that I wanted to harm myself earlier that night and nothing was done by staff. This also happened earlier in the week when I swallowed a razor." Patient E2-3 continued on 1:1 observation status throughout the weekend (05/07-5/09/10). Patient E2-3 went on to describe that he was able to obtain the petition at approximately 8:30 PM on 05/10/10 from a staff member's clipboard who was assigned to watch him on 1:1 observation, and now feels "abandoned and embarrassed" and "I don't know who to trust any more." "I don't feel safe anymore."

G. In an interview on 5/11/10 at 2:45 P.M., the Medical Director stated "there isn't any unit in this hospital that would be safe for this patient."

H. Review of the medical record revealed that Patient E2-3 had 10 (ten) emergency transfers to a general hospital for removal of foreign objects since October 18, 2009. Each time, Patient E2-3 had either endoscopic or laparoscopic removal of the objects.

I. The following information was documented on incident reports for the patient on the dates listed:

10/18/09: "Reported swallowing seven pens and one lighter at 11:55 P.M.- sent to (Community Hospital)."

12/20/09: "Swallowed one pen around 2 P.M. Told tx[treatment] team during day. Transferred to ER."

12/28/09: "Reportedly swallowed a plastic spoon at 7:30 P.M. Sent to ER."

12/30/09: "Swallowed plastic utensils (knife, fork, spoon) around 2:15 P.M. Sent to ER."

3/14/10: "Reportedly swallowed 2 pens. Sent to ER."

3/21/10: "While on 1:1, pt. stated he entered the bathroom of his room and swallowed the ear pieces of sunglasses - upon hearing death of his friend, sent to ER"

4/5/10: (time?) "Reported at 11:30 A.M. Swallowed a pen. Upset about not getting off observation status at night. Reported to staff about one half hour [sic] about swallowing object. c/o [complains of] abd. [abdominal] Pain. Sent to ER."

4/18/10 2:30 P.M.: "C/O abd. Pain after swallowing 4 pieces of antenna from radio. Sent to ER."

5/4/10 "Pt. reported he found 2 razorblades in garbage. Turned them in because he did not want (alternate personality) to get them." Pt. reported abdominal pain in the A.M. of 5/5/10 and was transferred to an ER after ingesting a disposable razor.

5/8/10 at 8:30: "Pt ingested coiled wire, c/o abd pain. Transferred to ER."

J. After the incident on 4/18/10, the Treatment Team met and developed a "Safety Objective Plan" on 4/19/10 (no time noted). Excerpts include the following (written verbatim with bolding and underlining left intact):

"ROOM: The room and all furnishing inside the room, the bathroom, and the shower area used shall be thoroughly searched by accompanying staff prior to his entering these areas. These areas shall be free of all swallowable [sic] and other potentially dangerous and/or restricted objects including wall hangings. He can only have paper products on his person, no envelopes, NO PENS. He can read books. The closets must be locked at all times. He will use HIS ROOM for ADL's, toileting needs, shower time preparation and night time sleep."

"PLEASE KEEP YOUR EYES ON (E2-3) AT ALL TIMES FOR SAFETY REASONS. ONE CANNOT BE TOO CAREFUL."

"Toiletries: (E2-3) will be allowed to use his electric razor and deodorant and other toileting items with supervision by staff only, and they must be kept locked up in a box with the items in it labeled on the box and the box in a specifically designated area when not in use: electric razor, toothbrush, deodorant, etc."

"CLOTHING: (E2-3) will be searched for contraband items especially where small items can be hidden (elastic waist bands, socks, etc.)" [no time frame or directions for searches were noted]

K. Medical Record notes for the two most recent events included the following:

1) Interdisciplinary Progress Notes for Patient E2-3 dated 05/04/10 at 9:30 P.M. noted "At 7 P.M., pt. requested to speak with nurses. Pt. reported to (nurse) that pt. found 2 razor blades in the garbage. Pt. stated 'I want to be safe and I don't want that (an alternate personality of the patient's) would find this.' Pt. gave the contraband to (nurse, name withheld). Nurse supervisor was notified. (On call psychiatrist, name withheld) was notified at 9 P.M. by this writer. MD said he does not have to evaluate pt. Patient E2-3 had been taken off of 1:1 observation on 5/3/10 at 11:30 A.M. and placed on Line of Sight Observation status. His observation status was changed to Intermittent Observation from 4 P.M. to 8 A.M. for safety daily."

At 5:30 A.M. on 05/05/10, Patient E2-3 was transferred to an emergency department after swallowing a disposable razor that was lodged in his stomach.

Upon return to the facility from the community hospital on 05/05/10, Patient E2-3 was placed back on 1:1 observation status.

2) On a Special Observation Monitoring Form dated 5/08/10 at 10:45 PM, the staff member monitoring the patient noted "Pt. reports he feels like harming himself. Nurse notified."

An Interdisciplinary Progress Note dated 5/08/10 at 10:49 PM, written by a staff nurse noted: "Pt. remains on 1:1 observation for PICA [sic] and self-injurious behavior. Pt. verbalized that he is depressed and upset, pt. verbalized that he feels like hurting himself. [On call MD] was notified about this, but no new orders made."

Progress notes that night noted that the patient complained of insomnia and continued to appear agitated. The Pt. complained of abdominal pain on 5/9/10 at 8:30 AM and reported to staff that he had ingested a "coiled wire" during the night. The patient was transferred to an emergency department for evaluation and treatment.

L. Notes that indicate problems with staff performance of one-to-one observations included the following:

a. An Incident Report dated 3/26/09 noted: "patient reported that one to one staff was asleep during the night shift after 12 A.M. and before 5:30 A.M. Reported to ADN (assistant director of nursing)."

b. An Incident Report dated 1/5/10 noted: "ADN observed employee sleeping while on assignment for 1:1 with high risk pt. (E2-3)."

M. On 05/12/10 at 4:15 PM, the facility presented an updated treatment plan and safety plan for Patient E2-3 to the surveyors for the purpose of removing the IMMEDIATE JEOPARDY. The updated Treatment Plan included added involvement of treatment staff for individual therapy and supportive counseling each shift, additional group activities with a focus on decreasing self-harm behaviors, enactment of a safety plan that included placement in a room ("recovery" room) with no loose objects, wearing of surgical scrubs, continued 1:1 monitoring, finger food meals, increased environmental safety checks (two searches per shift) and reassessment every 72 hours. These procedures were deemed acceptable to remove the Immediate Jeopardy.

The updated Treatment Plan failed to include any parameters aimed toward the goal of reintroducing Patient E2-3 into the general unit milieu, including moving the patient back into his assigned room rather than the "recovery room" (seclusion room), reducing the number of searches, return of his regular clothes and belongings, and reduction of his 1:1 observation status to a less restrictive observation status. Thus, the facility did not present a plan that included a road map for restoration of E2-3's rights, leaving the facility with a deficient practice still in place.

II. Based on interviews, record reviews and observations, it was determined that 9 of 16 active patients (A1-1, A2-23, B1-15, B2-13, D2-6, E2-3, E3-23, F2-20 and G2-4) lacked an active therapeutic program for significant periods of time during their hospital stay. Patients were left to themselves for long intervals, often entire days, without therapy being provided. Lack of active therapies results in patients being hospitalized without all interventions for recovery being provided to them, delaying their improvement.

Findings are:

A. Document Review

1. In the Medical Records Documentation Manual under the section Twenty (20) Hours of Programming, is stated "Every patient is expected to receive at least twenty [hours] a week."

2. The "Group Attendance Sheet" which the Facility uses to document each patient's attendance in group consisted of the name of group and the following comment choices - " Present, Excused, Absent, In bed, Off ward, Guest, Ill, Med/Dental [medication], Unstable, Refused, and Court." Choices for describing performance behaviors were - "Disruptive, attentive-limited participation, attentive - participated, and non-attentive - no participation." Individual goals that each patient was to achieve in each group were not included on the form. No specific progress notes on these groups related to patient goals were written in the records.

B. Specific Patient Findings

1. Patient A1-1

a. According to patient A1-1's Psychiatric Evaluation dated 4/16/10, her presenting problem was, "Mood Lability: Agitated, made a suicide threat." Recommendations were, "Medication monitoring and therapeutic activities as tolerated."

b. Review of Patient A1-1's Master Treatment Plan dated 4/27/10 revealed that she was assigned to the following groups for her problem of: Mood Lability: Agitated, made a suicide threat." Assigned groups were the following: a) Life Management Meeting (a brief community meeting) "To provide reality orientation, an opportunity to interact and participate in a structured activity with peers and staff, to provide reality orientation, and to provide orientation to time, place, person and events in the immediate environment"; b) Nursing groups (unspecified) "To provide a supportive environment; encourage appropriate socialization between group members, reinforce reality orientation, teach skill building for recovery-frequency as needed"; c) Nutritional Group/Assessment to "Provide patient with information on healthy foods and eating habits. Assess dietary needs and recommend diet" and d) Pre-discharge group "to prepare patient for reentry into the community (1 time per week)."

c. Review of patient A1-1's Individual Group Attendance Sheet from 4/16/10 to 4/30/10 revealed that patient A1-1 attended 6 activities and was absent from seven activities. There were no progress notes specifying reasons for these absences. No notes indicated alternative therapy was provided.

d. In an interview on 5/10/10 at 11:15 AM, PatientA1-1 stated that she did not attend any groups the previous week end. She did attend the brief Life Management Group (15 minute community meeting) that morning.

e. According to the schedule, she also was to attend two activities with computers scheduled for 2:00 PM and 6:15 PM that day, but the following day 5/11/10, in a brief interview, she stated she did not go.

2. Patient A2-23

a) According to the Psychiatric Evaluation annual update, dated 2/24/10, patient A2-23 had identified problems of: "Self injurious behavior, Aggression, Physical toward others." Recommendations for treatment were "a) The patient will continue to stay on A-2, which is a unit for deaf patients and the patient is receiving accommodative service, b) the patient will continue to get treatment for his psychiatric, as well as his medical conditions with the medications he is getting now, and c) the patient needs to be considered for a Level A+ group home with accommodative services for deaf patients in the community. The evaluation stated that the patient was not ready for discharge, and before starting the discharge process, the patient should start to go to the "Access" day program as per the planning of the Treatment Team."

b) Review of A2-23's Master Treatment Plan, updated 4/19/10, revealed that he was assigned the following groups for his problem of "Self Injurious Behavior, Aggressive Behavioral towards others:" "Equine Assisted Therapy for decrease in violence, Horticulture class to participate in hands on training in gardening and learning how to take care of plants, Physical exercise, and Changes Group to prepare patient for re-entry back into the community."

c. Review of patient A2-23's Individual Group Attendance Sheet from 4/1/10 to 4/30/10 revealed that the patient attended 28 groups and was absent from 26 groups. There were no progress notes specifying reasons for his absence from these groups. The attendance sheets also showed that the patient attended groups not listed in the Master Treatment Plan: "Deaf club, group readiness, leisure skills, mental health issues, social skills, ADL group."

d. Patient A2-23 was interviewed on 5/10/10 at 3:30 by the nurse surveyor with two interpreters who "signed." The patient stated that he did not attend groups, but that he enjoyed his time with the horses and his time planting flowers and shrubs. However, the activities were not specifically related to the treatment plan problem and goal/objectives.

3. Patient B1-15

a. According to patient B1-15's psychiatric evaluation dated 3/10/10, the patient had the identified problem, "Auditory hallucinations with suicide attempt and aggression." Recommendations were: "New views, DBT at discharge, and housing."

b. Review of patient B1-15's Master Treatment Plan, dated 3/23/10, revealed that the patient was assigned to the following groups for her problem of "auditory hallucinations with suicide attempt and aggression:" a) Life Management Meeting "to provide an opportunity for all members of the community to participate in the functioning of the ward and to encourage appropriate social interaction kills," b) Psychology group "Assist client in problem-solving issues of symptom Management, progress towards recovery, and establishing goals for the future" and c) "Chemical dependence program (New Views) to address chemical dependency problems, Individual 1x/week and predischarge group to prepare for re-entry back into the community."

c. Review of the Individual Group Attendance Sheet from 4/1/10 to 4/30/10 revealed that the patient attended 61 activities and was absent 22 times. There were no progress notes specifying reasons for absences. Activities that she attended but were not related to her Treatment Plan problems and goals/objectives included "physical activities, leisure activities, and healthy living."

d. Patient B1-15 was interviewed on 5/10/10 at 4PM; when asked about whether the activities helped her, she said she wasn't sure. She added "There isn't enough going on around here. We just sit around a lot."

4. Patient B2-13

a. According to patient B2-13's Psychiatric Evaluation dated 10/7/09, his identified problems were "Depression, Unable to care for self and threaten suicide. Hit 3 people in July and Oct. '09." Recommendations were: "Admit to unit, 1:1 observe for suicide/unpredictable behavior, continue prior meds."

b. Review of patient B2-13's Master Treatment Plan, updated 4/27/10 revealed that he was assigned to the following groups: a) Therapeutic Activity Group "to engage patient in group activities that stimulate cognitive processes and promote use of adaptive coping skills and social interaction," b) Canine Animal Assisted Therapy for ten weeks "for a decrease in violence," c) Life Management Meeting "to provide reality orientation, an opportunity to interact and participate in a structured activity with peers and staff, to provide reality orientation and to provide orientation to time, place, person and events in the immediate environment," and d) Illness Management and Recovery Group to prepare patient for re-entry back into the community."

c. Review of patient B2-13's Individual Group Attendance Sheet from 4/1/10 to 4/30/10 revealed that the patient attended 64 groups and was absent 20 times. There were no progress notes specifying reasons for absences.

d. In an interview on 5/11/10 at 2:00 PM, Patient B2-13 stated that he is just waiting to go to a nursing home, but they haven't found a place for him yet although he's very ready to leave. He stated that the unit "is very noisy" so he mostly stays in his room. He reported that he had no more activities scheduled for the rest of the day. His schedule reflected that.

5. Patient D2-6

a. According to the Psychiatric Evaluation, dated 08/31/09 patient D2-6 had the identified problems of, "poor insight into her psychiatric illness" and "poor impulse control with repeated inappropriate phone calls and repeated threats toward staff."

b. Review of D2-6's Individual Attendance Sheet revealed from 4/1/10 to 4/30/10, revealed that the patient had attended the following groups: "Creative Arts", "Current Events/Current Interests", "D2 - Physical Activities", "D2 - Walking Group", "D2 - Physical Activities", "Expressive Music", "Gardening and Landscape Program" (listed three times), "Group Readiness", "Healthy Living", "Karaoke", "Legal Status Group for DE2", "Leisure Skills", "Life Management" (listed twice), "Mental Health Issues", "Rehabilitation - Computer Skills", "Relaxation: Music Appreciation", "Social Hour", "Spirituality Group"; "Symptom Management" and "Women Issues."

c. Review of the patient's Master Treatment Plan, dated 4/20/10, revealed that 13 of the 23 group activities noted above were either leisure or relaxation groups not included on the Treatment Plan as interventions that would help the patient progress toward the Treatment Goals. Only two groups -- "Symptom Management" and "Legal Status Group" were listed as interventions on the Treatment Plan. The other activities on the Individual Attendance Sheet lacked specificity of how they would benefit patient D2-6 relative to his presenting problems.

d. On 5/10/10 at 10:45 AM, patient D2-6 was observed refusing to go attend the assigned "Legal Status Group." Staff G4 instructed the patient to attend, which she did, but walked back out to talk with staff G5.

e. On 5/10/10 at 11:00 A.M., staff G4 was interviewed and asked if patients could refuse groups. Staff G4 stated "Patients can refuse groups if they want to". Group attendance was not staff driven or treatment team specified, but left up to the patient. Staff G4 explained that patients could choose the activities they want to attend, but attendance was not required.

6. Patient E2-3

a. According to the Psychiatric Evaluation dated 10/30/08, patient E2-3 had an identified problem of "a long psych history of self injurious behavior swallowing any objects he can get hands on." The Recommendations were, "Medication monitoring, group therapy, supportive therapy."

b. Review of the Master Treatment Plan update of 2/3/10 revealed that the patient was assigned to the three following groups for his problem of "Depression with Self Injurious Behavior:" a) Life Management Meeting "to provide reality orientation, an opportunity to interact and participate in a structures activity with peers and staff, to provide reality orientation, and to provide orientation to time, place person, and events in the immediate environment"; "Nursing Groups to "Provide a supportive environment; encourage appropriate socialization between group members, reinforce reality orientation, teach skill building for recovery"; and Symptom Management to "Facilitate patient E2-3 learning/relearning or enhancement of cognitive and social skills."

c. Review of patient E2-3 Individual Group Attendance Sheet from 4/1/20/10 to 4/30/10 revealed that the following listed groups: "A1 Physical Activities - Gym"; "Communication and Leisure Skills"; "Healthy Living Group"; "Leisure Activities" (listed 3 times)"; "Life Management"; "Physical Activities"; "Predischarge Group 4"; "Social Skills"; "Spirituality Group Area 1" and "Symptom Management." Several of these were not specified on the patient's treatment plan as noted above. Of these groups and activities listed, patient E2-3 had only attended 6 times for the month.

d. In an interview on 5/11/10 at 2:05 PM, Patient E2-3 stated he did not attend any groups and the only active treatment he received was from staff G3 (individual therapy one hour a week on Wednesdays).

7. Patient E3-23

a. According to the Psychiatric Evaluation, dated 9/16/09, patient E3-23 had the following identified problems: "lack of insight into his mental illness"; "paranoid ideations with agitation and verbal aggression"; "...non-compliant with medication" and "claimed that people were looking for him and that they were going to hurt him."

b. Review of E3-23's Master Treatment Plan, updated 3/8/10, revealed that he was assigned to seven groups as interventions for his behavioral problems - "Life Management", "Medication", "Nursing Groups", "Computer Skills", "Music - Expressive Music", and "Nutrition."

c. A review of E3-23's "Group Attendance Sheet" for the week of 5/3/10 to 5/7/10 showed that he did not attend 3 of 6 groups listed for him on the sheet. These groups were: "Computer Skills for Beginners" held on Tuesdays from 9:30AM to 10:10 AM, "Nutrition" held Thursdays from 1:15 PM to 2:00 PM, and "Spanish Healthy Living Skills" held on Mondays from 2:05 PM to 2:50 PM.

d. A review of E3-23's individual group schedule revealed that all groups except one group (Life Management, also known as "Communing meeting") were held only once a week. Other than Life Management, patient E3-23 had no other groups scheduled on Sundays and Wednesdays. Therefore he had nothing specific to keep him occupied from 9:30 AM to 8:00 PM on Sundays and Wednesdays. Most of patient E3-23's groups were held only once weekly, thus he had around 8 hours of idle time during the day whenever he refused to go to a scheduled group.

e. Observations revealed the Patient E3-23's did not attend his assigned Computer Skills group on 5/11/10 from 9:30 A.M. to 10:00 A.M. in Room 318 on Ward E3. He was found sitting in the dayroom during this time period. Further observation of the Computer Skills group (see above), revealed 9 patients attending the group. During the half hour group, the group leader (Rehab W2) was playing cards with 3 patients. Three other patients sat around the same table watching the card game; 2 patients colored a picture, and another patient wandered around Room 318.

f. When it was pointed out to the group leader during an interview on 5/11/10 at 10:15AM that no one was observed using the computers during the Computer Skills group, the group leader stated that the patients elected to stop using the computers after Administrative staff blocked the Internet. He said "Since then, the patients just hang out in here doing whatever they want for the time period." When the group leader was asked why E3-23 was not in the group, he stated that the patient was supposed to be in another group from 9:30 AM to 10:00 AM.

g. After the staff interview above, patient E3-23's group schedule was again reviewed. It showed that he had two groups scheduled on the same day at the same time. The second group was one for Spanish speaking patients, called "Programa Latino [sic]."

h. Further observation revealed that patient E3-23 did not attend his scheduled off unit group, "Physical Activities" (gym) on 5/11/10 at 2:15PM. When asked where the patient was, HSTW1 (Health Services Technician) stated that the patient had gone to the barbershop. When asked why he went to the barbershop instead of to his scheduled group, HSTW1 stated that the patient had refused to go to the group. "We don't force patients to go to groups. We are instructed by the treatment team to keep them [patients] calm. So if they want to do another activity instead, we let them."

i. Patient E3-23 attended the "Life Management" group held on Ward 23 on 5/12/10 at 9:00 AM. The group was observed ending at 9:15 AM. When asked if patient E3-23 had attended, staff W3 stated, "Yes. He goes to this group because we serve coffee at the end."

j. In an interview on 5/11/10 at 2:15 PM, MD W4 was asked if it concerned him that patient E3-23 was not getting much active treatment. MD W4 stated that the patient was not dischargeable at this time. Therefore he wanted the staff to encourage, but not force the patient to attend groups. No alternative groups were listed on E3-23's treatment plan when the patient refused to go to a scheduled group.

8. Patient F2-20

a. According to the Psychiatric Evaluation, dated 9/17/09, Patient F2-20 had identified problems of "aggressive and violent behavior." The area for noting "Recommendations for Treatment (Address the Identified Problems)" was left blank.

b. Review of the Master Treatment Plan, updated 4/6/10, revealed the following interventions: a) "Life Management," b) "Nursing Groups," c) "Medication" and d) "Rehabilitation Services" to address the problem of "Psychotic Thinking: Hallucinations and Delusions." The Plan said "Frequency: 8 times per week from 11/02/2009 to 11/02/2010." The Long Term Goal was for Patient F2-20 to "display rational beliefs." Under the section, "Readiness," "Barriers, Motivation and Noncompliance with Aftercare," the intervention was "Nursing."

c. Review of Patient F2-20's Individual Group Attendance sheet revealed the following groups: "Acoustic Music Group", "CES-E" (listed twice), "CEC-Patient Library" (listed three times), "Creative Arts" (listed twice), "Expressive Music," "F1-Physical Activities" (listed twice), "Healthy Living on Ward Group", "Legal Status", "Leisure Skills" (listed twice), "Medication Education", Medical Health Issues". "Point of View", "Rehabilitation Computer Skills - ER" (listed twice), "Sunday out walk." Sixteen of the 24 listed activities were not on the Treatment Plan, thus it was unclear how they were to help the patient with the identified problem(s).

d. Patient F2-20 was interviewed on 5/10/10 at 10:15 A.M. regarding attending group activities. She stated, "I most spend my time sleeping and eating. I go to some of the groups sometimes"

e. The Director of Social Work (G7) was interviewed on 5/11/10 at 2:15 PM regarding Social Workers' facilitation of weekend gro

Based on record review and interview, the facility failed to ensure that the discharge summaries for 4 of 5 discharged patients (DC-2, DC-3, DC-4 and DC-5) contained a summary of the patient's mental status examination on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk was not available to the aftercare providers.

Findings are:

A. Record Review

1. Patient DC-2. The discharge summary dated 3/11/10 noted the following under the section "Final Assessment:" "At the time of discharge, the patient is no longer a danger to himself, others or property of others." There was no other description of a mental status examination.

2. Patient DC-3. The discharge summary dated 3/22/10 noted under the section "Final Assessment:" "Mental status examination was not done on patient."

3. Patient DC-4. The discharge summary dated 4/05/10 noted under the section "Final Assessment:" "The patient is presently stabilized and cooperative." There was no other description of a mental status examination.

4. Patient DC-5. The discharge summary dated 5/03/10 noted under the section "Final Assessment:" "No report of aggressive behavior. No symptoms of psychosis." There was no other description of a mental status examination.

B. Interview

In a joint interview on 05/13/10 at 10:45 AM, the Medical Director and the Chief of Psychiatry both agreed with the findings noted above.

Based on record review, policy review, observation and interview, it was determined that the Medical Director failed to: a) monitor the treatment planning process to ensure that patient problems were addressed with appropriate goals, modalities, diagnoses, and staff assignation; b) provide sufficient monitoring of staff to ensure that patients were receiving active treatment; c) ensure one active sample patient was safe from self harm behaviors; and d) monitor medical staff for adequate completion of history and physical examinations, psychiatric evaluations, and discharge summaries. Specifically the Medical Director failed to:

I. Assure that medical staff performed and documented a complete annual physical examination update; including a descriptive neurological examination, indicating what tests were performed to assess neurological functioning for 2 of 16 active sample patients (D1-6 and E1-19). The absence of this information limits the clinician's ability to accurately provide a comparison measure of baseline functioning to the patient's initial physical examination, potentially adversely affecting patient care. (Refer to B109)

II. Assure that medical staff provided psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 13 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, D1-6, D2-6, D3-11, E1-19, E3-21, E3-23, F1-19, G1-7 and G2-4). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

III. Assure that medical staff provided psychiatric evaluations that included an assessment of patient assets that could be used in designing treatment for 11 of 16 active sample patients (A1-1, A2-23, B1-15, B2-13, D1-6, E1-19, E2-3, E3-21, E3-23, G1-7 and G2-4). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

IV. Assure that medical staff provided a substantiated diagnosis that served as the primary treatment plan focus for 9 of 16 active sample patients (A1-1, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20 and G1-7) This deficient practice compromises the staff's ability to deliver clinically focused treatment. (Refer to B120)

V. Ensure that the Master Treatment Plans of 10 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D2-6, D3-11, E3-21, E3-23 and F2-20) defined short and long-term goals as specific, measurable patient behaviors to be achieved. This deficient practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans. (Refer to B121)

VI. Ensure that 11 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20 and G1-7) had Master Treatment Plans that delineated individualized treatment modalities. The treatment plan interventions were routine generic discipline functions. This failure results in staff being unable to provide direction and focused treatment for patients identified problems. (Refer to B122)

VII. Assure that the facility's treatment teams identified the persons responsible for the treatment interventions listed on the Master Treatment Plans of 14 of 16 active sample patients (A1-1, A2-23, A3-22, B2-13, D1-6, D2-6, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7 and G2-4). This deficient practice diffuses responsibility and result staff not knowing who is responsible for various aspects of treatment. (Refer to B123)

VIII. Protect 1 of 16 active sample patients (E2-3) from self-harm while hospitalized. The patient had repeated episodes of swallowing foreign objects while on 1:1 observation, necessitating transfer to an emergency room and emergency removal three times in the month prior to the survey. The facility failed to follow through with a safety plan put into place on 04/19/10 by the treatment team in order to prevent further harm to the patient. On 05/05/10, the patient ingested a disposable razor and then on 05/08/10 ingested a wire while on 1:1 observation. Both incidents necessitated emergency surgical procedures to remove the objects. The patient reported that the staff person responsible to do the one-to-one observation on 05/08/10 was asleep at the time of the most recent swallowing incident. These failures continue to place patient E2-3 at risk for further serious harm. On 05/11/10 at 4:00 PM, the facility was notified that a situation of IMMEDIATE JEOPARDY to patient safety existed. The facility provided a Plan of Correction that was accepted by the regional office on 05/13/10 at 10:00 am, The IMMEDIATE JEOPARDY was removed at that time with the Deficient Practice remaining. (Refer to B125-I)

IX. Assure that 9 of 16 active sample patients received sufficient active therapeutic programming during their hospital stay (A1-1, A2-23, B1-15, B2-13, D2-6, E2-3, E3-23, F2-20 and G2-4). Lack of active therapies results patients being hospitalized without all interventions for recovery being provided, potentially delaying patients' improvement. (Refer to B125-II)

X. Ensure that 16 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D1-6, D2-6, D3-11, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7 and G2-4) received sufficient therapeutic measures which focused on restoring and/or developing optimal levels of mental and psychosocial functioning during evening hours and on weekends. This deficiency results in patient inactivity and potentially prevents them from achieving their optimal level of functioning. (Refer to B125-III)

XI. Ensure that the discharge summaries for 4 of 5 discharged patients (DC-2, DC-3, DC-4 and DC-5) contained a summary of the patient's mental status examination on discharge. This failure results in critical information regarding the patient's psychiatric symptomatology and risk not being available to aftercare providers. (Refer to B135)

B. Interview

In a joint interview on 5/13/10 at 10:45 AM, the Medical Director and the Chief of Psychiatry agreed with the findings noted above.

Based on record review and interview, the Nursing Executive failed to:

I. Ensure that 11 of 16 active sample patients (A1-1, A2-23, A3-22, B1-15, B2-13, D3-11, E2-3, E3-21, E3-23, F2-20 and G1-7) had Master Treatment Plans that delineated individualized Nursing Treatment modalities. Nursing interventions on the treatment plans were routine generic tasks for nurses on psychiatric units. This failure results hampers nursing staffs' ability to provide direction and focused treatment for patients identified problems.

Findings are:

A. Record review

1. Patient A1-1 was admitted 4/16/10. Her treatment plan dated 4/27/10 noted the following routine, generic nursing discipline functions: "If needed, nursing to assist patient with personal care needs, Provide reality orientation."

2. Patient A2-23 was admitted 12/14/95. His treatment plan updated 4/19/10 noted the following routine, generic nursing discipline functions: "Nursing to establish firm and consistent limits on behavior, provide appropriate outlets for tension and agitation, encourage verbalization of feelings, encourage appropriate expressions of anger and hostility, provide positive feedback for acceptable behavior and provide reality orientation."

3. Patient A3-22 was admitted 3/7/07. Her Master Treatment plan updated 3/8/10 noted the following routine, generic nursing discipline function: "Oversight and supervision of direct care staff for patient care and resolution of related problems."

4. Patient B1-15 was admitted on 3/10/10. Her treatment plan dated 3/23/10 noted the following routine generic nursing discipline functions: "To provide an opportunity for all members of the community to participate in the functioning of the ward and to encourage appropriate social interaction skills by attending life management, (community meeting), Evaluate and prescribe medication as needed."

5. Patient B2-13 was admitted on 10/07/09. His treatment plan updated 4/27/10 noted the following routine generic nursing discipline function: "Nursing, if needed, to assist patient with personal care/needs."

6. Patient D3-11 was admitted 4/9/10. His Master Treatment plan dated 4/19/10 noted the following routine, generic nursing discipline function: "Life management to provide an opportunity for all members of the community to participate in the functioning of the ward and to encourage appropriate social intervention skills."

7. Patient E2-3 was admitted on 10/30/08. His treatment plan updated 2/3/10 noted the following routine generic nursing discipline functions: "1:1 with nursing if needed to assist patient with personal care/needs and provide support and reality orientation."

8. Patient E3-21 was admitted 2/4/10. Her Master Treatment plan updated 4/26/10 noted the following routine, generic nursing discipline function: "Provide instruction and insight into the common effect of mental illness."

9. Patient E3-23 was admitted 9/8/08. His Master Treatment plan updated 3/8/10 noted the following routine, generic nursing discipline functions: "Provide a supportive environment; encourage appropriate socialization between group members, reinforce reality orientation, teach skill building for recovery."

10. Patient F2-20 was admitted on 9/17/09. The treatment plan updated 4/6/10 noted the following routine generic nursing discipline function: "If needed, nursing to assist patient with personal care/needs and provide support and reality orientation."

11. Patient G1-7 was admitted 2/23/10. His Master Treatment plan updated 4/7/10 noted the following routine, generic nursing discipline functions: "Observe [name of patient] in a variety of situations; identify treatment progress; identify emerging problem areas; administer medication."

B. Interview

In an interview with RN W5 on 5/12/10 at 2:06 PM, she agreed that many of the interventions were generic, routine functions of disciplines.

II. Ensure that the Master Treatment plans of 14 of 16 active sample patients (A1-1, A2-23, A3-22, B2-13, D1-6, D2-6, E1-19, E2-3, E3-21, E3-23, F1-19, F2-20, G1-7 and G2-4) named the nursing staff responsible for seeing that the nursing interventions were carried out. This failed practice diffuses responsibility and hampers staffs' ability to know who is responsible for ensuring compliance with various aspects of treatment.

Findings are:

A. Record Review

The following sample patients' Master Treatment Plans listed "Department of Nursing staff" as the responsible person to be held accountable for nursing interventions (date of plans or updates in parenthesis): A1-1 (4/27/10), A2-23 (4/19/10), A3-22 (3/8/10), B1-15 (3/23/10), B2-13 (4/27/10), D1-6 (2/18/10), D2-6 (4/20/10), E1-19 (4/28/10), E2-3 (2/3/10), E3-21 (4/26/10), E3-23 (3/8/10), F1-19 (4/15/10), F2-20 (4/6/10), G1-7 (4/7/10), and G2-4 (5/4/10).

B. Interview

In an interview on 5/12/10 at 1:00 PM, the Nursing Administrator acknowledged that the treatment plans did not name specific nurses to be held accountable for the listed nursing interventions.