HospitalInspections.org

Based on observation, record review, staff interviews and policy review, the facility failed to:

I. Develop Master Treatment Plans for 11 of 11active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11) that identified individualized and focused interventions to address the patients' presenting problems and treatment goals. The modalities (individual or group method of delivery) also were not specified for nursing interventions on the MTPs of 5 of 11 sample patients (A1, A2, A3, A4 and A6) and for social work interventions on the MTPs of 2 of 11 sample patients (A9 and A11). In addition, the MTPs for patients A1, A2, A3, A5 and A6 failed to include group sessions that the patients actually attended. These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

II. Ensure proper documentation of restraint procedures for 1 of 1 non-sample patient (B1). Specifically, the patient was placed in a physical hold on 5/3/11 which resulted in the patient being injured. The physical hold was not documented until 5/5/11 after a fracture was diagnosed on 5/4/11. Failure to carry out all safety measures for patients placed in restraint and complete all required documentations in a timely manner poses a safety risk for patients and violates patient's rights to be free from seclusion/restraint except to ensure the immediate protection of self or others. (Refer to B125-I)

III. Ensure that the least restrictive procedures were used to de-escalate a confrontational situation with 1 of 1 non-sample patient (B1). Specifically, nursing staff incorrectly used a physical hold (restraint) rather than non-physical (verbal) de-escalation techniques to manage Patient (B1) when the patient was agitated, confrontational, and refusing to go to the quiet room. The use of physical intervention as a first choice rather than non-physical (verbal) intervention techniques to defuse disruptive patient behaviors creates an unsafe environment and places patients at risk of harm. (Refer to B125-II)

IV. Ensure that 1 of 1 non-sample patient (B1) received adequate nursing and medical assessments after being injured. Specifically, registered nurses failed to evaluate the extent, severity, and intensity of Patient's B1's injury sustained during a physical hold on 5/3/11, and failed to assess his level and severity of pain and to report the patient's condition to a physician or nursing supervisors. The Charge Nurse on duty at the time of the incident failed to adequately assess the patient, and failed to notify a supervisor when there was no physician response to the nurse's telephone call regarding the patient's injury. Therefore, there was no evaluation by the physician on the day of injury. Failure to assess, evaluate, and reassess patients who complain of having a fracture and pain results is unsafe nursing practice, and can result in serious medical and psychological outcomes for patients. (Refer to B125-III)

Based on record review and staff interview, the facility failed to provide social work assessments that integrated factual and historical information into conclusions and recommendations for 10 of 11 active sample patients (A1, A2, A4, A5, A6, A7, A8, A9, A10 and A11). This failure results in lack of information to identify the social work role in treatment and discharge planning.

Findings Include:

A. Record review

Review of social work assessments revealed no social work conclusions and recommendations for the following patients (psychosocial assessment dates in parentheses): A1 (4/25/11), A2 (4/27/11), A4 (4/29/11), A5 (5/5/11), A6 (4/27/11), A7 (5/4/11), A8 (5/18/11), A9 (4/27/11), A10 (4/28/11) and A11 (3/5/11).

B. Staff Interview

1. In an interview on 5/10/11 at approximately 2:30p.m., the Director of Social Work acknowledged that social work conclusions and recommendations were not present in the social work assessments for 10 active sample patients.

2. In an interview on 5/10/11 at 3p.m., the Medical Director agreed that the social work assessments for 10 of 11 of active sample patients did not include recommendations for treatment.

Based on the record review and staff interview, the facility failed to document individual patient strengths/assets in the psychiatric evaluations of 4 of 11 active sample patients (A1, A7, A9 and A11). There were no listed assets for patient A1; those for patients A7, A9 and A11 were limitations instead of assets. This failure can result in development of treatment plans that do not build on patient strengths/assets, potentially leading to patients not receiving adequate care and prolonging hospital stays.

Findings include:

A. Record review (psychiatric evaluation dates in parentheses)

The Psychiatric Assessments for the active sample patients (dates of psychiatric evaluations in parenthesis) revealed the following under subheading of "strengths":

Patient A1 (4/25/11): The section was blank.
Patient A7 (5/4/11): "Limited. Poor insight, poor judgment, aggressive behaviors."
Patient A9 (4/26/11): "Limited. Poor insight, poor judgment, aggressive behaviors."
Patient A11 (3/17/11): "Limited, given poor insight, poor judgment, recent psychosocial stressors consistent with moving into a shelter as well as removal of mother due to physical abuse."

B. Staff Interview

In an interview on 5/10/11 around 3:00p.m., the Medical Director acknowledged that an inventory of the patient's strengths was missing in the psychiatric evaluation of sample patient A1 and was incorrectly stated in the psychiatric evaluations of sample patients A7, A9 and A11. The Medical Director stated, "It is opposite. Problems are listed as assets. Assets are not listed."

Based on record review, observation and interview, the facility failed to ensure that Master Treatment Plans of 11 of 11active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11) identified individualized and focused interventions to address the patients ' presenting problems and treatment goals. The modalities (individual or group method of delivery) also were not specified for nursing interventions on the MTPs of 5 of 11 sample patients (A1, A2, A3, A4 and A6) and for social work interventions on the MTPs of 2 of 11 sample patients (A9 and A11). In addition, the MTPs for patients A1, A2, A3, A5 and A6 failed to include group sessions that the patients actually attended. These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Findings include:

A. Record Review

The treatment plans for the following sample patients were reviewed (dates of plans in parentheses): A1 (4/23/11); A2 (4/26/11); A3 (4/5/11); A4 (4/28/11); A5 (5/3/11); A6 (4/25/11); A7 (5/4/11); A8 (3/16/11); A9 (4/26/11); A10 (4/25/11) and A11 (3/14/11).

1. All 11 patients' MTPs contained the following generic and unfocused MD interventions: "MD will assess & or adjust medications as needed. Order lab work related to medication"; "Individual psychiatric sessions with patient (number of times inserted) per week for therapy& mental status."

2. Ten sample patients (A1, A2, A3, A4, A6, A7, A8, A9, A10 and A11) had the following generic and unfocused nursing interventions for the problem "Aggression/Violence/Assaultive Behavior": "Nursing staff will assess the patient for escalating anger/anxiety/aggression and intervene immediately to protect the patient and others in the milieu"; "Nursing will redirect the patient to a quiet environment if the patient is agitated or threatening others"; "RN[registered nurse] will assess the patient for the need of medication to relieve agitation"; "Nursing staff will monitor the patient for medication compliance and side effects and effectiveness of teaching provided q [every] shift."

3. Five sample patients (A1, A2, A3, A4 and A6) had a nursing intervention with no specified modality for the problem "Aggression/Violence/Assaultive Behavior": "Nursing staff will meet with the patient at least [number of times] weekly to educate about the consequences of violent behavior and identify alternative methods of coping with anger and frustration."

4. Patient A5 had the following generic nursing interventions for the Problem "Suicide Ideation": "Nursing will immediately search the patient belongings upon admission for any sharp objects or contraband"; "Nursing will assess the patient for risk of suicide q [every] shift and implement appropriate level of observation"; "Nursing staff will conduct environmental rounds/safety checks q shift to maintain patient safety."

5. Patients A2, A3, A4, A5, A6, A7 and A8 had the following generic and unfocused social work intervention: "Meet with Pt [patient] [number of sessions] weekly for ind. [individual] sessions [or therapy]"

6. Patients A9 and A11 had the following social work interventions with no specified focus (purpose) or modality: "Pt will meet w/SW [with Social Worker] 2-3 times a wk [week]."

7. Patients A1, A2, A3, A4, A5, A6, A7 and A8 had the following generic intervention for Expressive Therapy: "Pt [patient] will attend [or participate in][number] of ET groups (45 min) per week."

B. Observation

1. On 5/10/11 from 10:00 a.m. to 10:30a.m., Patients A2 and A3 were observed attending the "Emotion 1 Group" conducted by Mental Health Technician (MHT)3. This group was not on the treatment plan of either patient.

2. On 5/10/11 from 10:50a.m. to 11:15a.m., Patients A5 and A6 were observed in the "Drug Prevention Group" conducted by MHT1. The topic was "Signs of Drug Abuse." This group, posted on the Adolescent Program Schedule for 10:30a.m. to 11:15a.m., was not on patient A5's or A6's treatment plan.

C. Staff Interviews

1. In an interview on 5/10/11 at 10:50a.m., MHT3 confirmed that "Emotion 1 Group" was not on patient A2's or A3's treatment plans. MHT3 stated, "I am not sure how the treatment plan is developed. I do not attend treatment plan meetings."

2. In an interview on 5/10/11 at 11:25a.m., MHT1 confirmed that the 5/10/11 Drug Prevention group was not listed on the treatment plans for patients A5 and A6. MHT1 stated, "I have not read the chart. I'm not sure what the goals are for [Patients A5 and A6]."

3. In an interview on 5/10/11 at 11:40a.m. with the Director of Nursing, RN3, RN4 and Program Specialist( PS)2, Patient A4's treatment plan was discussed. RN3 acknowledged that nursing interventions failed to specify the modality (whether group or individual sessions were to be used).

4. In an interview on 5/10/11 at 2:10p.m., SW1 agreed that the interventions on patient A5's treatment plan failed to include a focus of treatment.

5. In an interview on 5/10/11 at 3:00p.m., Expressive Therapist ET1 acknowledged that there was no focus of treatment for the ET intervention for Patient A1.

6. In an interview on 5/10/11 at 3:15p.m., RN4 agreed that the listed interventions on the treatment plans of patient A1 and A5 did not specify the modality (method of delivery) to be used.

7. In an interview on 5/11/11 at 9:50a.m., which included a discussion of the ET interventions on the sample patients' MTPs, the Director of Clinical Services acknowledged that the ET interventions did not include a focus of treatment.

Based on record review and interview, the facility failed to identify the name of each person and the clinical discipline responsible for interventions listed on the Master Treatment Plans of 11 of 11 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11). The Master Treatment Plans only included staff initials next to the interventions instead of staff signatures. It was not possible to determine what initials correlated with signatures on the "Team Signatures" section of the plan. This practice potentially results in ineffective monitoring of staff's accountability for interventions.

Findings include:

A. Record Review

The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A1 (4/23/11); A2 (4/26/11); A3 (4/5/11); A4 (4/28/11); A5 (5/3/11); A6 (4/25/11); A7 (5/4/11); A8 (3/16/11); A9 (4/26/11); A10 (4/25/11); and A11 (3/14/11). The review revealed that for all 11 sample patients, staff initials were included next to the listed interventions instead of the name of the person and the discipline responsible for each intervention.

B. Staff Interviews

1. In an interview on 5/10/11 at approximately 2:10p.m., in which patient A5's Master Treatment Plan was discussed, SW1 acknowledged that only staff initials were included under the column entitled "Staff signature." SW1 agreed that it was difficult to determine who was responsible for some of the interventions.

2. In an interview on 5/10/11 at approximately 3:00p.m. with Expressive Therapist (ET)1, the treatment plan for Patient A1 was discussed. ET1 confirmed that only initials were included under the column entitled "Staff Signature."

3. In an interview on 5/10/11 at approximately 4:10p.m. with the Director of Nursing (DON), the treatment plans for A1, A2, A3, and A4 were discussed. The DON agreed that staff were using their initials instead of their names. The DON stated, "Staff got out of the habit of writing their names."

Based on record review and interview, the facility failed to ensure that the medical records of 5 of 11 active sample patients (A1, A2, A3, A4 and A6) contained documentation that nursing interventions listed on the patients' Master Treatment Plans were actually delivered. Nurses failed to document these patients' attendance or non-attendance in the prescribed nursing modalities, the topic(s) discussed, and/or the patient's level of response to the interventions. This failure hampers the treatment team's ability to determine the patient's response to treatment interventions, evaluating whether there are measurable changes in the patients' condition, and revising the treatment plan if/when needed.

Findings include:

A. Record Review

1. The Master Treatment Plans for the following patients were reviewed (dates of plans in parentheses): A1 (4/23/11); A2 (4/26/11); A3 (4/5/11); A4 (4/28/11); A5 (5/3/11); A6 (4/25/11); A7 (5/4/11); A8 (3/16/11); A9 (4/26/11); A10 (4/25/11) and A11 (3/14/11). The MTPs for patients A1, A2, A3, A4 and A6 had the following nursing intervention for the problem of "Aggression/Violence/Assaultive Behavior": "Nursing staff will meet with the patient at least [number of times] weekly to educate about the consequences of violent behavior and identify alternative methods of coping with anger and frustration."

2. Review of the treatment notes in the sample patients' medical records revealed no notes for Patients A1, A2, A3, A4 and A6 regarding the nursing intervention for the problem of "Aggression/Violence/Assaultive Behavior" listed on the treatment plans (noted above).

B. Staff Interview

In an interview on 5/10/11 at 3:15p.m. with RN4 and the Director of Nursing, the Master Treatment Plans and the nursing treatment notes for Patients A1and A3 were discussed. RN4 was unable to locate nursing treatment notes for these patients in their medical records. The Director of Nursing agreed that nursing treatment notes were missing and acknowledged that the documentation was vague when staff recorded information about the patients' participation in nursing groups or individual sessions.

Based on document review, interviews, and observation. the facility failed to:

I. Ensure proper documentation of restraint procedures for 1 of 1 non-sample patient (B1). Specifically, the patient was placed in a physical hold on 5/3/11 which resulted in the patient being injured. The physical hold was not documented until 5/5/11 after a fracture was diagnosed on 5/4/11. Failure to carry out all safety measures for patients placed in restraint and complete all required documentations in a timely manner poses a safety risk for patients and violates patient's rights to be free from seclusion/restraint except to ensure the immediate protection of self or others.

Findings include:

A. Document Review

1. A "Daily 24-HR RN [Registered Nurse] Progress Note" for Patient B1, written by a RN and dated 5/3/11 at 4:45p.m., documented the following: "Pt [B1] swung on staff. When staff tried to escort Pt [patient] in Q.R. [quiet room], Pt refused, and when he tried to avoid staff, Pt [patient] accidentally hit his R [right] elbow in the wall..."

2. The "Restraint/Seclusion/Physical Hold Physician Orders" was dated 5/3/11 and signed by a registered nurse on 5/5/11 at 4:40p.m. The form noted that Patient B1 was placed in a physical hold from 4:40 p.m. until 4:45p.m. Under the section of the form labeled, "What behaviors...did the patient display that warranted the restraint intervention," a written note said, "[Patient] Stating 'I will knock you out' to staff when asked to go to QR [Quiet Room]." The form did not document Patient B1's injury. The one hour face-to-face assessment form was left blank.

3. The required "Restraint/Seclusion Form" regarding the physical hold of patient B1 on 5/3/11 was not entered in the record until 5/5/11, after Patient B1 was transferred to the local emergency room on 5/4/11 and was diagnosed with a "right humerus fracture - Spiral fracture." A progress note, dated 5/5/11 and signed by a RN stated, "Late Entry...[no time specified]: On 5/3/11 pt [patient] in physical hold from 4:40p.m. till [sic] 4:45p.m. Taken to QR [Quiet Room]. C/o [Complained of] pain to ? [right] arm hitting wall with H [hand] [sic]. Rated pain 6/10..." This represented the first documentation in the medical record by a registered nurse that a physical hold (restraint) had occurred in the patient's room.

4. The facility's policy entitled "Restraint/Seclusion PC 615" stipulates that the "Nurse Manager/House Supervisor must examine the patient face-to-face within one hour and document patient behavior leading to restraint/seclusion, causes of behavior, physiological condition, and psychological condition on the restraint/seclusion form." The policy also states the following: "Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint....RN will initiate the seclusion/restraint form and document the events leading up to restraint/seclusion including least restrictive interventions implemented prior to initiation of restraint application..." There was no documentation in the record that these required procedures and documentations were completed.

B. Interview

During an interview on 5/10/11 at approximately 5:30p.m. with the Director of Nursing, the Corporate Director of Clinical Services, the Chief Operating Officer (COO), and Nurse Manager1, the incident regarding Patient B1 was discussed. Nurse Manager1 confirmed the late entry for documentation of the physical hold: the incident was documented in the progress notes two days after the incident. She also acknowledged that the Restraint/Seclusion Forms were completed late, and that the one-hour face-to-face assessment (on the form) was left blank.

II. Ensure that the least restrictive procedures were used to de-escalate a confrontational situation with 1 of 1 non-sample patient (B1). Specifically, nursing staff incorrectly used a physical hold procedure (restraint) rather than non-physical (verbal) de-escalation techniques to manage Patient B1 when the patient was agitated, confrontational, and refusing to go to the quiet room. The use of physical intervention as a first choice instead of non-physical (verbal) intervention techniques to defuse disruptive patient behaviors creates an unsafe environment and places patients at risk of harm.

Findings include:

A. Document Review

1. Review of a document entitled "Patient Advocate Team: Patient Relations Complaint Form" revealed the following:

a. "On 5/3/11 at approximately 4:45p.m., the patient [B1] had a verbal altercation in his room with staff [Staff ' s name] and [Staff's initials] later called for assistance of [Staff's initials] to help escort patient to the quiet room. During this time patient hit his elbow on the wall."

b. "Patient [B1] went back and forth as to who grabbed his arm. He first stated that [Staff initials] grabbed him by the arm and twisted it and then threw him against the wall. Then he stated that [Staff initials] grabbed one arm each and threw him toward the door and he ended up in the corner of the doorway, and his elbow hit the wall."

c. "Patient room mate [sic] was interviewed 5/6/11. [Patient's name] the alleged victim [sic] room mate at the time of the incident, was in the room lying on the bed. He states that [staff's initials] entered the room and [Patient's name] and [Staff's name] started arguing about some food that was in the room. [Patient's name] stood up and went near the dresser. He stated, 'They were going back and forth and next things I know they were by the doorway and I heard a lot of bumping. Then I hear something that sounded like a crack.'..."

d. "A hotline call was made and [policeman's name] phoned this writer at 9p.m. on the evening of 5/5/11... He asked if he could send over a detective to talk to the patient and staff...."

e. "There was no direct complaint from patient or mom regarding this situation. However the patient did later make a comment that staff made him hurt his arm."

2. A written report of the investigation of the incident, provided to the surveyor by the facility, had no date, title or signature. During interview on 5/23/11 at approximately 1:45p.m., the Assistant Director of Risk Management stated that the document was completed by Nurse Manager1 and was not part of the Patient Advocate Team Report. The document had the following documentations regarding the incident:

a. "On 5/4/11 it was brought to this writer's attention that the patient was complaining of pain to the right arm. Patient was observed standing at the nurses' station holding his arm. Upon investigation (reviewing the chart) it was discovered an incident occurred the evening prior (5/3)...Per patient, 'something happened to my arm'...[ Staff's name] entered his room and found food ... he [pt.] endorsed becoming angry and cursing at the staff member. He acknowledged he was resisting the staff. He then reported [Staff name] cursed at him...and then balled up his fists. Patient stated he also balled up his fists... He verbalized being given the directive to go to the quiet room and reported saying 'ok' and starting to walk toward the door however, he stated that staff thought he was resisting and then 'put their hands on me.'... He stated they pushed him up against the wall and had his arms behind his back and then he hit his arm on the wall and heard a 'crack'. He reported saying 'You broke my arm'. He then reported they walked him to the seclusion room and then to other room...."

b. "Upon watching the video [referring to video tape monitoring the hallways] it was observed [Staff's initials, Program Specialist (PS) 3] enters the patient's room at 16:29. It was then observed [Staff's initials, MHT4] enters the room at 16:32... The patient is then observed taken to the to the seclusion room for a brief period and then taken to the restraint room where he sat on the bed. The charge nurse at the time...was observed at the doorway of the seclusion room briefly talking to the patient..."

c. The following statements were from an interview with Program Specialist (PS)3.

"Per [Staff's name], he entered the patient's room to move his [patient's] roommate. He reported that the patient asked to get something out of the closet, and at this time, the staff reported the patient acting 'suspicious'. Per [Staff's initials] he then searched the patient's belongings and found peaches. He reported notifying the patient of unit rules and the patient becoming very agitated... Per the staff member the patient appeared defensive and was stating, 'you can't do this'. He reported being assertive with the patient and requesting the patient go to the quiet room to de-escalate. [Staff's initials] reported that the client resisted and balled up his fists, at which time he called for another staff member, [Staff's initials, MHT4]....[Staff's initials] stated that they again requested the patient to head to the quiet room, and the patient then stated, 'no, I ain't going.' Per the staff member the patient then stepped toward [Staff's initials]. It then that they placed hands on the patient...[Staff's initials - PS3] reported that they struggled and the patient got his right arm loose and hit the wall. It was at this time [Staff's initials] reported hearing 'a thud or a pop or something'. [Staff's initials] said the patient stated, 'You broke my arm', at which time [Staff's initials] reported they let the patient go, but they then "gently escorted him to the quiet room for safety."

d. The following statements were from an interview with MHT4:

"Per [Staff's initials], he heard yelling coming from the patient's room at which time he entered to assist. He then recalled the patient balling up his fists and walking toward him. He then stated that the staff member [PS3] and he placed his hands on the patient and the patient continued to struggle at which time his [patient's] right arm hit the wall. He then endorsed walking the patient to the quiet room for safety."

e. "Per recommendation of [name of hospital], the patient is to be scheduled for a surgical procedure..."

B. Observation

-The video tape (noted in item "b" above) was reviewed by the surveyor with the Director of Risk Management from 10:25a.m. to 11:45a.m. on 5/23/11. The Director of Risk Management stated that the facility had cameras in the hallways, dayrooms, quiet rooms, quiet room vestibule, back door, and front door. She stated that there were no cameras in bedrooms; therefore the video did not capture the actual confrontation between the staff and patient. The review of the video established the following timeline regarding circumstances surrounding the patient injury:

-At 16:29:17 [4:29p.m. and 17 seconds], Program Specialist 3 (PS3) entered Patient B1's bedroom

-At 16:32:11 MHT4 entered Patient B1's bedroom. (This showed that PS3 was in the room with the patient without another staff present for about 3 minutes and 6 seconds.)

-At about 40 seconds later at 16:32:51 [4:29p.m.; 51 seconds], the video showed MHT4 and PS3 walking the patient down the hall with one staff on each side of Patient B1. The two staff had their hands under the patient's upper arms. The video did not show staff using their finger tips as reported by MHT4 during interview on 5/23/11 at 4:30p.m.

-At 16:32:13-16:32:16 [4:32p.m., 13-14 seconds], the video showed RN5 (identified by the Director of Risk Management), observing the patient being escorted to the quiet room; RN5 then walked away.

-At 16:32:40 [4:32p.m.; 40 seconds], RN5 was seen in the doorway of the Quiet Room, apparently talking to the patient.

-At 16:34:28 - 16:34:33 [4:34p.m.; 28-33 seconds], Patient B1 was moved to another quiet room. (The Director of Risk Management said this was a quiet room with a bench, and that the first quiet room the patient entered did not have a bench where the patient could sit down.) The patient was observed sitting on the bench and not moving his right arm.

-At 16:35:52 [4:35p.m.; 52 seconds], RN5 was observed looking at and lightly touching the patient's arm. MHT4 was seen, moving the patient's fingers.

-At 16:36:22 [4:36p.m.; 22 seconds], RN5 placed an ice pack on the patient's forearm and attempted to place an ice pack on the back of his arm. The video tape showed the patient holding the ice pack on his upper arm.

-At 16:42:10 [4:42p.m.; 10 seconds], the staff was observed holding the ice pack and attempted to have the patient lay down. The patient appeared to be in pain and quickly sat back up, holding the arm in a stiff position.

-At 16:51 [4:51p.m.], a nurse gave the patient medication. (According to the progress note written by an RN and dated 5/3/11 at 4:45p.m., the patient received "Tylenol 650 mg.").

-At 17:00 [5p.m.], the day shift RN nurse (identified by Director of Risk Management) came into the room.

-At 17:08 [5:08p.m.], the patient was escorted out of the quiet room and was observed at 17:09 [5:09p.m.] in the hallway, walking to his room.

C. Policy Review

. Facility "Policy Number: PC 605 - Time Out" stipulated that "Time outs will be issued in a manner that starts from a less intensive point and when necessary, proceeds to a more intensive intervention...and implemented as follows: A. Request a patient to remove him/herself from a group/milieu and to take a time out in the corner of the room or hallway. B. Patient is unable to calm or follow directions, is then asked to go to his/her room for (specify duration). C. Patient cannot calm down, escalates, etc. and is asked to take a time out in the Quiet Room (QR)."

The staff failed to follow the least restrictive procedure of letting the patient stay in his room to calm down. The policy does not say what the staff is to do if the patient refuses to go to the quiet room when "asked" to go.

5. Facility "Policy Number: PC 605 - Time Out" also stated, "The duration, purpose and nature of each time out is to be promptly documented on the progress notes and Observation/Time Out Record in the patient's chart. This documentation should include cues/directives or other interventions the staff used with the patient prior to initiating a time out, a description of the behavior which prompted the time out...Staff who initiates the Time-Out documents each use in the progress note(s), including duration and purpose. Documents location of time-out intervention in Observation/ Time-Out Record."

There was no progress note by PS3 or MHT4 found in the patient's medical record that documented the circumstances related to the Time Out or other non-physical interventions used with Patient B1 prior to applying a physical hold (restraint) to take him to the quiet room for a Time Out.

D. Staff Interview

When the surveyor asked for the facility's procedure on escorting patients, the Staff Development Nurse provided a copy of the "CPI [Crisis Prevention Institute] Transport Position" on 5/23/11 at 10a.m. The CPI procedure displayed a picture of the "escort" technique. (This picture showed two people on each side and noted, "Reach under the individual's arm to grab you own wrist. This 'cross-grain grip' better secures the individual between staff during transport.") This technique was not consistent with what was observed being used by the staff on the video tape. The Staff Development Nurse reported that this is what staff was taught to use when escorting patients. The Staff Development Nurse stated, "Escorting the patient to the Quiet Room is a physical hold. This should be documented as a physical hold." The narrative on the CPI document stated "It is not recommended to transport an individual who is struggling. If necessary, return to the CPI Team Control Position (use of more than 2 staff) if the individual's and/or staff safety is at risk."

E.. Patient Interview

In an interview on 5/11/11 at 9:30a.m., Patient B1 reported that the staff did not want him to have food in his room and stated, "When I got upset, they told me to go to the quiet room. The staff grabbed me by my arm, twisted it against the wall, and then it popped. I walked to the quiet room. They left the door open. I was crying in pain. Then they gave me ice." The patient further reported that he received Tylenol in the night and was seen by a Physician the next day.

F. Other Staff Interviews

1. In a discussion with the Director of Nursing on 5/23/11 at 10:00a.m., the surveyor asked about training of the staff to handle confrontations by patients like Patient B1. The Director of Nursing stated, "We concluded there was a power struggle." The DON confirmed that a code for assistance was not called in the 5/3/11 incident with Patient B1. She acknowledged that staff needs more training on the use of verbal de-escalation techniques and safe use of physical restraints.

2. In an interview on 5/23/11 at approximately 2:10p.m., PS3 stated, "Around shift change, I had to move his [Patient B1's] roommate from the right side of the room, and [Patient B1] starting acting suspicious and wanted to get something out of his roommate's things. I looked in the pillowcase and found nectarines." PS3 stated that he told patient about the policy on hoarding food, and the patient started using profanity. PS3 stated, "I redirected [patient] for tone and using profanity." PS3 stated that patient replied, 'I'm not going anywhere." PS3 stated that Patient B1 then became uncontrollable, yelling, threatening, and using profanity, and he (PS3) directed him (patient) to go to the quiet room. PS3 stated he called for assistance. When the patient "advanced toward the other staff person [MHT4]," they (PS3 and MHT4) grabbed the patient, and he (patient) began struggling. PS3 stated, "I heard a pop and the patient said, 'I can't breathe. I broke my arm.'" PS3 stated that with the patient's arms at his side, they (PS3 and MHT4) "guided him" [patient] to the quiet room.

When the surveyor asked PS3 if he told the Charge Nurse about the physical hold applied in the patient's room and the patient's remarks about hearing a popping sound and saying his arm was broken, PS3 stated, "I can't recall." When the surveyor asked if other interventions were tried such as asking someone else to talk to the patient or walking away and asking the patient to take time to calm down in his room, PS3 stated that, because of the patient's threats and profanity, and to prevent an incident that, in PS3"s opinion, would lead to inciting the whole unit, he needed to isolate the patient.

3. In an interview with MHT4 on 5/23/11 at 4:30p.m., MHT4 stated he saw patient's B1's "fists ball" when he (MHT4) came into the room. MHT4 stated, "I didn't know why they were arguing." MHT4 stated, "We started CPI [Crisis Prevention Institute] and he [Patient B1] managed to break free. He [patient B1] was swinging and fell back into the bureau." When the surveyor asked if the Charge Nurse was told about the physical hold applied in the patient's room and the patient's remarks about hearing a popping sound and saying his arm was broken, MHT4 stated, "We did tell her."

III. Ensure that 1 of 1 non-sample patient (B1) received adequate nursing and medical assessments after being injured. Specifically, registered nurses failed to evaluate the extent, severity, and intensity of Patient's B1's injury sustained during a physical hold on 5/3/11, and failed to assess his level and severity of pain and to report the patient's condition to a physician or nursing supervisors. The Charge Nurse on duty at the time of the incident failed to adequately assess the patient, and failed to notify a supervisor when there was no physician response to the nurse's telephone call regarding the patient's injury. Therefore, there was no evaluation by the physician on the day of injury. Failure to assess, evaluate, and reassess patients who complain of having a fracture and pain results is unsafe nursing practice, and can result in serious medical and psychological outcomes for patients.

Findings include:

A. Document Review

1. A "Healthcare Peer Review Report" dated 5/4/11 noted that Patient B1 sustained an injury on 5/3/11. Under "Type of Injury," the report had "other" checked with the following notes: "Swelling, C/O [complained of] pain." The report also stated that a physical hold (restraint) was applied for 5 minutes and that first aid was given by a non-physician.

2. The "Health Peer Review Report" (noted above) and documents from the medical record (incident report, restraint/seclusion forms, progress notes, and physician consult record) revealed that Patient B1 was not examined by a physician for the injury until 5/4/11, and that there was lack of proper documentation of the physical hold and patient injury incident at the time of the incident. Findings were as follows:

a. A "Daily 25-HR Progress Note" for Patient B1, written by a RN and dated 5/3/11 at 4:45p.m., documented the following: "Pt [B1] swung on staff. When staff tried to escort Pt [patient] in Q.R. [quiet room], Pt refused, and when he tried to avoid staff, Pt [patient] accidentally hit his R [right] elbow in the wall. c/o [complained of] pain. No swelling noted...Tylenol 650 mg given PO [by mouth]. Will refer to House MD tomorrow for evaluation. "

b. A later nursing progress note dated 5/3/11 at 5p.m. stated, "Call made to House MD's answering service for MD on call."

c. A progress note dated 5/3/11 at 11p.m. by a registered nurse stated, "No return call made [by MD] Pt [patient] sleeping, no C/O [complaints of] pain noted after Tylenol was given. Will endorse to Midnight staff to monitor pt's [patient's] condition."

d. The facility's "Patient Safety Precautions Record" documented that patient B1 was in his room from 5p.m. to 5:30p.m. and in the hallway at 5:54p.m. and in his room from 6:00p.m. through 12:00a.m.

e. A review of the medical record revealed a progress note, written by a RN and dated 5/4/11 at 8:45a.m., that stated, "Tylenol given earlier ineffective. Pain level +10. Pt [patient] holding arm which appears swollen...[Physician initials] here examined Pt [patient]; ordered Toradol 3 mg IM XL [extended release] now... To be transferred to medical hospital for X-ray & further tx [treatment]."

f. Patient B1 was examined by a physician the day after the incident on 5/4/11. The Consult Form regarding the injury was dated 5/3/11 by a registered nurse and dated 5/4/11 by a physician. The form noted, "? [right] arm in [sic] motion @ elbow and shoulder. Unable to examine... Transfer to ER [emergency room] for STAT X-ray."

g. A progress note dated 5/4/11 at 4:45p.m. stated, "Received Pt [patient] from [Hospital's name] ER [emergency room]... Denies any current pain. Per [Hospital's name] ER RN, Pt [patient] sustained a ? [right] Humerus Fx [fracture] - Spiral Fx (X-ray results)."

h. A progress note by a registered nurse dated 5/6/11 at 3:30p.m. recording a follow-up visit to the treating hospital, stated, "Patient transferred to [Hospital's name] for follow-up appointment. Prior to appointment, patient observed isolative and providing minimal participation in group. Patient did not C/O [complain of] pain this morning. Per information from [Hospital's name] patient's arm is broken and he will require surgery. Cast placed on right arm and pain is to be continuously monitored."

B. Video Tape Review

On 5/23//11, a video tape of the incident involving patient B1's injury, sustained on 5/3/11 during a physical hold at 4:45p.m., was reviewed. The video tape revealed that the patient received medications at 16:51 [4:51p.m.]. The video tape also showed that, at that time, a registered nurse, (identified as RN1, the charge nurse, by the Director of Risk Management), entered the quiet room where Patient B1 was located and was seen standing briefly in the room. The video tape showed that from 17:09 [5:09p.m.] to approximately 23:55 [11:55p.m.], Patient B1 did not come out of the room. No licensed nurse entered the patient room during this period- approximately 6 hours.

C. Additional Document Review

The Director of Nursing submitted a staffing schedule for the evening shift on 5/3/11. The schedule showed that on the evening of 5/3/11, there were 2 Registered Nurses, 1 Licensed Practical Nurse, and 5 Specialists (4 Mental Health Specialists and 1 Program Specialist) assigned to the unit. This staffing pattern provided sufficient numbers of licensed nursing staff to complete the needed assessments for Patient B1.

D. Staff Interview

In an interview on 5/23/11 at 4:05p.m., RN5 stated, "When I talked to the patient he stated, 'I hit my elbow on the wall, can you get me some meds?'" When asked if she evaluated the patient for a fracture, RN5 stated, "I looked his arm and it was not swollen ...asked him to move his fingers and offered him medications for pain." When asked if staff told RN5 about the physical hold applied in the patient's room and the patient's remarks about hearing a popping sound and saying his arm was broken, RN5 said, "I was not told." RN5 confirmed that she did not reassess Patient B1 after he received pain medications at 4:51p.m. RN5 stated, "I had 3 admissions and I didn't receive a complaint from him. He is such a needy patient; I thought that if he needed something, he would come out of the room." When the surveyor asked about contacting the MD about the patient's condition, RN5 stated that she called the MD and left message but did not receive a return call. RN5 confirmed that she did not contact a supervisor or manager to assist with getting medical attention for Patient B1.

Based on record review and staff interview, the facility failed to provide the specific dates and times for aftercare follow-up appointments on the day of discharge for 3 of 5 discharged patients (D2, D4 and D5) whose records were reviewed. Specifically the discharge appointments for the aftercare services were not documented in the discharge summaries or the Aftercare Plan Instructions. This failure compromises appropriate and timely follow up care for patients.

Findings Include:

A. Record Review

Review of the Discharge Summaries and Aftercare Plan Instructions reveled the following:

1. Patient D2 had a discharge date of 3/28/11. The Discharge Summary dated 4/5/11 did not contain a specific date and time for a follow-up appointment. The "After Care Plan Instructions," dated 3/27/11 under "Date/Time of follow up Appt." only stated, "make appointment by April 10th, 115p.m."

2. Patient D4 had a discharge date of 3/25/11. The Discharge Summary dated 4/4/11 did not contain a specific date and time for a follow-up appointment. The "Aftercare Plan Instructions" dated 3/25/11 under "Date/Time of follow up Appt" only stated, "call for follow up appointment."

3. Patient D5 had a discharge date of 3/11/11. The Discharge Summary dated 3/23/11 did not contain a specific date and time for a follow-up appointment. The "After Care Plan Instructions" dated 3/10/11 under "Date/Time of follow up appointment" only stated, "Call for follow up appointment."

B. Staff Interview

1. In an interview on 5/10/11 at 2:30p.m., the Director of Social Work acknowledged that the Date/Time of the follow up appointment was missing in the Discharge Summary Aftercare Plan Instructions for patients D2, D4 and D5. The Director of Social work commented "Some agencies do not give these appointments."

2. In an interview on 5/10/11 around 3:00p.m., the Medical Director acknowledged that the Discharge follow up appointments were missing in the Discharge Summaries for 3 of 5 discharged patients. He stated, "I see that it is not there."

Based on observation, record review, and interview the facility failed to ensure that an allegation of patient abuse regarding 1 of 1 non-sample patient (B1) was adequately investigated. Specifically, the facility failed to provide sufficient oversight of an investigation of a patient's arm fracture that occurred during an allegedly unreported restraint on 5/3/11. After becoming aware of the patient's injury, the facility failed to follow it own policies regarding investigations of abuse, and instead relied on results of investigations of two outside groups (Police and Department of Child and Family Services), and concluded that the patient's injury was an accident. In addition, the facility failed to protect patients during the investigation by failing to reassign the staff members who were involved in the incident to other units. During the investigation, these staff members continued to work on the Adolescent Unit where the incident occurred. These failures expose patients to an unsafe environment and unsafe patient care. (Refer to B144-III)

Based on the record review, policy and document review and staff interview, the Medical Director failed to monitor and evaluate the quality and appropriateness of services and treatment provided by the Medical Staff. Specifically, the Medical Director failed to:

I. Ensure proper documentation of restraint procedures for 1 of 1 non-sample patient (B1). Specifically, the patient was placed in a physical hold on 5/3/11 which resulted in the patient being injured. The physical hold was not documented until 5/5/11 after a fracture was diagnosed on 5/4/11. Failure to carry out all safety measures for patients placed in restraint and complete all required documentations in a timely manner poses a safety risk for patients and violates patient's rights to be free from seclusion/restraint except to ensure the immediate protection of self or others. (Refer to B125-I)

II. Ensure that the least restrictive procedures were used to de-escalate a confrontational situation with 1 of 1 non-sample patient (B1). Specifically, nursing staff incorrectly used a physical hold procedure (restraint) rather than non-physical (verbal) de-escalation techniques to manage Patient B1 when the patient was agitated, confrontational, and refusing to go to the quiet room. The use of physical intervention as a first choice instead of non-physical (verbal) intervention techniques to defuse disruptive patient behaviors creates an unsafe environment and places patients at risk of harm. (Refer to B125-II)

1II. Ensure that an allegation of patient abuse regarding 1 of 1 non-sample patient (B1) was adequately investigated. Specifically, the facility failed to provide sufficient oversight of an investigation a patient's fracture. Once becoming aware of the patient's injury the facility failed to follow its own policies and made the conclusion that the patient's injury was an accident, based on alleged verbal conclusions of outside agencies, In addition, the facility failed to protect patients by failing to reassign staff during the investigations to a non-patient location, and allowed the staff to continue to work on the Adolescent Unit where the incident occurred. These failures expose patients to an unsafe environment and unsafe patient care.

Findings include:

A. Document Review and Interview

1. During an interview on 5/10/11 at approximately 5:30p.m. with the Director of Nursing, Corporate Director of Clinical Services, Chief Operating Officer, and Nurse Manager1, the incident regarding Patient B1's arm fracture during an undocumented restraint procedure (refer to B125-III for the findings) was discussed. Findings from the interview were as follows:

a. When asked about the facilities investigation of the incident, the DON, COO, Director of Risk Management and Nurse Manager1 all agreed that the incident had been investigated and that they had concluded that the injury was an accident, not abuse. This conclusion was not found in any investigative documents submitted by the facility for review during the survey on 5/9/11 to 5/11/11, nor on 5/23/11.

b. When asked how the investigation was conducted, Nurse Manager1 stated that the investigation included talking to staff and the patient.

c. They stated a call was made to the "hotline" to report the incident. (The telephone number used to report incidents to the Department of Child and Family Services.) Progress notes dated 5/6/11 at 2:15 by the Assistant Director Risk Management recorded, "DCFS investigator came unexpected to interview pt. [patient] today. [DCFS Staff's name]...spoke briefly with SW and unit manager. [DCFS Staff's name] interviewed writer about the situation and asked writer to have staff involved call her at her office on Monday."

d. They stated the "authorities" (police) met with the patient. Progress notes dated 5/8/11 documented a detective interview with Patient B1.

e. They stated the staff involved in the incident was moved to another wing of the unit so they would have no further contact with Patient B1 during the investigation.

f. When asked about the X-ray report and documents related to the patient's evaluation at the other treating hospital, the COO stated that they did not have the consult from the treating hospital.

2. In an interview on 5/23/11 at approximately 8:40a.m. with the Director of Nursing, Director of Risk Management, Medical Director, and Chief Operating Officer (COO), the incident regarding Patient B1's arm fracture was discussed. The following information was provided:

a. When asked about the spiral fracture documented in the progress notes, the Medical Director stated that the verbal report from the emergency room nurse at the treating hospital was incorrect. He stated "There was no spiral fracture. The X-ray report showed a break." The surveyor asked for a copy of the X-ray report substantiating no spiral fracture and was told that the treating hospital had not returned any written documentation, but the COO said he would try to get this information.

b. At 12:30 p.m. on 5/23/11, the surveyor received a faxed document from the COO with the treating hospital's logo. The fax date and time was 5/23/11 at 9:45a.m. The document entitled, "Report: Consultation" contained no signature and was difficult to read. "X-ray" was circled next to "Tests" and documented, "Oblique ? mid/distal humerus fx [fracture]." When asked about the written X-ray report, the COO stated that the facility had not received the documents because of the treating hospital's concerns "about HIPAA [Health Insurance Portability and Accountability Act]."

c. A review of B1's medical record confirmed that the facility still did not have documents from the treating hospital except, "Discharge Instructions to Patient" dated 5/4/11, a prescription for "Motrin 400 mg" dated 5/4/11, and a prescription noting, "The above pt [patient] is being evaluated /treated for a ? [right] humerus fx [fracture] which requires an orthopedic surgical procedure. Hospital will contact pt [patient] and [Facility's name] staff when surgery is scheduled." The medical record showed no communication between the facility's physicians and the treating facility about the X-ray report and the conflicting information as to the type of fracture documented.

d. In the interview on 5/23/11 at approximately 8:40a.m., the Director of Nursing stated that there was the possibility that the patient sustained the fracture prior to admission to the facility. She noted that the Nursing Assessment showed that the patient's right upper arm was red and swollen. A review of the "Comprehensive Nursing Tool: Initial Nursing Assessment" dated 5/2/11 confirmed this statement. However, a review of the "History & Physical Examination" performed by a physician, which was dictated 5/3/11 and signed 5/6/11, revealed conflicting findings and did not record the redness or swelling on the right upper arm. The physician recorded: "Extremities: Symmetrical joints. No joint swelling. No joint effusions, Circulation is good...Patient is able to move shoulders and clavicular area normally...Referral for a more detailed examination is not necessary."

e. During the above interview (see item d), the Director of Nursing alleged that the two staff involved in the physical hold (restraint) had received disciplinary actions.

f. During the same interview, the administrative staff noted that they still did not have the reports from the Police Department and the Department of Child and Family Services. (Child and Family Services had up to 60 days to get a report back to the facility). The COO stated that he would try to get the police report. During a follow-up discussion on 5/23/11 at approximately 3:00p.m., the COO stated he was not able to get the police report.

3. During a discussion on 5/23/11 at approximately 9:45a.m., when asked about when the facility knew about the fracture, the Director of Nursing stated they knew on 5/4/11, based on the 24 hour nursing report. She stated that all of the administrative staff meets with the CEO each morning in what they call a "Flash Meeting." The Director of Nursing stated she instructed Nurse Manager1 to do the paperwork and a late entry regarding the incident. A review of the medical record revealed that a late entry about the incident was not documented until 5/5/11.

4. In an interview on 5/23/11 at 1:45p.m., the Assistant Director of Risk Management (Patient Advocate) was asked the facility's investigation procedure. The Assistant Director of Risk Management reported the following information:

a. The Assistant Director of Risk Management stated that there was no conclusion on the report ("Patient Advocate Team Report" dated 5/6/11) because, "I have to take it to the Unit Manager for her to look at it. She has to follow-up."

b. The staff under investigation was removed from contact with Patient B1. The Assistant Director of Risk Management stated, "One staff was moved to days [Day shift] and one staff was still on the same shift." When asked about why the staff was not moved from contact with patients, the Assistant Director of Risk Management stated, "We don't have the staff to move staff off the unit."

c. The protocol is to call Department of Child and Family Services (DCFS). The Director of Risk Management called the "Hotline." (This is the telephone line used to report incidents to DCFS).

d. The Assistant Director of Risk Management accompanied the Detective on 5/8/11 when Patient B1 was interviewed and received a verbal report that the police thought it was an accident. The Assistant Director stated, "The police asked [Patient B1] if he thought that the staff did it on purpose. The patient stated 'no but my arm got broken anyway.'" This information was not documented in the progress notes recorded by the Assistant Director of Risk Management on 5/8/11 that reported the Detective's interview of Patient B1.

5. During interview with the Director of Risk Management, Assistant Director of Risk Management (Patient Advocate), and Director of Nursing on 5/23/11 at approximately 2:30p.m. the investigation procedure used by the hospital was discussed. The surveyor asked for the facility's policy regarding patient abuse and neglect. The facility eventually presented three different policies to address allegations of abuse and neglect. Review of the policies revealed the facility failed to follow all of the requirements outlined in these policies. The following findings were revealed regarding these policies and the investigation process:

a. "Policy No: R12-120: Grievance Policy/Patient Advocate" was submitted on 5/23/11 at 12:30p.m. When asked if this was the facility's policy for allegations of patient abuse and neglect, the Director of Risk Management, Patient Advocate, and Chief Operating Officer affirmed that it was their policy.

b. "Policy No: R12-120: Grievance Policy/Patient Advocate" stipulated that, "The Patient Advocate and Director/Manager to whom follow-up was assigned will: Investigate the grievance, including but not limited to: Patient interview; Witness interview; Staff interview; Chart review; and Communication with other directors/managers; Record findings of the investigation. Complete a written report for the patient and present the finding of the grievance to the patient; The patient will sign the written report...Forwarded to the Chief Executive Officer who will review and sign the final report..."

The facility was not able to produce a copy of the written report stipulated in the policy to be signed by the patient and the Chief Executive Officer.

c. When asked if these requirements had been followed, the Patient Advocate acknowledged that she did not interview staff but talked to the patient and his roommate. The Patient Advocate stated that both she and Nurse Manager1 submitted a written investigation report. A review of these written documents submitted to the surveyor, showed that Patient B1, Patient B1's roommate, and the two staff involved with the physical hold were interviewed by Nurse Manager1. This document had no date or time mentioned in the report. The Nurse Manager's investigation report did not include an interview of the Charge Nurse involved.

d. As an additional written investigation report , the facility presented a document entitled, "UHS BH [Universal Health Services Behavior Health] Intensive Analysis," which recorded a meeting held 5/17/11 two weeks after the incident. This was with the Director of Nursing, Nurse Manager1, Director of Risk Management, and the three staff involved. The findings from this document included the following: "Some late entry. Not all restrictive measures papers done. RN not told of hold. Level of acuity high on unit due to number of patients admitted from juvenile detention. Restrictive Measures paperwork incomplete. Nurse to be re-educated." The analysis report failed to include the following: The lack of re-assessment and evaluation of the patient's condition and level of pain; the failure of the "House MD" to respond to the Charge Nurse's telephone call regarding the patient on 5/3/11; and the failure of the Charge Nurse to obtain assistance from a supervisor to ensure that Patient B1 obtained timely medical attention.


e. The Director of Risk Management stated that they had another policy regarding patient abuse. This policy was received at 3:00p.m. and was "Policy No. PC 861 9a: Investigation and Report of Abuse and Neglect Patients by Staff." This policy stipulated that, "Charge RN/ RN Supervisor - Consults with the treatment team and attending physician regarding the information that indicates abuse or neglect." There was no evidence in any of the written reports of investigation that this was done.

Policy No. PC 861 9a. also stated, "RM [Risk Manager]- Takes photographs of any physical evidence of abuse. Obtain written statements from alleged victim, witness, and any staff on duty at the time of the alleged incident."

The Director of Risk Management acknowledged that written statements were not obtained from the staff involved. She stated that this was not done because "You can't read the [their] writing."

f. The surveyor also received Policy No. R1-1.3.4. This policy stated, "The Patient Advocate communicates the patient's complaint/ grievance to the treatment team and together, determines the following appropriate steps..."

There was no evidence in any of the written investigation reports that showed that the treatment team was involved, as stipulated in the policy.

g. When asked why the facility moved the two staff involved in the physical hold after concluding it was an accident and not abuse, the Director of Risk Management stated, "We have not concluded the investigation. We can't determine during an investigation, the Department of Child and Family Services is involved." She stated they received a verbal report that DCFS concluded it was an accident.

IV. Ensure the psychiatric evaluations for 4 of 11 active sample patients (A1, A7, A8 and A9) documented an inventory of patients' assets. This failure compromises the development of a meaningful treatment plan and can result in patients not receiving individualized care that utilizes theirs strengths/assets (Refer to B117).

V. Assure the development of Master Treatment Plans for 11 of 11active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11) that identified individualized and focused interventions to address the patients' presenting problems and treatment goals. The modalities (individual or group method of delivery) also were not specified for all nursing interventions on the MTPs of 5 of 11 sample patients (A1, A2, A3, A4 and A6) and all social work interventions on the MTPs of 2 of 11 sample patients (A9 and A11). In addition, the MTPs for patients A1, A2, A3, A5 and A6 failed to include group sessions that the patients actually attended. These failures result in lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital. (Refer to B122)

VI. Ensure that the specific appointment dates and times for the aftercare appointments were provided to the patient on the day of discharge. Specifically, the discharge appointments and times for the aftercare services were not present in the Discharge Summaries or in the Aftercare Plan Instruction for3 of 5 discharged patients (D2, D4 and D5) whose discharge records were reviewed. This failure compromises appropriate and timely follow up care for the patient. (Refer to B134)

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Ensure that Master Treatment Plans (MTPs) of 11 of 11 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11) identified patient-specific nursing interventions and specified the modality that would be used to deliver the interventions. The treatment plans for these patients included generic nursing tasks instead of specifying what specific nursing interventions would be used to assist patients accomplish their treatment goals. The modalities (individual or group) for some nursing interventions also were not identified on the MTPs of 5 sample patients (A1, A2, A3, A4 and A6). This failure results in lack of guidance for nursing staff in providing individualized and focused patient care.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (4/23/11); A2 (4/26/11); A3 (4/5/11); A4 (4/28/11); A5 (5/3/11); A6 (4/25/11); A7 (5/4/11); A8 (3/16/11); A9 (4/26/11); A10 (4/25/11); and A11 (3/14/11). The findings were:

1. Ten sample patients (A1, A2, A3, A4, A6, A7, A8, A9, A10 and A11) had the following generic and unfocused nursing interventions for the problem "Aggression/Violence/Assaultive Behavior": "Nursing staff will assess the patient for escalating anger/anxiety/aggression and intervene immediately to protect the patient and others in the milieu"; "Nursing will redirect the patient to a quiet environment if the patient is agitated or threatening others"; "RN will assess the patient for the need of medication to relieve agitation"; "Nursing staff will monitor the patient for medication compliance and side effects and effectiveness of teaching provided q [every] shift."

2. Patient A5 had the following generic nursing interventions for the Problem "Suicide Ideation:" "Nursing will immediately search the patient belongings upon admission for any sharp objects or contraband"; "Nursing will assess the patient for risk of suicide q [every] shift and implement appropriate level of observation"; "Nursing staff will conduct environmental rounds/safety checks q shift to maintain patient safety."

3. Five sample patients (A1, A2, A3, A4 and A6) had a nursing intervention for the problem "Aggression/Violence/Assaultive Behavior" with no specified modality. The intervention was stated as "Nursing staff will meet with the patient at least [number of times] weekly to educate about the consequences of violent behavior and identify alternative methods of coping with anger and frustration."

B. Staff Interviews

1. In an interview on 5/10/11 at 11:40a.m. with the Director of Nursing, RN3, RN4 and Program Specialist (PS)2, Patient A4's treatment plan was discussed. RN3 acknowledged that nursing routine functions were listed as interventions on the patient's treatment plan.

2. In an interview on 5/1011 at 3:15p.m. the Master Treatment Plans for Patients A1 and A5 were discussed. RN4 confirmed that routine nursing tasks were listed on the plans instead of interventions to assist the patients to accomplish treatment goals.

II. Ensure that the medical records of 6 of 11 active sample patients (A1, A2, A3, A4, A5 and A6) contained documentations of the delivery of nursing interventions listed on the patients' treatment plans. Nurses failed to document patients' attendance or non-attendance in nursing treatment modalities, including the topic(s) discussed and patients' level of response to interventions. This failure hampers the treatment team's ability to determine the patient's response to treatment interventions, evaluating whether there are measurable changes in the patients' condition, and revising the treatment plan if/when the patient does not respond to treatment interventions. (Refer to B124)

III. Ensure proper nursing documentation of restraint procedures for 1 of 1 non-sample patient (B1). Specifically, the patient was placed in a physical hold on 5/3/11 which resulted in the patient being injured. The physical hold was not documented until 5/5/11 after a fracture was diagnosed on 5/4/11. Failure to carry out all safety measures for patients placed in restraint and complete all required documentations in a timely manner poses a safety risk for patients and violates patient's rights to be free from seclusion/restraint except to ensure the immediate protection of self or others. (Refer to B125-I)

IV. Ensure that the least restrictive procedures were used to de-escalate a confrontational situation with 1 of 1 non-sample patient (B1). Specifically, nursing staff incorrectly used a physical hold procedure (restraint) rather than non-physical (verbal) de-escalation techniques to manage Patient (B1) when the patient was agitated, confrontational, and refusing to go to the quiet room. The use of physical intervention as a first resort instead of non-physical intervention techniques to defuse disruptive situations creates an unsafe environment and places patients at risk of harm. (Refer to B125- II.)

V. Ensure that 1 of 1 non-sample patient (B1) received adequate nursing and medical assessments after being injured. Specifically, registered nurses failed to evaluate the extent, severity, and intensity of Patient's B1's injury sustained during a physical hold on 5/3/11, and failed to assess his level and severity of pain and to report the patient's condition to a physician or nursing supervisors. The Charge Nurse on duty at the time of the incident failed to adequately assess the patient, and failed to notify a supervisor when there was no physician response to the nurse's telephone call regarding the patient's injury. Therefore, there was no evaluation by the physician on the day of injury. Failure to assess, evaluate, and reassess patients who complain of having a fracture and pain results is unsafe nursing practice, and can result in serious medical and psychological outcomes for patients. (Refer to B125-III)

Based on record review and staff interview, it was determined that the Director of Social Work failed to monitor and ensure that Social Work Assessments integrated factual and historical information into professional conclusions and recommendations for 10 of 11 patients (A1, A2, A4, A5, A6, A7, A8, A9, A10 and A11). This failure results in lack of information to identify the social work role in treatment and discharge planning.

Findings Include:

A. Record review

Review of social work assessments revealed no social work conclusions and recommendations for the following patients (psychosocial assessment dates in parentheses): A1 (4/25/11), A2 (4/27/11), A4 (4/29/11), A5 (5/5/11), A6 (4/27/11), A7 (5/4/11), A8 (5/18/11), A9 (4/27/11), A10 (4/28/11) and A11 (3/5/11).

B. Staff Interview

1. In an interview on 5/10/11 at approximately 2:30p.m., the Director of Social Work acknowledged that social work conclusions and recommendations were not present in the social work assessments for 10 active sample patients.

2. In an interview on 5/10/11 at 3p.m., the Medical Director agreed that the social work assessments for 10 of 11 of active sample patients did not include recommendations for treatment.