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Based on record review, observation and interviews, the facility failed to ensure that: (1) patients unable or unwilling to attend group activities were provided alternative individualized treatment; (2) facility policy and procedure for seclusion/restraints were followed by the clinical staff; and (3) active sample patients who could not leave the units on their own to attend scheduled off unit centralized groups offered on the weekends were provided with on-unit therapeutic activities on these days. Specifically, the facility failed to:

1. Ensure that 3 of 12 active sample patients (E1-21, E3-22 and F1-1) had an active therapeutic program for significant periods of time during their hospital stay. Patients were left to themselves for long intervals, often 5 to 9 hours several days per week, 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. (Refer to B125-I)

2. Ensure that: (a) physicians included the length of time in restraints for 1 of 6 non-sample patients (SR1) whose charts were reviewed for policy and procedure compliance and that: (b) 1 of 6 non-sample patients (SR6) was released from seclusion at the earliest possible time. These failures result in restriction of patient's rights without adequate documented justification. (Refer to B125-II)

3. Ensure that 11 of 12 active sample patients (A1-22, A1-23, A2-22, D1-3, D3-4, E1-21, E3-22, F1-12, F2-1, G2-26 and G3-23) received sufficient hours of on-unit therapeutic measures which focused on restoring and/or developing optimal levels of mental and psychosocial functioning on weekends. The Facility's failure to provide on unit therapeutic activities on the weekend potentially impairs patients' attainment of treatment goals, and may prolong their hospitalization. (Refer to B125-III)

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 4 of 12 active sample patients (A1-22, A2-22, F1-12 and F2-1). 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 include:

A. Record Review

1. Patient A1-22. A Psychiatric Evaluation dated 7/26/10, noted (handwritten on a preprinted form) under Section 22 titled "Assets/Strengths": "pt.[patient] has knowledge of medication effects and side effects."

2. Patient A2-22. An "Assessment of Assets/Strengths Form" dated 8/6/10, noted (handwritten on a preprinted form) under the section titled "Assets/Strengths useful for this Treatment": "(A2-22) can be pleasantable (sic)" and "Pt have (sic) high school education."

3. Patient F1-12. A Psychiatric Evaluation dated 7/26/10, noted under Section 22 titled "Assets/Strengths": Preprinted "Assets" had no assets listed.

4. Patient F2-1. An "Assessment of Assets/Strengths Form" dated 8/6/10, noted (handwritten on a preprinted form) under the section titled "Assets/Strengths useful for this Treatment" (handwritten on a preprinted form): "He attend [sic] group therapy."

B. Interview

The Clinical Director and Director of Psychiatry were interviewed together on 8/16/10 at 4:40 PM. When shown the records noted above, they both agreed with the surveyor's findings. The Director of Psychiatry stated "This is not acceptable."

I. Based on record review, observation and interviews, it was determined that 3 of 12 active sample patients (E1-21, E3-22 and F1-1) lacked an active therapeutic program for significant periods of time during their hospital stay. These patients were left to themselves for long intervals, often 5 to 9 hours several days per week, 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 include:

A. Document Review

1. The facility policy "Treatment Teams and Meetings", section CL-TX-0206, dated 9/15/09, states "Team leader [psychiatrist] insures that the patient is scheduled for a minimum of 20 hours of total programming per week."

2. The "Individual Patient Schedule" sheets listed the names of the groups, start and stop times, days of week, room location of each group, and the total hours of group time assigned to each patient. In addition to the "Individual Patient Schedule," an "Individual Group Attendance" sheet was put into the computer periodically (approximately every 2 weeks). For each patient, the Individual Group Attendance sheet listed the names of the assigned groups, the number of times the patient attended or was absent, and the total percentage of time the patient attended his or her groups.

B. Specific patient findings

1. Patient E1-21

a. Record Review

1) Patient E1-21's Annual Psychiatric Evaluation dated 3/3/10 stated that the patient's presenting problem was "Long History of Mental Problems" and "Long history of poor treatment compliance, including psychiatric and medical treatments and follow-ups." Recommendations for Treatment included: "a) the patient will continue his treatment at (Facility name)", "b) The Treatment Team will continue to encourage the patient to comply with his necessary psychiatric and medical treatments and appropriate follow-up schedules.", "c) The Treatment Team will continue to encourage the patient to comply with his unit activities and programs and off-unit activities appropriate for his level of status.", "d) The Treatment Team will continue to encourage the patient to be actively involved in his discharge planning.", "e) The Treatment Team will continue to encourage the patient to communicate his needs and desires to the staff as the need arises."

2) Review of Patient E1-21's Master Treatment Plan dated 7/27/10 revealed a problem of: "Socially Isolative, Reticent, Withdrawn, refuses to participate in programming." The assigned groups were the following:

"Life Management Meeting: (5 times per week for 30 minutes from 10/09/08 to 3/08/2011); Current Events Group: (1 time per week for 40 mins from 10/09/08 to 3/08/2011); Mental Health Issues: (1 time per shift for 40 mins from 10/09/08 t0 3/08/2011); Life Management Meetings- Evenings: (5 times per week for 30 mins from 06/03/2010 to 03/18/2010); Coping Strategies Group: (1 time per week for 40 mins from 06/03/2010 to 03/08/2011); Mental Health Education: (1 time per week for 40 mins from 06/03/2010 to 03/08/2011); Self-Awareness Group: (1 time per week for 40 mins from 06/03/2010 to 03/08/2011); Leisure Activities/Skills: (2 times per week from 10/09/2008 to 03/08/2011); Creative Arts: (1 time per shift for 45 mins from 10/09/2008 to 03/08/2011); Physical Activity: (3 times per week for 45 mins from 10/09/2008 to 03/08/2011); and Symptom Management Group: (1 time per week for 40 mins from 10/09/2008 to 03/08/2011)."

3) The surveyor reviewed all of the progress notes in Patient E1-21's medical record dated from July 6, 2010 to August 18, 2010. There was no evidence of progress notes describing a staff member carrying out Creative Arts or Mental Health Issues activities during any shift within this time period.

4) Review of patient E1-21's Individual Group Attendance Sheet from 6/1/10 to 8/18/10 revealed that patient E1-21 attended 52 activities (41 of which were Life Management group) and was absent from 103 activities. There were no progress notes specifying reasons for these absences.

b. Interviews

1) In an interview on 8/16/10 at 3:00p.m., PhD-H1 (Psychologist for Patient E1-21) stated "(E1-21) isn't involved too much with treatment and is just waiting for a nursing home placement."

2) In an interview with the Clinical Director on 8/16/10 at 4:15p.m., E1-21's case was discussed. The Clinical Director stated that "(E1-21) hasn't participated in treatment for years and we're waiting to get him in a nursing home."

3) In an interview on 8/18/10 at 2:45p.m., HST-H1 (Health Services Technician) noted that "(E1-21) doesn't really ever go to groups and we can't get him to do anything." When the surveyor inquired about alternative activities for Patient E1-21, HST-H1 stated "We don't have anything else to offer him. He (E1-21) has been here too long."

c. Observations

1) Patient E1-21 was observed on 8/17/10 between 9:00 a.m. and 9:10a.m., sitting on the floor in the hallway across from the nurse's station while morning "Life Management" meeting was occurring. An attempt was made to engage the patient in conversation without success due to hypophonia (very soft voice) as part of Parkinson's disease. The Life Management Group was observed from 9:10a.m. to 9:20a.m.; ten non-sample patients (unit census was 25) were present, the group leader went over the day's activities, discussed changes in the schedule and reminded people of their medical appointments. No therapeutic interactions were observed.

2) Patient E1-21 was observed on 8/18/10 between 9:35a.m. and 9:50a.m. sitting in a chair in the day room asleep while his assigned group, "Physical Activities" was occurring in another area on the unit.

3) Patient E1-21 was observed on 8/18/10 between 2:25p.m. and 2:45p.m. sitting in a chair in the dayroom while his assigned group, "Leisure Skills" was occurring in another area on the unit.

2. Patient E3-22

a. Record Review

1) According to the Psychiatric Evaluation dated 9/16/09, patient E3-22 was admitted for the sixth time to the facility on 9/8/09. The evaluation stated: "The patient mostly remained on Level I due to disorganized thoughts and being noncompliant with the rules and regulations...The patient continues to be agitated, at times difficult to be managed [sic], shouting, yelling, and not responding to redirection."

2) Patient E3-22's Master Treatment plan, updated 7/29/10, stated "He has limited mental capacity and he [patient] states he cannot read." Review of this plan revealed that the patient was currently assigned to 4 groups as interventions for his behavioral problems - "Life Management [community meeting]", "Spanish Healthy Living", "Programa Latino", and "Exercise Group/Physical Activities".

3) Review of E3-22's "Individual Attendance Sheet" for the period of 8/2/10 to 8/13/10 revealed that the patient had 100 percent attendance at the "Life Management" group, and zero attendance at the "Physical Activities" and "Programa Latino" groups. The Interdisciplinary Progress Notes from 8/2/10 to 8/18/10 did not contain any documentation of alternative approaches to providing activities for the patient.

4) Review of E3-22's "Individual Group Schedule" revealed that all groups except "Life Management" and "Physical/Activities" were held only once a week. Other than "Life Management," patient E3-22 had no other groups scheduled on Sundays, Wednesdays and Fridays. On the patient's individual schedule, dated 8/16/10, he had the "Equine Therapy" group scheduled at 9:00a.m. on Fridays. However, in an interview on 8/16/10 at 3:05p.m., RN-W1 stated that the Equine group had ceased to exist on June 16, 2010. Therefore E3-22 had no specific activities from 9:30a.m. To 8:00p.m.on the above mentioned days, potentially yielding about 10 hours of idle time during that time on those 3 days.

b. Observations

Observations on Unit E3 on 8/17/10 revealed that patient E3-22 did not attend the "Life Management" group held from 9:00 a.m. to 9:15a.m. The patient walked up and down the hallway, yelling loudly.

c. Interviews

1) In an interview on 8/16/10 at 4:15a.m., PhD-W1 was asked about patient E3-22's attendance at the weekly "Program Latino" group that she conducted. PhD-W1 stated that the patient has never attended this group. The "Programa Latino" was held on 8/17/10 on unit F3 in room 325 from 9:30a.m.to 10:10a.m. The group was observed for 10 minutes. Patient E3-22 did not attend.

2) In an interview on 8/18/10 at 9:50a.m. with MD-W1 (doctor), the surveyor noted that, with the exception of the "Life Management" group, the patient was not attending two of the four groups to which he had been assigned. It was also pointed out to MD-W1 that the patient had around 9 hours of idle time during the day on Sundays, Wednesdays, Thursdays and Fridays because of no scheduled activities. MD-W1 stated that patient E3-22 was difficult to manage. "He shouts, yells, lies on the floor frequently, and cannot sit still for more than a few minutes at a time." When it was pointed out that there was no documentation in the patient's chart about alternative activities, MD-W1 stated "Well, you know some schedules are not suitable for all patients. All the people on my team have different supervisors. I don't have the power to tell them what to do." MD-W1 clearly was not going to tell his treatment team to revamp the patient's activities.

3) In an interview with RN-W2 on 8/18/10 at 3:45p.m., the lack of active treatment for patient E3-22 was discussed. He agreed that the patient had long periods of idle time, especially on Sundays, Wednesdays, Thursdays and Fridays. On the other days of the week, the patient had 1 or 2 scheduled groups ("Physical activities" and "exercise") that he did not attend. RN-W2 stated that correction of this problem was "a work in progress."

3. Patient F1-12

a. Record Review

1) The Psychiatric Evaluation dated 7/26/10 stated that patient F1-12's presenting problem was "Cognitive Impairment, needs total care." Recommendations listed under the section titled Treatment Objective were: "N/A" (handwritten). "Patient only speaks Arabic and did not respond to a telephone interpreter's questions."

2) Review of Patient F1-12's Master Treatment Plan dated 8/12/10 revealed that the patient was assigned to the following group for his problem of: "Dementia with Cognitive Skills Decline [sic]": Life Management Meeting: "Group provides orientation and the education of ward structure, safety rules, and schedules. Appointments and pertinent issues to foster successful understanding of hospital based treatment and expectations (5 times per week for 30 mins from 8/10/10 to 7/26/2011)." No other group activities were included on the treatment plan.

3) Review of patient F1-12's "Individual Group Attendance" Sheet from 6/1/10 to 8/18/10 revealed that patient F1-12 attended 7 activities (5 of which were Life Management group) and was absent from seven activities. There were no progress notes specifying reasons for the absences. [Note: The facility's computer program could only generate information from 6/1/10 forward; the staff was not successful in obtaining data from 8/5/10 forward].

b. Observations

1) Patient F1-12 was observed on the F1 unit on the following dates and times:

2) [8/16/10; 1:15p.m. to 2:00p.m.]: Patient F1-12 was observed in the unit hallway outside the dayroom area sitting in a wheelchair, head down and not interacting with the milieu, with an HST (Health Services Technician) maintaining 1:1 observation status for safety, due to fall precautions. Although not on his treatment plan, the patient was assigned to be attending "Leisure Activities" group according to the "Individual Patient Schedule" dated 8/16/10. No interpreter was present.

3) [8/17/10; 9:05 a.m. to 9:15 a.m.]: Patient F1-12 was observed in his wheelchair, head down, eyes closed while attending "Life Management" group in the dayroom. No interpreter was present. No progress note regarding the patient's participation in this group was found in the medical record.

4) [8/18/10; 9:10a.m.to 9:20a.m.]: Patient F1-12 was observed in his wheelchair, head down, eyes closed while attending "Life Management" group in the dayroom. No interpreter was present.

c. Interviews

1) In an interview with the Director of Psychiatry on 8/16/10 at 4:15p.m., F1-12's case was discussed. The Director stated "This is a very demented person who really can't get much out of being here. We just need to place him in a nursing home."

2) In an interview with MD-H1 on 8/16/10 at 2:45p.m., the physician stated "(F1-12) hasn't been in the hospital long enough for us to figure out how to help him."

3) In an interview on 8/16/10 at 2:35p.m., SW-H1 was asked about what specific activities could be provided for Patient F1-12. SW-H1 replied "We don't have a lot to give him (F1-12). He doesn't respond to anyone and maybe we need to have an interpreter come in to the hospital to interview with him because the phone interpreter wasn't helpful. He's [the patient] not appropriate for any groups. We're just going to work on getting him into a nursing home."

II. Based on record review and interview, the facility failed to: (A) ensure that physicians included in their orders the length of time in restraints for 1 of 6 non-sample patients (SR1) whose charts were reviewed for policy and procedure compliance, and (B) ensure that 1 of 6 non-sample patients (SR6) was released by clinical staff from seclusion at the earliest possible time. These failures result in restrictions of patient's rights without adequate documented justification.

Findings include:

A. Record Review

1. Facility Policy

The facility's policy for seclusion and restraints, section CL-PC0284, dated 2/2/10, under "Procedure" reads "The attending psychiatrist or covering psychiatrist writes an order for up to or no more than one hour...the order must include the behavior criteria that need to be present before the RN can discontinue the seclusion or restraint." Under the section "Release from Seclusion or Restraint," the policy states: "The nurse...assesses the patient's readiness for release prior to the expiration of the order....May release the patient if clinically appropriate in accordance with the behavioral criteria listed by the physician."

2. Non-sample patient SR1 was placed in four point restraints on 6/3/10 at 3:45p.m. The physician order, dated 6/3/10 at 3:45p.m., did not include the maximum duration of time the patient could be in restraints. The pre-printed "Seclusion/Restraint physician's Order" sheet left the section on "length of time" blank.

3. Non-sample patient SR6 was placed in locked seclusion on 6/20/10 from 1:10a.m.to 7:10a.m. Physician orders, per facility policy, were reviewed every hour up though 7:10a.m. The criteria for renewal on the physician's orders, documented from 1:10a.m.to 7:10a.m., was: "Patient out of control and is dangerous to self." The release criteria were: "Not agitated and non-combative." The "Seclusion/Restraint nursing flow Sheet," documented on 6/20/10, described behaviors which differed from the physician's descriptions at the same times: 1:10a.m. - 2:10a.m. - "Patient sleeping in comfort room with normal breathing [sic]"; 2:10a.m.- 3:10a.m. - "Sleeping, lying on bed"; 3:10a.m.- 4:10a.m. - "Laying on back, awake"; 4:10a.m.- 5:10a.m. - "Aware --- resting in comfort room"; 5:10a.m. - 6:10a.m. - "Sleeping, --- lying on back"; 6:10a.m. -7:10a.m. - "Sleeping, ...calming, lying." Thus, the patient was documented as sleeping or quiet for 6 hours, without any attempt to remove him from seclusion.

B. Interview

1. In an interview with the Nursing Director on 8/18/10 at 11:35a.m., the findings of not releasing non-sample patient SR6 in a timely manner after he calmed down was discussed. The Nursing Director agreed with the findings.

2. In an interview with the Director of Psychiatry on 8/19/10 at 11:15a.m., the issue of physician's renewing a seclusion order for non-sample patient SR6 every hour on 6/20/10 from 1:10a.m.to 7:10a.m. when the patient was either quiet or asleep was discussed. The Director of Psychiatry agreed that the continued seclusion order for a patient who was not "being a danger to himself" was not appropriate.

III. Based on interviews and record review, the facility failed to ensure that 11 of 12 active sample patients (A1-22, A1-23, A2-22, D1-3, D3-4, E1-21, E3-22, F1-12, F2-1, G2-26 and G3-23) received sufficient hours of on-unit therapeutic measures which focused on restoring and/or developing optimal levels of mental and psychosocial functioning on weekends. Failure to provide on unit therapeutic activities. on the weekend potentially impairs patients' attainment of treatment goals, and may prolong their hospitalization.

Findings include:

A. Interviews

1. In an interview on 8/16/10 at 9:35 a.m., Patient G2-26 stated "On weekends I sleep in late and then watch sports on TV all day. We don't do anything in the evenings except go to Park Place [an off unit canteen] or watch a movie."

2. In an interview on 8/16/10 at 11:20 a.m. active sample patient G3-23 stated "There is a lot of down time, especially on weekends. I don't like sitting around." The patient stated that she asked to go to the library a lot.

3. In an interview on 8/16/10 at 1:45p.m., Patient F2-1 stated "I just lay in bed most of the days [weekend] [sic] and sometimes watch TV. We don't have groups on the weekend."

4. In an interview on 8/17/10 at 10:30a.m., active sample patient A1-22 stated that he had nothing to do on weekends "What I do is lay [sic] around, sleep, and be more and more depressed."

5. In an interview on 8/17/10 at 12:45p.m., Patient D1-3 stated "I sleep until lunch and then watch TV; nothing happens on the weekend."

6. In an interview on 8/18/10 at 10:30a.m., the Director of Rehabilitation Services stated that his staff worked on the patient units Monday - Friday from 8:00p.m. to 4:30p.m. Therefore any on ward activities were to be provided by nursing staff.

7. In an interview on 8/18/10 at11:35a.m., the Nursing Director acknowledged that no formalized nursing therapeutic groups were being offered on a consistent basis on the weekends. He added that any nursing groups held on the weekend are not specific and are not listed on the program schedules.

B. Record Review

Review of the "Home Unit Group Schedules" revealed that, with the exception of "Life Management" groups held on Saturday and Sunday at 9:00a.m. and 8:00p.m., there were no listed weekend therapeutic activities for any of the 11 active sample patients. One of the 12 active sample patients has been in the facility since 1989; four of 12 sample patients have been hospitalized for over a year.

Based on record review, observation and interview, the Medical Director failed to ensure that the medical staff:

I. Provided Psychiatric Evaluations that included an assessment of patient assets that could be used to design treatment for 4 of 12 active sample patients (A1-22, A2-22, F1-12 and F2-1). 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)

II. Provided adequate monitoring to ensure that 3 of 12 active sample patients (E1-21, E3-22 and F1-12) received sufficient active therapeutic program for significant periods of time during their hospital stay. These patients were left to themselves for long intervals, often 5 to 9 hours for several days per week, without therapy being provided. Lack of active therapies resulted in patients being hospitalized without all interventions for recovery being provided to them, delaying their improvement. (Refer to B125-I)

III. Specified the length of time in restraints for 1 of 6 non-sample patients (SR1) whose charts were reviewed for policy and procedure compliance and assured that clinical staff released 1 of 6 non-sample patients (SR6) from seclusion at the earliest possible time. These failures result in restriction of a patient's rights without adequate documented justification. (Refer to B125-II)

IV. Ensured that 11 of 12 active sample patients (A1-22, A1-23, A2-22, D1-3, D3-4, E1-21, E3-22, F1-12, F2-1, G2-26 and G3-23) received sufficient hours of on-unit therapeutic measures which focused on restoring and/or developing optimal levels of mental and psychosocial functioning on weekends. Failure to provide on unit therapeutic activities on the weekend potentially impaired patients' attainment of treatment goals and may prolong their hospitalization. (Refer to B125-III)


In an interview with the Director of Psychiatry on 9/19/10 at 11:15a.m., the issues related to physician seclusion and restraint responsibilities and the deficiencies noted in B125-11 were discussed. The Director of Psychiatry agreed with the findings and stated "I need to do some more supervision on these issues."

Based on record review and interview, the Nursing Director failed to ensure that nursing staff followed facility policy for releasing 1 of 6 non-sample patients (SR6) whose records were reviewed for policy and procedure compliance at the earliest possible time. This failure results in a restriction of patient rights without adequate documented justification.

Findings include:

A. Record Review

According to the medical record, non-sample patient SR6 was placed in locked seclusion on 6/20/10 from 1:10a.m. to 7:10a.m. Physician orders per facility policy were reviewed every hour up though 7:10a.m. The criteria for continued use of seclusion on the physician's orders from 1:10a.m. to 7:10a.m. was: "Patient out of control and is dangerous to self." The "Seclusion Restraint Nursing flow sheet" documented the following on 6/20/10: 1:10a.m. - 2:10a.m. - "Patient sleeping in comfort room with normal breathing"; 2:10a.m. - 3:10a.m. - "Sleeping, laying on bed"; 3:10a.m. - 4:10a.m. - "Lying on back, awake"; 4:10a.m. - 5:10a.m. - "Aware...resting in comfort room"; 5:10a.m.- 6:10a.m. - Sleeping, ...lying on back"; 6:10a.m.- 7:10a.m. - "Sleeping, ...calming, lying." Thus, the patient was documented as sleeping or quiet for 6 hours without any staff attempt to remove him from seclusion.

B. Interview

In an interview with the Nursing Director on 8/10/10 at 11:35a.m., the findings regarding staff not releasing non-sample patient SR6 from seclusion in a timely manner after hours of being calm and/or sleeping was discussed. The Nursing Director agreed with the findings.