HospitalInspections.org

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

I. Ensure that social service assessments include conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample records (A1, A3, A7, A9, A11, A12, A15, and A17). This failure results in a lack of professional social work treatment services and lack of input to the treatment team for eight (8) of eight (8) active patients. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). Specifically, the MTPs did not include the following: 1) behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119); 2) observable and measurable short term goals written in behavioral terms (Refer to B121); and 3) specific individualized active treatment interventions (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that adequate active treatment measures and care were provided to one (1) of eight (8) active sample patients (A7) in order to move the patient to a higher level of functioning. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies the patient the care required to ensure his/her optimal improvement. (Refer to B125, Part1)

Based on review of facility documents and staff interview (EMP), it was determined the Quality Assessment and Improvement (QAPI) committee failed to review the results of the quality data collected for all fall rates in the Behavioral Health Unit for 2014 and the Behavioral Health Patient Satisfaction Survey.

Findings include:

Review on February 12, 2015, of the facility's "Quality Assessment and Performance
Improvement (QAPI) Program" last reviewed July 2014, revealed "Purpose Consistent with our mission, vision, and values, the QAPI Program reflects Susquehanna Health's and Divine Providence Hospital's commitment to improve the quality and the safety of the care we deliver. ... Methodology and Tools The key to Performance Improvement at SH [Susquehanna Health] is the transformation of data into information and ultimately into knowledge. Data is collected from multiple sources in order to measure and monitor performance. Priority of collection as well as the frequency of collection is determined by leadership. Statistical analysis of the data collected occurs on an ongoing basis and is displayed in several formats. ... Monitoring for Effectiveness The QAPI Program is evaluated on an ongoing basis for its effectiveness in managing change and improving performance. Reporting occurs on a regular basis to the Corporate Operations/Quality Council, appropriate committees, the DPH Quality and Safety Committee, the SH Quality and Safety Committee and ultimately the Board(s). ..."

1) Review on February 12, 2015, of the facility's "DashBoard Report" for 2014, revealed the fall rates for the Adult Inpatient Behavioral Health Unit for 2014 was: January 9.90 percent, May 2.72, June 2.66 percent and July 8.00 percent. February, March, April, August, September, October, November and December 2014, the facility reported no falls with zero percent for the Adult Inpatient Behavioral Health Unit.

Review on February 12, 2015, of the facility's "DashBoard Report" for 2014, revealed the fall rates for the Older Adult Psychiatric Unit for 2014 were: January 19.23 percent, March 16.85 percent, April 28.04 percent, June 6.76 percent, July 6.76 percent, October 14.39 percent, November 8.86 percent and December 19.80 percent. The February, May, August and September 2014 fall rates were zero percent for the Older Adult Psychiatric Unit.

Review on February 12, 2015, of the facility's Quality and Safety Committee meeting minutes for February 7, 2014, August 22, 2014, and October 3, 2014, revealed EMP2 reported on the Adult Inpatient Behavioral Health unit fall rates. Further review revealed no documentation EMP2 reported the falls rates for the Older Adult Psychiatric Unit.

Review on February 12, 2015, of the facility's Special Combined Quality and Safety Strategy Committee meeting minutes for June 4 and December 17, 2104, revealed no documentation EMP2 reported the fall rates for the Adult Inpatient Behavioral Health Unit or the Older Adult Psychiatric Unit.

Interview with EMP1 and EMP2 on February 12, 2015, confirmed the DashBoard Report for falls for the Adult Inpatient Behavioral Health unit and the Older Adult Psychiatric Unit. Further interview confirmed the fall rates for the Adult Inpatient Behavioral Health Unit were reported to the Quality and Safety Committee. EMP1 and EMP2 confirmed the fall rates for the Older Adult Psychiatric Unit were higher and should have been reported to the Quality and Safety Committee.

Continued interview with EMP2 confirmed the fall rates for the Adult Inpatient Behavioral Health Unit and the Older Adult Psychiatric Unit were not reported to the facility's Special Combined Quality and Safety Strategy Committee.

2) Interview with EMP10 and EMP11 on February 12, at approximately 11:00 AM revealed the expected overall Behavioral Health Patient Satisfaction Survey rate was 90 percent.

Review on February 12, 2015, of the facility's Behavioral Health Patient Satisfaction Survey report for 2014 revealed the facility reported the following satisfaction rate for Therapeutic Activities Available as: January 85.0 percent; February 92.6 percent; March 90.7 percent; April and May 90 percent; June 85.4 percent; July 81.9 percent; August 87.5 percent; September 88.2 percent; October 79.2 percent; November 89.3 percent and December 89.5 percent.

Review on February 12, 2015, of the facility's Behavioral Health Council Shared Decision Making meeting minutes for January 29, 2014, March 7, 2014, April 23, 2014, July 23, 2014, September 24, 2014, October 22, 2014, and November 19, 2014, revealed no documentation the facility reviewed the results from the Behavioral Health Patient Satisfaction Survey data collection, analyzed the data and made decisions regarding the low Therapeutic Activities Available rates during 2014.

Interview with EMP10 on February 12, 2015, at approximately 12:00 PM revealed the Behavioral Health Council Shared Decision Making meeting purpose is to deal with unit issues, review satisfaction survey results, and determine resources needed on the unit. Further interview with EMP10 confirmed there was no documentation the facility reviewed the results from the Behavioral Health Patient Satisfaction Survey data collection, analyzed the data, and made decisions regarding the low Therapeutic Activities Available rates during 2014.

Based on review of facility documents and staff interview (EMP), it was determined the Governing Body failed to document the reasons for conducting the Quality Improvement projects, Wrong Patient Events, Antibiotics and Patient Experiences, selected for 2014.

Findings include:

Review on February 11, 2015, of the facility's "Quality Assessment and Performance Improvement (QAPI) Program," last reviewed July 2014, revealed "Purpose Consistent with our mission, vision, and values, the QAPI Program reflects Susquehanna Health's and Divine Providence Hospital's commitment to improve the quality and the safety of the care we deliver. ... QAPI Program Structure The ultimate responsibility and accountability for quality and safety rests with the Board of Directors for DPH [Divine Providence Hospital] and Susquehanna Health. ... Priorities and Goals System-wide priorities are determined annually at the combined meeting of all Quality and Safety Committees. Traditionally three priorities with accompanying goals are established which then cascade to all entities. The DPH Quality and Safety Committee determined additional goals as needed and monitors and appraises ongoing improvement activities. ... Methodology and Tools The key to Performance Improvement at SH [Susquehanna Health] is the transformation of data into information and ultimately into knowledge. Data is collected from multiple sources in order to measure and monitor performance. Priority of collection as well as the frequency of collection is determined by leadership. ..."

Review on February 11, 2015, of the facility ' s Governing Body Meeting minutes for December 2013 revealed the Governing Body selected the following three performance improvement projects for the calendar year of 2014: Wrong Patient Events, Antibiotics and Patient Experiences.

Review on February 11, 2015, of the facility's Quality Improvement projects for 2014, revealed no documentation regarding the reasons the Governing Body selected those Quality Improvement projects for 2014.

Interview with EMP1 and EMP2 on February 11, 2015, at approximately 2:00 PM confirmed there was no documentation regarding the reasons the Governing Body selected the Quality Improvement projects for 2014. Further interview with EMP1 and EMP2 revealed the nursing department had some oversight and input into the selection of the Quality Improvement projects, and the remaining facility departments' Quality Improvement projects stayed at the department level.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) monitoring was performed for of all services provided under contract with an outside company and services provided under arrangement between the facility and the main campus.

Findings include:

Review on February 11, 2015, of the facility's "Quality Assessment and Performance Improvement (QAPI) Program" last reviewed July 2014, revealed "Purpose Consistent with our mission vision, and values, the QAPI program reflects Susquehanna Health's and Divine Providence Hospital's commitment to improve the quality and the safety of the care we deliver. The QAPI Program drives patient safety, delivery of effective care and provision of an excellent patient experience. The QAPI serves as a tool to assure compliance with CMS Conditions-of-Participation and PA DOH Requirements [sic] As defined in the QAPI Program, quality assessment and performance improvement are data driven, proactive, on-going and involve all departments and services, including contracted services. ..."

1) Review on February 11, 2015, of the facility's arranged services revealed central sterilization, laboratory/pathology and medical records were services provided to the facility under arrangement between the facility and the main campus.

Review on February 11, 2015, of the facility's "Housekeeping Quality Assurance" policy, last reviewed April 2014, revealed "Purpose: This policy provides guidelines to b followed by the SH [Susquehanna Health] - Hospitality zones to determine the effectiveness of housekeeping operations and to use this information to improve the services we provide. Statement of Procedure: Scheduled and unscheduled inspections will be completed on a routine basis. These inspections will systematically evaluate all aspects of service that we provide. When quality indicators fall below acceptable levels an action plan will be implemented to address the issue ... E. The Hospitality department participates in the Health System's Performance Improvement program. The Hospitality Department will evaluate procedures and will select certain areas to evaluate and will the collect, track and report data to the Health Quality Improvement Department to be included in the System wide quality assurance program."

Interview with EMP1 and EMP2 on February 11, 2015, at approximately 10:00 AM confirmed central sterilization, laboratory/pathology and medical records were services provided to the facility under arrangement between the facility and the main campus. Further interview with EMP1 and EMP2 revealed some QAPI monitoring was performed for the services under arrangement. EMP1 and EMP2 confirmed the monitoring results were not reported to the QAPI committee.

2) Review on February 11, 2015, of the facility's contracted services revealed nutrition, housekeeping, and maintenance services were provided to the facility under contract with an outside company.

Review on February 11, 2015, of the housekeeping monitoring of room cleanliness revealed the facility completed observations of cleaned rooms following the cleaning by housekeeping.

Interview with EMP1 and EMP2 on February 11, 2015, at approximately 10:30 AM revealed this was a contracted service provided by an outside company.

Interview with EMP9 on February 11, 2015, at approximately 11:00 AM revealed the results of the housekeeping monitoring of room cleanliness observations remained at the department level and were not reported to the QAPI committee.

Phone interview with EMP2 on February 18, 2015, at approximately 3:15 PM revealed the contracted services of nutrition and housekeeping were not reported to the QAPI committee.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure containers used to transport specimens between campuses, physician offices and off-campus collections sites were transported in a biohazard labeled transport container.

Findings include:

Review on February 10, 2015, of the facility's "Laboratory" policy, last revised June 2014, revealed "Purpose A. This policy is established to protect our patients and employees from infection risk in the laboratory environment. B. The purpose of this policy is to protect employees, from possible infections from blood and body fluid exposure. ... Department Specific Topics ... I. Transporting Specimens ... 2. Specimens transported between campuses, physician offices and off-campus collections sites within Susquehanna Health (SH) will be packaged in a leak proof biohazardous labeled container and placed inside a closed durable container (i.e., igloo cooler). The cooler/secondary container will be labeled with a biohazard label. ..."

Observation of the facility's laboratory on February 10, 2015, revealed one soft sided red container. Interview with EMP2 revealed this soft sided red container was used to transport specimens between campuses, physician offices and off-campus collections sites, and the facility had five of these soft sided containers. Further observation of this soft sided red container revealed no visible biohazard labeling.

Interview with EMP2 on February 10, 2015, at approximately 2:15 PM confirmed this soft sided red container had no visible biohazard labeling. EMP2 confirmed the five soft sided red containers did not have visible biohazard labeling.

Based on observation and staff interview (EMP), it was determined the facility failed to maintain a sanitary environment on the loading dock.

Findings include:

A request was made of EMP1 and EMP2 on February 9 and 10, 2015, for facility policies and procedures addressing facility cleanliness. No policy was provided.

Interview with EMP1 on February 11, 2015, revealed the facility did not have a policy or procedure addressing facility cleanliness.

Observation on February 10, 2015, of the facility's loading dock area, where food products were unloaded, revealed two hanging lights with a heavy accumulation of dirt, dust, webs, and dead bugs on the light fixtures and extending to approximately 10 inches around the light fixtures.

Interview with EMP8 on February 10, 2015, at approximately 11:15 AM confirmed the loading dock was used to unload food products from delivery trucks. The food products were then transported to the refrigerator, freezer, dry storage, and patient care areas. Further interview with EMP8 confirmed the hanging lights on the loading dock area had a heavy accumulation of dirt, dust, webs, and dead bugs on the light fixtures and extended approximately 10 inches around the light fixtures.

Repeat deficiency cited September 14, 2011

Based on review of hospital documents, personnel file (PF), and staff interview (EMP), it was determined the facility failed to ensure the Director of Infection Prevention was certified by the Certification Board of Infection Control and Epidemiology (PF15).

Findings include:

Review on February 12, 2015, of the facility document "Job Description- Dir Infection Prevention," last revised December 16, 2014, revealed "Job Summary The Director of Infection Prevention and Control is responsible for the development, implementation, assessment and evaluation of the multi-disciplinary infection prevention and control activities of the Susquehanna Health Infection Prevention and Control Program. The Director must promote the vision, values, and mission of SH [Susquehanna Health], acts as director and leader in infection prevention and control, as well as performs the functions of an Infection Preventionist. ... Education BSN or RN, or college-prepared Epidemiologist. ... License/Certification/Registration Certified in Infection Control by the Certification Board of Infection Control and Epidemiology, Inc. ..."

Review on February 12, 2015, of PF15 revealed the facility hired this employee on December 16, 2014, as the Dir Infection Prevention. Continued review of PF15 revealed the job description for PF15 stated the position required certification in Infection Control by the Certification Board of Infection Control and Epidemiology, Inc. Further review of PF15 revealed no documentation of this certification.

Interview of PF15 at 2:15 PM on February 9, 2015, confirmed this employee did not have certification by the Certification Board of Infection Control and Epidemiology, Inc.

Interview of EMP2 at 1:50 PM on February 12, 2015, confirmed the job description for Dir Infection Prevention stated certification by the Certification Board of Infection Control and Epidemiology, Inc. was required and that PF15 does not have certification by the Certification Board of Infection Control and Epidemiology, Inc.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to follow industry standards for spiking intravenous (IV) bags for three of three IV bags observed, failed to ensure adequate hair coverage in Operating Room 1, and failed to ensure two multi-dose medication vials (used for more than one patient) were stored and accessed away from the immediate area where direct patient contact occurred.

Findings include:

1) Review on February 12, 2015, of the facility provided document from the Association for Professionals in Infection Control and Epidemiology (APIC) 2015 Edition "Medication Safety," revealed "Intravenous solution containers should be punctured as close as possible to time of use. Opened and unused medication vials, solution bags, bottles, syringes, and compound sterile preparations should be discarded within one hour of opening. The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that spiked IV solutions be used within one hour of being prepared. ..."

Observation on February 11, 2015, at 8:55 AM in the Pre-Admission Care Unit revealed three IV bags of Normal Saline spiked with tubing prepped for patient use. Further observation of the bags revealed February 11, 2015, as the date the bags were prepped for use.

Interview with EMP5 on February 11, 2015, at 8:55 AM confirmed the IV bags were prepped for use on February 11, 2015, at 6:00 AM. EMP5 revealed IV bags are prepped for the surgical cases for the day, first thing in the morning. EMP5 revealed they were told the prepped IV bags were good for 24 hours after they were prepped for use.

2) Review on February 11, 2015, of the facility's "Surgical Services-OR [Operating Room] Dress Code/OR" policy, last reviewed September 2014, revealed "Responsible Person(s): All perioperative and birthplace personnel Purpose: To maintain environmental control and promote a high level of cleanliness and hygiene within the Surgical Department. ... Guidelines A. All persons entering the semi-restricted and restricted areas shall wear the following: ... 6. Surgical Hat/Hoods a. Disposable scrub hats (bouffant) or surgical hoods that completely cover all possible head and facial hair are to be worn by all personnel entering the OR semi-restricted and restrictive areas of the OR. Skull caps must cover the side hair above the ears and hair at the nape of the neck. ..."

Observation on February 11, 2015, at 9:35 AM in OR1 revealed EMP6 and EMP7 wearing skull caps provided by the facility. Further observation revealed the skull caps did not provide coverage of their hair at the back of the head in the neck area.

Interview with EMP3 and EMP4 on February 11, 2015, at 9:35 AM confirmed the skull caps worn by EMP6 and EMP7 did not provide full coverage of their hair.

3) On February 11, 2015, the facility was requested to provide their policy for storing multi-dose vials. No policy was provided.

Observation on February 11, 2015, at 9:00 AM, in Post Anesthesia Care Unit (PACU) revealed one opened multi-dose bottle of Lidocaine 1% (used in PACU for local anesthesia for IV insertions) stored in an IV insertion storage cart.

Interview on February 11, 2015, at 9:00 AM, with EMP5 confirmed one opened multi-dose bottle of Lidocaine 1% stored in the IV insertions storage cart. EMP5 also confirmed the multi-vials are used for multiple patients.

Interview on February 11, 2015, at 11:00 AM, with EMP6 revealed one opened multi-dose vial of Neostigmine (a parasympathomimetic used in treatment of myasthenia gravis and to reverse the effects of muscle relaxants) in OR1 anesthesia cart. Further interview with EMP6 confirmed one opened multi-dose vial of Neostigmine in OR1 anesthesia cart and the multi-vials are used for multiple patients.

Based on record reviews, interviews, and policy review, the facility failed to ensure that social service assessments include conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample records (A1, A3, A7, A9, A11, A12, A15, and A17). This failure results in a lack of professional social work treatment services and lack of input to the treatment team for eight (8) of eight (8) active patients.

Findings include:

A. Record Review:

1. Patient A1 - The psychosocial assessment dated 01/12/14 (sic - 01/12/15) does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

2. Patient A3 - The psychosocial assessment dated 01/09/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

3. Patient A7 - The psychosocial assessment dated 11/17/14 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

4. Patient A9 - The psychosocial assessment dated 12/31/14 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

5. Patient A11 - The psychosocial assessment dated 01/06/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

6. Patient A12 - The psychosocial assessment dated 01/06/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

7. Patient A15 - The psychosocial assessment dated 01/09/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

8. Patient A17 - The psychosocial assessment dated 01/07/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

B. Staff Interviews:

1. The Supervisor of Social Services/Behavioral Health In-Patient Unit stated in an interview on 01/13/15 at 9:30 a.m., "The Psychosocial Assessment is not necessarily a conclusion yet. The Assessment is part of a process and the information comes together in the progress notes and the discharge summary."

2. The Manager of Patient Care on the In-Patient Unit stated in an interview on 01/13/15 at 2:00 p.m., "The new Psychosocial Assessment electronic form that goes live tomorrow can be more explicit about saying that the social work goals are conclusions and recommendations."

3. The Medical Director stated in an interview on 01/13/15 at 11:30 a.m., "The issue is the documentation of the psychosocial assessment. The information can be found in the progress notes, but the conclusions and recommendations are not in a standardized place."

C. Policy Review:

1. Policy 1179319: Elements of the Psychosocial Assessment, revised 10/2012, includes the required element: "Evaluation summary ends in problem statement/recommendations."

Based on record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:

1. Behaviorally descriptive psychiatric problem statements to be used as the basis for developing the plans for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17) and medical problems identified in clinical assessments for three (3) of eight (8) active sample patients (A3, A9, and A17). Refer to B119

2. Observable and measurable goals for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). Refer to B121

3. Individualized treatment interventions for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). Refer to B122

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

Based on record review and interview, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on the Master Treatment Plans (MTPs). Instead, the stated problems on the treatment plans included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive psychiatric problems based on clinical assessment data and how presenting symptoms were manifested specific to each of eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A12, A15, and A17). In addition, the facility failed to address medical problems identified during the assessment process on the Master Treatment Plan for three (3) of eight (8) active sample patients (A3, A9, and A17). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric and medical problems.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/9/15), A3 (1/9/15), A7 (1/9/15), A9 (1/8/15), A11 (1/8/15), A12 (1/6/15), A15 (1/9/15) and A17 (1/12/15). This review revealed that the MTPs had the following psychiatric problem statement with diagnostic terms and/or generalized symptoms with no supporting documentation to reflect how presenting symptoms and/or problems were precisely manifested for each patient.

1. Patient A1's MTP included the following psychiatric problem statement on the problem list: "Manic Mood: acute agitation/threatening statements & behavior, disorganized/
grandiose/persecutory thought processes, ineffective coping. "There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems. The patient's Psychiatric Evaluation dated 1/10/15 noted the following description of the patient's problem, "The patient is experiencing hyperreligious [sic] ideas...saying, 'I am the metatron'...[MD's name] is spying on [him/her]...government is spying upon [him/her] through [his/her] television."

2. Patient A3's MTP included the following psychiatric problem statement on the problem list: "Depressed Mood: SI [suicidal ideation], acute anger/irritability, racing thoughts, ineffective coping, relationship conflict, chronic psych illness mgmt. [management] challenges...' The patient's Psychiatric Evaluation dated 1/9/15 noted the following description of the patient's problem, "...[S/he] has increasing agitation with the [boy/girl] friend... [boy/girl] friend told [him/her] [s/he] had anger problems... [s/he] thinks maybe that people would be better if [s/he] was dead...reports impulsively hitting other people when angry." Patient A3's "History and Physical" dated 1/9/15 noted the following medical problem: "Gastroesophageal Reflux" There was no problem statement, goal, and intervention formulated to address this medical condition.

3. Patient A7's MTP included the following psychiatric problem statement on the problem list: "Altered thought processes: decreased self-care, disorganized thought processes, behavior, auditory hallucinations, religious preoccupation/grandiosity, ineffective coping, chronic psych illness, management challenges, compliance, acute anxiety/restlessness." The psychiatric evaluation dated 11/15/14 noted the following description of the patient's problem: "The patient has not been caring for [himself/herself] and has redden areas between [his/her] buttocks and on the perineum...The patient reports auditory hallucinations of the devil telling him not to move and that [s/he] cannot walk."

4. Patient A9's MTP included the following psychiatric problem statement on the problem list: "Depressed Mood: Suicidal ideation's, flat affect, sleep disturbance." The psychiatric evaluation dated 12/31/14 noted the following problems: The patient reports a depressed mood, decreased sleep, decreased appetite, low energy, low motivation, poor concentration, increased tearfulness, decreased enjoyment in activities, increased irritability, and suicidal ideation. [Note: The psychiatric evaluation did not provide a clear description of the patient's depressed mood, decreased sleep, suicidal ideation, etc.] Patient A9's "History and Physical" dated 12/30/15 noted the following medical problems: "Gastroesophageal Reflux and mild anemia" There were no problem statements, goals, and interventions formulated to address these medical conditions.

5. Patient A11's MTP included the following psychiatric problem statement on the problem list: "Depressed Mood: Suicidal ideation's, constricted affect, poor sleep pattern, ineffective coping, chronic psych and addition challenges." The psychiatric evaluation dated 1/3/15 noted the following description of the patient's problem: "The patient can feel extremely depressed and not wanting to get out of bed, have low energy, crying spells, no motivation, endorsing a sense of hopelessness, helplessness, and worthlessness and have suicidal thoughts."

6. Patient A12's MTP included the following psychiatric problem statement on the problem list: "Manic Mood: SI [suicidal ideation], constricted affect, acute anxiety, ineffective coping, adjusting to re-entry [after] incarceration, chronic impulse control challenges..." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems. The patient's Psychiatric Evaluation dated 1/6/15 noted that the patient had been recently released from prison and "describes a fear of 'slipping up'...experiencing physical symptoms...consistent with panic attack."

7. Patient A15's MTP included the following psychiatric problem statement on the problem list: "Depressed Mood: SI [suicidal ideation], tearful affect, acute irritability, aggressive behaviors, ¿ self care, ineffective coping, recent medical challenges...medical condition DM mgmt. [management] challenges." There was no documentation which provided behavioral descriptions of how this patient individually manifested these problems. The patient's Psychiatric Evaluation dated 1/10/15 noted the following description of the patient's problem, "In recent episodes the patient has externalizing behaviors including appearing to choke himself, swinging [his/her] fist as if to strike [his/her] [spouse]...has demonstrated symptoms consistent with organic brain syndrome including easy fatigability [sic], mood lability and poor frustration tolerance."

8. Patient A17's MTP included the following psychiatric problems statement on the problem list: "Altered thought processes, command auditory hallucination to harm someone (non-specific), constricted/dysphoric affect, poor sleep pattern, ineffective coping, chronic psych illness, mgmt. [management] challenges." Patient A17's "History and Physical" dated 1/9/15 noted the following medical problem: "Hypertension, Iron-deficiency anemia, Type 2 diabetes, and Gastroesophageal Reflux." There was no problem statements, goals, and interventions formulated to address these medical condition.

B. Staff Interviews:

1. In an interview on 1/13/15 at 1:37 p.m. with the Treatment Team Specialist, the MTPs for Patients A1, A3, A12, and A15 were reviewed. He agreed that problem statements were not individualized descriptions of the patients' behaviors and presenting symptoms as identified in clinical assessments.

2. In interview with the Director of Nursing (DON) on 1/13/15 at 11:35 a.m., she agreed that the records did not address medical problems but had concerns about the number of medical problems some patient have and noted they [nursing] would have to prioritize what medical problems would be included on the MTP.

C. Policy Review:

The facility policy titled, "Interdisciplinary Treatment Planning" stipulated, "List problem and describe how the problem is manifested in that particular individual." The clinical staff failed to follow this policy procedure.

Based on document review and interviews, the facility failed to develop individualized treatment plans that identified short-term goals stated in observable, measureable, and behavioral terms for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). This failure hinders the ability of treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify treatment plans in response to patient needs, as well as staff being unable to provide consistent and focus active treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/9/15), A3 (1/9/15), A7 (1/9/15), A9 (1/8/15), A11 (1/8/15), A12 (1/6/15), A15 (1/9/15) and A17 (1/12/15). This review revealed that MTPs included but not limited to the following short term goals (STG) that were not stated in observable, behavioral, and measurable terms with an alternative or replacement behavior that would show the patient's increased level of functioning. In addition, some STGs stated what the patient will "deny or reframe from" instead of stating what the patient would be saying and/or doing to eliminate, reduce, and/or improve his/her presenting problems. Several patients had identical STGs despite having different presenting psychiatric symptoms.

1. Seven (7) patients (A1, A3, A9, A11, A12, A15, and A17) had the following preprinted identical or similarly worded STG: "Pt [Patient] will deny suicidal/homicidal ideation and will refrain from self-harm/assaultive behaviors by (Date was inserted)."

This STG related to what the patient will "deny and refrain from" failed to reflect what the patient would be saying and/or doing to eliminate, reduce, and/or improve his/her presenting problems.

2. Six (6) patients (A3, A9, A11, A12, A15, and A17) "PT [Patient] will exhibit broadening range of affect, be out of bed between (time inserted), and demonstrate appropriate psychomotor activity by (date inserted)."

This STG did not stated "affect and appropriate psychomotor activity" in observable, behavioral and measurable terms with an alternative or replacement behavior that would show the patient's increased level of functioning.

3. Two (2) patients (A3 and A12) had the following preprinted identical or similarly worded STG: "Pt [Patient] will report significantly decreased - 'excessive worry' and will process appropriately in conversation by (date inserted)."

The STG was not stated in behavioral and measurable terms with an alternative or replacement behavior that would show the patient's increased level of functioning.

4. For Patient A1 only: "Pt [Patient] will exhibit stable affect, appropriate level of psychomotor activity, and appropriate social interactions x (days inserted) days by (date inserted)."

This STG did not stated "affect and appropriate psychomotor activity" in observable, behavioral and measurable terms with an alternative or replacement behavior that would show the patient's increased level of functioning.

B. Staff Interviews:

1. In an interview on 1/13/15 at 1:37 p.m. with the Treatment Team Specialist, the MTPs for Patients A1, A3, A12, and A15 were reviewed. He agreed that goal statements were not written in observable, behavior, and measurably terms. He also agreed that most short term goals were not individualized and were identical or similarly worded on the MTPs of most patients.

2. In an interview on 1/13/15 at 1:00 p.m. with the Occupational Therapist, the MTPs for Patients A1, A3, A12, and A15 were reviewed. She agreed that goal statements were not written in observable and behavioral terms and stated that the goals identified in the occupational therapy assessment were more specific to each patient and stated, "These [goals on the OT assessment] don't appear to get on the MTP."

C. Policy Review:

The facility policy titled, "Interdisciplinary Treatment Planning" stated that, "Define behavioral objectives for each treatment intervention which will be indicator of movement towards the goal. Objectives must be specific and measurable, and representing steps toward reaching the goal." The clinical staff failed to follow this policy procedure requiring that goals be specific and measurable.

Based on review of the records and interviews the facility failed to develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). Specifically, Master Treatment Plans (MTPs): (1) included routine and generic discipline functions that were written as active treatment interventions, (2) failed to identify a delivery method (group or individual sessions) and a focus of treatment for active treatment interventions assigned to the physician and registered nurses, and (3) failed to include a focus of treatment approach based on the each patient's presenting symptoms or problems for active treatment groups. In addition, there were no treatment interventions for the recreational therapist included at all on MTPs. These deficiencies potentially result in staff being unable to provide consistent and focus active treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/9/15), A3 (1/9/15), A7 (1/9/15), A9 (1/8/15), A11 (1/8/15), A12 (1/6/15), A15 (1/9/15) and A17 (1/12/15). This review revealed that MTPs did not include individualized active treatment interventions but contained routine and generic discipline functions (such as "encouraging," "monitoring," "assessing," and "dispense medication") written as active treatment interventions to be delivered by the physician, registered nurse and other nursing staff , activity therapist (occupational therapist), and the Treatment Team Specialist. Several intervention statements were identical or similarly worded.

1. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: "Nursing will monitor pt [patient] [every] 15 mins. [minutes] for safe behavior and ensure that pt's [patient's] environment is free from means of self-harm / harm to others."

2. Six (6) patients (A3, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: "Nursing will waken pt [patient] at (time inserted) daily and monitor q [every] 30 mins. [minutes] for changes in affect / psychomotor activity."

3. Four (4) patients (A3, A9, A11, and A12) had the following identical generic and routine nursing intervention: "Nursing will maintain quiet milieu between 2300 and 0630, monitor pt's [patient's] sleep pattern, and provide pt [patient] with 1:1 interaction as needed to process immediate stressors and encourage pt [patient] to return to bed."

4. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: "Nursing will meet with pt [patient] > [greater than] 1 X [time] per waking shift to build rapport, encourage verbalization of feelings, identify stressors, and explore adaptive strategies for coping with stressors."

5. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical nursing intervention: "Nursing will dispense medication, monitor pt [patient] q [every] shift for tolerance /therapeutic effect and provide medication education great than 1x/week. Nursing and pt [patient] will focus on the following medication related to: (the following items were consistently checked) - Compliance, dosage/schedule, interactions with food, ETOH, etc., therapeutic purpose." The "provide medication education" part of the intervention statement was a treatment intervention but failed to include how the intervention would be delivered (group or individual sessions), the duration of the contact with the patient, and the focus of treatment based on each patient's educational needs, such as, knowledge, side effects, benefits of a specific medication(s).

6. Seven (7) patients (A1, A3, A7, A9, A11, A12, and A17) had the following identical nursing interventions that were not individualized. The intervention statement included a list of groups with no specific focus of treatment for each group based on how the patient's precisely manifested presenting the problem(s). "Nursing will facilitate identification of adaptive coping strategies with pt [patient] during the following activity and psychoeducational groups: Sunrise/Rap, 30 mins [minutes] each X 7/week; Illness Ed. [Education] 30 mins [minutes] X 2/week; Relaxation, 30 mins [minutes] X 3/week; Coping and Communication, 60 mins [minutes] X 1/week; Weekly Goals Group 30 mins [minutes] X 1 week." These groups except for the "Relaxation" group were assigned to registered nurses on the MTPs, however, the Treatment Team Specialist during interview on 1/12/15 at 1:37 stated that nurses were no longer responsible for these groups and noted that this change had been made about a year ago. The Director of Nursing confirmed this during an interview on 1/12/15 at but stated that the "Sunrise Group" had been discontinued about the year ago but the other groups had been changed recently.

7. Seven (7) patients (A1, A3, A7, A9, A12, A15, and A17) had the following identical generic and routine physician intervention that was not individualize and did not include the focus or rationale for the medication ordered based on each patient's presenting symptoms: "Physician will order scheduled/PRN antipsychotic/anxiolytic medication by (date inserted) and provide pt [patient] with medication education." The "provide medication education" part of the intervention statement was an active treatment intervention but did not state how the intervention would be delivered (group or individual sessions), duration of contact with the patient, and the focus of treatment based on each patient's educational needs, such as, knowledge, side effects, benefits of a specific medication(s).

8. Seven (7) patients (A3, A7, A9, A11, A12, A15, and A17) had the following identical occupational therapy interventions that were not individualized and was just a list of groups with no focus of treatment for each group based on how patients precisely manifested presenting symptoms and/or problems: "Occupational Therapy will facilitate identification of adaptive coping strategies with pt [patients] during the following groups: Community Re-entry, 30 mins [minutes] X 4 days/week; Life Skills, 60 mins [minutes] X 4 days/week; Leisure Awareness Activity Group, 60 mins [minutes] X 4 days/week."

9. Seven (7) patients (A1, A3, A7, A9, A11, A12, and A17) had the following identical Treatment Team Specialist interventions that were not individualized and was just a list of groups with no focus of treatment for each group based how patients precisely manifested presenting symptoms and/or problems: "Treatment Team Specialist will facilitate identification of adaptive behavioral strategies with pt [patient] during the following groups: Wellness Ed. [Education], 30 mins [minutes] X 1/week."

10. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had no activity therapy interventions on the MTPs assigned to the recreational therapists.

B. Staff Interview:

In an interview on 1/13/15 at 1:37 p.m. with the Treatment Team Specialist, the MTP for Patients A1, A3, A11, and A15 were reviewed. He agreed that interventions were not individualized and were identical for each patient's presenting symptoms. He also acknowledged that some of the group intervention statements were very broad and did not include a specific focus of treatment based on each patient's presenting symptom.

C. Policy Review:

The facility policy titled, "Interdisciplinary Treatment Planning" stipulated, "Define specific treatment modalities which will be utilized to help patient achieve objectives and goals..." The clinical staff failed to follow the requirement for "specific treatment modalities" on the treatment plan.

Based on observation, record review, and interview, the facility failed to ensure that the medication education intervention listed on the Master Treatment Plans (MTPs) was documented by registered nurses for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A7). Specifically, there was no documentation showing patients' participation or non-participating in medication education sessions; the duration of contact with the patient, the topic(s) discussed; and patients' level of response to the medication education provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/9/15), A3 (1/9/15), A7 (1/9/15), A9 (1/8/15), A11 (1/8/15), A12 (1/6/15), A15 (1/9/15) and A17 (1/12/15). This review revealed that there were no treatment notes documented by registered nurses showing that they met with patients in group and/or individual sessions to provide the patient teaching identified on MTPs.

1. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following nursing intervention: "Nursing will...provide medication education great than 1x /week." Nursing and pt [patient] will focus on the following medication related to: (the following items were consistently checked) - "Compliance," "dosage/schedule," "interactions with food, ETOH," etc., "therapeutic purpose." There was no documentation that included the topic and/or medication(s) discussed, the duration of contact, and the patient's response to the intervention such as the patient's level of understanding and behavior(s) exhibited during the intervention.

2. Patient A15 had the following nursing intervention: - "Nursing will provide pt [patient] teaching regarding: illness mgmt. [management], wellness recovery strategies." There was no documentation found in the medical record showing that the registered nurse had contacts with the patient to provide these specific interventions. There was no documentation that included the topic and/or medication(s) discussed, the duration of contact, and the patient's response to the intervention such as the patient's level of understanding and behavior(s) exhibited during the intervention.

B. Staff Interview:

During interview on 1/13/15 at 3:15 p.m. with the Director of Nursing, she stated that registered nurses documented patient teaching in the medical record. After reviewing the medical records on the unit for A1, A3, and A15, she acknowledged that documentation which showed that patients had received medication education was not found in the medical record. In addition, the Director of Nursing admitted that there was no documentation that registered nurses provide Patient A15 teaching sessions regarding "illness management" and "wellness recovery strategies."

Based on observations, interviews, record reviews, and other documentation, the facility failed to:

I. Ensure that adequate active treatment measures and care were provided to one (1) of eight (8) active sample patients (A7) in order to move the patient to a higher level of functioning. Failure to provide a treatment setting that provides active treatment in addition to psychopharmacology, denies patients the care required to ensure their optimal improvement.

II. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a seclusion and/or restraint (S&R) procedure was documented for two (2) of two (2) discharged patients (B1 and B 2) whose records were reviewed for seclusion and restraint episodes. Review of physician notes during the first hour after S&R revealed that notes did not document a comprehensive assessment that included: an evaluation of the patient's medical condition with a complete review of systems; a behavioral assessment; a review of medications and recent laboratory results if available; and the need to continue or discontinue the seclusion and/or restraint procedure. The lack of a complete evaluation a patient during the first hour of seclusion or restraint may potentially result in failure to identify adverse physical and mental effects of a seclusion or restraint procedure.

Findings include:

I. Failure to provide active treatment

A. Record Review:

1. Patient A7 was admitted to the unit on 11/15/14 with a diagnosis of schizophrenia, paranoid type. This was the patient's fifth admission in 2014. Throughout the survey, the patient was observed to be in his/her room and not interacting with other patients of staff. The patient attended no therapeutic groups and ate all his/her meals in his/her room.

2. A review of the Patient Rounds pages for each day from 1/6/15 until 1/12/15 reflected that the patient remained in his/her room for an average of 21 hours per 24-hour time period.

3. The Master Treatment Plan dated 11/17/14 identified one clinical problem: altered thought processes. The interventions, identified to decrease hallucinations and disorganized thinking, include anti-psychotic medication prescribed by the psychiatrist and monitoring of cognition by the nursing staff. The only other interventions to address altered thought processes, other than routine nursing monitoring, were 1) one-to-ones with nursing and activity and 2) psychoeducational groups. Groups assigned to this patient include: Sunrise and Rap Groups 7x/week; Illness Education 2x/week, Relaxation 3x/week, Coping and Communication 1x/week, Weekly Goals Group 1x/week, Community Re-entry Group 4x/week, Leisure Awareness Activity Group 4x/week, and Group Psychotherapy 5x/week. Although the total number of groups assigned to the patient was 22 groups per week, the patient had attended a total of one (1) group during his entire 8-week hospitalization.

4. There were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient isolating in his/her room. There were no revisions to the treatment provided despite ten of the fourteen Treatment Plan Reviews reporting that the patient "remains essentially unchanged."

5. In patient and staff interviews, it was confirmed that the patient does not attend groups and that no alternative treatment plan has been developed to identify appropriate interventions for the patient.

B. Interviews:

1. The patient stated, in interviews on 1/12/15 at 1:00 p.m. and on 1/13/15 at 10:00 a.m. that he/she does not attend groups and that he/she has no intentions of doing so.

2. The Therapeutic Activities Director stated, in an interview on 1/12/15 at 3:00 p.m., that she did not offer groups to Patient A7 because there is an 11/17/14 physician order (written 2 days after admission) documenting: "Patient is not appropriate for Occupational Therapy at this time." The Therapeutic Activities Director stated that she was unaware of and did not know why the treatment plan included group occupational therapy (OT) interventions, when OT groups are not ordered by the physician. In an interview on 1/13/15 at noon, the Therapeutic Activities Director stated that this physician order to not offer OT groups still stands.

3. The RN Clinical Supervisor stated, in an interview on 1/12/15 at 3:30 p.m., that Patient A7 has not attended groups during this hospitalization and that "medication is the only treatment" that the patient is receiving at this time.

4. SW1 stated, in an interview on 1/13/15 at 10:30 a.m., that Patient A7 does not attend groups and that the patient's "main issue is medication management." She stated that most of her work regarding the patient has been "done on the phone and is not reflected in the treatment plan."

5. The Medical Director stated, in an interview on 1/13/15 at noon that Patient A7's delusions keep the patient from participating in therapeutic interactions and that it is difficult to do anything with the patient other than medication management. The Medical Director stated that he was aware that the patient does not attend groups.

II. Failure to document one hour face-to-face assessments after initiation of S&R:

A. Record Review:

1. Patient B1, admitted 7/9/14, was placed in a physical hold on 7/10/14 to administer intramuscular medications. Physician orders were documented but there was no comprehensive one hour face-to-face assessment which included: an evaluation of the patient's medical condition would include a complete review of systems; a review of medications; and recent laboratory results.

2. Patient B2, admitted 6/17/14, had multiple episodes of seclusion and/or restraints. On 7/9/14, the patient had one episode of seclusion and one episode of restraint. On 7/10/14, the patient had one episode of seclusion. There were physician orders documented for each of these episodes but there were no comprehensive one hour face-to-face assessments which included: an evaluation of the patient's medical condition would include a complete review of systems; a behavioral assessment; a review of medications; and recent laboratory results. A review of the Master Treatment Plan for this patient revealed that there were no specific short term goals aimed at the patient developing non harmful behaviors when feeling angry. The MTP also contained clinical tasks such as ordering restraints, restraining per orders, and assessing the patient written as active treatment interventions instead of specific interventions to assist the patient to learn and identify non harmful behaviors

B. Staff Interviews:

1. In interview with the Director of Nursing (DON) on 1/13/15 at 11:35 a.m., episodes of seclusion and restraints were reviewed in the electronic medical record. She agreed that the above cited records did not contain comprehensive one hour face-to-face assessments.

2. In an interview at 9:00 a.m. on 1/14/15, the Medical Director stated that the physician's progress note written at the time of the face-to-face evaluation is the complete documentation written by the MD when seclusion or restraint occurs. He acknowledged that there was not information documented regarding the patient's medical condition, labs, or need to continue or terminate seclusion.

C. Policy Review:

The facility policy titled, "Restraint and Seclusion" stipulated, "One-hour face-to-face assessment: The physician shall perform a face-to-face assessment of the patient's physical and psychological status within one hour of the initiation of restraint." The physician's note failed to include information regarding the patient's physical status for the seclusion and restraint procedures reviewed for Patient B1 and B2. The facility's policy failed to include a requirement for one-hour face-to-face assessment for episodes of seclusion. In addition, there was no stipulation in the policy which required the one-hour face-to-face assessment to include the CMS requirement to evaluate each episode of seclusion and restraint regarding: The patient's immediate situation; the patient's reaction to the intervention; the medical and behavioral condition; and the need to continue or terminate the restraint or seclusion.

Based on interviews, record reviews, and document reviews, the Medical Director failed to:

I. Ensure that social service assessments include conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). This deficiency results in a lack of professional social work treatment services and lack of input to the treatment team. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). Specifically, the MTPs did not include the following: 1) behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119); 2) observable and measurable short term goals written in behavioral terms (Refer to B121); and 3) specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that adequate active treatment measures and care were provided to one (1) of eight (8) active sample patients (A7) in order to move the patient to a higher level of functioning. This deficiency results in the patient being denied care, other than psychopharmacology, to ensure his/her optimal improvement. (Refer to B125, Part I)

IV. Ensure that a comprehensive face to face evaluation of the patient's status within one hour of initiation of a seclusion and/or restraint (S&R) procedure was documented for 2 of 2 discharged patients (B1 and B 2) whose records were reviewed for recent seclusion and restraint episodes. The lack of a complete evaluation a patient during the first hour of seclusion or restraint may potentially result in failure to identify adverse physical and mental effects of a seclusion or restraint procedure. (Refer to B125, Part II)

Based on observation, interview, and record review, it was determined that the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that treatment plans included individualized active treatment interventions to be implemented by nursing staff for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A17). This deficiency potentially results in nursing staff being unable to provide consistent active treatment and focus psychiatric nursing care.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/9/15), A3 (1/9/15), A7 (1/9/15), A9 (1/8/15), A11 (1/8/15), A12 (1/6/15), A15 (1/9/15) and A17 (1/12/15). This review revealed that MTPs did not include individualized active treatment interventions but contained routine and generic discipline functions (such as "encouraging," "monitoring," "assessing," and "dispense medication") written as treatment interventions to be delivered by registered nurse and other nursing staff. Several intervention statements were identical or similarly worded.

1. Eight (8)patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: "Nursing will monitor pt [patient] [every] 15 mins. [minutes] for safe behavior and ensure that pt's [patient's] environment is free from means of self-harm / harm to others."

2. Six (6) patients (A3, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: " Nursing will waken pt [patient] at (time inserted) daily and monitor q [every] 30 mins. [minutes] for changes in affect / psychomotor activity. "

3. Four (4) patients (A3, A9, A11, and A12) had the following identical generic and routine nursing intervention: "Nursing will maintain quiet milieu between 2300 and 0630, monitor pt's [patient's] sleep pattern, and provide pt [patient] with 1:1 interaction as needed to process immediate stressors and encourage pt [patient] to return to bed."

4. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical generic and routine nursing intervention: "Nursing will meet with pt [patient] > [greater than] 1 X [time] per waking shift to build rapport, encourage verbalization of feelings, identify stressors, and explore adaptive strategies for coping with stressors."

5. Eight (8) patients (A1, A3, A7, A9, A11, A12, A15, and A17) had the following identical nursing intervention: "Nursing will dispense medication, monitor pt [patient] q [every] shift for tolerance /therapeutic effect and provide medication education great than 1 x /week. Nursing and pt [patient] will focus on the following medication related to:" (the following items were consistently checked) - "Compliance," "dosage/schedule," "interactions with food, ETOH, etc.," "therapeutic purpose." The "provide medication education" part of the intervention statement was a treatment intervention but failed to include how the intervention would be delivered (group or individual sessions), the duration of the contact with the patient, and the focus of treatment based on each patient ' s educational needs, such as, knowledge, side effects, benefits of a specific medication(s).

6. Seven (7) patients (A1, A3, A7, A9, A11, A12, and A17) had the following identical nursing interventions that were not individualized. The intervention statement included a list of groups with no specific focus of treatment for each group based on how the patient's precisely manifested presenting the problem(s). "Nursing will facilitate identification of adaptive coping strategies with pt [patient] during the following activity and psychoeducational groups: Sunrise/Rap, 30 mins [minutes] each X 7/week; Illness Ed. [Education] 30 mins [minutes] X 2/week; Relaxation, 30 mins [minutes] X 3/week; Coping and Communication, 60 mins [minutes] X 1/week; Weekly Goals Group 30 mins [minutes] X 1 week." These groups except for the "Relaxation" group were assigned to registered nurses on the MTPs, however, during interview on 1/12/15 at 3:15, the Director of Nursing confirmed that except for the relaxation group, these groups were no longer conducted by registered nurses and should not have been included on the MTP for nurses. She stated that the "Sunrise Group" had been discontinued about the year ago but the other groups had been changed recently.

B. Staff Interview:

During interview on 1/13/15 at 3:15 p.m. with the Director of Nursing, she acknowledged that nursing interventions on the MTPs were nursing tasks and/or functions not active treatment interventions to assist the patient accomplished treatment goals and resolve or improve presenting problems.

C. Policy Review:

The facility policy titled, "Interdisciplinary Treatment Planning" stipulated, "Define specific treatment modalities which will be utilized to help patient achieve objectives and goals..." Registered nurses failed to follow the requirement for "specific treatment modalities" on the treatment plan.

II. Ensure that the medication education intervention listed on the Master Treatment Plans (MTPs) was documented by registered nurses for eight (8) of eight (8) active sample patients (A1, A3, A7, A9, A11, A12, A15, and A7). Specifically, there was no documentation showing patients' participation or non-participating in medication education sessions; the duration of contact with the patient, the topic(s) discussed; and patients' level of response to the medication education provided. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)