HospitalInspections.org

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

I. Ensure that the Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included detail information on areas such as education, family issues, religion, vocation, and employment. The major focus of the assessments was on psychiatric and/or substance abuse. Four (4) of eight (8) active sample patients (B1, B2, B3 and B4), the specific role of the social worker in discharge planning was not defined. As a result, the specific social work recommendation regarding psychosocial issues and discharge planning were not described for the treatment team. (Refer to B108)

II. Provide Psychiatric Evaluations that included an assessment of patient personal assets in descriptive, not interpretive fashion for five (5) of eight (8) active sample patients (A1, A2, A3, B2, and B3). The failure to identify patient assets impairs the treatment teams' ability to choose treatment interventions/modalities that utilize the patients' attributes in therapy. (Refer to B117)

III. Ensure that the Master Treatment plans (MTPs) were revised after the application of seclusion or restraint for one (1) of eight (8) active sample patients (A3) and five (5) non-sample patients (C1, C2, C3, C4, and C5) selected to review episodes of seclusion and restraint. Specifically, MTPs were not modified to reflect individualized goals and active treatment interventions to prevent further episodes of these restrictive measures. This failure impedes the provision of active treatment to meet the specific needs of patients. (Refer to B118-II)

IV. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4).

Specifically, the MTPs were missing:

A. Individualized short-term and long-term goals written in measurable, observable, and behavioral terms. (Refer to B121)

B. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems. (Refer to B122)

C. The full name of each staff responsible and accountable for assigned active treatment interventions. (Refer to B123)

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 treatment needs not being met.

V. Provide active treatment, including alternative interventions for three (3) of four (4) active sample patients (A2, A3 and A4) who were unwilling and/or unable to attend groups provided on the unit. 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)

VI. Ensure that Discharge Summaries for two (2) of six (6) sample patients (D1 and D2) contained a recapitulation of the patients' treatment during the hospital stay. This deficiency results in a failure to communicate in a timely manner the specific care that was given to outpatient provider. (Refer to B133)

Based on record review and interview, it was determined that the facility failed to ensure that the Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included detailed information on areas such as education, family issues, religion, vocation and employment. The major focus of the assessments was on psychiatric and/or substance abuse. For four (4) of eight (8) active sample patients (B1, B2, B3, and B4), the specific role of the social worker in discharge planning was not defined. As a result, the specific social work recommendations regarding psychosocial issues and discharge planning were not described for the treatment team.

Findings include:

A. Record Review

Lack of information on psychosocial issues such as education, family issues, religion, vocation, and/or employment

1. Patient A1, Psychosocial Assessment, dated 7/7/17, stated patient was "homeless" --- "patient's perception of problem(s): 'I lost my meds [medications] and fell off the wagon.'" "Patient presents as experiencing detox from ETOH [Alcohol] with reported depressive symptoms of hopelessness and S/I [Suicidal Ideation]." The section on "Family/guardian control and family systems/family history" was blank. The information under "Clinical formulation" related to patient's psychiatric and/or substance problems.

2. Patient A2, Psychosocial Assessment, dated 7/7/17, stated, "Pt presented as irritable, annoyed, angry, and declined to participate in the psychosocial interview." The report went on to describe contact with the patient's husband/wife and of present preference on treatment and discharge. The "Clinical formulation" focused on the patient's psychiatric disorders and hospitalizations.

3. Patient A3, Psychosocial Assessment, dated 4/14/17, stated, "Unable to verbalize reason for admission due to psychosis." For patient's expectation of this hospitalization, "Unknown at this time." The "Clinical formulation" focused on the psychiatric issues, which lead to admission of trying to bring a bank teller a gift and diagnosis of schizophrenia.

4. Patient A4, Psychosocial Assessment, dated 5/27/17, stated, "Patient's perception of the problem as 'a suicide attempt.' My meds were being shipped Missoula, MT (Montana) and either they were being stolen by roommates or they were just not getting to me." The "Clinical formulation" focused on the psychiatric issues that brought the patient to the facility such as "a suicide attempt where [s/he] overdosed on Benadryl and possibly Gabapentin and Paxil."

5. Patient B1, Psychosocial Assessment, dated 6/29/17, stated, "[Name of patient] was admitted to WBI [Wyoming Behavioral Institute] after experiencing what [s/he] described as [s/he]'s first psychotic episode." The information on the rest of the assessment dealt with psychiatric problems and treatment needs only. No family issues, education, development, mental issues etc. for this teenager were described.

6. Patient B2, Psychosocial Assessment, dated 7/8/17, stated, "Pt reports very classic ADHD [Attention Deficit Hyperactive Disorder]. Reports [s/he] gets angry and upset that [s/he] is in trouble for forgetting things. Have regrets about yelling and blowing up. Reports impulsive behavior." The "Clinical formulation" focused on the patient's treatment needs.

7. Patient B3 [a teenager], Psychosocial Assessment, dated 6/28/17, stated, "Because is [sic] mad." "Reports that [s/he] took [his/her] brother [name of brother] to get high and get mad for getting in trouble. States it is bull shit and refused more discussion." The "Clinical formulation" focused on the patient's treatment needs.

8. Patient B4 [a teenager], Psychosocial Assessment, dated 6/26/17, stated, "Patient's perception of the problem(s) that [s/he] was upset and agitated when [s/he] returned to YCC [Youth Crisis Center]. Pt noted that when [s/he] returned to the Henry House [s/he] became agitated because [his/her] ex fiancé rejected [him/her]. In addition, pt reported that [his/her] peers were making lies about [him/her] and [s/he] thought it would be best if [s/he] left." The "Clinical formulation" focused on the patient's treatment needs.

The lack of social worker's role in discharge planning

1. Patient B1, Psychosocial Assessment, dated 6/29/17, had under "Discharge needs/preliminary plan," "[Name of patient] will discharge to PRTF [Psychiatric Residential Treatment Facility]."

2. Patient B2, Psychosocial Assessment, dated 7/8/17, had under "Discharge needs/preliminary plan," "Pt will need to stabilize in [his/her] behavioral outburst and then discharge home with outpatient and medication management."

3. Patient B3, Psychosocial Assessment, dated 6/28/17, had under "Discharge needs/preliminary plan," "[S/he] will be evaluated for possible PRTF placement or stabilization and discharge home."

4. Patient B4, Psychosocial Assessment, dated 6/26/17, had under "Discharge needs/preliminary plan," "Return to YCC."

B. Interview

In an interview on 7/11/17 at 2:56 p.m., the lack of psychosocial information on the Psychosocial Assessments and the lack of role of the social worker on discharge planning were discussed with the Director of Social Work. She stated that all this information was taken off the initial assessments from admission, "Nursing Assessments and Psychiatric Evaluations." She agreed that all the psychosocial information should be included on their forms.

Based on record review and interview, the facility failed to provide Psychiatric Evaluations that included an assessment of patient personal assets in descriptive, not interpretive fashion for five (5) of eight (8) active sample patients (A1, A2, A3, B2, and B3). The failure to identify patient assets impairs the treatment teams' ability to choose treatment interventions/modalities that utilize the patients' attributes in therapy.

Findings include:

A. Record Review

The Psychiatric Evaluations (dates in parenthesis), for the following patients did not contain specific assets or personal attributes, which could be useful in treatment:

1. Patient A1 (7/7/17) - The Psychiatric Evaluation listed the asset as "I don't know."

2. Patient A2 (7/6/17) - The Psychiatric Evaluation listed the asset as "Not responsive."

3. Patient A3 (4/16/17) - The Psychiatric Evaluation listed the asset as "Lifting weights."

4. Patient B2 (7/9/17) - The Psychiatric Evaluation listed the asset as "Basketball."

5. Patient B3 (6/28/17) - The Psychiatric Evaluation did not identify an asset.


B. Interview

In an interview 7/11/17 at 4:00 p.m., the lack of personal assets on the Psychiatric Evaluations was discussed with the Medical Director. He stated that this issue had been mentioned by other surveyors and that he was aware of and working with the medical staff on correcting this problem.

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

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4).

Specifically, the MTPs were missing:

A. Individualized short-term and long-term goals written in measurable, observable, and behavioral terms. (Refer to B121)

B. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems. (Refer to B122)

C. The full name of each staff responsible and accountable for assigned active treatment interventions. (Refer to B123)

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 treatment needs not being met.

II. Ensure that the Master Treatment plans (MTPs) were revised after the application of seclusion and restraint for one (1) of eight (8) active sample patients (A3) and five (5) non-sample active patients (C1, C2, C3, C4, and C5) selected to review episodes of seclusion and restraint. Specifically, MTPs were not modified to reflect individualized goals and active treatment interventions to prevent further episodes of these restrictive measures. This failure impedes the provision of active treatment to meet the specific needs of patients.

Findings include:

1. Patient A3, an adult patient, experienced an episode of restraint (physical hold) on 5/6/17 from 3:25 a.m. to 3:32 a.m. because the patient was "hitting a peer & swinging at staff- verbalizing threats that [s/he] will hurt people." The patient was given Zyprexa 10 mg. Intramuscular (IM) and Ativan 2 mg. IM to help control his/her behavior. A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" was used by the facility to modify each patient's treatment after episodes of seclusion or restraint. This form initiated for Patient A3 on 5/6/17, included an individualized problem statement; however, the reprinted goal statements on the form were not individualized or based on this patient's specific needs. Therefore, the identical goals statements were included for all patients who were secluded or restrained. Under the section of the form titled, "Interventions" was used for collecting assessment information. There were no interventions formulated with specific strategies or approaches to be implemented by assigned staff conducted in individual or group sessions to help the patient to use healthy and non-harmful behaviors. In addition, there were no interventions that identified the frequency of contacts with the patient or the particular focus of treatment based on the patient's needs and aggressive issues.

2. Patient C1, a child patient, was restrained (physical hold) on 5/20/17 from 10:55 a.m. to 10:57 a.m. because the patient was "attacking staff, screaming, yelling, ripping [sic] scanners off the wall." The patient also experienced an episode of seclusion on 5/22/17 from 8:05 a.m. to 8:36 a.m. for "throwing milk at staff. A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" had all three preprinted goal statements circled, and the word "unknown" was written in the section identified as "other." There were no interventions on this form that included what each discipline would do to assist this patient in preventing future occurrences of restraint. There were no clinical disciplines assigned to be responsible for meeting with the patient in individual or group sessions. In addition, the frequency of contact and the particular focus of treatment based on the patient's needs and aggressive issues were not identified for interventions.

3. Patient C2, an adult patient, was restrained (physical hold) on 5/1/17 from 8:30 p.m. to 8:53 p.m. because the patient was "verbally threatening staff ... picking up a chair to throw at staff ..." The patient was given Zyprexa 10 mg. Intramuscular (IM) and Ativan 2 mg. IM to help control his/her behavior. A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" had none of three preprinted goal statements circled. There were no interventions on this form that included what each discipline would do to assist this patient in preventing future occurrences of restraint. In addition, there were no intervention statements that identified a delivery method (individual or group sessions with the patient), the frequency of contact, and the particular focus of treatment based on the patient's needs and aggressive issues.

4. Patient C3, a child patient, was restrained (physical hold) and secluded on 6/28/17. The restraint was from 5:44 p.m. to 6:10 p.m. and the seclusion was from 6:10 p.m. to 6:18 p.m. because the patient "tore cover off of name badge and tried to slam door on a staff's hand." The patient was given Geodon 20 mg. Intramuscular (IM) and Benadryl 50 mg IM to help to control his/her behavior. A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" had all three preprinted goal statements circled, and the word "unknown" was written in the section identified as "other." There were no interventions on this form that included what each discipline would do to assist this patient in preventing future occurrences of restraint or seclusion. There was no staff identified to be responsible for individual or group sessions with the patient, In addition, there was no intervention statement on this form that identified the frequency of contacts with the patient and the particular focus of treatment based on the patient's needs and aggressive issues.

5. Patient C4, an adolescent patient, experienced five (5) episodes of restraint on 6/6/17 from 3:51 p.m. to 3:53 p.m. and from 10:00 p.m. to 10:19 p.m.; on 6/7/17 from 9: 25 p.m. to 9:35 p.m. and from 9:48 p.m. to 10:07 p.m.; and on 6/24/17 from 10:30 a.m. to 10:40 a.m. The patient was also secluded on 6/21/17 from 1:20 p.m. to 2:11 p.m. These restrictive procedures were employed for a variety of aggressive behaviors including: " ... attacked staff," "attempting to grab badge to elope," and "cutting [his/her] wrist with a plastic paper clip." The patient was also given Geodon 20 mg. Intramuscular (IM) and Benadryl 50 mg IM on 6/7/17 and 6/24/17, and Ativan 0.5 mg on 6/6/17 to help to control his/her behavior. A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" was completed for each use of restrictive procedure. Despite these multiple episodes, there was no modification of this MTP to formulate active treatment interventions to show what each discipline would do to assist this patient in preventing future use of restrictive procedures. In addition, there was no evidence documented in this MTP that assigned the clinical disciplines responsible for meeting with the patient in individual or group sessions at an identified frequency to assist the patient in using non-harmful methods to address his/her aggressive behaviors.

6. Patient C5, an adolescent patient, experienced an episode of restraint (physical hold) on 6/23/17 from 9:08 p.m. to 9:16 p.m. because the patient "made threatening movement toward staff with glass." A form titled, "Master Treatment Plan - Plan to eliminate use of Seclusion and/or Restraint" had none of three preprinted goal statements circled. There were no interventions on this form that included what each discipline would do to assist this patient in preventing future occurrences of restraint. In addition, there were no intervention statements that identified the clinical disciplines responsible and accountable for individual or group sessions with the patient, the frequency of contact, and the particular focus of treatment based on the patient's needs and aggressive issues.

B. Policy Review

The facility's policy titled, "Seclusion and Restraint for Behavior Management" last reviewed June 2016 stipulated that, "... When the patient has presented behavior that is dangerous to themselves or to others so the R/S [Restraint/Seclusion] were indicated, a review and modification of the treatment plan is indicated ... The updated treatment plan shall reflect ... Interventions which defines alternative approaches to address the identified problem. Responsibility for each intervention assigned ..." The special MTP form used by the facility after use of restrictive procedures did not conform to the facility's requirement for interventions with alternative approaches and assigned with staff responsibility.

C. Interview

In a discussion on 7/11/17 at approximately 2:00 p.m., with the Director of Nursing, the form titled, "Master Treatment Plan- Plan to eliminate use of Seclusion and/or Restraint" for Patient A3 was discussed. She did not dispute the finding that there were no targeted interventions that showed the assigned clinical disciplines responsible for meeting with patients in individual or group sessions to address strategies to prevent further use of restrictive procedures. She also acknowledged that there was no identified frequency of contact and focus of treatment based on each patient's individualized needs regarding the exhibited aggressive behavior(s).

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included specific long-term goals (LTGs) and short term goals (STGs) written in behavioral, observable, and measurable terms, in language understandable to patients, and free of non-descriptive psychiatric jargon for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, the goal statements on MTPs did not reflect what the patient would do to lessen the severity of the identified psychiatric problem(s). The absence of defined goals against which to measure progress, made it difficult to judge the effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Patient A1's MTP, dated 7/7/17, had the following deficient goals for the problem, -"Depression [with] S/I [Suicide Ideations] - Evidenced by: [Patient] ... making suicidal statements while intoxicated stating [s/he] was going to drink [himself/herself] to death ..."

LTG: "Alleviate or control depressive symptoms at a manageable level."

STG: "To identify contributing factors to [his/her] depressive symptoms, such as [his/her] drinking."

2. Patient A2's MTP, dated 7/7/17, had the following deficient goals for the problem, -"Depression [with] Suicidal thoughts - Evidenced by: [Patient] ... expressed suicidal [sic] states 's/he wishes s/he was dead.' Significant history of mental issues and hospitalizations."

LTG: "Stabilize suicidal crisis."

STG: "Identify factors that triggered suicidal ideation."

3. Patient A3's MTP, dated 4/14/17 and updated 7/6/17, had the following deficient goals, identified on a preprinted form, for the problem, "Psychotic Symptoms - Behavioral Manifestations/Observations: [This section was left blank]."

LTG: "Patient will be free from hallucinations for 4 days prior to discharge."

STG: "Patient will demonstrate decreased hallucinative [sic] episodes to 4 times per day."

4. Patient A4's MTP, dated 7/6/17, had the following deficient goals for problem #1, "Suicidality - Evidenced by: [Patient] admitted s/p [special precaution] OD [overdose]. [Patient] has 'numerous' prior s/a [suicide attempt] [od] ... [Patient] reports increased feelings of depression/hopelessness."

LTG: "Alleviate the suicidal impulses/ideation and return to the highest level of previous daily functioning."

STG: "Achieve a level of symptom stability that allows for the meaningful participation in psychotherapy and increased quality of life."

5. Patient B1's MTP, dated 6/29/17, had the following deficient goals for the problem, - "Psychosis - Evidenced by: [Patient] and [his/her] mother report [Patient] had a psychotic episode in which [s/he] appeared to be in a dreamlike state in which [s/he] was hallucinating and [s/he] did not appear to be oriented to time and place."

LTG: "[Patient] will work to manage [his/her] symptoms of psychosis to the point [s/he] is able to function WNL [within normal limits] outside the acute facility."

STG: "[Patient] will work to identify a minimum of 3 triggers and stressors for the onset of [his/her] psychosis symptoms."

6. Patient B2's MTP, dated 7/8/17, had the following deficient goals for the problem, - "Depression - Evidenced by: Pt [Patient] expresses self-worthlessness& hopelessness & has risky Bx [behavior] when stressed."

LTG: No long-term goal was identified.

STG: "Pt [Patient] will improve in coping skills use."

7. Patient B3's MTP, dated 6/28/17, had the following deficient goals for the problem, "Depression [with] S/I [Suicide Ideations]. This patient had no MTP formulated with a descriptive problem statement, no long and short-term goals, and no intervention statements. The MTP only contained a preprinted from stating, "Discharge Planning: Problem" with "Home" checked from a list of options.

8. Patient B4's MTP, dated 6/26/17, had the following deficient goals for the problem, "Suicidal Ideation [with] plan - Evidenced by: reports wanted to suffocate [himself/herself]. Self-harming on arm after being rejected by peers."

LTG: No long-term goal was identified.

STG: "Terminate SI [suicidal ideations] and increase utilization of coping skills when rejected."

None of the long and short-term goals above were individualized or written in measurable, observable, and behavioral terms. Goal statements failed to reflect what each patient would be saying or doing to improve presenting psychiatric symptoms. Therefore, it would be hard for the patient and staff to determine progress and improvement. For goals that required the patient to identify triggers and stressors, the goal statements did not spell out possible replacement behaviors or strategies the patient could use, practice, or learn once triggers and stressors were identified. Many symptoms identified in goal statements such as depression, suicidal ideations, psychotic behavior, hallucinations, were not clearly or behaviorally described. This also made it difficult for the patient and staff to know what to observe to determine progress or improvement. For goals regarding coping skills, there was no information related to the focus of skills based on clinically assessed psychiatric problems or needs.

B. Policy Review

The facility's policy last revised March 2016 and titled "Treatment Planning" stated, " ... Measurable goals and objectives based on assessed needs are documented in the plan. Objectives are specific enough to evaluate the patient's progress and expressed in behavioral terms. The facility policy failed to follow its own as well as CMS requirements for goals to be written in measurable, observable, and behavioral terms.

C. Interview

In an interview on 7/12/17 at 9:50 a.m. with the Director of Nursing, MTPs plans of the active sample patients were discussed. She did not dispute the findings that goals were not written in measurable, observable, or behavioral terms.

Based on record review, observation, and interview, the facility failed to provide eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) with Master Treatment Plans (MTPs), which included individualized active interventions that stated specific treatment modalities with a specific focus or purpose based on the each patient's identified psychiatric problems. Instead, the MTPs included generic job description functions or global statements written as treatment interventions rather than specific interventions to assist in recovery. In addition, MTPs contained no recreational therapy (RT) and occupational therapy (OT) intervention statements. These groups were not included on MTPs despite the facility's expectations that all patients attend the scheduled OT and RT groups. Also, three (3) of four (4) active sample patients (B1, B3, and B4) on the Youth Acute Unit were observed attending and participating in the scheduled OT and RT groups assigned to OT staff. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient A1's MTP dated 7/17/17 had the following deficient interventions for the identified psychiatric problem of "Depression [with] S/I [Suicide Ideations] - Evidenced by: [Patient] ... making suicidal statements while intoxicated stating [s/he] was going to drink [himself/herself] to death ..."

Psychiatrist Intervention: "Evaluate [Patient] continuing need for psychotropic medications if necessary. Monitor for side effects and attain commitment for compliance once [s/he] leaves the hospital."

Nursing Intervention: "Monitor [Patient] on SW [suicide watch], Assess suicidality daily, No Medications are ordered @ this time." "Treatment Modality - Patient Education, Assessment."

Therapist Intervention: "Identify strategies in which to manage depressive symptoms on a daily basis." "Treatment Modality - Individual, Group 7-60 minutes therapy groups."

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient.

Patient A2's MTP dated 7/17/17 had the following deficient interventions for the identified psychiatric problem of "Depression [with] Suicidal thoughts - Evidenced by: [Patient] ... expressed suicidal [sic] states 'she wishes she was dead.' Significant history of mental issues and hospitalizations."

Psychiatrist Intervention: "Assess [Patient] need for psychotropic medications."

Nursing Intervention: There was no nursing intervention identified for this patient.

Therapist Intervention: "Encourage [Patient] to attend daily therapy groups to assist in identifying factors that were significant precursors to the beginning of [his/her] suicidal ideation." "Treatment Modality - "Individual, Group 7-60 minutes therapy groups."

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient.

3. Patient A3's MTP dated 7/6/17 had the following deficient interventions from a preprinted list of options for the identified psychiatric problem of "Psychotic Symptoms - Behavioral Manifestations/Observations: [This section was left blank]."

Psychiatrist Intervention: "Assess effectiveness of medications and need for titration."

Nursing Intervention: "Establish trusting relationship, to provide support and reality testing."

Therapist Intervention: There were no options checked for this patient.

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient.

4. Patient A4's MTP dated 7/6/17 had the following deficient interventions for the identified psychiatric problem #1, "Suicidality - Evidenced by: [Patient] admitted s/p OD. [Patient] has 'numerous' prior s/a [od] ... [Patient] reports increased feelings of depression/hopelessness."

Psychiatrist Intervention: "Restart the patient's psychotropic medications, monitor for adverse side effects and work with patient to attain commitment to medication compliance once [s/he] is discharged from the hospital." "Treatment modality - Individual, Group." No option was checked.

Nursing Intervention: "Redirect aggressive behavior and discuss appropriate ways to make requests. Provide schedule and [sic] pt [patient] of group times especially CD [Chemical Dependent] group." "Treatment Modality - "Patient Education."

Therapist Intervention: "Encourage [Patient] to attend 60 minutes chemical dependency groups daily to assist the client in increasing [his/her] awareness of factors that led to the development of chemical dependency and serve as risk factors for relapse." Treatment Modality - "Group."

Therapist Intervention: "Get an ASI [Addition Severity Index] or update current ASI for pt [patient] to determine appropriate level of tx [treatment] for cd [chemical dependency]."

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient.

5. Patient B1's MTP dated 6/29/17 had the following deficient interventions for the identified psychiatric problem of "Psychosis - Evidenced by: [Patient] and [his/her] mother report [Patient] had a psychotic episode in which [s/he] appeared to be in a dreamlike state in which [s/he] was hallucinating and [s/he] did not appear to oriented to time and place."

Psychiatrist Intervention: "Pt [Patient] will attend group 7 days per wk [week] and do individuals 7 days per week. Cont [Continue] to assess need to have extended care and med management." Treatment modality - "Individual, Group."

Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills." Treatment Modality - "Patient Education, Assessment."

Therapist Intervention: "Patient will attend 7-60 minute individual therapy session per week and 1-60 minute family therapy session per week. Treatment Modality - "Individual, Group."

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient. Patient B1 was observed, on 7/11/17. attending and participating in the "COTA [Certified Occupational Therapist] Recreational Therapy" Group from 10:10 a.m. to 10:40 a.m. in the group room.

6. Patient B2's MTP dated 7/8/17 had the following deficient interventions for the identified psychiatric problem of, "Depression - Evidenced by: Pt [Patient] expresses self-worthlessness& hopelessness & has risky Bx [behavior] when stressed."

Psychiatrist Intervention: "Patient will focus on impulsivity and hyperactivity- use coping skills for anger and commit to being safe [sic] discharging home. Continue to participate in [sic] outpatient therapy." Treatment modality - "Individual, Group." No option was checked. This was a statement of what the patient will do instead of an active treatment intervention to be provided by the psychiatrist reflecting meetings with the patient provide information about prescribed medications and the patient's psychiatric illness.

Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills." Treatment Modality - "Patient Education, Assessment."

Therapist Intervention: "[Patient] will participate in improving [sic] coping skills effective understanding of this bx [behavior] Treatment Modality - "Individual, Group." This was a statement regarding what the patient will do instead of a specific intervention statement about what the therapist would do to assist the patient in individual or group sessions.
Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient.

7. Patient B3's MTP dated 6/28/17 had no interventions for the identified psychiatric problem of, -"Depression [with] S/I [Suicide Ideations]. In addition, there were no descriptive problem statements, long and short-term goals, and intervention statements. The MTP only contained a preprinted form stating, "Discharge Planning: Problem" with "Home" checked from a list of options.

Patient B3 was observed on 7/11/17, attending and participating in the "COTA Recreational Therapy" Group from 10:10 p.m. to 10:40 a.m. in the group room. However, there was no RT or OT intervention included on his/her MTP.

8. Patient B4's MTP dated 6/28/17 had the following deficient interventions for the identified psychiatric problem of - "Suicidal Ideation [with] plan - Evidenced by: reports wanted to suffocate [himself/herself]. Self-harming on arm after being rejected by peers."

Psychiatrist Intervention: "Evaluate pt's [patient's] need for psychotropic medication. Monitor pt for adverse side effects and work [with] pt to attain commitment." Treatment modality - "Individual, Group." No option was checked.

Nursing Intervention: "Monitor pt [patient] at intervals not to exceed 15 minutes for safety, administer prescribe medications and frequency ordered by providers and complete room checks for hazards." Treatment Modality - "Patient Education, Assessment." No option was checked.

Therapist Intervention: "Encourage client to identify [his/her] specific needs that are not met and how [s/he] can use coping skills when depressed instead of SI [suicidal ideations]." Treatment Modality - "Individual, Group."

Therapist Intervention: "Encourage pt to identify 5 positive things about [himself/herself] that will be independent traits."

Therapeutic Activity Staff: There were no therapeutic activity staff interventions for this patient. Patient B4 was observed, on 7/10/17, attending and participating in the "COTA Recreational Therapy" Group at 2:45 p.m. in the gymnasium.

The intervention statements above were not individualized, non-specific, and failed to include a focus of treatment based on this patient's presenting problems and/or treatment goals. Interventions with statements such assess, evaluate, encourage, monitor, administer medications, establish a relationship were all generic, routine tasks, or normal job duties rather than specific active treatment interventions to assist the patient to improve. Several interventions did not circle the choice of treatment modality (individual or group). Therefore, it was unclear whether the discipline planned to use both modalities. The nursing group intervention statement was non-specific and failed to identify the particular medications or category of medications to be discussed. In addition, the statement failed to specify the focus of treatment for stress management and coping skills.

B. Policy Review

The facility's policy last revised March 2016 and titled, "Treatment Planning" stated, " ... specific behavioral interventions are to be recorded on the Treatment Plan and identification of the specific staff who is going to deliver the intervention." The facility policy failed to follow its own requirements regarding intervention statements. Also, the policy did not guide staff regarding CSM requirements stipulating individualized and specific modalities with a focus of treatment for each patient.

C. Interviews

1. In an interview on 7/12/17 at 9:50 a.m. with the Director of Nursing, MTPs plans of the active sample patients were discussed. She did not dispute the findings that several intervention statements were routine job duties or clinical tasks. She agreed that nursing interventions failed to be individualized and did not specify particular medications or categories of medications to be taught in the Nursing Group. She also acknowledged that interventions failed to identify the specific focus of treatment regarding stress management and coping skills for each patient.

2. In an interview on 7/11/17 at 3:55 p.m. with the Registered Occupational Therapist (OTR) responsible for coordinating Occupational and Recreational Therapy, the absence of OT and RT interventions on MTPs was discussed. She stated, "I absolutely agree that interventions should be on the plans."

Based on record review and interview, the facility failed to ensure that the name of each staff responsible for treatment interventions was listed on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, the full name of staff responsible was not included for each intervention on MTPs. In addition, several names of staff responsible for interventions were not legible. This practice results in the facility's inability to monitor staff accountability for specific active treatment interventions.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (7/7/17), A2 (7/7/17), A3 (4/14/17; updated 7/6/17), A4 (7/6/17), B1 (6/29/17), B2 (7/8/17), B3 (6/28/17), and B4 (6/26/17). This review revealed the following findings:

1. Patient A1:

a. Psychiatrist Intervention: "Evaluate [Patient] continuing need for psychotropic medications if necessary. Monitor for side effects and attain commitment for compliance once [s/he] leaves the hospital."

b. Therapist Intervention: "Identify strategies in which to manage depressive symptoms on a daily basis." Treatment Modality - "Individual, Group 7-60 minutes therapy groups."

The psychiatrist and therapist names were illegible for the assigned interventions on the MTP and on the signature page.

Patient A2:

Psychiatrist Intervention: "Assess [Patient] need for psychotropic medications."

The psychiatrist signature was illegible for the assigned intervention on the MTP and on the signature page.

3. Patient A3

a. Nursing Intervention: "Establish trusting relationship, to provide support and reality testing."

b. Therapist Intervention: There were no options checked for this patient.

c. Occupational Therapy Intervention: "Establish trusting relationship, to provide support and reality testing."

The assigned intervention for the nursing staff, OT, and therapist had the first names listed but no last name.

4. Patient A4:

a. Psychiatrist Intervention: "Restart the patient's psychotropic medications, monitor for adverse side effects and work with patient to attain commitment to medication compliance once [s/he] is discharged from the hospital." Treatment modality - "Individual, Group." No option was checked.

b. Therapist Intervention: "Encourage [Patient] to attend 60 minutes chemical dependency groups daily to assist the client in increasing her awareness of factors that led to the development of chemical dependency and serve as risk factors for relapse." Treatment Modality - "Group."

The psychiatrist and therapist names were illegible for the assigned intervention on the MTP and on the signature page.

5. Patient B1:

a. Psychiatrist Intervention: "Pt [Patient] will attend group 7 days per wk and do individuals 7 days per week. Cont [Continue] to assess need to have extended care and med management." Treatment modality - "Individual, Group."

b. Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills." Treatment Modality - "Patient Education, Assessment."

c. Therapist Intervention: "Patient will attend 7-60 minute individual therapy session per week and 1-60 minute family therapy session per week. Treatment Modality - "Individual, Group."

The psychiatrist and nurse names were illegible for the assigned intervention on the MTP and there was no signature page. The therapist assigned intervention only included the initials of the staff responsible for the intervention.

6. Patient B2:

a. Psychiatrist Intervention: "Patient will focus on impulsivity and hyperactivity- use coping skills for anger and commit to being safe [sic] discharging home. Continue to participate in [sic] outpatient therapy."

b. Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills."

c. Therapist Intervention: "[Patient] will participate in improving [sic] coping skills effective understanding of this bx [behavior]."

The psychiatrist, nurses, and therapist names were all illegible for the assigned interventions on the MTP.

7. Patient B3:'s MTP dated 6/28/17 had no interventions for the identified psychiatric problem of, -"Depression [with] S/I [Suicide Ideations]."

8. Patient B4:

a. Nursing Intervention: "Monitor pt [patient] at intervals not to exceed 15 minutes for safety, administer prescribe medications and frequency ordered by providers and complete room checks for hazards."

b. Therapist Intervention: "Encourage client to identify [his/her] specific needs that are not met and how [s/he] can use coping skills when depressed instead of SI [suicidal ideations]."

c. Therapist Intervention: "Encourage pt to identify 5 positive things about [himself/herself] that will be independent traits."

The assigned intervention for nursing staff, OT, and therapist had the first names listed but no last name.

B. Staff Interviews

1. In an interview on 7/11/17 at 2:56 p.m. with the Director of Clinical Services/Social Work, MTPs were reviewed. She agreed that full name of the clinical staff responsible for implementing treatment interventions was not included but should be included on treatment plans.

2. In an interview on 7/12/17 at 9:50 a.m., the Director of Nursing agreed that MTPs had first names and often just the initial.

Based on record review, observation, and interviews, the facility failed to provide active treatment, including alternative interventions for three (3) of four (4) active sample patients (A2, A3, and A4) who were unwilling and/or unable to attend groups provided on the unit. 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. Record Review

Patient A2

1. Patient A2was admitted on 7/5/17. The Psychiatric Evaluation, dated 7/6/17, stated, "The patient is a 31-year-old Caucasian [male/female] involuntary hold due to suicidal mood, impaired concentration, excessive feelings of hopelessness, excessive feelings of worthlessness, excessive feelings of guilt, and endorses severe anhedonia." The patient was previously diagnosed with bipolar disorder, PTSD [Post-Traumatic Stress Disorder] and generalized anxiety disorder.

2. RN1 was asked on 7/10/17 around 10:13 a.m. to identify any patients on the unit who were not regularly attending the groups. RN1 identified patient A2 as a patient who seldom attended group on the unit. RN1 stated, "[S/he] just stays in [his/her] room most of the time." RN1 reported that all patients were expected to attend the groups on the unit as scheduled.

3. Patient A2 was observed in [his/her] bed on 7/10/17 around 10:40 a.m. with eyes open. The patient refused to answer any questions asked by surveyor. A "Recreation Group" was currently taking place in the Dayroom from 10:30 a.m. to 11:30 a.m.

4. The "Adult Unit Main Hall Program Schedule" provided 9 groups per day seven days a week between 8:45a.m. to 9:00p.m.

5. Patient A2's Master Treatment Plan (MTP), dated 7/7/17, did not list any specific groups from the unit's activity schedule. It just stated, "Encourage [name of patient] to attend daily therapy groups."

6. A review of patient A2's progress notes between 7/7/17 - 7/10/17, listed one progress note on 7/7/17 at 1:30p.m. that addressed the patient's group attendance. The note stated, "Pt presents with a dysphoric affect, was easily irritable & was isolative. Pt declined medications, management group, therapies, unit activities & meals."

7. The "Patient Observation Record," between 7/7/17 - 7/10/17, showed zero attendance at any groups on the unit during this period.

Patient A3

1. Patient A3 was admitted on 4/13/17. The Psychiatric Evaluation, dated 4/13/17, stated, "[Name of patient] is a 48-year-old Hispanic American [male/female], born and raised in Torrington, Wyoming. [S/he] had never been married and is the [father/mother] of three children, a 24-year-old daughter, a 27-year-old son and a 29-year-old son, respectively. [S/he] is now living in Scottsbluff, Nebraska" --- "This is [his/her] eighth admission to [name of facility]. When [name of patient] was evaluated, [s/he] was not saying anything that made sense. [Name of patient] said something about the sun and winning the lottery in Scottsbluff, Nebraska, another state, and said [s/he] donated the money to Saint Joseph. [Name of patient's] facial expression is suspicious and perplexed. [S/he] is polite, illogical, nonsensical, rambling, under talkative, controlled, confused, delusional and psychotic. [S/he] has experienced auditory hallucinations."

2. RN1, on 7/10/17 around 10:12a.m., identified patient A3 as one who did not attend groups regularly on the unit.

3. Patient A3 was observed walking around the hallways of the unit on 7/10/17 around 10:33 a.m. When approached [s/he] kept talking about winning the lottery and getting [his/her] Accu-checks done for diabetes. This was during the "Recreation Group" being conducted in the Dayroom from 10:32a.m. to 11:30 a.m.

4. A3's MTP, dated 4/14/17 and updated 7/6/17, listed no specific groups from the unit schedule on the patient's MTP.
A Nursing Progress Note, dated 7/9/17 at 10:30 a.m., stated "Pt continues to be compliant with diet, continues to refuse diabetic meds [insulin]. Given opportunities to attend groups - pt refused; isolated in room following breakfast."

5. Another Nursing Progress Note, dated 7/10/17, stated, "Patient has been agitated today and asked for an AMA [Against Medical Advice] form which was denied. [S/he] has been isolating and when in the milieu, very irritable and verbally aggressive. [S/he] is visibly mad, stomping around and has a negative look."

6. The "Patient Observation Record," dated 7/7/17 - 7/9/17, showed that patient attended a "Community Group/Goals" at 9:00 a.m. on 7/7/17 and time outside at 5:15 p.m. and "personal reflective time/assignments/vital signs" from 6:00 p.m. to 7:00 p.m. [S/he] attended same 9:00 a.m. group listed above at 9:00 a.m. on 7/8/17 and no groups on 7/9/17.

Patient A4

1. Patient A4 was admitted on 7/4/17 at 6:37p.m. The Psychiatric Evaluation, dated 7/5/17 stated, "This is the second [name of facility] for [name of patient] 45-year-old [male/female] who was born in Everett, WA and currently resides in Casper, Wyoming. [Name of patient] was admitted to [name of facility] on 7/4/17 at 6:37p.m., for acute stabilization. "Has been staying at the mission since [his/her] last [name of facility] a month ago [overdosed on Benadryl]. On the morning of 7/2/17, [s/he] got kicked out of shelter for not checking back in and doing proper paper work. Admits to leaving shelter the night before to hang out with a male friend [[not a boyfriend], named [name of friend] who [s/he] met at the men's mission 1 all night. Says they drank alcohol, smoked meth. When [s/he] was denied entrance into the shelter the following morning, [s/he] continued to drink. Was feeling suicidal at that time because [s/he] realized [s/he] was homeless and couldn't go back to the mission. [Name of friend] left at some point. Later that day overdosed on [his/her] pills. Asked for help, somebody else called ambulance. [S/he] lost consciousness, admitted to [name of friend] on 7/2/17."

2. In an interview on 7/10/17 around 10:30a.m., patient A4 stated this was [his/her] second admission to the facility. When asked why [s/he] was not in the Recreation Group being conducted on the unit from 10:30a.m. to 11:30a.m., the patient did not give a reason. [S/he] decided [s/he] was through talking to the surveyor.

3. A review of patient A4's MTP, dated 7/6/17, listed no specific groups on the plan. There was a nursing intervention that stated, "Provide schedule and remind pt of group times, especially CD [Chemical Dependency] groups." No alternatives to non-attendance at groups.

4. During the period of 7/7/17 to 7/10/17, a Nursing Progress Note, dated 7/8/17, stated, "Pt continues to be demanding of staff. Pt given several opportunities to leave North Hall. Pt declined. Isolated most of day in [his/her] room."

Nursing Progress Note, dated 7/9/17, stated, "Pt given opportunities to attend group. [S/he] refused. Isolated in [his/her] room."

5. Patient Observation Record, dated 7/7/17 - 7/10/17, showed zero attendance of patient at any group offered on these days.

6. Again, in an interview on 7/10/17 around 10:13 a.m. with RN1, s/ he stated that patient A4 spent most of [his/her] time in [his/her] room, instead of going to groups.


Staff Interviews

1. In an interview on 9/10/17 at 1:11 p.m. with MD1, the lack of active treatment for active sample patient A2 was discussed. He stated that he was aware of the patient's resistance to treatment, was monitoring the patient's medications to help improve [his/her] mental condition.

2. In an interview on 7/12/17 around 8:45 a.m., the lack of active treatment for active sample patients A3 and A4 was discussed with MD2. He felt that these two patients were seriously ill and probably needed 1:1 [one to one] interventions with staff for short periods of time at this point.

Based on record review and interview, the facility failed to ensure that Discharge Summaries for two (2) of six (6) active sample patients (D1 and D2), continued a recapitulation of the patients' treatment during the hospital stay. This deficiency results in a failure to communicate in a timely manner the specific care that was provided in the facility to give to outpatient providers.

Findings include:

A. Record Review

The following Discharge Summaries, dates of review in parenthesis (D1 (6/7/17) and D2 (6/7/17)) had for hospital course. "[Name of patient] was provided with supportive group and family therapy. Now [s/he] is ready for discharge."


B. Interview

The lack of a recapitulation of the patients' course of treatment in the Discharge Summaries of D1 and D2 were discussed with the Medical Director on 7/11/17 at 4:00 p.m. He did not dispute the findings.

Based on record review, observation, and interview, it was determined that the medical director failed to adequately monitor the care provided at the facility. The medical director failed to ensure that:

I. Psychiatric Evaluations included an assessment of patient personal assets in descriptive, not interpretive fashion for five (5) of eight (8) active sample patients (A1, A2, A3, B2 and B3). The failure to identify patient assets impairs the treatment teams' ability to choose treatment interventions/modalities that utilize the patients' attributes in therapy. (Refer to B117)

II. Master Treatment Plans (MTPs) were revised after the application of seclusion and restraint for one (1) of eight (8) active sample patients (A3) and 5 non-sample patients (C1, C2, C3, C4, and C5) selected to review episodes of seclusion and restraint. Specifically, MTPs were not modified to reflect individualized goals and active treatment interventions to prevent further episodes of these restrictive measures. This failure impedes the provision of active treatment to meet the specific needs of patients. (Refer to B118-II)

III. Master Treatment Plans (MTPs) were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, the MTPs were missing:

A. Individualized short-term and long-term goals written in measurable, observable, and behavioral terms. (Refer to B121).

B. Individualized and specific treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems. (Refer to B122).

C. The full name of each staff responsible and accountable for assigned active treatment interventions. (Refer to B123).

Failure to develop Master Treatment Plans with all necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's treatment needs not being met.

IV. Active treatment was provided including alternative interventions for three (3) of four (4) active sample patients (A2, A3, and A4) who were unwilling and/or unable to attend groups provided on the unit. 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)

V. Discharge Summaries for two (2) of six (6) sample patients (D1 and D2), contained a recapitulation of the patients' treatment during the hospital stay. This deficiency results in a failure to communicate in a timely manner the specific care that was given to outpatient providers. (Refer to B133)

VI. Employment of a sufficient number of activity therapy staff to complete assessments and ensure appropriate input into the formulation of active treatment interventions for the Master Treatment Plans (MTPs) of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, occupational therapy staff responsible for occupational therapy (OT) and recreational therapy (RT) groups were not involved in planning and formulating appropriate treatment interventions based on each patient's presenting psychiatric problems. This failure potentially leads to patients not receiving a full complement of therapeutic activities based on assessed needs, capabilities, and the identified psychiatric problems of each patient. (Refer to B158)

Based on record review and interview the nursing director failed to monitor the quality and appropriateness of the nursing interventions on the Master Treatment Plans (MTP) for seven (7) of eight (8) active sample patients. (A1, A2, A3, A4, B1, B2, and B4). This deficiency results in a failure to guide treatment of nursing staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

1 Patient A1's MTP dated 7/17/17 had the following deficient nursing interventions for the identified psychiatric problem of, A1 -"Depression [with] S/I [Suicide Ideations]- "Monitor [Patient] on SW [Suicide Watch], Assess suicidality daily, No Medications are ordered @ this time." Treatment Modality - Patient Education, Assessment."

2. Patient A2's MTP dated 7/17/17 had the following deficient interventions for the identified psychiatric problem of, "Depression [with] Suicidal thoughts - Evidenced by: [Patient] ... expressed suicidal [sic] states 'she wishes she was dead.' Significant history of mental issues and hospitalizations."
Nursing Intervention: There was no nursing intervention identified for this patient.

3. Patient A3's MTP dated 7/6/17 had the following deficient interventions from a preprinted list of options for the identified psychiatric problem of, "Psychotic Symptoms - Behavioral Manifestations/Observations: [This section was left blank]."

Nursing Intervention: "Establish trusting relationship, to provide support and reality testing."

4. Patient A4's MTP dated 7/6/17 had the following deficient interventions for the identified psychiatric problem #1, "Suicidality - Evidenced by: [Patient] admitted s/p OD.

Nursing Intervention: "Redirect aggressive behavior and discuss appropriate ways to make requests. Provide schedule and [sic] pt [patient] of group times especially CD [Chemical Dependent] group." "Treatment Modality - "Patient Education."

[Patient] has 'numerous' prior s/a [od] ... [Patient] reports increased feelings of depression/hopelessness."

5. Patient B1's MTP dated 6/29/17 had the following deficient interventions for the identified psychiatric problem of, "Psychosis - Evidenced by: [Patient] and [his/her] mother report [Patient] had a psychotic episode in which [s/he] appeared to be in a dreamlike state in which [s/he] was hallucinating and [s/he] did not appear to oriented to time and place."

Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills." Treatment Modality - "Patient Education, Assessment."

6. Patient B2's MTP dated 7/8/17 had the following deficient interventions for the identified psychiatric problem of, "Depression - Evidenced by: Pt [Patient] expresses self-worthlessness & hopelessness & has risky Bx [Behavior] when stressed."

Nursing Intervention: "[Patient] will attend 7-45 minute Nursing Groups [sic] that will focus on medication education, health & hygiene, stress management & coping skills." Treatment Modality - "Patient Education, Assessment."

7. Patient B4's MTP dated 6/28/17 had the following deficient interventions for the identified psychiatric problem of, "Suicidal Ideation [with] plan - Evidenced by: reports wanted to suffocate [himself/herself]. Self-harming on arm after being rejected by peers."

Nursing Intervention: "Monitor pt [patient] at intervals not to exceed 15 minutes for safety, administer prescribe medications and frequency ordered by providers and complete room checks for hazards." Treatment Modality - "Patient Education, Assessment." No option was checked.

Based on record review and interview the director of social work failed to ensure that the Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included detailed information on areas such as education, family issues, religion, vocation and employment. The major focus of the assessments was on psychiatric and/or substance abuse. For four (4) of eight (8) active sample patients (B1, B2, B3 and B4, the specific role of the social worker in discharge planning was not defined. As a result, the specific social work recommendations regarding psychosocial issues and anticipated discharge planning were not described for the treatment team. (Refer to B108)

Based on staff interview and record review, the facility failed to employ a sufficient number of activity therapy staff to complete assessments and ensure appropriate input into the formulation of active treatment interventions for the Master Treatment Plans (MTPs) of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, occupational therapy staff responsible for occupational therapy (OT) and recreational therapy (RT) groups were not involved in planning and formulating appropriate treatment interventions based on each patient's presenting psychiatric problems. There were no OT or RT interventions on MTPs of any active sample patients including those attending and participating in these groups. This failure potentially leads to patients not receiving a full complement of therapeutic activities based on assessed needs, capabilities, and the identified psychiatric problems of each patient. This failure may deprive patients of important OT and RT activities to help them to alleviate presenting psychiatric symptoms.

Findings include:

A. Document Review

1. The facility's document titled, "Overview of Services - Adolescent Acute Inpatient Program" stated, "Recreational activities are provided for every adolescent utilizing a therapeutic approach with and [sic] an educational goal. Most adolescents must relearn how to increase their leisure time management skills. They also need to re-acquaint themselves with their physical capabilities as well as build self-esteem and anger management ... Recreational activities are offered twice per day. They may include cardiovascular exercise, therapeutic competitions, leisure skill enhancement and planning ..." This identical statement was in the document for the child and adult services provided by the facility. There was no overview included regarding the occupational therapy offered and provided by the facility during the survey.

2. The facility submitted four unit schedules of active treatment programming both weekday and weekend for Adolescent Girls, Adolescent Boys, Children, and Adult Programming.

a. The Adolescent Girl's Unit schedule had a "Recreational Therapy Group" from 9:00 a.m. to 10:00 a.m. and "COTA Recreational Therapy" from 2:00 p.m. to 3:00 p.m. There were no RT or OT groups included for Saturday on the weekend unit schedule.

b. The Adolescent Boy's Unit schedule contained the following therapeutic activities groups: Monday -Friday from 10:00 a.m. to 10:45 a.m. "Occupational Therapy Group" and noted "If OT is unable to make it, please run an Expectation group." There were no RT or OT groups included on the weekend unit schedule for boys.

c. The Children's Unit Schedule had an "Occupational Therapy" group from 3:00 p.m. to 3:45 p.m. Monday through Friday and an OT group scheduled on Sundays.

d. The Adult Unit schedule had a "Recreational Group" scheduled Monday through Friday from 10:30 a.m. to 11:30 a.m.

None of these groups were included on the MTPs of the active sample patients.

B. Medical Record Review

1. There were no Therapeutic Activities Assessments completed by occupational therapy staff. Adolescent patients were required to complete a self-report form titled, "Capacity for Activities of Daily Living." The adult patients also completed a form titled, "Vocational/ Educational/ Occupation Assessment." After this form had been completed, the OT staff wrote a statement under the section titled, "Additional comments/observations" on the adolescent form and under "Therapists Comments on the form completed by adult patients. These forms were submitted for the active sample patients A1, B1, and B3. The Director of Clinical services reported on 7/12/17 at approximately 10 a.m. that active sample patients A2, A3, and A4 had refused to complete the form. There was no form found or submitted for active sample B2 and B4. B4 attended and participated in OT and RT groups during the survey. The following information written by OT staff was included on the forms submitted:

a. Patient A1: "Patient would benefit from [increased] stress management / sensory regulation, [decreased] substance abuse/usage, [increased /time leisure] management." All of these areas were checked on the form completed by the patient. There were no goals or OT/RT interventions formulated and included on the patient's MTP to address these issues.

b. Patient B1: "Patient would benefit from services to address emotional regulation/reality orientation, socialization/communication/relationship skills, and self-care/life management for [increased] participation in daily occupation." All of these areas were checked on the form completed by the patient. There were no goals or OT/RT interventions formulated and included on the patient's MTP to address these issues.

c. Patient B3: "Patient would benefit from services to address substance usage/abuse, verbal expression, and learning how to cope [with] illness more effectively to [increase] performance in daily occupations." All of these areas were checked on the form completed by the patient. There were no goals or OT/RT interventions formulated to address these issues and included on the patient's MTP.

2. The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (7/7/17), A2 (7/7/17), A3 (4/14/17; updated 7/6/17), A4 (7/6/17), B1 (6/29/17), B2 (7/8/17), B3 (6/28/17), and B4 (6/26/17). These plans contained no recreational or occupational therapy interventions despite these group interventions being listed on unit schedules, offered, and attended by active sample patients B1, B3, and B4.

C. Interviews

1. In an interview on 7/11/17 at 3:35 p.m., the OTR contracted by the facility to coordinate therapeutic activities reported that OT provided both OT and RT at the hospital. She stated that she was contracted for 20 hours per week and the hospital employed two full-time Certified Occupational Therapy Assistants (COTAs), and used one per diem COTA. She stated that one COTA was on leave. She stated that with this number of staff, "We have a shortage of staff and it is difficult to cover the hospital." She noted that "All patients are required to complete a self-assessment. There is no OT assessment unless ordered by the psychiatrist." The Master Treatment Plans were reviewed and she did not dispute that there were no OT or RT interventions. She stated, "They definitely should be on the treatment plan. We [OT] were on the treatment plans at one time, if they [interventions] came off, I wasn't aware of it." She admitted that currently, no OT staff attended the treatment planning meetings on the adult unit.

2. In an interview on 7/12/17 at 8:25 a.m., with the Director of Clinical Services/Social Worker, the therapeutic activities program was discussed. She did not dispute that therapeutic activity assessments were not completed to determine each patient's specific need in treatment. She agreed that without an Activity Therapy Assessment for use in treatment planning, it would be difficult to determine appropriate OT and RT group interventions and activities based on each patient's actual assessed needs. She agreed that patients needed OT and RT and stated, adolescents in particular need to have structured RT.

3. In an interview on 7/12/17 at 12:30 p.m. the Director of Clinical Services/Social Work confirmed the current OT staffing. She stated that one COTA and the half-time contracted OTR was currently covering the OT and RT groups. She also reported that they also pulled staff from Residential Services to assist with covering groups.