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Based on observation, document review, and interview, the hospital failed to ensure laboratory services met the requirements of part 493.15 for one of two laboratory tests provided in-house.

Findings include:

1. Review of the Clinical Laboratory Improvement Amendments (CLIA), part 493.15(c) reads: "A laboratory may qualify for a certificate of wavier under section 353 of the PHS Act if it restricts the tests that it performs to one of more of the following test or examinations...urine pregnancy tests - visual color comparison tests..." and part 493.15(d) reads: "HHS will determine whether a laboratory test meets the criteria listed under paragraph (b) of this section for a waived test."

2. Review of the hospitals CLIA certificate indicated the hospital has a CLIA Certificate of Waiver.

3. On 4-30-2018 at 2:08 PM, two "Accu-Clear 2 minute pregnancy test" kits were observed in the Omnicell in the medicine room of the inpatient unit, available for use.

4. Review of a package insert titled "Accu-Clear 2 minutes pregnancy test," copyright 2011, did not indicate the test was classified as waived.

5. Review of Food and Drug Administration (FDA) test categorization database indicated the test was not classified as waived, nor was is approved or cleared by FDA. Therefore, the test is classified a high complexity.

6. In interview on 5-2-2018 at 10:14 AM, L9, customer service representative for Accu-Clear, was unaware of CLIA and didn't know if the test was classified as waived.

7. Review of patient test reports indicated urine pregnancy testing was performed on patients # 32 (4-5-2018), # 33 (3-17-2018) and #36 (11-17-2017).

Based on observation, document review, and interview, the hospital failed to include two of two laboratory tests performed in-house in their written description of laboratory services provided to the medical staff.

Findings include:

1. On 4-30-2018 at 2:08 PM, while accompanied by staff member #L2, a "Quintet AC" glucometer was observed on the counter and two "Accu-Clear 2 minute pregnancy test" kits were observed in the Omnicell in the medicine room on the patient unit, available for use.

2. A document titled: "E-Labs Master List," effective date unknown, did not include glucometer or urine pregnancy testing.

3. Review of patient records indicated the following:
a. Glucometer testing was performed on patient #16 (4-20-2018; 4-21-2108; 4-22-2018; 4-23-2018; 4-24-2018; 4-25-2018; and 4-26-2018), and patient #18 (3-16-2018; 3-17-2018; 3-18-2018; 3-19-2018; 3-20-2018; 3-21-2018; and 3-22-2018).
b. Urine pregnancy testing was performed on patient #32 (4-5-2018), patient #33 (3-17-2018), and patient #36 (11-17-2017).

4. In interview on 4-30-2018 at 2:36 PM, staff member #L2 indicated the "E-Labs Master List" is the hospital's list of laboratory tests provided to medical staff and acknowledged the glucometer and urine pregnancy tests are not listed on the "E-Labs Master List."

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.3.2.1 states all valves shall be inspected weekly. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, visitors, and staff in the facility, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
Section 19.7.2.3.2 states: All health care occupancy personnel shall be instructed in the use of a code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person.
(2) During a malfunction of the building fire alarm system.
This deficient practice could affect all patients, visitors, and staff in the facility, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

1. Based on review of Brenneco's "Quarterly Fire System Sprinkler Inspection" documentation dated 03/26/2018, 12/19/2017, 09/18/2017, and 06/14/17 with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 during record review at 11:17 a.m., weekly sprinkler gauge inspection documentation was not available for review. In addition, weekly inspection documentation for all sprinkler system control valves was also not available for review. Based on interview at the time of record review and observation, the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged weekly sprinkler system gauge and control valve inspection documentation for the aforementioned periods was not available for review and added that they did not know they were required to be inspected as such. During the exit, no additional information or evidence could be provided contrary to this deficient finding.

2. Based on review of the "Disaster Manual - Fire Protection Plan" documentation with the Chief Executive Officer and the Operations Supervisor / Security Officer during record review at 10:45 a.m. on 05/10/18, the written fire safety plan did not address the coded announcement or page when the PBX operator was not present, or after normal business hours. Based on interview at the time of record review, both the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged that there was no documentation as to how the coded announcement was made when the PBX operator was not on site. The Chief Executive Officer stated that staff could make the announcement from any phone within the facility, but agreed that their written fire safety plan did not state that information. During the exit conference, no additional information or evidence could be provided contrary to this deficient finding.

3. Based on record review with the Chief Executive Officer and the Operations Supervisor / Security Officer at 10:43 a.m. on 05/10/18, the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Chief Executive Officer and the Operations Supervisor / Security Officer advised that they did not know about the above mentioned generator requirement. During the exit, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches. This deficient practice could affect patients, visitors, and staff in the foyer immediately outside the A unit.

Findings include:

Based on observation with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 at 12:31 p.m., the foyer area immediately outside the A unit had a smoke detector approximately 14 inches from an air duct. Based on interview at the time of the observation, both the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged the aforementioned condition, and verified the above listed measurement. This smoke detector was then later checked, at the request of the Chief Executive Officer, and found to have been moved by the maintenance staff to a satisfactory area that met the 36 inch or more distance from a direct airflow requirement.

Based on record review and interview, the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice could affect all patients, visitors, and staff in the facility.


Findings include:

Based on record review of the "Fire Drill Report" form with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 at 11:18 a.m., there was no documentation available for review of a second quarter (April, May, June) of 2017 fire drill for either the 1st or 3rd shifts. Based on interview at the time of record review, the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged the fire drills were missing and indeed not available for review. During the exit conference, no additional information or evidence could be provided contrary to this deficient finding.

Based on observations, record review, and interview, the facility failed to ensure that active treatment measures, such as group activities and therapeutic activities, were provided for two (2) of eight (8) active sample patients on Unit D (G3 and P7), who were unable, unwilling, or not motivated to attend or participate in active treatment groups. The MTPs for these patients failed to address as a problem the patients' lack of participation in therapeutic activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on medical record review. policy review, and interview, the facility failed to provide psychosocial assessments that met professional social work standards. These assessments failed to include conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for six (6) of eight (8) sample patients (G1, G2, G3, G4, P5, and P7). This failure results in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings Include:

A. Medical Records Review

1. Patient G1's Social Service Evaluation, dated 04/30/18, listed "Conclusions" that were merely a recapitulation of collected data rather than conclusions based on the collected data. The "Recommended Interventions" stated "N/A" [not applicable].

2. Patient G2's Social Service Evaluation, dated 04/26/18, listed "Conclusions" that were a repeat listing of the admitting date rather than an assessment of the data. The "Recommended Interventions" stated "N/A."

3. Patient G3's Social Service Evaluation, dated 01/23/18, listed "Conclusions" that described the patient's current condition as "very psychotic" and patient could not cooperate with the interview process. The "Recommended Interventions" section however, listed the intervention of "Individual Therapy."

4. Patient G4's Social Service Evaluation, dated 04/28/18, listed "Conclusions" as non-social work functions rather than assessment conclusions; "Will work to stabilize symptoms, work on getting [patient] back into a sleeping routine and lower caffeine intake." The social work "Recommended Interventions" stated "N/A."

5. Patient P5's Social Service Evaluation, dated 4/30/18, listed "Conclusions" as "Stabilize symptoms, clear up [his/her] disorganized thinking and refer to WBA [sic] for ongoing medication monitoring and therapy rather than treatment options to assist the patient toward recovery." The "Recommended Interventions" stated "Group therapy" and "N/A."

6. Patient P7's Social Service Evaluation, dated 04/3018, and listed "Conclusions" as "Monitor through detox ...." The "Recommended Interventions" stated "N/A."

B. Policy Review

Review of the hospital policy entitled, "Social Services Evaluation," (Assessment IPSS 3.2 revised 03/2015, Page 5) revealed that there were no Conclusions and Recommendations requirements for the Social Service Evaluation. Procedure 2 of the policy stated, "The evaluation identifies such important factors as family support, housing, insurance, Advance Directives, and whether or not the patient has outpatient support in place. All these could be considered prognostic indicators for a more successful release from the hospital."

C. Interview

1. In an interview on 5/01/18 at 9:45 p.m., the Director of Social Work concurred with the lack of Conclusions and Recommendations in the Social Service Evaluations.

Based on record review and interview the facility failed to develop Master Treatment Plans (MTPs), that identified patient-centered, short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients (G1, G2, G3, G4, P1, P2, P3, and P4). The lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

A. Medical Record Review

1. Patient G1 was admitted on 4/27/18. The MTP, dated 4/28/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable short-term goals (STGs) were, "Patient will not be observed responding to hallucinations for 2 days" and "Patient will report ignoring or being less distressed by voices or having no voices for 2 days."

2. Patient G2 was admitted on 04/26/18. The MTP, dated 4/27/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perceptions," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be observed responding to hallucinations for 2 days."

3. Patient G3 was admitted on 1/21//18. The MTP, dated 1/23/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be responding to hallucinations for 2 days."

4. Patient G4 was admitted on 4/2/18. The MTP, dated 4/2/18, listed for the problem, "Manic Behavior," the non-measurable STG were, "Patient will show consistent enjoyment in group recreation."

5. Patient P5 was admitted on 04/18/18. The MTP, dated 4/19/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be observed responding to hallucinations for 2 days."

6. Patient P6 was admitted on 4/15/18. The MTP, dated 4/15/18, listed for the problem, "Depression," the STGs were, "[Patient] will not cry excessively for 2 days" and "[Patient] will have organized give and take talk for 2 days."

7. Patient P7 was admitted on 4/19/18. The MTP, dated 04/19/18, listed for the problem, "Unrealistic/Disorganized/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will report ignoring or being less distressed by voices or having no voices for 2 days."

8. Patient P8 was admitted on 4/24/18. The MTP, dated 04/24/18, listed for the Problem, "Depression," the non-measurable STGs were, "[Patient] will engage others socially daily for 2 days" and "[Patient] will not cry excessively for 2 days."

B. Interviews

1. In an interview on 05/02/18 at 9:45 a.m., the Director of Social Work confirmed that the short- term goals were not behavioral, observable, and measurable.

2. In an interview on 5/2/18 at 11:30 a.m., the Administrator concurred with the surveyors' findings regarding short-term goals.

Based on record review and interview, the facility failed to ensure that specific, patient-centered nursing treatment interventions were included on the Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (G1, G2, G3, G4, P5, P6, P7, and P8). The treatment interventions included routine, generic nursing discipline functions listed as individualized treatment modalities unrelated to the specific patient's short-term goal. This failure to document patient-specific nursing treatment approaches on the MTP interferes with the assurance of consistency of approach to each patient's problem(s).

Findings include:

A. Medical Record Review

1. Patient G1 was admitted on 4/27/18. The MTP, dated 4/28/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable short-term goals (STGs) were, "Patient will not be observed responding to hallucinations for 2 days" and "Patient will report ignoring or being less distressed by voices or having no voices for 2 days." The interventions for these goals included the nursing intervention, "Staff will redirect talk onto realistic topics, under the direction of the nurse supervising Nursing Interventions."

2. Patient G2 was admitted on 04/26/18. The MTP, dated 4/25/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perceptions," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be observed responding to hallucinations for 2 days." The interventions for these goals included the nursing intervention, "Nursing staff will initiate and maintain elopement precautions and re-evaluate daily, under the direction of nurse supervising Nursing Interventions."

3. Patient G3 was admitted on 1/21//18. The MTP, dated 1/23/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be responding to hallucinations for 2 days." The interventions for these goals included the nursing intervention, "Staff will prompt [patient] to bathe, groom, wear clean clothes, brush teeth, shave, etc., under the direction of nurse supervising Nursing Interventions."

4. Patient G4 was admitted on 4/2/18. The MTP, dated 4/2/18, listed for the problem, "Manic Behavior," the non-measurable STG was, "Patient will show consistent enjoyment in group recreation." The interventions for this goal included the nursing intervention, "Mood-stabilizing medication as prescribed by [physician name]."

5. Patient P5 was admitted on 04/18/18. The MTP, dated 4/19/18, listed for the problem, "Unrealistic/Disorganized Thinking/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will not be observed responding to hallucinations for 2 days." The interventions for these goals included the nursing intervention, "Nursing staff will initiate and maintain self-harm precautions and re-evaluate daily, under the direction of nurse supervising Nursing Interventions."

6. Patient P6 was admitted on 4/15/18. The MTP, dated 4/15/18, listed for the problem, "Depression," the STGs were, "[Patient] will not cry excessively for 2 days" and "[Patient] will have organized give and take talk for 2 days." The interventions for these goals included the nursing intervention, "Staff will prompt [patient] to stay out of bed and active, under the direction of nurse supervising Nursing Interventions."

7. Patient P7 was admitted on 4/19/18. The MTP, dated 04/19/18, listed for the problem, "Unrealistic/Disorganized/Perception," the non-measurable STGs were, "[Patient] will respond coherently to questions for 24 hours" and "[Patient] will report ignoring or being less distressed by voices or having no voices for 2 days." The interventions for these goals included the nursing intervention, "Staff will prompt [patient] to stay out of bed and active, under the direction of nurse supervising Nursing Interventions."

8. Patient P8 was admitted on 4/24/18. The MTP, dated 04/24/18, listed for the Problem, "Depression," the non-measurable STGs were, "[Patient] will engage others socially daily for 2 days" and "[Patient] will not cry excessively for 2 days." The interventions for these goals included the nursing intervention, "Mood stabilizing medication as prescribed by [physician name]."

B. Interview

During an interview on 5/1/18 at 9:30 a.m., the Director of Nursing agreed that the nursing interventions on the MTPs were generic nursing interventions and were often not related to the stated STGs.

Based on record review and interview, the facility failed to ensure that the nursing staff member responsible for each nursing intervention was specifically identified in eight (8) of eight (8) patients' treatment plans (G1, G2, G3, G4, P5, P6, P7, and P8). This failure results in the patient and other staff being unaware of which nursing staff is responsible for the intervention being implemented and documented.

Findings Include:

A. Medical Record Review

1. Patient G1 was admitted on 4/27/18. The MTP, dated 4/28/18, contained nine (9) nursing interventions. Only one (1) intervention listed a responsible nursing name. The remaining eight (8) listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

2. Patient G2 was admitted on 04/26/18. The MTP, dated 4/27/18, contained ten (10) nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

3. Patient G3 was admitted on 1/21//18. The MTP, dated 1/23/18, contained ten (10) nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

4. Patient G4 was admitted on 4/2/18. The MTP, dated 4/2/18, contained six (6) nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

5. Patient P5 was admitted on 04/18/18. The MTP, dated 4/19/18, contained nine (9) nursing interventions. Only one (1) intervention listed a responsible nursing name. The remaining eight (8) listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who was "under the direction of the nurse supervising Nursing Interventions."

6. Patient P6 was admitted on 4/15/18. The MTP, dated 4/15/18, contained 10 nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

7. Patient P7 was admitted on 4/19/18. The MTP, dated 04/19/18, contained 11 nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

8. Patient P8 was admitted on 4/24/18. The MTP, dated 04/24/18, contained 14 nursing interventions. None of the interventions listed a responsible nursing name but instead listed the responsible persons as "Staff "or "Psych Tech [Psychiatric Tech]" who were "under the direction of the nurse supervising Nursing Interventions."

B. Interview

During an interview on 5/1/18 at 9:30 a.m., the Director of Nursing agreed that the nursing interventions on the MTPs did not have the responsible nursing staff listed by name.

Based on observations, record review, and interview, the facility failed to ensure that active treatment measures, such as group activities and therapeutic activities, were provided for two (2) of eight (8) active sample patients on Unit D (G3 and P7), who were unable, unwilling, or not motivated to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address as a problem the patients' lack of participation in therapeutic activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Patient G3

Patient G3 was admitted on 1/21/18. The Psychiatric Evaluation, dated 1/21/18, listed the diagnosis as "Schizoaffective Disorder; Bipolar Disorder." Since this patient's admission he/she has been a difficult management problem regarding the ability to engage in treatment. The initial MTP was dated 01/23/18. The latest treatment plan, updated 5/01/18, listed the same admitting treatment plan problem of "Description in [patient] words 'That I don't what to say [sic]'." "Per ED [XX] and family, Pt. was screaming, throwing chairs, and responding to unseen stimuli." Discharge goal: [Patient] will function without interference from unrealistic stimuli or disorganized thinking or perceptions. Goal in [Patient's] words: 'No. not now.' Pt unable to answer at this time." Review of the patient's Master Treatment Plan and Treatment Plan update revealed no new treatment goals or interventions for this patient regarding his/her inability to consistently engage in active treatment activities. There were no listed alternative activities scheduled when he/she did not attend group.

1. Observations
a. The unit census on 4/30/18 was nine (9) patients (plus one in the emergency room for a respiratory infection). On 04/30/18 at 1:00 p.m., Patient G3 attempted to attend a Therapy Group and stayed in the group approximately 1.5 minutes before returning to his/her room.

b. On 04/30/18 at 2:45 p.m., Patient G3 was observed in his/her room rather than attending a scheduled Activity Group.

c. On 05/01/18 at 9:15 a.m., Patient G3 was observed in bed rather than attending Community Meeting.

d. On 05/01/18 at 10:00 a.m., Patient G3 was observed in bed rather than attending the Activity Group.

e. On 05/01/18 at 1:00 p.m., Patient G3 was observed in bed. There was a Therapy Group in session but Patient G3 had not been "invited."

f. On 05/01/18 at 2:30 p.m., Patient G3 was observed in bed rather than attending the Activity Group.

2. Record Review
Review of the electronic medical record (Service List) revealed the following group attendance for Patient G3:
a. 4/22/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient G3 did not attend and the refusal note read, "Patient reason given for refusal A/S [apparently sleeping]."

b. 04/23/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient G3 did not attend and the refusal note read, "[Patient] was asleep and could not be waken [sic]."

c. 04/25/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient G3 did not attend and the refusal note read, "Patient refused group despite staff prompts; patient stated 'No' when asked."

4:00 p.m. - A Patient Education group was scheduled. Patient G3 did not attend and the refusal note read, "Pt states did not want to attend and was focused on getting fluids."

d. 04/27/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient G3 did not attend and the refusal note stated, "Patient was showering at the time of group."

4:00 p.m. - A Patient Education group was scheduled. Patient G3 did not attend and the refusal note read, "Pt was upset and didn't want to attend [s/he] states [s/he] was not receiving fluids in a timely manner."

e. 04/29/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient G3 did not attend and the refusal note read, "Patient elected to stay in his room for group."

3. Interviews

a. In an interview on 05/01/18 at 1:15 p.m., RN 2 indicated that Patient G3 rarely gets out of bed; if so it is usually in the afternoon or for meals or fluids.

b. In an interview on 05/02/18 at 9:15 a.m., the Medical Director agreed with the surveyor's observations of group attendance and patients not attending groups.

B. Patient P7

Patient P7 was admitted on 4/19/18. The diagnoses on the Psychiatric Evaluation dated 4/19/18 included, "Unspecified schizophrenia spectrum disorder and other psychotic disorder," and "amphetamine use disorder, severe." The MTP, dated 4/19/18, listed as problems, "Unrealistic/Disorganized Thinking /Perception," "General Medical Conditions," and "Discharge Planning." Although Patient P7 did not regularly attend groups, the MTP did not address this as a problem nor did it address alternative treatment.

1. Observations
Observations were made on Unit D from 1:00 p.m.-3:30 p.m. on 4/30/18 and from 9:15 a.m.-2:45 p.m. on 5/1/18.

a. The census at this time was nine (9) patients (plus one in the emergency room for a respiratory infection). At 1:15 p.m., the surveyor observed a Therapy Group being conducted in the therapy room. There were five (5) patients in the group. The remaining four (4) patients were either pacing the hallway or in their rooms. Patient P7 was pacing the hallway.

b. Observations on the unit at 2:45 p.m., revealed that an Activity Group was in progress. Three (3) patients were in attendance. The remaining six (6) patients were either pacing the hallway, in bed or watching television. Patient P7 was watching television.

c. Observations on the unit on 5/1/18 at 9:15 a.m., revealed that a Community Meeting Group was in progress. The census at this time was 10 patients. Eight (8) patients were in attendance, and two (2) patients were in bed. Patient P7 was in bed.

d. Observations on the unit on 5/1/18 at 10:30 a.m., revealed that an Activity Group was in progress. Four (4) patients were in attendance, two (2) patients were watching television, one (1) was washing clothes and three (3) patients were in bed. Patient P7 was in bed.

e. Observations on the unit on 5/1/18 at 12:30 p.m., revealed that a 30-minute exercise group had been held outside and had just ended. Three (3) patients had attended. The remaining seven (7) patients were either in their rooms or walking in the hallway. Patient P7 attended the group.

f. Observations on the unit on 5/1/18 at 1:15 p.m., revealed that a Therapy Group was in progress. Three (3) patients were in attendance, one (1) patient was meeting with the physician, two (2) patients were walking the hallway, one (1) patient was sitting alone at a table, and three (3) patients were in bed. Patient P7 was in bed.

2. Record Review
a. Review of the electronic medical record (Service List) revealed the following group attendance for Patient P7:

4/19/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient P7 did not attend and the refusal note read, "Patient refused group despite staff prompts. Spent group time pacing unit and talking to self."

4:00 p.m. - A Patient Education group was scheduled. Patient P7 did not attend and the refusal note read, "Patient declined to go stating [he/she] didn't need to and continued to pace the halls instead."

4/20/18
2:30 p.m. - An Activity Therapy group was scheduled. Patient P7 did not attend and the refusal note read, "Patient was asleep and could not be woken [sic]."

4:00 p.m. -A Patient Education group was scheduled. Patient P7 did not attend and the refusal note read, "I don't feel well, I don't want to go."

8:15 p.m. - A Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note read, "Patient was sleeping during patient relaxation."

4/21/18
3:45 p.m. - A Patient Education group was scheduled. Patient P7 did not attend and the refusal note read, "Pt. [patient] was sleeping and did not want to attend group."

4/22/18
10:00 a.m. - An Activity Therapy group was scheduled. Patient P7 did not attend and the refusal note read, "A/S" (Apparently Sleeping).

8:00 p.m. - A Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note read, "Patients either declined to attend or were asleep."

4/23/18
2:30 p.m.-An Activity Therapy group was scheduled. Patient P7 did not attend and the refusal note read, "Patient refused group despite staff prompts."

4/24/18
4:00 p.m.-A Patient Education group was scheduled. Patient P7 did not attend and the refusal note read, "I don't feel like getting up. I don't feel very good."

8:00 p.m. - A Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note read, "Patient elected to pace the halls instead."

4/26/18
8:00 p.m. - a Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note was blank.

4/28/18
8:00 p.m.-A Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note read, "Patient elected to pace the halls instead."

4/29/18
4:00 p.m.-A Patient Education group was scheduled. Patient P7 did not attend and the refusal note read, "Patient chose to stay in room."

4/30/18
8:00 p.m.-A Relaxation Training group was scheduled. Patient P7 did not attend and the refusal note read, "Patients were either asleep or declined to attend relaxation."

C. Interview

1. During an interview on 4/30/18 at 2:00 p.m., Patient P7, when asked about attending groups, stated that he/she did not like going to groups and being around that many people.

2. During an interview on 5/1/18 at 1:15 p.m., Psych Tech 4 stated that Patient P7 usually walked the halls but would go to his/her room to take "cat naps". She further stated that Patient P7 did go to some groups.

3. During an interview on 5/2/18 at 9:45 a.m., the Director of Nursing acknowledged that some patients refused to go to group and that there were no alternative treatment options provided.

4. During an interview on 5/2/18 at 11:30 a.m., the Administrator agreed that more active treatment needed to be provided to the patients.

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

1. The facility develop Master Treatment Plans (MTPs), that identified patient-centered, short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients (G1, G2, G3, G4, P1, P2, P3, and P4). The lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' need. (See B121)

2. That the facility provides active treatment measures, such as group activities and therapeutic activities, were provided for two (2) of eight (8) active sample patients on Unit D (G3 and P7), who were unable, unwilling, or not motivated to attend or participate in active treatment groups. The MTPs for these patients failed to address as a problem the patients' lack of participation in therapeutic activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (See B125)

Based on record review and interview the Director of nursing failed to ensure that:

1. Specific, patient-centered nursing treatment interventions were included on the MTPs for eight (8) of eight (8) sample patients (G1, G2, G3, G4, P5, P6, P7, and P8). The treatment interventions included routine, generic nursing discipline functions listed as individualized treatment modalities unrelated to the specific patient's short-term goal. This failure to document patient- specific nursing treatment approaches on the MTP interferes with the assurance of consistency of approach to each patient's problem(s). (Refer to B122)

2. The nursing staff member responsible for each nursing intervention was specifically identified in eight (8) of eight (8) patients' treatment plans (G1, G2, G3, G4, P5, P6, P7, and P8). This failure results in the patient and other staff being unaware of which nursing staff is responsible for the intervention being implemented and documented. (Refer to B123)