HospitalInspections.org

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

1. Provide Master Treatment Plans that included a substantiated diagnosis for 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). The Master Treatment Plans listed the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) categories from AXIS I - V with only the words "code description" next to each AXIS diagnosis. Specific diagnoses were not included. Absence of a substantiated diagnosis (or diagnoses) on patients' treatment plans hinders the treatment team from focusing on specific treatment issues. This can result in the patients ' problems not being adequately addressed during the hospitalization. (Refer to B120)

2. Develop Master Treatment Plans that included physician interventions for 3 of 10 active sample patients (B12, C21, and D17). In addition, the Master Treatment Plans listed interventions which were routine, generic discipline functions that lacked a focus for treatment for 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

3. Ensure that physician orders and appropriate evaluations were obtained for 1 of 1 active sample patient (E10) who was subjected to manual holds (also called "therapeutic holds" by the facility). The "holds" lasted less than 10 minutes, and restraint procedures were not implemented. There was no documentation of what alternative (de-escalation) measures were used to address patient E10's behavior. There also was no evidence that any physician order or 1 hour face to face physician evaluations was obtained for the manual holds. This violates a patient's right to be free from unnecessary restrictions. It also potentially results in physical harm due to lack of a face to face evaluation by a physician within 1 hour of the restraint procedure. (Refer to B125)

Based on record review and staff interview, the facility failed to provide Psychosocial Assessments that included recommendations for specific inpatient social work interventions for 9 of 10 active sample patients (A2, A7, A13, B12, C15, C21, D17, D19 and E10). This results in social work recommendations regarding treatment of psychosocial problems not being unavailable for the treatment team.

Findings include:

A. Record review

1. Records (dates of Psychosocial Assessments in parenthesis) of A2 (6/17/11), A7 (6/10/11), A13 (6/3/11), D17 (6/22/11), D19 (4/15/11), E10 (12/17/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed treatment recommendations were "psychopharmacology, group therapy, therapeutic milieu, 24 hr nursing care, individual therapy."

B. Record B12 (3/13/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed treatment recommendations were "psychopharmacology, therapeutic milieu, 24h [24 hour] nursing care."

C. Record C15 (6/11/11) and Record C21 (6/5/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed treatment recommendations were "psychopharmacology, group therapy, therapeutic milieu, 24 hr nursing care."

B. Interview

The Licensed Clinical Social Worker (Masters Level) responsible for oversight of Social Work services was interviewed on June 28 at 3:30p.m. The above findings were reviewed and acknowledged by this Social Worker.

Based on record review and interview, the facility failed to document Master Treatment Plans that included an inventory of individual strengths and disabilities for use in treatment planning for 10 of 10 active ample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). This failure potentially diminishes the effectiveness of treatment by not utilizing the specific individual strengths of each patient in their treatment, with an awareness of disabilities.

Findings include:

A. Record Review

For the following Master Treatment Plans (dates of plans in parenthesis), no inventory of strengths and disabilities were included: A2 (6/17/11), A7 (6/10/11), A13 (6/3/11), B12 (3/9/11), B17 (6/8/11), C15 (6/11/11), C21 (6/15/11), D17 (6/22/11), D19 (4/25/11), and E10 (1/3/11).

B. Interview

In an interview on 6/29/11 at 9:30a.m., the Nursing Director acknowledged that the treatment plans listed above did not contain an inventory of specific strengths and disabilities which could be used in treatment planning.

Based on record review and interview, the facility failed to provide Master Treatment plans that included substantiated diagnosis/diagnoses for 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). The Master Treatment Plans of these patients only listed the DSM -IV AXIS I - V diagnoses with the words "code description" next to each diagnosis. Specific diagnoses were not included. [Note: The facility has computerized records. The system automatically puts the words "code description" next to each of the five AXIS diagnostic categories]. Absence of a substantiated diagnosis (or diagnoses) on patients' treatment plans hinders the treatment team from focusing on specific treatment issues. This can result in patients' problems not being adequately addressed during the hospitalization.

Findings include

A. Record Review

For the following Master Treatment Plans (dates of plans in parenthesis), no specific AXIS-I-V diagnoses were included: A2 (6/17/11), A7 (6/10/11), A13 (6/3/11), B12 (3/9/11), B17 (6/8/11), C15 (6/11/11), C21 (6/5/11), D17 (6/22/11), D19 (4/25/11), and E10 (1/3/11)). The AXIS-I-V categories were listed only with the words "code description" next to each one.

B. Interview

1. In an interview on 6/28/11 at 4:00p.m., the absence of AXIS-I-V diagnoses on the Master Treatment Plans was discussed with the Medical Director. He did not dispute the findings.

2. In an interview on 6/29/11 at 9:30a.m., the Nursing Director acknowledged that the treatment plans of the active sample patients did not contain specific AXIS-I-V diagnoses.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for 7 of 10 active sample patients (A2, A7, A13, B17, C15, C21 and D17) that included long term goals (LTG). In addition, some of the short term goals (called "outcomes") on the MTPs for 9 of 10 active sample patients (A2, A7, A13, B17, C15, C21, D17, D19 and E10) were either not measurable or were stated as staff goals or interventions rather than patient behavioral outcomes. These deficient practices hamper the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in patient behaviors.

Findings include:

A. Record Review (MTP dates in parenthesis)

1. Patient A2

The MTP (6/17/11) did not include a long term goal (LTG). Non-measureable short term goals (STGs) were: "During sessions patient will be able to discuss at least one trigger that results in aggression when in community" and "During session patient will be able to discuss at least one instance which connect feeling with behavior." Staff interventions incorrectly listed under the patient goals section of the MTP were "RN [registered nurse] will meet with the patient daily for 15 minutes to assist patient with identifying 2 triggers for loss of control" and "RN will encourate [sis] to come to staff if thought of self harm arrise [sic]."

2. Patient A7

The MTP (6/10/11) did not include a LTG. Non-measurable STGs were "Patient will be able to reality test - related to delusional thoughts x 2 [times 2] week [sic]" and "There will be an absence of delusional thought and overt behavioral manifestation of said delusion." A staff intervention incorrectly listed as a patient goal was "RN will meet with the patient daily for 15 minutes to assist with labeling and recognizing anxiety."

3. Patient A13

The MTP (6/3/11) did not include a long term goal. Non-measurable STGs were "During group patient will demonstrate two positive coping strategies"; "During groups patient will be able to identify or sobriety maintenance techniques [sic]"; "There will be an absence of suicidal ideation" and "There will be no instances of substances misuse."

4. Patient B17

The MTP (6/8/11) did not include a long term goal. Non-measurable STGs were: "During groups patient will demonstrate two positive coping strategies" and "There will be an absence of suicidal ideation." A staff intervention, incorrectly listed under the patient goal section was "RN will encourage patient to talk about 2 positive feelings about self."

5. Patient C15

The MTP (6/11/11) did not include a long term goal. Non-measurable STGs were "During groups patient will demonstrate two positive coping strategies" and "There will be an absence of suicidal ideation (MD goal)." A staff intervention incorrectly listed under the patient goal section was "RN will encourate [sic] patient to come to staff if thoughts to self harm arrise [sic]."

6. Patient C21

The MTP (6/5/11) did not include a long term goal. Non-measurable STGs were "During group patient will demonstrate two positive coping strategies" and "There will be an absence of suicidal ideation (MD goal)." A staff intervention incorrectly listed under the patient goal section was "RN will encourage patient to talk about 2 positive feelings about self."

7. Patient D17

The MTP (6/22/11) did not include a long term goal. Non-measurable STGs were "During groups patient will demonstrate two positive coping strategies" and "There will be an absence of suicidal ideation (MD goal)." A staff intervention incorrectly listed under the patient goal section was "RN will encourage patient to talk about 2 positive feelings about self."

8. Patient D19

The MTP (4/15/11) listed the following non-measurable goals: "Pt [patient] will be able to identify three statements that reflect the acceptance of responsibility for misbehavior" and "Pt will be able to recognize three situations when their [sic] feelings are connected to misbehavior."

9. Patient E10

The MTP (1/3/11) listed the following non-measurable goals: "Pt will be able to identify three statements that reflect the acceptance of responsibilities for misbehavior"; "Pt will be able to recognize three situations when their [sic] feelings are connected to misbehavior" and "Pt will decrease two paranoid thoughts resulting in a decrease in aggressive behavior [sic]."

B. Interviews

1. In an interview on 6/28/11 at approximately 2:30p.m., the non-measurable short term goals and nursing staff interventions stated as short term patient goals were discussed with the Nursing Director. The Nursing Director did not dispute the findings.

2. In an interview on 6/28/11 at 4:00p.m., the absence of long term goals on the Master Treatment Plans and the inclusion of non-measurable goals or staff goals on the MTPs were discussed with the Medical Director. The Medical Director acknowledged the findings.

Based on record review and interviews, the facility failed to develop Master Treatment Plans that included physician interventions for 3 of 10 active sample patients (B12, C21 and D17). In addition, the Master Treatment Plans of 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10) included a list of interventions which were routine, generic discipline functions that lacked a specific focus. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Failure to include physician interventions on MTPs

1. Document/Record Review

a. Hospital policy "THH-V-5.5," titled "Treatment Plans" (undated) states, "Every effort should be made to attain a truly integrated treatment plan. That means each discipline should identify objectives and methods for commonly identified problems."

b. A review of the Master Treatment Plans of the following patients revealed that the MTPs failed to include any interventions by the attending psychiatrist (dates of plans in parenthesis): B12 (3/9/11), C21 (6/5/11) and D17 (6/22/11).

2. Interview

In an interview on 6/28/11 at 4:00p.m., the Medical Director acknowledged the above findings.

B. Failure to provide individualized interventions on MTPs

1. Record Review

a. Patient A2

The Master Treatment plan, dated 6/17/11, listed the following generic and routine discipline functions for the problem "alteration in thought process-sensory perception and delusions psychosis": LPN [licensed practical nurse]]/RN [registered nurse] - "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities." SW [social worker] - "Will meet with the patient 5 times per week for 15 minutes to discuss pt's group attendance and medication compliance." MD [physician] - "Medication management."

b. Patent A7

The MTP, dated 6/10/11, listed the following generic and routine discipline functions for the problem "Alteration in thought process-sensory perception and delusion-psychosis":
LPN [licensed practical nurse]/RN [registered nurse] - "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities." SW - "Will meet with the patient 5 times per week for 15 minutes to discuss pt's group attendance and medication compliance." MD - "Medication management."

c. Patent A13

The MTP, dated 6/3/11, listed the following generic and routine discipline functions for the problem "Alteration in mood - depressed/hopeless": LPN [licensed practical nurse]]/RN [registered nurse] - "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities." SW - "Will meet with the patient two times per week per 60 minutes to discuss pt's group attendance and medication compliance." MD - "Medication management."

d. Patient B12

The MTP, dated 3/9/11, listed the following generic and routine discipline functions for the problem "Alteration in thought process - sensory perception, delusions - psychosis": "RN - evaluate patient activity level and monitor patient involvement in unit activities." CM [case manager] - "SW will meet with the patient five times per week for 10 minutes to discuss pt's group attendance and medication compliance."

e. Patient B17

The MTP, dated 6/8/11, listed the following generic and routine discipline functions for the problem "alteration in mood - depressed/hopeless": RN - "Evaluate patient activity level and monitor patient involvement in unit activities." CM - "SW will meet with the patient five times per week for 15 minutes to discuss pt's group attendance and medication compliance." MD - "medication management."

f. Patient C15

The MTP, dated 6/11/11, listed the following generic and routine discipline functions for the problem "alteration in mood - depressed/hopeless": LPN/RN - "RN will meet with the patient daily for 15 minutes to evaluate response to medication"; "RN - Evaluate patient activity level and monitor patient involvement in unit activities." MD - "medication management." CM - "SW will meet with the patient five times per week for 15 minutes to discuss pt's group attendance & [and] medication compliance."

g. Patient C21

The MTP, dated 6/5/11, listed the following generic and routine discipline functions for the problem "alteration in mood - depressed/hopeless": CM/RN - "RN will meet with the patient daily for 15 minutes to evaluate response to medication." "RN - Evaluate patient activity level and monitor patient involvement in unit activities." MD - "medication management." CM - "SW will meet with the patient 5xw (five times per week) for 10 minutes to discuss pt's group attendance & [and] medication compliance."

h. Patient D17

The MTP, dated 6/22/11, listed the following generic and routine discipline function for the problem "alteration in mood - depressed/hopeless." "LPN/RN - RN will meet with the patient daily for 15 minutes to evaluate response to medication regime"; "RN - evaluate patient activity level and monitor patient involvement in unit activities." CM - "SW will meet with the patient five times per week for 15 minutes to discuss pt's group attendance & medication compliance." MD - "medication management."

i. Patient D19

The MTP, dated 4/15/11, listed the following generic and routine discipline functions for the problem "aggression - related to poor frustration tolerance." "RN will meet with patient regarding aggressive acting out." LPN/RN - "RN will offer medication to assist with agitation." There were no physician interventions on the Master Treatment plan.

j. Patient E10

The MTP, dated 1/3/11, listed the following generic and routine discipline functions for the problem "aggression related to PTSD [post traumatic stress disorder]": LPN/RN - "RN will offer medication to assist with agitation." MD - "medication management, monitor for side effects."

2. Staff Interview

In an interview on 6/28/11 at 4:00p.m., the Medical Director acknowledged the generic interventions and absence of physician interventions on some patients' Master Treatment Plans. He stated "These are easy fixes."

Based on record review and interview, the facility failed to ensure that the specific names of all staff persons responsible for interventions were listed on the Master Treatment Plans of 9 of 10 active sample patients (A2, A7, A13, B17, C15, C21, D17, D19 and E10). There was an absence of names listed on the Master Treatment Plans to identify the initials of most staff members. This failure can result in lack of staff accountability for specific treatment modalities.

Findings include:

A. Record Review

Review of the following Master Treatment Plans (MTP dates in parenthesis) revealed that they did not consistently identify the names of treatment team members responsible for the listed interventions except for the case managers: A2 (6/17/11), A7 (6/10/11), A13 (6/3/11), B17 (6/8/11), C15 (6/11/11), C21 (6/5/11), D17 (6/22/11), D19 (4/25/11), and E10 (1/3/11). The MTPs for these patients only listed the initials and disciplines of team members next to each intervention.

B. Interviews

1. In an interview on 6/28/11 around 2:30p.m., the Nursing Director acknowledged the lack of specific nursing names on the MTPs.

2. In an interview on 6/28/11 at 4:00p.m., the Medical Director did not dispute the findings about the lack of specific staff names on the MTPs.

Based on interview and record review, the facility failed to ensure appropriate physician orders and evaluations for 1 of 1 active sample patient (E10) who was subjected to manual holds (also called "therapeutic holds" by the facility). This patient had "holds" which lasted less than 10 minutes, and restraint procedures were not implemented. There was no documentation of what alternative (de-escalation) measures were used to address patient E10 ' s behavior. There also was no evidence that any physician order or 1 hour face to face physician evaluations was obtained for the manual holds. This violates a patient's right to be free from unnecessary restrictions. It also potentially results in physical harm due to the lack of a face to face evaluation by a physician within 1 hour of the restraint procedure.

Findings include

1. In an interview on 6/27/11 around 12:10p.m., RN #1 was asked about seclusion/restraint use on her unit (1N). She stated that she had been on duty when active sample patient E10 (a 5 year old child) had been placed in a manual hold around the first of June, 2011 for acting out behavior. When asked about the "Seclusion/Restraint Monitoring Form" for the incident, RN #1 stated "We don't have to get a doctor's order for a hold under 10 minutes - we just write about the incident in the progress notes." RN #1 also said that no logs of therapeutic holds are kept by the facility.

2. Review of a nursing note for patient E10, dated 6/1/11 at 5:23p.m., revealed the following statement: "Behavior was oppositional and aggressive this morning; was given 1m prn [intramuscular injection as needed] at 11:45a.m. with good result." The note did not mention the need to hold the patient to administer the medication.

3. Review of the facility policy "NSG-11-7, 152," titled "Therapeutic Holding" (undated) revealed the following statement: "Therapeutic holds may not exceed 10 minutes in duration. If a patient requires holding for more than 10 minutes, and shows no indication of calming down or regaining control, the MD [doctor] on duty must be called to further assess the patient."

4. Review of a nursing progress note for patient E10, dated 4/7/11 at 6:45p.m., revealed the following documentation: "Pt [patient] continues to attack staff and peers with no known provocation. Received im prn [intra muscular injection as needed] today. Therapeutic hold done by staff." There was no physician's order in the chart for the therapeutic hold. The Master Treatment Plan had not been amended since 1/3/11 to address alternative measures for this patient's acting out behavior instead of using manual holds.

D. Additional Staff Interviews

1. In an interview on 6/27/11 at 11:55a.m., the nurse practitioner stated that no doctor's order was required in this facility for a physical hold of 10 minutes or less.

2. In an interview on 6/28/11 around 2:30p.m., the Nursing Director was asked about the policy on therapeutic holds and the fact that nurses could restrain a patient without implementing restraint protocol if the procedure did not exceed 10 minutes. The Nursing Director replied, "I guess we need to work on our policy."

3. In an interview on 6/28/11 at 4:00p.m., the Medical Director acknowledged that therapeutic holds under 10 minutes do not require a physician's order.

Based on record review and staff interview, it was determined that the facility failed to provide a Discharge Summary that described the services and supports appropriate for the patient's needs at the time of discharge for 5 of 5 discharged patients (G1, G2, G3, G4, and G5) whose records were reviewed. Information on dates, times, names and/or phone contacts were not documented in the aftercare plan. This deficient practice results in failure to assure appropriate and timely follow-up care to the patient.

Findings include:

A. Record Review

1. Patient G1 (discharged 5/18/11). The Discharge Summary dated 5/18/11 stated for the Discharge and Aftercare Plan: "May return to prior residence, Aftercare at BCC [sic]; appt following discharge; home care services with visiting nurse."

2. Patient G2 (discharged 5/11/11). The Discharge Summary dated 5/14/11 stated for the Discharge and Aftercare Plan: "Return to shelter with after care services."

3. Patient G3 (discharged 4/25/11). The Discharge Summary dated 4/28/11 stated for the Discharge and Aftercare Plan "as per MSW note."

4. Patient G4 (discharged 4/12/11). The Discharge Summary dated 4/11/11 stated for the Discharge and Aftercare Plan "Discharged to rehab."

5. Patient G5 (discharged 5/18/11). The Discharge Summary dated 5/23/11 stated for the Discharge and Aftercare Plan "Return to shelter with outpatient services."

B. Interview

The hospital Medical Director was interviewed on June 28 at 4:00p.m. The above findings were reviewed. The Medical Director acknowledged the findings and the need to make corrections.

Based on record review and interview, the Medical Director failed to monitor the quality of care provided to patients. Specifically, the Medical Director failed to:

I. Ensure that Master Treatment Plans included an inventory of individual strengths and disabilities for use in treatment planning for 10 of 10 active ample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). This failure potentially diminishes the effectiveness of treatment by not utilizing the specific individual strengths of each patient in their treatment, with an awareness of disabilities. (Refer to B119)

II. Ensure that Master Treatment Plans included substantiated diagnosis/diagnoses for 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). The Master Treatment Plans of these patients only listed each DSM -IV AXIS I - V category with the words "code description." Specific diagnoses were not included. Absence of a substantiated diagnosis or diagnoses hinders the treatment team from focusing on specific treatment issues. It also can result in patient problems not being adequately addressed during the hospitalization. (Refer to B120)

III. Ensure that Master Treatment Plans of 7 of 10 active sample patients (A2, A7, A13, B17, C15, C21 and D17) included long term goals (LTG). In addition, some of the short term goals (called "outcomes") on the MTPs for 9 of 10 active sample patients (A2, A7, A13, B17, C15, C21, D17, D19 and E10) were either not measurable or the goals were stated as staff interventions rather than patient behavioral outcomes. These deficient practices hamper the ability of the treatment team to provide goal directed treatment and determine the effectiveness of interventions, based on changes in patient behaviors. (Refer to B121)

IV. Ensure that Master Treatment Plans for 3 of 10 active sample patients (B12, C21 and D17) included physician interventions. In addition, the Master Treatment Plans of 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10). Included interventions which were routine, generic discipline functions that lacked a focus for treatment. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

V. Ensure that the specific names of staff responsible for specific aspects of patient care were listed on the Master Treatment Plans of 9 of 10 active sample patients (A2, A7, A13, B17, C15, C21, D17, D19 and E10). This failure results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

VI. Ensure that a physician order and appropriate evaluations were obtained for 1 of 1 active sample patient (E10) who was subjected to manual holds (also called "therapeutic holds" by the facility). The "holds" lasted less than 10 minutes, and restraint procedures were not implemented. There was no documentation of what alternative (de-escalation) measures were used to address patient E10's behavior. There also was no evidence that any physician order or 1 hour face to face physician evaluations was obtained for the manual holds. This violates the patient's right to be free from unnecessary restrictions. It also potentially results in physical harm due to the lack of a face to face evaluation by a physician within 1 hour of the restraint procedure. (Refer to B125)

VII. Ensure that Discharge Summaries for 5 of 5 discharged patients (G1, G2, G3, G4 and G5) whose records were reviewed described the services and supports appropriate to the patient's needs at the time of discharge. Information on dates, times, names and/or phone contacts were not documented in the aftercare plan. This deficient practice results in failure to assure appropriate and timely follow-up care for patients. (Refer to B134)

Based on record review and interview, the Nursing Director failed to monitor the quality and appropriateness of care by the nursing staff. Specifically, the Director of Nursing failed to:

I. Ensure that the Master Treatment Plans (MTP) of 7 of 10 active sample patients (A2, A7, B17, C15, C21 and D17) included short term goals stated as patient outcome behaviors. Some of the short term goals for these patients also were stated as nursing interventions rather than behaviors for the patients to achieve. This deficient practice can hamper the staff's ability to provide goal directed treatment to patients and to determine the effectiveness of treatment, based on changes in patient behaviors.

Findings include:

A. Record Review

A review of the sample patients MTPs showed the following nursing interventions incorrectly listed under "patient goals" section of the MTPs:

1. Patient A2- MTP dated 6/17/11.
"RN [registered nurse] will meet with the patient daily for 15 minutes to assist patient with identifying 2 triggers for loss of control." "RN will encourate [sis] to come to staff if thought of self harm arrise [sic]."

2. Patient A7-MTP dated 6/10/11.
"RN will meet with the patient daily for 15 minutes to assist with labeling and recognizing anxiety."

3. Patient B17-MTP dated 6/8/11.
"RN will encourage patient to talk about 2 positive feelings about self."

4. Patient C15-MTP dated 6/11/11.
"RN will encourate [sic] patient to come to staff if thoughts to self harm arrise [sic]."

5. Patient C21-MTP dated 6/5/11.
"RN will encourage patient to talk about 2 positive feelings about self."

6. Patient D17-MTP dated 6/22/11.
"RN -Evaluate patient activity level and monitor patient involvement in unit activities."

7. Patient D19-MTP dated 4/15/11.
"LPN/RN will offer medication to assist with agitation."

B. Interview

In an interview on 6/28/11 around 2:30p.m., the non-measurable short term goals and nursing staff interventions stated as patient short term goals were discussed with the Nursing Director. She did not dispute the findings.

II. Ensure that nursing interventions on the Master Treatment Plans of 10 of 10 active sample patients (A2, A7, A13, B12, B17, C15, C21, D17, D19 and E10) were individualized for the patients. The listed nursing interventions were generic routine nursing functions expected for any patient regardless of the problem(s). This deficiency results in Master Treatment Plans that fail to provide specific guidance to nursing staff in providing individualized treatment for patients.

Findings include:

A. Record Review (MTP dates in parentheses)

Review of the sample patient's treatment plans revealed the following generic nursing interventions:

1. Patient A2 (6/17/11).
LPN [licensed practical nurse]]/RN [registered nurse] - "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities."

2. Patent A7 (6/10/11).
LPN [licensed practical nurse]]/RN [registered nurse] - "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities."

3. Patent A13 (6/3/11).
LPN [licensed practical nurse]/RN [registered nurse] "RN will meet with the patient daily for 15 minutes to evaluate patient activity level and monitor patient involvement in unit activities."

4. Patient B12 (3/9/11).
"RN - Evaluate patient activity level and monitor patient involvement in unit activities."

5. Patient B17 (6/8/11).
RN - "Evaluate patient activity level and monitor patient involvement in unit activities."

6. Patient C15 (6/11/11).
LPN/RN - "RN will meet with the patient daily for 15 minutes to evaluate response to medication." RN - Evaluate patient activity level and monitor patient involvement in unit activities."

7. Patient C21 (6/15/11).
CM/RN - "RN will meet with the patient daily for 15 minutes to evaluate response to medication." "RN - Evaluate patient activity level and monitor patient involvement in unit activities."

8. Patient D17 (6/22/11).
LPN/RN - "RN will meet with the patient daily for 15 minutes to evaluate response to medication regime." "RN - Evaluate patient activity level and monitor patient involvement in unit activities."

9. Patient D19 (4/25/11).
"RN will meet with patient regarding aggressive acting out." LPN/RN - "RN will offer medication to assist with agitation."

10. Patient E10 (1/3/11).
LPN/RN - "RN will offer medication to assist with agitation."

B. Interview

In an interview on 6/28/11 around 2:30p.m., the generic nursing interventions on the patient's MTPs were discussed with the Nursing Director. She did not dispute the findings.

III. Ensure that the names of nursing staff responsible for specific aspects of patient care were listed on the Master Treatment Plans of 4 of 10 active sample patients (A2, A7, A12 and C21). This failure can result in lack of staff accountability for specific nursing interventions.

Findings include:

A. Record Review (MTP dates in parentheses)

Review of the sample patients' Master Treatment Plans revealed that the following plans did not list the specific names of RN staff members responsible for the nursing interventions: A2 (6/17/11), A7 (6/10/11), B12 (3/9/11), and C21 (6/5/11). Only the initials of a nurse or simply "RN" were listed.

B. Interview

In an interview on 6/28/11 around 2:30p.m., the Nurse Director acknowledged the lack of specific nursing names on the MTPs.

IV. Ensure that nursing staff obtained a physician order for manual holds (also called "therapeutic holds" in the facility) for 1 of 1 active sample patient (E10). This patient was placed in "holds" for less than 10 minutes, and restraint procedures were not implemented. There was no documentation of what alternative (de-escalation) measures were used to address patient E10's behavior. There also was no evidence that any physician order or 1 hour face to face physician evaluations was obtained for the manual holds. This violates a patient's right to be free from unnecessary restriction. It also potentially results in physical harm due to the lack of a face to face evaluation by a physician within 1 hour of the restraint procedure.

Findings include:

A. Policy Review

Policy "NSG-11-7, 152," titled "Therapeutic Holding" (undated) states "Therapeutic holds may not exceed 10 minutes in duration. If a patient requires holding for more than 10 minutes, and shows no indication of calming down or regaining control, the MD [doctor] on duty must be called to further assess the patient."

B. Staff Interview

In an interview on 6/27/11 around 12:10p.m., RN #1 was asked about seclusion/restraint use on her unit (1 N). She stated that active sample patient E10 (a young child) had been placed in a manual hold around the first of June, 2011 for "acting out behavior." When asked about the "Seclusion/Restraint Monitoring Form" for the incident, RN #1 stated, "We don't have to get doctor's order for a hold of less than 10 minutes. We just write about the incident in the progress notes." RN #1 also said that no logs of therapeutic holds are kept by the facility.

C. Record/Document Review

1. Review of a nursing note for patient E10, dated 6/1/11 at 5:23p.m., revealed the following statement: "Behavior was oppositional and aggressive this morning; was given im prn (intramuscular injection as needed) at 11:45a.m. with good result."

2. Review of an incident report for active sample patient E10, dated 4/7/11 at 6:45p.m., revealed the following documentation: "Pt [patient] continues to attack staff and peers with no known provocation. Received im prn [intra muscular injection as needed] today. Therapeutic hold done by staff." There was no documentation of what alternative (de-escalation) measures were used to address patient E10's behavior. There also was no evidence of a physician's order or a 1 hour face to face physician evaluation for the manual hold.

D. Additional Staff Interviews

1. In an interview on 6/27/11 at 11:55a.m., the nurse practitioner stated that no doctor's order was required in this facility for a physical hold of 10 minutes or less.

2. In an interview on 6/28/11 around 2:30p.m., the Nursing Director was asked about the policy on therapeutic holds and the fact that nurses could restrain a patient without implementing restraint procedures if the procedure did not exceed 10 minutes. She replied, "I guess we need to work on our policy."

Based on record review and interview, the LCSW (Licensed Clinical Social Worker) designated by the Chief Executive Officer/Medical Director to direct social work services failed to monitor the quality and appropriateness of Psychosocial Assessments for 9 of 10 active sample patients (A2, A7, A13, B12, C15, C21, D17, D19 and E10). This results in social work recommendations regarding treatment of patients' psychosocial problems not being available to the staff for treatment planning.

Findings include:

A. Record review

1. Records (dates of Psychosocial Assessments in parenthesis) A2 (6/17/11), A7 (6/10/11), A13 (6/3/11), D17 (6/22/11), D19 (4/15/11), and E10 (12/17/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed Treatment Recommendations were "psychopharmacology therapeutic milieu, 24 hr nursing care, individual therapy."

2. Record.B12 (3/13/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed Treatment Recommendations were "Psychopharmacology, therapeutic milieu, 24h nursing care."

3. Record C15 (6/11/11) and Record C21 (6/5/11): The Psychosocial Assessment recommendations did not mention social work inpatient interventions. The listed treatment recommendations were "psychopharmacology, therapeutic milieu, and 24 hr nursing care."

B. Interviews

1. In an interview on 6/28/11 at 3:30p.m., the Licensed Clinical Social Worker (Masters Level) responsible for oversight of Social Work services stated that the Director of Social Work position had been eliminated due to budget cuts. The findings listed above were reviewed and acknowledged by this Social Worker.

2. In an interview on 6/28/11 at 4:00p.m., the Chief Executive Officer/Medical Director confirmed that the Director of Social Work position had been eliminated. He/she reported that the Directors of the clinical programs (adult, adolescent and children services) manage the social workers in their respective programs. The Directors of these programs were psychologists and one masters level social worker. The qualified LCSW (MSW) is responsible for meeting with the social workers and monitoring the quality of social work services as defined in her job description.