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Based on observation, patient and staff interviews, incident review, record review and policy review, the hospital failed to initiate, assess, and document restraint/seclusion for 2 non-sample patients (B3 and B10). This failure exposes patients to potential harm from unnecessary seclusion/restraint and violates patients' rights to a safe treatment in the least restrictive manner possible. (Refer to B125)

Specifically the hospital failed to:

I. Ensure that 2 non-sample patients (B3 and B10) had a licensed independent practitioner provide the following: a) an order for seclusion/restraint, b) a one hour face-to-face evaluation of patient in seclusion/restraint and c) documentation of the reasons for seclusion/restraint. These failures result in a restriction of a patient's right to supervision, monitoring and documentation by a licensed independent practitioner.

II. Ensure that 1 non-sample patient (B10) had been placed in seclusion using standard techniques for aggression management instead of utilizing an unsafe maneuver referred to as a "choke-hold." This resulted in injury to the patient and unsafe environment of care for patients.

III. Ensure that seclusion for 2 non-sample patients (B3 and B10) was used under the direction of an RN. Staff also failed to notify hospital leadership of the use of seclusion. These failures result in an environment that fails to ensure that seclusion or restraint was used safely or appropriately in the hospital.

IV. Ensure that all elements of seclusion use were documented including 15-minute observation, RN safety assessments, release criteria assessments and patient debriefing upon release for 2 non-sample patients (B3 and B10). These failures resulted in an unsafe environment of care.

Based on observation, interview and record review, the hospital failed to provide adequate numbers of qualified nursing staff to ensure a safe environment of care for patients. Specifically, the hospital failed to:

I. Ensure that the Director of Nursing had a Master's Degree or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing. This failure results in a lack of over-site, exposing patients to potential harm from unnecessary seclusion/restraint and violating patients' rights to safe treatment in the least restrictive manner possible. (Refer to B147)

II. Ensure that licensed nursing staff who are trained in psychiatric nursing or aggression management provide care and oversee the work of unlicensed nursing personnel. This failure exposes patients to potential harm and violates patients' rights to safe treatment in the least restrictive manner possible. (Refer to B148)

III. Provide sufficient numbers of Registered Nurses to oversee the use of seclusion/restraint and the work of unlicensed personnel. This failure results in potential safety hazards and violation of patients rights to safe treatment in the least restrictive manner possible. (Refer to B149)

Based on record review and staff interview, the facility failed to ensure that memory functioning was described in specific and measureable terms for 6 of 8 active sample patients (A11, A12, A15, B1, B4, and B9).This failure to test the memory functioning results in a lack of a baseline measure from which future treatment can be planned.

A. Record Review

1. Patient A11 had an initial Psychiatric admission note completed on 12/28/2010. On the form "Inpatient Psychiatric Admission Note" where memory function assessment was listed under section "Memory: digit forward (blank) and backward (blank)"; both areas were left blank.

2. Patient A12 had inpatient psychiatric note completed on1/18/2011. This note listed "Memory: digit forward as "N/A" and digit backward as "N/A"." There was no evidence of specific and measurable testing.

3. Patient A15 had an inpatient psychiatric admission note completed on 1/9/2011. This note had a positive (+) sign where section for "Memory digit forward (blank)" designated space was located. "Memory digit backward" had a negative (-) sign in the designated space. There was no evidence of specific and measurable testing.

4. Patient B1's inpatient psychiatric admission note which was completed on 1/3/11 had "N/A" marked for "memory: digit forward (blank) and backward (blank)". There was no evidence of specific and measurable testing.

5. Patient B4 had inpatient psychiatric admission note completed on 1/15/2011. In this note "memory: digit forward" was listed as "WNL" and "memory: digit backward" was listed as "WNL" as well. There was no evidence of specific and measurable testing.

6. Patient B9's Inpatient Psychiatric Admission Note of 1/8/2011 noted that memory and digit span both forward and backward were listed as "WNL". There was no evidence of specific and measurable testing.

B. Staff Interview.

In an interview on 1/25/2011 at 2:00p.m., the Medical Director agreed with the surveyor's findings and added "they fill that form with such care, why would they leave that section out."

Based on record review, staff interview and policy review, the facility failed to develop treatment plans that identified individualized interventions for 8 of 8 active sample patients (A6, A11, A12, A15, B1, B4, B8 and B9) to address specific patient problems. Instead, interventions on the treatment plans included routine, generic discipline functions inappropriately listed as individualized interventions. This deficiency results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

A. Record Review

1. Psychiatrist Interventions

a. On the treatment plan for patient A6 dated 12/21/10, the psychiatrist's intervention was "AP will meet daily with pt. to assess paranoia, suspiciousness and AH + treat with meds. As tolerated and indicated."

b. On the treatment plan for patient A11 dated 12/29/10, the psychiatrist's intervention was "AP will meet daily to assess paranoia, suspiciousness, delusional thinking and treat with meds. As tolerated and indicated."

c. On the treatment plan for patient A12 dated 1/20/11, the psychiatrist's intervention was "AP will meet daily to assess paranoia, suspiciousness, delusional thinking."

d. On the treatment plan for patient A15 dated 1/10/11, the psychiatrist's intervention was "AP will meet daily with pt. to assess (illegible word), AH/delusional thinking and treat with meds (illegible word)."

e. On the treatment plan for patient B1 dated 1/6/11, the psychiatrist's intervention was "MD will meet with pt. daily to assess meds for indication (illegible word) will assess interplay between substances and meds."

f. On the treatment plan for patient B4 dated, 1/17/11, the psychiatrist's intervention was "MD will meet with pt. daily to assess need for medication adjustment. Will assess interplay between psychosis and THC use."

g. On the treatment plan for patient B8 dated 1/21/11, the psychiatrist's intervention was "MD will meet with pt. daily to assess need for medication adjustment. Will assess interplay between."

h. On the treatment plan for patient B9 dated 1/8/11, the psychiatrist's intervention was "MD will meet with pt. daily to assess interplay between mania and compliance."

2. Nursing Interventions

a. On the treatment plan for patient A6 dated 12/21/10, the nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

b. On the treatment plan for patient A11 dated, 12/29/10, the nursing intervention was "Nurse will provide contact time each shift to assess mental status and encourage patient to participate in treatment."

c. On the treatment plan for patient A12 dated 1/20/11, the nursing intervention was "Nurse will provide contact time each shift to assess mental status."

d. On the treatment plan for patient A15 dated 1/10/11, the nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

e. On the treatment plan for patient B1 dated 1/6/11, the nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

f. On the treatment plan for patient B4 dated 1/17/11, the nursing intervention was "NSG will meet patient daily to assess mood, encourage pt. to report any changes in mood."

g. On the treatment plan for patient B8 dated 1/21/11, the nursing intervention was "NSG will meet with pt. daily to assess mood, encourage pt. to report any (illegible word)."

h. On the treatment plan for patient B9 dated 1/8/11, the nursing intervention was "Nurse will provide contact time each shift to assess mood."

3. Social Work Interventions

a. On the treatment plan for patient A6 dated 12/21/10, generic social work interventions were "SW will meet with patient daily to monitor and assess patient's auditory hallucinations"; "SW will meet with patient weekly to develop coping skills"; "SW will meet with patient weekly to develop crisis plan."

b. On the treatment plan for patient A11 dated 12/29/10, generic social work interventions were "SW will monitor and assess pt. daily for decrease in auditory hallucinations"; "SW will meet with patient weekly to develop crisis plan."

c. On the treatment plan for patient A12 dated 1/20/11, generic social work interventions were "SW will meet with patient daily to monitor and assess auditory hallucinations"; "SW will meet with patient weekly to develop crisis plan."

d. On the treatment plan for patient A15 dated 1/10/11, generic social work interventions were "SW will meet with patient daily to monitor and assess AH and VH [sic]"; "SW will meet patient weekly to develop coping skills"; "SW will meet with patient weekly to develop crisis plan."

e. On the treatment plan for patient B1 dated 1/6/11, a generic social work intervention was "SW will meet with patient weekly to assess mood and develop crisis plan."

f. On the treatment plan for patient B4 dated 1/17/11, a generic social work intervention was "SW will meet with patient weekly to assess patient's mood."

g. On the treatment plan for patient B8 dated 1/21/11, a generic social worker intervention was "SW will meet with patient weekly to assess mood and develop crisis plan and refer patient to rehab upon stabilization."

h. On the treatment plan for patient B9 dated 1/8/11, a generic social work intervention was "social worker will assess patient's mood weekly."

B. Staff Interview:

1. In an interview on 1/25/11 at 2:00p.m. with the Clinical Director, the above findings were shared with him. He agreed that the interventions looked the same and needed to be more individualized.

2. In a staff interview on 1/25/11 at 3:00p.m. with the Director of Social Services, findings were shared with her. She stated "The patients are coming with similar problems; that's why the interventions look the same."

C. Policy Review

Hospital policy "Treatment Planning" effective 10/97 and revised on 4/29/2007 stated that the "treatment plan for each patient being considered must be individualized and reflect the collaborative work between the patient and the inter-disciplinary treatment team".

Based on observation, patient and staff interviews, incident review, record review and policy review, the hospital failed to initiate, assess, and document restraint/seclusion for 2 non-sample patients (B3 and B10). This failure exposes patients to potential harm from unnecessary seclusion/restraint and jeopardizes a patients' right to safe treatment in the least restrictive manner possible.

Specifically the hospital failed to:

I. Ensure that 2 non-sample patients (B3 and B10) had a licensed independent practitioner provide the following: a) an order for seclusion/restraint, b) a one hour face-to-face evaluation of patient in seclusion/restraint and c) documentation of the reasons for seclusion/restraint. These failures result in a restriction of a patient's right of supervision, monitoring and documentation by a licensed independent practitioner.

II. Ensure that 1 non-sample patient (B10) had been placed in seclusion using standard techniques for aggression management instead of utilizing an unsafe maneuver referred to as a "choke-hold". This resulted in injury to the patient and unsafe environment of care for patients.

III. Ensure that seclusion for 2 non-sample patients (B3 and B10) was used under the direction of an RN. Staff also failed to notify hospital leadership of the use of seclusion. These failures result in an environment that fails to ensure that seclusion or restraint was used safely or appropriately in the hospital.

IV. Ensure that all elements of seclusion use were documented including 15-minute observation, RN safety assessments, release criteria assessments and patient debriefing upon release for 2 non-sample patients (B3 and B10). These failures resulted in an unsafe environment of care.

Findings include:

A. Patient B3

1. Incident Review and Record Review

An Incident Report dated 11/18/10 at 8:45a.m. referring to patient B3 stated "Observed by staff approaching another client attempted and succeeded to strike client [sic]. Redirected by staff to quiet room."

In a nursing progress note for B3 dated 11/18/10 at 8:45a.m. reads "Client observed by staff approaching another client with attempts to hit her as she approached client staff walked over to intervene but she still proceeded to hit the other person after redirected, B3 was placed in the quiet room."

The Shift Director on duty 1/25/11 at 1:40p.m. was unable to find any documentation in the medical record of Seclusion or Restraint nursing assessment, Seclusion or Restraint Record Sheet, Documentation by an LIP within 1 hour of restraint, or a progress note indicating the duration of 'quiet room/or seclusion room' use.

2. Policy Review

a. The Seclusion and Restraint policy (revised 5/18/10) was received on 1/24/11 at 4:15p.m. In the definition section pg2, bullet 2, seclusion was described as "The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion requires a physician's order and may be initiated by the charge nurse, pending a written or verbal order from an LIP."

In the definition section pg2, bullet 3, the policy described restraint as "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Restraint required a physician's order and may be initiated by the charge nurse, pending a written or verbal order from an LIP."

b. The Seclusion and Restraint policy required the following additional documentation: Seclusion or Restraint nursing assessment (page7, Section 3a), Seclusion or Restraint Record Sheet (Page 4, Section 1e v.b.), and documentation by an LIP within 1 hour of restraint (page 4, Section1h).

On page 4, Section 1e iv., the S&R policy described the requirement for the Shift Director to be notified of all episodes of seclusion or restraint. It also stated that the Shift Director is to notify the Director of Nursing.

B. Patient B10

1. Patient interviews

a. In an interview on 1/24/11 at 12:15p.m. in the Unit N4 day area, patient B8 reported that patient B10 pushed patient B3 to the ground several days prior. There was no documentation in patient B10's medical record that this event happened. Patient B8 also reported that in another incident, patient B10 was grabbed by staff, placed in the 'quiet room,' and remained there for the night of 1/22/11.

b. In an interview on 1/24/11 at 3:00p.m. in the Unit N4 day area, patient B8 stated that B10 was placed in a "choke-hold" by one staff, and that two other staff had her (B10) by the arms as B10 was taken to 'quiet room.' According to patient B8, this event occurred at 10:00p.m. on 1/22/11.

c. In an interview on 1/24/11 at 1:30p.m. in the med room of Unit N4, with LPN1 present, patient B10 reported that she chased after the LPN2 on 1/22/11 at 10:00p.m. and blocked the LPN in the nursing station. Patient B10 reported that she then "dove over" the nursing station counter. She reported that one staff grabbed her from behind and put her in a "choke-hold" while two other staff grabbed her arms. They put her in the 'quiet room' and told her she couldn't leave; she remained there throughout the night. Patient B10 said she was banging on the door and screaming, and that at some point in the night, the door was locked. Patient B10 showed the surveyor 3 finger print bruises on her right arm and some minor scratches on her neck. She informed the surveyor that her throat was sore from screaming, and that she was requesting lozenges from LPN1. During the interview, LPN1 (present in the med room) did not comment. (See LPN1's later explanation of the event in the staff interview section below).

2. Staff Interviews

a. In an interview on 1/24/11 at 1:15p.m. in the medication room, LPN1 reported she was unaware that patient B10 had been in seclusion or that she had been placed in a physical restraint on 1/22/11. After LPN1 heard the patient's report at 1:30p.m., she was asked to find the documentation of the restraint and seclusion event. LPN1 was unable to find any information about the physical restraint. The only documentations in the medical record were notes regarding the patient's behavior leading up to the event, patient B10's initial placement in the quiet room, and completion of 'routine 15 minute checks.'

b. In an interview on 1/24/11 at 2:15p.m. in the DON's office, the DON reported she was unaware of the seclusion/physical restraint event for patient B10. She searched for a description of the event in the daily shift report for 1/22/11. She was unable to find a description of the event or even a shift report for 1/22/11 at that time.

c. In an interview on 1/24/11 at 2:50p.m. in the nursing station, MD2 reported he was unaware that patient B10 had been in seclusion or had been placed in a physical restraint on 1/22/11. He was unable to find documentation of a description of event or an order for seclusion or physical restraint in patient B10's medical record.

d. In an interview on 1/24/11 at 4:30p.m., the Executive Director reported that he was unaware of the seclusion/physical restraint event for patient B10. He did not identify her as one of the 5 patients restrained in the past 12 months when he was asked for this data on 1/24/11 at 10:00a.m.

C. Record Review

1. Review of the record for B10 revealed no documentation of the following required Seclusion/Restraint documents: Seclusion or Restraint nursing assessment, Seclusion or Restraint Record Sheet, Documentation by an LIP within 1 hour of restraint, and a progress note with a description of B10 having spent the entire night in the "quiet room" (seclusion room on unit N4).

2. LPN2 was on duty on 1/22/11 for 7:00p.m. to 7:00a.m. shift on Unit N4 when the incident with B10 occurred. LPN2 was assigned from an outside agency and she functioned as the charge nurse for the shift. The Shift Director on duty on 1/25/11 at 2:45 p.m., said that the facility did not have a personnel file or competency assessment for LPN2 (as of 2:45p.m. on 1/25/11). At 3:30p.m. on 1/25/11, Human Resources staff member HR1 presented a file with LPN2's resume. The resume did not include any psychiatric experience. When asked about this, HR1 validated the information.

Based on record review, staff interview and policy review the facility failed to: 1) ensure that patient discharge summaries include an individualized description of the patient's hospitalization (treatment summary) for 11 of 12 discharged patients (D1, D2, D3, D4, D5, D6, D7, R1, R2, R3, R4), and 2) failed to provide a dictated discharge summary in the medical record within 30 days of discharge for 4 of 7 discharged patients (D2, D7, R3 and R4) with a length of stay greater than 10 days. These failures compromise the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

A. Inadequate Treatment Summaries

1. Record Review

a. Patient D1's treatment summary stated "Patient was admitted on 11/23/10. He was provided with individual, group and med milieu, coping skills and crisis plan. He exhibited no acute symptoms. He was discharged on 12/1/10."

b. Patient D2's treatment summary stated "Patient was admitted on 11/20/10. He was provided with individual, group and med milieu, coping skills and crisis plan. He exhibited no acute symptoms. He was discharged on 12/1/10."

c. Patient D3's treatment summary stated "Patient was admitted on 11/27/10. He was provided with individual, group and med milieu, coping skills and crisis plan. He exhibited no acute symptoms. He was discharged on 12/1/10."

d. Patient D4's treatment summary stated "Patient was admitted on 11/29/10. He was provided with individual, group and med milieu, coping skills and crisis plan. He exhibited no acute symptoms. He will be discharged on 12/1/10."

e. Patient D5's treatment summary stated "Patient was admitted on 12/17/10 on 201 for paranoid and disorganized behaviors. Provided with individual, group and med milieu. No acute psych symptoms noted. Discharged to home and outpatient." He was discharged on 12/23/10.

f. Patient D6's treatment summary stated "Patient was admitted on 9/18/10 on 302 for paranoid and disorganized behaviors. Signed 201. Provided with individual, group and med milieu. No acute psych symptoms. Discharged on 12/2/10 to Oak Lane PCH and day program at Hall Manor."

g. Patient D7's treatment summary stated "Patient was admitted on 12/8/10. She was provided with individual, group and med milieu, coping skills and crisis plan. She exhibited no acute symptoms. She was discharged on 12/22/10."

h. Patient R1's treatment summary stated "Patient was admitted on 2/17/10 on 201 for + SI. Provided with individual, group and med milieu. No acute symptoms noted. Discharged on 2/22/10 to shelter and outpatient."

i. Patient R2's treatment summary stated "Patient was 302'd for explosive behaviors, dangerous to self and others. Patient is being d/c to shelter until she gets her own room. Pt has stabilized on her meds. Patient was provided with individual sessions, group and med milieu." She was discharged on 7/28/10.

j. Patient R3's treatment summary stated "Patient was admitted on 5/29/10 on 302. Signed 201. Provided with individual, group and med milieu. No acute symptoms noted. Discharged on 6/17/10 to home and IOP."

k. Patient R4's treatment summary stated "Patient was admitted on 6/18/10 on 302. 303 obtained at mental health court. Provided with individual, group and med milieu. No acute symptoms noted. Discharged on 7/2/10."

2. Staff Interviews

1. In an interview on 1/24/11 at 1:05p.m., the Executive Director agreed that the treatment summary descriptions for patients D1, D2, D3, and D4 did not describe each patient's individualized course of treatment.

2. In an interview on 1/25/11 at 2:00p.m., MD2 agreed that the treatment summary descriptions did not describe each patient's individualized course of treatment.

B. Lack of dictated summary within 30 days

1. Policy/Document Review

The Medical Staff Handbook (dated February 2005) notes the following on Page 5: "...Dictated discharge summaries are required on all stays of 11 days or more. In all cases, discharge summaries must be dictated within 30 days of discharge."

2. Record Review

a. Patient D2 was admitted on 11/20/10 and discharged on 12/1/10. The patient had a length of stay of greater than 10 days and had no dictated discharge summary in the record as of the date of the survey (1/24-26/11).

b. Patient D7 was admitted on 12/8/10 and discharged on 12/22/10. The patient had a length of stay of greater than 10 days and had no dictated discharge summary in the record as of the date of the survey (1/24-26/11).

c. Patient R3 was admitted on 5/29/10 and discharged on 6/17/10. The patient had no dictated discharge summary in the record as of 1/25/11 at 2:00p.m. MD1 found the document on the secretary's computer and signed it on 1/25/11 at 3:00p.m. (beyond the 30 day requirement).

d. Patient R4 was admitted on 6/18/10 and discharged on 7/2/10. The patient had no dictated discharge summary in the record as of 1/25/11 at 2:00p.m. MD1 found the document on the secretary's computer and signed it on 1/25/11 at 3:00p.m. (beyond the 30 day requirement).

3. Staff Interviews

a. In an interview on 1/24/11 at 1:05p.m., the Executive Director acknowledged that he could not find the dictated discharge summaries for patients D2, D7, R3 and R4 in the patients' medical records.

b. In an interview on 1/25/11 at 2:00p.m., the Medical Director reported that he thought he had completed the dictations for some of the patient records above. He found two of the summaries on a secretary's computer, and at this time, he printed and signed them, and placed them in the medical record (beyond the 30 day requirement).

Based on record review and staff interview, the facility failed to provide discharge summaries that contained a detailed summary of the patient's condition on discharge for 7 of 7 discharged patients (D1, D2, D3, D4, D5, D6 and D7). This failure compromises the effective transfer of the patient's care to the next care provider by not giving information that identifies an accurate description of the patient's condition on discharge.

A. Record Review

1. Patient D1: In a Discharge Summary dated 12/1/10, the condition on discharge was noted as patient "in stable condition."

2. Patient D2: In a Discharge Summary dated 12/1/10, the condition on discharge was noted as patient "in stable condition."

3. Patient D3: In a Discharge Summary dated 12/1/10, the condition on discharge was noted as patient "in stable condition."

4. Patient D4: In a Discharge Summary dated 12/1/10, the condition on discharge was noted as patient "in stable condition."

5. Patient D5: In a Discharge Summary dated 12/23/10, the condition on discharge was blank.

6. Patient D6: In a Discharge Summary dated 12/2/10, the condition on discharge was not described. It stated "pt. discharged to personal care home (illegible word) transportation accompanied by escort (illegible word)."

7. Patient D7: In a Discharge Summary dated 12/22/10, the condition on discharge was noted as "condition stable, no c/o pain discomfort. No c/o pain discomfort. Patient verbalizes understanding of discharge instructions."

B. Staff Interviews

1. In an interview on 1/24/11 at 1:05p.m., the Executive Director agreed that the condition on discharge descriptions for patients D1, D2, D3, D4, D5, D6, and D7 were not descriptive of patient's specific condition on discharge.

2. In an interview on 1/25/11 at 2:00p.m., the Medical Director agreed that the condition on discharge descriptions were not descriptive of patient's specific condition on discharge.

Based on record review, staff interview and policy review, the Clinical Director failed to:

1. Ensure that the mental status examinations of 6 of 8 active sample patients (A11, A12, A15, B1, B4, and B9) were completed with a specific, measureable and reproducible assessment of their memory functioning. This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions could be measured. (Refer to B116)

2. Ensure that Master Treatment Plans included individualized treatment modalities (interventions) for 8 of 8 sample patients (A6, A11, A12, A15, B1, B4, B8 and B9). The interventions on the treatment plans were generic discipline tasks incorrectly listed as patient-specific interventions. This failure results in a lack of clarity and specificity as to how the staff will address patient problems. (Refer to B122)

3. Ensure that discharge summaries were completed in a timely fashion and contained a recapitulation of patient's hospitalization and condition on discharge, as defined by hospital policy and procedure for 11 of 12 discharged patients (D1, D2, D3, D4, D5, D6, D7, R1, R2, R3 and R4). These failures result in lack of continuity of care for patients on their discharge to the next care provider. (Refer to B133-A and B135)

4. Ensure complete discharge summaries in patients' medical records within 30 days of discharge for 5 of 7 discharged patients (D2, D5, D7, R3 and R4) with a length of stay greater than 10 days (as required by hospital policy). This failure compromises the effective transfer of the patient to the next care provider by not providing information that identifies effective or ineffective treatment strategies. (Refer to B133-B)

Based on document review and staff interviews, it was determined that the facility failed to have a Director of Nursing with a Master's Degree or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing.

A. Document Review

Review of the Curriculum Vitae for the Director of Nursing, provided by the facility on 1/24/11 at 4:00p.m., revealed that the DON's highest level of education was a diploma in nursing. According to information on the Vitae, she has eight years of psychiatric nursing experience, no continuing education in psychiatric nursing, and no documented experience in nursing management.

B. Staff Interviews

1. In an interview on 1/24/11 at 2:00p.m., the Director of Nursing (DON) reported that she had a diploma in nursing and was in school for her BSN. She reported she has received no formal clinical supervision from a nurse with a Master's degree in Psychiatric/Mental Health Nursing during her tenure as Director of Nursing. She had been the Director of Nursing for eight months at the time of the survey.

2. In an interview on 1/24/11 at 2:15p.m., the Executive Director acknowledged that the DON does not have clinical supervision or consultation with a nurse with a Master's degree in Psychiatric Mental Health Nursing. He stated that the facility attempted to obtain the consultation/supervision from Temple University in Fall 2010, but the contract negotiations failed at that time.

Based on observation, record review, patient and staff interview, incident review and policy review the Director of Nursing failed to:

I. Monitor nursing interventions on the Master Treatment Plans of 8 of 8 active sample patients (A6, A11, A12, A15, B1, B4, B8 and B9) to ensure that they included patient-specific approaches that nurses could use to assist patients to meet their individual treatment goals. The nursing interventions on the plans were generic nursing tasks that were identical or very similar for all patients. This results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

II. Ensure that nursing staff appropriately initiated, assessed, and documented Seclusion and or restraint for 2 of 2 non-sample patients (B3 and B10). This failure exposes patients to potential harm from unnecessary seclusion/restraint and violates patients' rights to safe treatment in the least restrictive manner possible.

II. Ensure that nursing staff on Unit N4 carried out all required patient care safety checks, including 15 minute observations for all patients on the unit, and provided adequate oversight of patient activities. There were documented incidents of sexual encounters and aggressive interactions occurring between patients on the unit. This failed practice exposes patients to potential harm and violates patients' rights to a safe treatment environment.

IV. Ensure adequate numbers of Registered Nurses on all tours of duty to provide needed supervision of patient care on units N3 and N4. This failure results in staffing patterns that negatively affect the provision of care and supervision of non-professional nursing personnel. (Refer to B149)

Findings include:

I. Lack of individualized nursing interventions on treatment plans

A. Policy Review

Hospital policy "Treatment Planning" effective 10/97 and revised on 4/29/2007, states that the "treatment plan for each patient being considered must be individualized and reflect the collaborative work between the patient and the inter-disciplinary treatment team."

B. Record Review

1. On the treatment plan for patient A6 dated 12/21/10, the only nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

2. On the treatment plan for patient A11 dated 12/29/10, the only nursing intervention was "Nurse will provide contact time each shift to assess mental status and encourage patient to participate in treatment."

3. On the treatment plan for patient A12 dated 1/20/11, the only nursing intervention was "Nurse will provide contact time each shift to assess mental status."

4. On the treatment plan for patient A15 dated 1/10/11, the only nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

5. On the treatment plan for patient B1 dated 1/6/11, the only nursing intervention was "Nurse will provide contact time each shift to assess mood and mental status."

6. On the treatment plan for patient B4 dated 1/17/11, the only nursing intervention was "NSG will meet patient daily to assess mood, encourage pt. to report any changes in mood."

7. On the treatment plan for patient B8 dated 1/21/11, the only nursing intervention was "NSG will meet with pt. daily to assess mood, encourage pt. to report any (illegible word)."

8. On the treatment plan for patient B9 dated 1/8/11, the only nursing intervention was "Nurse will provide contact time each shift to assess mood."

II. Failure to Follow Proper Procedures for Seclusion/Restraint

A. Specific Patient Findings

1. Patient B10

a. Patient interviews

1). In an interview on 1/24/11 at 12:15p.m. in the Unit N4 day area, patient B8 reported that patient B10 pushed patient B3 to the ground several days prior. Patient B8 also reported that in another incident, patient B10 was grabbed by staff and placed in the 'quiet room' and remained there for the night on 1/22/11.

2). A review of patient B10's medical record revealed no documentation that the above events had occurred.

3). In an interview on 1/24/11 at 1:30p.m., with LPN1 present, patient B10 reported that on 1/22/11 at 10:00 p.m., she chased after the RN on the unit and blocked LPN2 in the nursing station. Patient B10 said that she then "dove over" the nursing station counter. Patient B10 reported that one staff grabbed her from behind and put her in a "choke-hold". and that two other staff grabbed her arms. They then put her in the 'quiet room' (facility's term for the seclusion room) and told her she couldn't leave. Patient B10 said she remained there throughout the night. Patient B10 reported that she was banging on the door and screaming, and that at some point in the night, the door was locked. Patient B10 showed the surveyor 3 finger print bruises on her right arm and some minor scratches on her neck. Patient B10 informed the surveyor that her throat was sore from screaming; she said that she was requesting lozenges from LPN1.

4). On 1/24/11 at 3:00p.m., patient B8 reported that in the incident above, patient B10 had been placed in a "choke-hold" by one staff, and that two other staff had her by the arms as she (B10) was taken to the quiet room.

b. Staff Interviews

1). In an interview at 1/24/11 at 1:15p.m., LPN1 reported she was unaware that patient B10 had been in seclusion or was placed in a physical restraint on 1/22/11. LPN1 was asked to find the documentation of the seclusion/restraint event. She (LPN1) was unable to find specific documentations regarding the physical restraint or seclusion event. The only documentations in patient B10's medical record were notes about the patient's behavior leading up to the event, her initial placement in the quiet room, and completion of routine 15 minute checks.

2). On 1/24/11 at 2:50p.m., MD2 reported he was unaware that patient B10 had been in seclusion or was placed in a physical restraint on 1/22/11. He was unable to find documentation in the patient's medical record of the seclusion/restraint event, including a physician order for seclusion or physical restraint or a LIP (licensed independent practitioner) one hour check (after initiation of the S/R event).

3). In an interview on 1/24/11 at 2:15p.m., the DON reported she was unaware of the seclusion/physical restraint event for patient B10. She searched for a description of the event in the daily shift report for 1/22/11 but was unable to find a description of the event.

4). In an interview on 1/24/11 at 4:30p.m., the Executive Director reported that he was unaware of the seclusion/physical restraint event for patient B10. He did not identify her as one of the 5 patients restrained in the past 12 months.

5). According to the Shift Director on duty on 1/25/11 at 2:45p.m., the LPN on duty (LPN2) on 1/22/11 for the 7:00p.m. to 7:00a.m. shift was from an agency. LPN2 was the only nurse on duty for Unit N4 and was the designated charge nurse.

c. Record and Document Review

1). Review of the medical record for patient B10 revealed no documentation of the following required seclusion/restraint documents: Seclusion or Restraint nursing assessment, Seclusion or Restraint Record sheet, documentation by an LIP (Licensed Independent Professional) within 1 hour of restraint, progress note with a description of the patient spending a night in the 'quiet room' (seclusion room).

2). As of 2:45p.m. on 1/25/11, the facility did not have a personnel file or competency assessment for LPN2, the nurse in charge of Unit N4 when the above cited incident with patient B10 occurred. At 3:30p.m. on 1/25/11, a Human Resources staff person (HR1) presented a file with LPN2's resume. According to the resume, LPN2 did not have any psychiatric experience. HR1 also reported that the Human Resources Department had no "competencies" or "competency for managing aggression" on file for LPN2.

2. Patient B3

a. Incident Report Review and Record Review

1). An incident report dated 11/18/10 at 8:45 a.m. for patient B3 stated "Observed by staff approaching another client attempted and succeeded to strike client. Redirected by staff to quiet room."

2) A nursing progress note for B3 dated 11/18/10 read "Client observed by staff approaching another client with attempts to hit her as she approached client staff walked over to intervene but she still proceeded to hit the other person after redirected, B3 was placed in the quiet room."

3) The Shift Director on duty (1/25/11 at 1:40p.m.) was unable to find any documentation of the above seclusion event, including a Seclusion or Restraint nursing assessment, Seclusion or Restraint Record Sheet, Documentation by an LIP within 1 hour of restraint, or a progress note indicating the duration of 'quiet room/or seclusion room' use in Patient B3's medical record.

B. Policy Review

1). The Seclusion and Restraint policy (revised 5/18/10), received on 1/24/11 at 4:15p.m., in the definition section (page 2, bullet 2) describes seclusion as "The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion requires a physician's order and may be initiated by the charge nurse, pending a written or verbal order from an LIP."

In the definition section (page 2, bullet 3), the S/R policy describes restraint as "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Restraint required a physician's order and may be initiated by the charge nurse, pending a written or verbal order from an LIP."

2). The R&S policy requires the following additional documentation: Seclusion or Restraint nursing assessment (page 7, Section 3a), Seclusion or Restraint Record Sheet (Page 4, Section 1e v. b.), and Documentation by an LIP within 1 hour of restraint (page 4, Section 1h).

On page 4. Section 1e iv., the S/R policy also says that the Shift Director is to be notified of all episodes of seclusion or restraint, and that the Shift Director is to notify the Director of Nursing.

III. Failure to Implement Required Patient Observations and Provide a Safe Environment of Care

A. Observations

1. An observation on Unit N4 on 1/25/11 at 10:25a.m. through 11:00a.m. revealed that the 15 minute nursing rounds sheet was blank for 10:15a.m., 10:30a.m. and 10:45a.m. MHW1 was sitting at desk documenting group notes. MHW1 later indicated that another MHW was responsible for completing the sheet for that period of time. The "other MHW" was assigned to Unit N3 in the surveyor's presence prior to 10:15a.m. After the observation, LPN1 was asked who was responsible for rounds; she informed the surveyor that it was MHW1.

2. On 1/25/11 at 3:20p.m., the 15 minute required nursing rounds sheet for Unit N4 were observed to be blank for the 2:45p.m.; 3:00p.m., and 3:15p.m. checks. After validation of the information by LPN1, the surveyor made a copy of the sheet (to compare with another copy to be requested on 1/26/11). MHW1 who had responsibility to complete the 15 minute rounds sheet was away from the unit and arrived back on the unit at 3:25p.m.

3. On 1/26/11 at 11:10a.m., a review of the nursing rounds sheet for 1/25/11 revealed that the required documentations for 10:15a.m., 10:30a.m. and 10:45a.m. checks had been completed.

B. Staff Interview

In an interview on 1/25/11 at 3:20p.m., LPN1 (the charge nurse for the shift) stated that she had talked to MHW1 about completing the nursing rounds sheet earlier in the day at 11:00a.m. She said she didn't know why the sheet was not completed.

C. Policy Review

The facility's Nursing Observation Policy (dated October 2004) (no policy number), received by the surveyor on 1/24/11 at 4:00p.m., states on page 1: "At a minimum, all patients admitted to the Acute Psychiatric Units - either voluntarily or involuntarily - are placed on 15-minute checks by staff."

D. Incident Review

A review of Incident Reports for September through December 2010 for unit N4, provided by the Executive Director on 1/26/11 at 1:00p.m., revealed 23 total incidents involving patients. Five of the incidents reported patients engaging in sexual encounters, 8 of the reports were for aggressive patient behaviors.

Based on observation, patient interview, staffing review, policy review, staff interview and incident review, it was determined that the facility failed to provide adequate numbers of Registered Nurses on all tours of duty. This staffing pattern negatively affected the provision of care by resulting in a lack of nursing direction for patient treatment and a lack of supervision for non-professional nursing personnel on one patient unit (N4). This failure results in potential patient and staff safety issues and inability to provide for individual patient needs.

A. Observation

1. In an observation on 1/24/11 at 3:15p.m. on N4, patient B3 was seen throwing her walker against the wall repeatedly. The only person to intervene was the mental health worker.

B. Patient Interviews

1. In an interview on 1/24/11 at 12:15p.m., Patient B8 reported that patient B10 pushed patient B3 to the ground several days prior.

2. In an interview on 1/24/11 at 1:30p.m., patient B10 reported she was manually restrained and placed into seclusion on 1/22/11. There was no documentation of the restraint or seclusion use.

C. Staffing Review

1. On the first day of the survey, one LPN was in charge of the 7:00 a.m. to 7:00p.m. shift on unit N4 with three mental health workers.

2. Staffing review for the dates of 12/10/10 through 12/17/10 revealed that 2 of 16 (12 hour) shifts on Unit N4 were staffed with only an LPN on duty. There was no RN present on N4 during these shifts.

3. A Staffing Review (report) for Oct 1 - 25, 2010 showed that when both N3 and N4 units were open, 48 of the 120 total shifts (40%) were staffed by an LPN as the only licensed professional. This data was verified by the Shift Director.

4. A nursing needs assessment for 1/24/11 revealed that 4 of 17 patients on unit N4 had the potential for assaultive behavior, and that 1 of 17 patients was actively assaultive. One of 17 patients was assessed as an intermediate suicide risk; two of 17 patients were on assault precautions; one of 17 patients was on line of sight precautions. And one of 17 patients was on 1:1 supervision.

D. Policy Review

The "Staffing Ratios for Acute Psychiatric Units" policy dated 4/2/07, and received on 1/24/11 at 4:00p.m., pg 2 Procedure for Inpatient Hospital Treatment and Rehabilitation states "The facility will follow internal staffing standards for non-primary care staff, which includes both Nurses and Mental-Health Technicians. The internal staffing standards are: 7a.m. to 11p.m.: One Nurse or Mental-Health Technician for every 5 patients.; 11p.m. to 7a.m.: One Nurse of (sic) Mental Health-Technician for every 8 patients. There is no minimum or maximum number of RNs or LPNs identified in the policy.

E. Staff Interview

1. In an interview on 1/24/11 at 1:15p.m., LPN1 reported that she was the only licensed nurse on duty for N4. She reported that her lunch break is relieved by the RN Shift Director who has responsibilities throughout the hospital.

2. In an interview on 1/24/11 at 2:15p.m., the Director of Nursing (DON) reported that it is common for an LPN to be the only licensed nurse on duty and to be in charge of the unit. She said that "if the census is above 17 a second nurse (either LPN or RN) was assigned to the unit, but at times it wasn't possible." The DON said that she would prefer to staff with RNs but it's not possible. She didn't explain why.

3. In an interview on 1/25/11 at 11:30a.m., the Shift Director provided a summary list of 21 items that were within her scope of responsibilities. The summary showed that her duties include supervision of the care of the patients on the two acute psychiatric units as well as the Drug and Alcohol units for the hospital. These activities include but are not limited to: supervising the care of patients when an LPN is on duty on the unit, completing nursing admission assessments for the LPN, ensuring that the hospital has adequate staffing, managing medical issues and emergencies in the hospital, managing AMA/AWOL's, ensuring that all logs are completed, managing the hospital census, verifying that restraint and seclusion paperwork is completed, and checking all verbal orders.

4. In an interview on 1/25/11 at 2:40p.m., the Shift Director stated that it is the responsibility of the LPN to contact the Shift Director when assistance is needed. "The Shift Director does not have time to regularly be on the unit besides the twice per 8 hours required." She stated "that if she is involved in a medical emergency elsewhere, she will rely on other RNs in the hospital to leave their unit without RN coverage to assist the LPN." The DON has the Shift Director responsibilities from 7:00a.m. until 3:00p.m. There are no nurse managers for Units N3 or N4.

E. Review of Incident Reports

1. Incidents reports were reviewed for the dates of 10/1/10 through 12/31/10 for Units N3 and N4. The reports showed a range of 6 -13 patient incidents (aggression, falls, medical intervention errors, sexual activity between patients) per month occurring between the two units.

2. A review of Incident Reports for September through December 2010 for unit N4, provided by the Executive Director on 1/26/11 at 1:00p.m., revealed 23 total incidents involving patients. Five of the incidents reported patients engaging in sexual intercourse, 8 of the reports were for aggressive patient behaviors.