HospitalInspections.org

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

I. Describe the specific focus of social work modalities chosen from a preprinted list of generic interventions on the Master Treatment Plans of 5 of 8 sample patients (A8, A12, A15, B2 and B12). The MTPs of 2 of 8 sample patients (C9 and C12) also had no modalities to address the listed medical problems. In addition, the MTPs of 6 sample patients (A8, A12, A15, B12, C9 and C12) listed no physician interventions. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients. (Refer to B122)

II. Provide scheduled therapeutic groups that directly related to the identified problems listed on the Master Treatment Plans of 8 of 8 active sample patients (A8, A12, A15, B2, B8, B12, C9 and C12). The facility scheduled large groups which only provided general information or generic activities instead of individualized interventions. These failures compromise the delivery of specified treatments based on identified therapeutic needs, potentially resulting in unsuccessful treatment of patients. (Refer to B125)

III. Provide specific dates and times of aftercare follow-up appointments on the discharge plans of 3 of 5 discharged patients (D2, D3 and D5) whose records were reviewed. This failure compromises continuity of care once patients are discharged to the community. (Refer to B134)

Based on record review and interview, the facility failed to provide an inventory of assets on the psychiatric evaluations of 8 of 8 active sample patients (A8, A12, A15, B2, B8, B12, C9 and C12). This failure hampers staff's ability to develop a meaningful treatment plan, potentially compromising individualized care.

Findings include:

A. Record Review

The following patients' psychiatric evaluations did not include any patients' assets (dates of psychiatric evaluations are in parenthesis): A8 (9/7 /11), A12 (8/25 /11), A15 (9/7/ 11), B2 (9/6/11), B8 (9/7/11) B12 (8/27/11), C9 (9/10/11), and C12 (9/3/11).

B. Staff Interview

In an interview on 9/13/11 at 3p.m., the Medical Director acknowledged that inventory of assets was missing in all 8 active sample patients' psychiatric evaluations.

Based on record review and interview, the facility failed to describe the specific focus of social work modalities chosen from a preprinted list of generic interventions on the Master Treatment Plans of 5 of 8 sample patients (A8, A12, A15, B2 and B12). The MTPs of 2 of 8 sample patients (C9 and C12) also had no modalities to address the listed medical problems. In addition, the MTPs of 6 sample patients (A8, A12, A15, B12, C9 and C12) listed no physician interventions. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. Social Work Staff listed modalities on the MTPs, but these were generic and lacked specific focus.

a. Patient A8 (Master Treatment Plan (MTP) dated 9/7/11): Preprinted interventions included "Process group therapy: Focus on processing feelings in an interactive group" and "Individual therapy."

b. Patient A12 (MTP 8/26/11): Preprinted interventions listed included "Process group therapy: Focus on processing feelings", "Activity therapy groups" and "Individual therapy."

c. Patient A15 (MTP 9/3/11): Preprinted interventions included "Process group therapy: Focus: processing feelings", "Activity therapy groups" and "Individual therapy."

d. Patient B2 (MTP 9/8/11): Preprinted interventions included "Activity therapy groups: Group Activities", "Individual therapy" and "Individual CBT coping skills."

e. Patient B12 MTP (8/29/11): Preprinted interventions included "Process group therapy Focus: Process feelings", "Individual therapy Focus: Insight gained from group, d/c plan, homework assignments."

2. Two patients' MTPs had no interventions listed for medical concerns.

a. Patient C9 (MTP 9/10/11): There were no interventions listed for resolving the short term goal "Vital signs will remain stable during detox period..."

b. Patient C12 (MTP 9/6/11): The preprinted short term goal was "Vital signs will remain stable during detox period with appropriate medication intervention. Patient will develop life management skills applicable to their situation." There were no interventions listed for dealing with these short term goals.

3. Six of the 7 plans noted above (A8, A12, A15, B12, C9 and C12) listed no physician interventions.

B. Interview

In an interview on 9/13/11 at 3:00p.m., the Medical Director acknowledged that the intervention modalities on patients' treatment plans were non-specific.

Based on observation, interview and record review, it was determined the facility failed to provide scheduled therapeutic groups that related directly to the identified problems and interventions listed on the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (A8, A12, A15, B2, B8, B12, C9 and C12). The scheduled groups provided general information or generic activities, and the therapeutic modalities listed on the patients' MTPs were not available as scheduled activities. These failures compromise the delivery of specific treatments based on patients' assessed needs.

Findings include:

A. Observation

1. On September 12, 2011 at 11a.m., a "Nursing Group" posted on the unit schedule was observed in the hospital cafeteria. There were more than 40 patients in attendance. The group had no specific focus. The group leader, RN A, fielded general questions about where patients might obtain medications after discharge. There were many distracting side conversations by patients with no attempts by the leader to re-focus the group members. Furthermore, the group was scheduled to end at 12p.m. but ended abruptly at 11:30a.m. when a group of patients from the residential program started through the cafeteria line.

2. On September 12, 2011 at 3:15p.m., an unscheduled outdoors recreation therapy group was observed. Recreational Therapist, RT A, began the group by calling the names of 19 patients listed on a piece of paper. Once the patients moved outside, they were left on their own in deciding how they would use the time. For example, some went for a walk, others tossed a football, and some sat quietly. No specific interventions were observed.

B. Interviews

1. In an interview on September 12, 2011 at 11:35a.m., RN A, who conducted the "Nursing Group" in observation #1 above, acknowledged that the nursing group was very large and noted that this related to the high census. This RN also acknowledged that the cafeteria was not a good place to hold a group and that the focus of the group was not specific to the identified treatment needs of the patients.

2. On September 12, 2011 at approximately 1p.m. the Clinical Director was observed writing the names of patients on 4 group assignment sheets of paper. When asked if patients knew in advance what specific groups they were to attend, the Clinical Director stated, "Patients know they have a group scheduled, but they may not know exactly which group."

3. On September 12, 2011 at approximately 3:45p.m., RT A was asked how s/he decided who would attend the RT group noted in observation # 2 above. The RT said that it was a recreation group and that most patients can benefit from these kinds of activities. When asked if the activities in progress were directly related to the treatment modalities listed on the patients' MTPs, the RT stated they were not. RT A reiterated that most patients can benefit from physical activity.

4. In an interview on September 13, 2011 at 9:15a.m., patient A8 stated that he was admitted because of abuse of alcohol and suicidal ideation. When asked if he attended scheduled groups for these problems, the patient stated that he got medication but had no scheduled classes or groups. When asked if he thought the nursing group on September 12, 2011 (noted above) was helpful, patient A8 stated it was so noisy that he couldn't hear much.

C. Record Review

In addition to the unstructured nursing and recreation groups noted above, a record review identified a discrepancy between what was listed on patients' MTPs as treatment modalities and what was available according to the facility published "Daily Schedule."

1. Review of the 8 active sample patients' MTP's revealed that 7 patients (A8, A12, A15, B2, B12, C9 and C12) were assigned to psychosocial-educational groups. The psychosocial education groups were not an available therapy listed on the facility published "Daily Schedule." There was no evidence that they were provided.

2. Further review of the 8 active sample patients' MTP's revealed that 7 patients (A8, A12, A15, B2, B12, C9 and C12) were scheduled for process groups. The process groups were not an available therapy listed on the facility published "Daily Schedule" and there was no evidence that they were provided.

Based on record review and staff interview, the facility failed to provide the specific dates and times for aftercare follow-up appointments at the time of discharge for 3 of 5 discharged patients (D2, D3 and D5) whose records were reviewed. The discharge appointments for the aftercare services were not documented in the discharge summaries of the Transfer/Discharge Form or anywhere else in the record. This failure compromises appropriate and timely follow up care for patients.

Findings include:

A. Record Review

Review of the Discharge Summaries and Transfer/Discharge Forms revealed the following:

1. Patient D2 had a discharge date of 7/4/11. The Discharge Summary dated 8/2/11 did not contain a specific date and time for a follow up appointment. The "Transfer/Discharge Form" dated 7/4/11, stated the following for the Appointment Date: "Clt (Client) will arrange." No specific time and date for aftercare follow up was found during the record review.

2. Patient D3 had a discharge date of 7/1/11. The Discharge Summary dated 8/8/11 did not contain a specific date and time for a follow up appointment. The "Transfer/Discharge Form" dated 7/1/11, stated the following for the appointment date: "Patient will arrange." No specific time and date for aftercare follow up was found during the record review.

3. Patient D5 had a discharge date of 7/11/11. The Discharge Summary dated 8/13/11 did not contain a specific date and time for follow up appointment. The "Transfer/Discharge Form" dated 7/11/11 did not list a date and time for a psychiatric follow up or appointment.

B. Staff Interview

1. In an interview on 9/13/11 at approximately 2:15p.m., the Director of Social Services acknowledged that the "Transfer/Discharge Form" for patients D2, D3 and D5 did not contain specific appointment dates and times. The Director of Social Services stated, "The Discharge Coordinator works very hard, but the providers, at times, do not give appointments."

2. In an interview on 9/13/11 at approximately 3p.m., the Medical Director acknowledged that the discharge summaries for patients D2, D3 and D5 did not contain specific follow-up appointment dates and time. The Medical Director stated, "The Aftercare provider wants the patient to make the appointment."

Based on observation and interview it was determined the facility failed to:

I. Respect patients' needs for privacy and dignity. The facility admitted patients over the licensed capacity and housed some patients in seclusion rooms and a quiet room (common lounge area). This prevented the facility from having a seclusion room available as a safe place to which to remove dangerous patients. Use of seclusion rooms and quiet rooms (common lounge areas) as bedrooms also results patients not having adequate privacy and dignity. (Refer to B144-I and B148)

II. Monitor the development and implementation of treatment plans. The Master Treatment Plans of 5 of 8 sample patients (A8, A12, A15, B2, B12, C9 and C12) failed to include the focus of treatment for social work modalities. The MTPs for patients C9 and C12 had no interventions for identified medical issues, and the MTPs of 6 sample patients ((A8, A12, A15, B12, C9 and C12) had no physician interventions (Refer to B144-III). In addition, the offered therapeutic groups on the unit schedule did not directly relate to the problems and listed interventions on the sample patients' Master Treatment Plans (Refer to B125). These failures compromise the ability of the facility to provide comprehensive, individualized treatment.

III. Provide adequate numbers of staff to assure provision of care to all patients. Observations and interviews revealed inadequate monitoring of a dementia patient. This failure compromises the ability of the facility to provide comprehensive, individualized care. (Refer to B150)

Based on observation, interview and record review, it was determined that the Medical Director failed to monitor and assure the quality of medical and psychiatric care provided in the facility. Specifically the Medical Director failed to assure that the facility:

I. Properly housed patients on the units. The facility admitted patients over the licensed capacity and housed them in seclusion rooms and a quiet room (common lounge area). This prevented the facility from having a seclusion room available as a safe place to which to remove dangerous patients. Use of the seclusion rooms and a quiet room as bedrooms also resulted in patients not having adequate privacy and dignity.

Findings include:

A. Observation

On September 12, 2011 at approximately 10a.m., the surveyor observed that 2 seclusion rooms were being used as patient bedrooms. In addition, a quiet room (common lounge area) had been converted into a two patient bedroom. It was further observed that one of the seclusion room beds was bolted to the floor. The patients housed in the seclusion room also had no place to store clothing, thus their clothing was on the floor. These practices result in a lack of privacy and dignity for patients.

B. Staff Interview

On 9/14/11 around 10:30a.m., the Medical Director informed the surveyors that, at times, the facility uses seclusion rooms and/or patient quiet rooms (common lounge areas) to house patients when the facility admits more patients than the number of licensed beds. The Medical Director stated that the facility had not needed to use the seclusion room for seclusion for over two months, but acknowledged that "seclusion is one of the interventions" the facility should have available.

II. Provided an inventory of assets on the psychiatric evaluations of 8 of 8 active sample patients (A8, A12, A15, B2, B8, B12, C9 and C12). This failure hampers staff's ability to develop a meaningful treatment plan, potentially compromising individualized care. (Refer to B117)

III. Described the specific focus of social work modalities on the Master Treatment Plans of 5 of 8 sample patients (A8, A12, A15, B2 and B12). The MTPs of 2 of 8 sample patients (C9 and C12) also had no modalities to address the listed medical problems. In addition, the MTPs of 6 sample patients (A8, A12, A15, B12, C9 and C12) listed no physician interventions. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients. (Refer to B122).

IV. Provided scheduled therapeutic groups that related directly to the identified problems listed on the Master Treatment Plans of 8 of 8 active sample patients (A8, A12, A15, B2, B8, B12, C9 and C12). The offered groups provided general information or generic activities, and the therapeutic modalities listed on the patients' MTPs were not available as scheduled activities. These failures compromise the delivery of specific treatments based on individual patients' assessed needs. (Refer to B125)

V. Provided the specific dates and times for aftercare follow-up appointments at the time of discharge for 3 of 5 discharged patients (D2, D3 and D5) whose records were reviewed. The discharge appointments for the aftercare services were not documented in the discharge summaries of the Transfer/Discharge Form or anywhere else in the record. This failure compromises appropriate and timely follow up care for patients. (Refer to B134)

Based on observation and interview it was determined the Chief Nursing Officer (CNO) failed to assure all patients were treated with dignity and privacy. Two seclusion rooms and a quiet room (open lounge) were used to house patients when the census was over the unit capacity of 48 beds. The patients housed in the seclusion room had no place to store clothing, thus their clothing was on the floor. This deficient practice results in failure to assure patients' rights to dignity and privacy.

Findings include:

A. Observations

On September 12, 2011 at approximately 10a.m., the surveyor observed that 2 seclusion rooms were being used as patient bedrooms. One of the seclusion room beds was bolted to the floor. In addition, a quiet room (open lounge) had been converted into a two patient bedroom. The patients housed in the seclusion rooms had no place to store clothing, thus their clothing was on the floor.

B. Interview

1. In an interview on 9/12/11 at approximately 10:20a.m., RN A acknowledged the unit capacity was 48 beds. RN A acknowledged that the quiet room (lounge) and two seclusion rooms were being used as bedrooms to accommodate an over capacity census of 52 patients.

2. In an interview on September 13, 2011 at approximately 4:15p.m., the CNO acknowledged that the over capacity (high census) compromises the ability of staff to meet individual patient needs for privacy and dignity.

Based on observation and interview, it was determined the facility failed to provide adequate nursing staff to care for the varied patient population, including the monitoring of patients with dementia. Failure to monitor a non-sample patient with dementia resulted in sample patient A8's personal space being violated. Insufficient monitoring of patients on treatment units potentially results in unsafe conditions for patients.

Findings include:

A. Observations

On September 13, 2011 at 9:45a.m., sample patient A8's room was observed. The patient's roommate, a non-sample patient, was lying in bed and not attending any groups.

B. Interviews

1. On September 13, 2011 at 9:15a.m., patient A8 was interviewed. The patient stated that his roommate was very confused, and that on 2 occasions, the roommate had tried to climb in bed with patient A8. Patient A8 further revealed his roommate once defecated in his (patient A8's) bed.

2. On September 13, 2001 at approximately 1:15p.m., Community Counselor (CC) A acknowledged that the roommate of patient A8 had dementia. CC A also acknowledged the high census (over unit capacity), and stated that nursing was short of staff and that there was not always time to care for and redirect elderly, confused patients.