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Based on observation, interview, record review, policy review and the Missouri Food Code, the facility failed to ensure that the Director of Nutrition and Dietary Services (NDS) enforced basic food sanitation policies and procedures, including appropriate food storage, cleaning of equipment and general kitchen sanitation. (A-0620) and failed to ensure the current Therapeutic Diet Manual was available to patient care staff to use as a diet reference, on two units (One West and Three West) of two units reviewed for availability. (A-0631)

These deficient practices placed all patients at risk for unsanitary food service, cross contamination of food and possible food poisoning.

These systemic failures contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Food and Dietetic Services.

The facility census was 50.

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

l. Provide Master Treatment Plans (MTPs) that identified patient-related short-term and long-term goals stated in observable, measurable, behavioral terms for seven (7) out of eight (8) sampled patients (A1, A2, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, leading to patient stays beyond the resolution of the behaviors requiring admission. (Refer to B121)

2. Document specific treatment modalities/interventions based on the individual needs for six (6) of eight (8) sample patients (A1, A2, A4, A5, A6, and A8). Each goal was accompanied by preprinted treatment modalities describing the specific focus of treatment for each short-term goal. In addition, treatment modalities frequently included routine, generic discipline functions listed as individualized treatment modalities unrelated to the specific patient's short-term goal. This failure to document specific treatment approaches on the MTP interferes with the assurance of consistency of approach to each patient's problem(s). (Refer to B122)

3. Ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the master treatment plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

4. Ensure that active treatment measures, such as group and/or individual treatment were provided for five (5) of eight (8) active sample patients (A1, A2, A3, A4, and A5) who were unwilling, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

5. Ensure that Social Work progress notes were individualized and identified progress towards goals for one (1) of eight (8) sample patients (A8). Specifically the Social Work progress notes for four (4) weeks were identical in wording for patient A8. Failure to accurately document patient progress hinders the treatment team's ability to set goals and can increase patient length of stay. (Refer toB128)

6. Ensure that Nursing Progress Notes complied with hospital policy for one (1) of eight (8) active sample patients (A7). Specifically, the last weekly Nursing Progress Notes for patient A7 was on 12/13/17. There were no weekly notes on the record from 12/13/17-1/22/18. Failure to have nursing progress notes on the record limits the knowledge of the staff regarding patient progress and could increase patient length of stay. (Refer to B130)

Based on interview, record review and policy review, the facility failed to ensure that patient treatment plans were modified to include goals and interventions when patients were placed in seclusion for one current patient (#1) out of two patients reviewed that had been placed in seclusion and/or manual restraint. This had the potential to affect all patients that were placed in seclusion and/or restraints by failing to ensure the patients' physical and psychological needs were met. The facility census was 50.

Findings included:

1. Review of the facility's policy titled, "Restraint and Seclusion," revised 11/16/16 showed the following directives for staff:
Personal Safety Plan:
(A) Completion of the "Personal Safety Plan" that includes data about the individual's history of exposure to sexually, physically or emotionally traumatic events, or other trauma - including trauma from previous use of seclusion and restraints or other prior mental health interventions;
(B) Staff should discuss with each individual, strategies to both identify and reduce the specific triggers for agitation, anger, hostility, impulsivity, ect.;
(C) That might ultimately lead to the use of restraint and seclusion. Such discussion shall include what kind(s) of treatment or interventions would be most helpful and least traumatic for the individual;
(D) Staff shall discuss with each individual options they will be offered for de-escalation such as time out in a quiet area, PRN (as needed) medications by mouth or injection, diversionary activities, relaxation activity, physical restraints, and verbal redirection;
(E) Designation of a family member, legal guardian , or other person the individual wishes to be informed if restraint or seclusion is used. This information shall be used in the development of the individual's treatment plan; and
(F) During the next treatment team meeting following a restraint or seclusion, the treatment team will meet with the patient to review the interventions identified on the Personal Safety Plan. At this time, revisions will be made to the interventions listed on the Personal Safety Plan and the individual treatment plan.
Debriefing Following Restraint or Seclusion Procedure:
(C) During the next treatment team meeting the treatment team shall review the treatment plan and Personal Safety Plan to assess the need for modification to reduce the likelihood of reoccurrence.

2. Review of the facility's policy, "Treatment Planning," revised 11/16/16 showed the following directives for staff:
- The Master Treatment Plan (MTP) is a document that summarizes the team's agreement on the focus and direction of treatment. The MTP identifies problems, sets goals (for which the patient is responsible) and coordinates and prioritizes the modalities (for which the team is responsible).
- Filling out the MTP from the information derived from the patient, staffing, the treatment team discussions regarding reasons for admission, diagnosis, assets, long and short term goals, and individual problem plans.
- Once the MTP has been completed, subsequent changes in the plan must be documented.

3. Review of Patient #1's medical record showed she was admitted to the facility on 08/17/17 with complaints of incompetent to stand trial related to an assault in the second degree and armed criminal action.

Review of the patient's Progress Notes showed the following:
- On 09/29/17 at 4:45 PM, staff documented that the client (patient) became verbally aggressive after she asked for IM (intramuscular) Abilify (antipsychotic medication used to treat schizophrenia) and was told that was not an ordered medication. She then began to throw chairs in the alcove and dayroom. Client threw chair into TV, which broke. Staff tried to redirect client, but client became more agitated. Client began to throw chairs at staff and peers. Client then pulled a piece of laminate off the nurse's station and attempted to use it to cut her wrists. Client placed in manual hold and placed into seclusion. Client also placed on one-to-one (1:1) observation.
- On 09/29/17 at 5:45 PM, staff documented client in seclusion room on one-to-one.
- On 09/29/17 at 6:05 PM, staff documented client contracts for safety. Client released from seclusion and put on 1:1.

Review of the patient's Restraint/Seclusion Documentation - MD (physician) Order dated 09/29/17 at 5:40 PM, showed staff wrote a telephone order for the patient to be placed in manual restrain (maneuver that immobilizes or reduces the ability of an individual to move their arms, legs, body or head freely) to place in seclusion (the involuntary confinement of an individual alone in a room or area from which the individual is physically prevented from leaving).

Review of the patient's Master Treatment Plan - Problem List dated 08/17/17 and 09/08/17 showed staff did not update or modify the Master Treatment - Problem List to include short/long term goals or interventions to address the episode when the patient was placed in seclusion on 09/29/17.

Staff did not update the patient's Master Treatment Plan or Master Treatment Plan - Problem List to include short/long term goals and interventions for the episode when she was placed in seclusion for aggressive behavior towards staff and peers and when she displayed self injurious behavior.

Record review of the patient's Master Treatment Plan - Weekly Update dated 10/04/17 showed staff documented the treatment team met with the patient to discuss episode of aggression from 09/29/17. No reports of suicidal ideations (SI - thoughts of harming self) at this time.

Staff did not address in the Master Treatment Plan - Weekly Update short/long term goals or interventions to address the patient's aggressive and self injurious behavior that caused her to be placed in seclusion.

During an interview on 01/24/18 at 1:39 PM, Staff B, PSDY (Doctor of Psychology), Chief of Clinical Services, stated that neither Patient #1's Master Treatment Plan nor the Master Treatment Plan - Problem List included the problem for the incident on 09/29/17 when the patient was placed in seclusion for self injurious and aggressive behavior towards staff and peers.

Based on interview, record review and policy review, the facility failed to perform a comprehensive re-assessment and implement individualized goals and interventions to prevent patient elopement/escape (a patient that is aware he is not permitted to leave but attempts with intent to leave the facility) for one current (#3) patient of one reviewed that had attempted to elope/escape from the facility. This had the potential to affect all patients assessed at risk for elopement/escape. The facility census was 50.

Findings included:

1. Review of the facility's policy titled, "Assessment," reviewed 01/2018 showed directives for staff that each client (patient) shall have initial and ongoing assessments by nursing staff. Nursing staff is responsible to utilize skills and knowledge to conduct assessment of client needs and the Registered Nurse is to direct and implement the appropriate level of nursing care as determined by the assessment. Assessment data is used to develop an individualized Treatment Plan.

2. Review of the facility's policy titled, "Recent Predictive Behaviors (RPB)," revised 09/18/15 showed:
Definitions:
- Recent Predictive Behaviors Category: A categorical score assigned to a client, which is based upon status and recent behaviors along a continuum of risk.
- Critical Path: A set of procedures that should follow the initial assignment or a change in the Recent Predictive Behaviors category.
Procedure:
- The attending psychiatrist assigns initial category of Recent Predictive Behaviors (Client RPD Level) upon completion of the Medical/Psychiatric Assessment and initiates the appropriate Critical Path requirements.
- All clients shall have a Recent Predictive Behaviors category assigned as part of the Master Treatment Plan and any subsequent Treatment Plan Reviews.
- Any Change in Legal Status or Client Behavior Warranting an Increase in Category: When the attending psychiatrist is made aware that a behavior warranting an increase in CLIENT RPD LEVEL category has occurred, the psychiatrist completes a new Recent Predictive Behaviors form, assigns the appropriate category, and initiates the appropriate Critical Path requirements.
- The psychiatrist shall order any changes in escort ratios, use of security escort devices, privileges or location of activities as needed.
- Any change to the Recent Behaviors category is documented on the form and in a progress note by the psychiatrist. Any changes in escort ratio, use of security escort devices, privileges or location of activities dictated by the Critical Path requirements of the Recent Predictive Behaviors form are documented in the Progress Notes.

3. Review of the facility's policy titled, "Escorting Clients and the Use of Security Escort Devices," revised 12/15/17 showed when moving groups of clients and only one staff is escorting (which would limit the total number of clients to be 8 or less), the staff member shall remain at the rear of the group so all clients are visible to him or her.

4. Review of Patient #3's medical record showed he was admitted to the facility on 08/16/17 with complaints of incompetent to stand trial and police hold.

Review of the patient's Recent Predictive Behaviors dated 08/16/17 showed:
- CATEGORY II: Recent behaviors predictive of escape (elopement), violence, arson, suicide or major self-injurious behaviors;
- Police hold; and
- Maximum privileges allowable are "Escorted Within Building or Perimeter", with escort ration of 1:1. Note: If only item in Category II is "Police Hold", may have Escorted within Building Perimeter with escort ratio of 1:8.

Review of the patient's Progress Notes showed:
- On 09/16/17 at 11:35 AM, rehab staff documented Rehab services library group. Client left the group of 7 unnoticed when exiting the library to return to the unit. 3W (Three West) Unit was called to assist in searching for client and client was found inside the double doors heading to the 2 East hallway.
- On 09/16/17 at 12:00 PM, nursing staff documented the psychiatrist was notified and order given to restrict client to unit for above behaviors and his safety.
- On 09/26/17 at 2:23 PM, social services staff documented this review period the client was placed on restrictions due to leaving group area (library) reported he stated he had to use the restroom but was found by staff in hall unable to leave area due to locked doors. Team discussed this with the client to assess for elopement risk.

The patient's medical record did not show that staff:
- Assessed the patient for elopement/escape risk;
- Updated his Treatment Plan to include short/long term goals and intervention for the attempted elopement/escape; and
- Performed a Recent Predictive Behaviors to address the attempted elopement/escape by the patient on 09/16/17.

During an interview on 01/24/18 at 3:12 PM Staff C, Activity Aide, stated that:
- The incident with the patient happened on a Saturday morning and this was the first time he had been in the library.
- She went to the unit and brought seven patients to the library and only one unit goes at a time.
- She was the only staff present when bringing the patients off the unit and she was located behind the patients during the escort to the library area.
- When it was time to leave the library, she unlocked the door and held it open for the patients to exit and line up in the hall by the library.
- When all the patients were out of the library area, she closed and locked the library door and she was toward the back of the patient line but not at the very end.
- After she had secured the library door, she had the patients start to walk to the end of the hallway.
- About half way down the hallway she did a count of the patients and noticed one was not in line.
- She did not see or know when the patient first broke out of the patient line and left the group.
- She had the patients walk to the end of the hallway and she looked down both directions to see if the patient was anywhere but he was not.
- She waked the patients back down the hallway and looked in both restrooms on the hall but the patient was not in either restroom.
- She walked the patients back to the library, called the unit the patient was on, and reported he had broken line and she did not know where he was.
- The unit sent staff to the area and began searching for the patient.
- The patient was found by unit staff behind double doors looking out the window.
- The patient was able to push the double doors open and go through to a hallway, however; when the double doors shut they were locked and he was unable to exit from either side. The area the patient was in was secured and all doors were secured and locked, so the patient was caught in the area and unable to exit the facility property.
- The patient was out of staff sight and presence approximately 10 minutes before he was located and taken back to the unit.
- After the incident with the patient, no process changes were made but staff was reminded to stay at the end of the line when one staff is escorting/transporting patients off the unit.
- The facility does have a policy of one staff to eight patient ratio during escort/transportation.

During an interview on 01/24/18 at 2:43 PM, Staff B, PSYD (Doctor of Psychology), Chief of Clinical Services, stated that the elopement/escape assessment was not done after the patient left group on 09/16/17. Staff B stated that the patient's Master Treatment Plan does not address the patient's leaving the group and no problem was added after the incident.

During an interview on 01/25/18 at 3:15 PM, Staff B, PSYD, Chief of Clinical Services, stated that the patient should have had another Recent Predictive Behavior assessment performed after his incident of breaking line and being out of staff sight. Staff B stated that all employees were re-educated about transporting patients off the unit and staff had to sign they received the education.

Staff failed to complete a new Recent Predictive Behaviors form, update the patient's category based on the re-assessment and initiate appropriate Critical Path requirements after the patient attempted to elope/escape on 09/16/17.

Based on interview, record review, policy review, the facility failed to ensure staff updated the Master Treatment Plan (MTP) that included a comprehensive individualized plan that included short/long term goals, measurable objectives and timetables for one (#3) current patient reviewed that attempted to escape from the facility. The facility census was 50.

Findings included:

1. Review of the facility's policy, "Treatment Planning," revised 11/16/16 showed the following directives for staff:
- The Master Treatment Plan (MTP) is a document that summarizes the team's agreement on the focus and direction of treatment. The MTP identifies problems, sets goals (for which the patient is responsible) and coordinates and prioritizes the modalities (for which the team is responsible).
- Filling out the MTP from the information derived from the patient, staffing, the treatment team discussions regarding reasons for admission, diagnosis, assets, long and short term goals, and individual problem plans.
- Once the MTP has been completed, subsequent changes in the plan must be documented.

2. Review of the facility's policy titled, "Recent Predictive Behaviors (RPB)," revised 09/18/15 showed
all clients shall have a Recent Predictive Behaviors category assigned as part of the Master Treatment Plan and any subsequent Treatment Plan Reviews.

3. Review of Patient #3's medical record showed he was admitted to the facility on 08/16/17 with complaints of incompetent to stand trial and police hold.

Review of the patient's Recent Predictive Behaviors dated 08/16/17 showed:
- CATEGORY II: Recent behaviors predictive of escape (elopement), violence, arson, suicide or major self-injurious behaviors;
- Police hold; and
- Maximum privileges allowable are "Escorted Within Building or Perimeter", with escort ration of 1:1. Note: If only item in Category II is "Police Hold", may have Escorted within Building Perimeter with escort ratio of 1:8.

Review of the patient's Progress Notes showed:
- On 09/16/17 at 11:35 AM, rehab staff documented Rehab services library group. Client left the group of 7 unnoticed when exiting the library to return to the unit. 3W (Three West) Unit was called to assist in searching for client and client was found inside the double doors heading to the 2 East hallway.
- On 09/16/17 at 12:00 PM, nursing staff documented the psychiatrist was notified and order given to restrict client to unit for above behaviors and his safety.
- On 09/26/17 at 2:23 PM, social services staff documented this review period the client was placed on restrictions due to leaving group area (library) reported he stated he had to use the restroom but was found by staff in hall unable to leave area due to locked doors. Team discussed this with the client to assess for elopement risk.

Review of the patient's MTP dated 08/16/17 showed staff did not update the MTP that included individualized short/long term goals, measurable objectives and timetables for the attempted escape on 09/16/17.

Staff failed to update the patient's MTP to reflect re-assessment, added short/long term goals, measurable objectives and timetables after he attempted to escape, for example, staff did not include interventions to prevent escape seeking behaviors (standing near/close to exit doors).

The patient's medical record did not show that staff:
- Assessed the patient for elopement/escape risk upon admission that included short/long term goals, measurable objectives, and interventions in the MTP;
- Updated his Treatment Plan to include long/short term goals, measurable objectives and intervention for the attempted elopement/escape on 09/16/17; and
- Performed a Recent Predictive Behaviors to address the attempted elopement/escape by the patient on 09/16/17.

During an interview on 01/24/18 at 3:12 PM Staff C, Activity Aide, stated that:
- When it was time to leave the library, she unlocked the door, held it open for the patients to exit and line up in the hall by the library.
- When all the patients were out of the library area, she closed and locked the library door and she was toward the back of the patient line but not at the very end.
- After she had secured the library door, she had the patients start to walk to the end of the hallway.
- About half way down the hallway she did a count of the patients and noticed one was not in line.
- She did not see or know when the patient first broke out of the patient line and left he group.
- She walked the patients back to the library, called the unit the patient was on, and reported he had broken line and she did not know where he was.
- The unit sent staff to the area and began searching for the patient.
- The patient was found by unit staff behind double doors looking out the window.
- The patient was able to push the double doors open and go through to a hallway, however; when the double doors shut they were locked and he was unable to exit from either side. The area the patient was in was secured and all doors were secured and locked, so the patient was caught in the area and unable to exit the facility property.
- The patient was out of staff sight and presence approximately 10 minutes before he was located and taken back to the unit.

During an interview on 01/24/18 at 2:43 PM, Staff B, PSYD (Doctor of Psychology), Chief of Clinical Services, stated that the elopement/escape assessment was not done after the patient left group on 09/16/17. Staff B stated that the patient's Master Treatment Plan does not address the patient's leaving the group and no problem was added after the incident.

During an interview on 01/25/18 at 3:15 PM, Staff B, PSYD, Chief of Clinical Services, stated that the patient should have had another Recent Predictive Behavior assessment performed after his incident of breaking line and being out of staff sight.

Staff failed to complete a new Recent Predictive Behaviors form, update the patient's category based on the re-assessment and initiate appropriate Critical Path requirements after the patient attempted to elope/escape on 09/16/17.

Based on observation, interview and policy review, the facility failed to ensure that multidose medications, stored outside of the pharmacy, were dated with a beyond use date (BUD) when the medication bottles were opened. This had the potential to affect all patients who were administered multidose medications that may be outdated and ineffective, and lead to poor outcomes. The facility census was 50.

Findings included:

1. Review of the facility's policy titled, "Infection Control/Safety Procedures - Medication Preparation and Distribution," dated 06/2009, showed that all multiple dose containers stored outside the pharmacy, will have a beyond use dated of 28 days after opening or entering, unless otherwise specified by the manufacturer.

2. Observation on 01/24/18 at 11:00 AM, showed 15 open multidose medication bottles on top of a medication cart. The open bottles were not labeled with a BUD. The medications were as follows:
- Three bottles of Lithium Oral Solution (treatment for psychiatric disorder), labeled with patients' #11, #16 and #17 information.
- Four bottles of Chlorhexidine Gluconate (mouth wash that prevents infections of the mouth), labeled with patients' #16, #17, #18 and #19 information.
- Seven bottles of Miralax (laxative), labeled with patients' #11, #17, #21, #22, #23, #24 and #25 information.
- One bottle of Pepto Bismol (decreases acid indigestion), labeled with patient #20's information.

Observation on 01/24/18 at 11:09 AM, showed Staff S, Licensed Practical Nurse (LPN) and Medication Nurse for One West, administered open, undated Miralax from a multidose bottle to Patient #23.

During an interview on 01/24/18 at 10:27 AM, Staff S stated that previously, multidose medication bottles required a BUD label of 30 days from the date it was opened. Staff S stated that she was told by leadership that she no longer needed to label the bottles.

During an interview on 01/25/18 at 2:25 PM, Staff H, Regional Director of Pharmacy, stated that multidose medications did not require a BUD, based on research. Staff H stated that the facility used the manufacturer's date as the BUD.

Based on observation, interview, record review, policy review and review of the Missouri Food Code, the facility failed to ensure that the Director of Nutrition and Dietary Services (NDS) enforced basic food sanitation policies and procedures including appropriate food storage, cleaning of equipment and general kitchen sanitation. These failed practices had the potential to negatively impact patient food and nutrition services. The facility census was 50.

Findings included:

1. Review of the facility's NDS policy titled, "Dress and Personal Hygiene for Dietary Employees," dated 02/27/17, showed that the Food Service Supervisors/Dietitians were responsible for general maintenance of correct and sanitary food handling procedures and for adherence to safe and proper dress, which included that all employees must wear dietary caps or hairnets.

2. Review of the facility's undated NDS policy titled, "Food Preparation Equipment: Operation and Care," showed:
- The cleaning process for the can opener did not detail the frequency of cleaning.
- Carts should be washed with sanitizing solution and power hosed weekly.
- The convection oven exterior should be cleaned daily.

3. Record review of the facility's undated NDS policy titled, "Garbage," showed that all containers should be provided with tight-fighting lids or covers and be kept covered when stored or not in continuous use.

4. Review of the facility's NDS policy titled, "Purchasing, Receiving and Storage of Food and Non-Food Items," dated 02/27/17, showed:
- All dry foods shall be labeled and dated.
- Perishable foods shall be maintained under refrigeration at 41 degrees or below.
- All foods stored in refrigerators/freezers shall be covered/sealed, dated and labeled.

5. Review of the facility's policy titled, "Infection Control - Dietary Services," dated 10/23/17, showed that dietary staff should wear hair and beard restraints to prevent contamination of food, equipment or supplies, and that staff should follow the Missouri Food Service Code for food labeling, dating, and storage.

6. Review of the Missouri Food Code 3-501.17, showed that ready-to-eat, potentially hazardous food, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty four (24) hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. The day the original container is opened in the food establishment shall be counted as Day 1 and the day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety.

7. Observation on 01/24/18 from 11:17 AM to 11:45 AM and 1:39 PM to 3:30 PM in the NDS, showed the following failures in basic food sanitation and general kitchen sanitation:
- Staff U and Staff V, Food Service Assistants, with uncovered facial hair, who worked in and around the tray line area (area where inpatient meals are placed on plates, according to their specific dietary needs) during lunch preparation.
- Staff Z, Food Service Helper, with approximately two inches of hair exposed in the front and back hairline, who worked in and around the tray line area during lunch preparation.
- Three uncovered trash cans.
- A mounted can opener that had brownish/red food residue on the blade, and the can opener holder was covered with specks of dirt and debris.
- The top of the steamer, top of the combination oven, top of the convection oven (all baking/cooking appliances/equipment) were covered with thick dirt and debris.
- A tray rack (where patient trays are stored) with dirt and debris.
- A storage rack, with inverted pots and pans (pots and pans were placed upside down, where the lip of the pan rested on the top of the rack), was covered with wipeable dust and debris.
- Employee lunch boxes and water bottles, stored in the reach in cooler, which contained food used for patients, staff and visitors.
- Bulk sized salad dressings, cottage cheese and sour cream were opened and were not labeled with an open date.
- Bulk sized storage containers of cornstarch, sugar and brown sugar which were not labeled with an open date.
- Bulk sized white, powdery substance (similar in appearance to flour), was not labeled with the contents or an open date.
- Greater than 20 bulk spices were open and were not labeled with an open date.
- Bulk sized vinegar and cider vinegar were open and were not labeled with an open date.
- Bulk sized mayonnaise was open and was not labeled with an open date.
- Bulk stalks of celery, onions, potatoes, sweet potatoes, cucumbers and oranges were uncovered in the walk in cooler, and not protected from splash or spill.

Review of "Reach-In Refrigerator (line side) temperature recordings," with "safe temperatures" of 41 degrees or below, showed that on:
- 01/16/18, the "closing temperature" was 45 degrees;
- 01/17/18, the "closing temperature" was 44 degrees;
- 01/19/18, the "closing temperature" was 42 degrees; and
- 01/20/18, the "opening temperature" was 42 degrees.
The temperature was not rechecked within a reasonable amount of time, nor were the times of the documented temperatures recorded, to ensure that food did not remain at an unsafe temperature for an extended amount of time.

During an interview on 01/24/18 from 11:30 AM to 11:45 AM and 1:39 PM to 3:30 PM, Staff W, Director of Nutrition and Dietary Services, who verified all sanitation findings, stated that:
- All hair, beyond stubble, should be covered while in the kitchen.
- Trash cans were to be covered when not in use.
- The cooks should have cleaned the top of the steamer.
- The outside of all equipment should be cleaned daily.
- Tray racks should be cleaned daily.
- Storage racks should be cleaned weekly.
- Bulk food wasn't labeled with the open date, "because we go through it so fast."
- The bulk "flour" storage container should have been labeled with the containers contents.
- Items such as bulk celery, potatoes, etc. were not required to be covered.
- As of 01/15/18, the kitchen had implemented a new process to recheck out of range temperatures on the reach-in refrigerators within one hour, and document the temperature, to ensure that the food did not remain at an unsafe temperature.

During an interview on 01/24/18 at 2:20 PM, Staff W stated that she was unsure if opened food items required an open date. Staff W added that the Environment of Care (EOC) Committee, which included Staff AA, Infection Preventionist, completed quarterly rounding (every three months, or four times per year), and the City Health Inspector completed inspections quarterly, and had no concerns.

Review of the "Infection Control and Environment of Care Rounding - Nutritional Services," dated 03/20/17, showed that the environment was inspected for:
- Dishes stored in a clean environment;
- Completed refrigerator logs;
- No staff items mingled with patient food;
- Opened food products tightly sealed and dated; and
- No employee food stored in the client kitchen.

During an interview on 01/25/18 at 1:56 PM, Staff AA, Infection Preventionist, stated that:
- Staff should cover all hair, including facial hair if it was more than stubble.
- The kitchen had run out of beard covers, and she became used to the men not covering their beards, that when the beard covers were restocked, she failed to enforce the use of the beard covers.
- She completed EOC rounding in the kitchen two times per year.
- She rounded in March, 2017, and then rounded continuously through the remainder of the year, but did not document the continuous rounding.
- Open food should be labeled with the date it was open, and when it would expire.
- She was unaware of the out of range cooler temperatures.

29047

Based on observation, interview and policy review, the facility failed to ensure the current Therapeutic Diet Manual was available to patient care staff to use as a diet reference, on two units (One West and Three West) of two units reviewed for availability. This deficient practice had the potential to permit staff to serve patients on therapeutic diets inappropriate or unapproved foods. The facility census was 50.

Findings included:

1. Review of the facility's undated form titled, "The Department of Mental Health Diet Manual Availability," showed that hard copies of the "Mental Health Diet Manual" were available in the nursing stations on One West and Three West, as well as an electronic diet manual, located on the facility's intranet.

2. During an interview on 01/23/18 at 10:10 AM, Staff P, Registered Nurse (RN) did not know what the diet manual was, where it was located, or if there was one available to the nursing staff on One West.

During an interview on 01/25/18 at 11:52 AM, Staff F, Licensed Practical Nurse, Medication Nurse-3 West, stated that she did not know where the diet manual was located on the unit.

During an interview on 01/24/18 at 2:20 PM, Staff X and Y, Registered Dieticians, stated that the Diet Manual was available on each unit, as well as on the intranet, and accessible from any computer in the nurses' stations. Staff W, Director of Dietary Services, verified that the diet manual was available on both of the nursing units, through hard copy or electronically.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-related short-term and long-term goals stated in observable, measurable, behavioral terms for seven (7) out of eight (8) sampled patients (A1, A2, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, leading to patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Specific Patient Findings

1. Patient A1's MTP, dated 12/13/17, listed for the problem, "Psychotic Sx [symptoms]" as evidenced by "persecutory delusions and paranoia," the following non-measurable preprinted Short-Term Goal (STG): "Be free from speech or behaviors indicative of delusions. Specifically talking about paranoia or being followed."

2. Patient A2's MTP, dated 12/18/17, listed for the problem, "Psychotic Symptoms" as evidenced by "grandiose delusions, bizarre statements, tangential and [illegible] incoherent speech," the following non-measurable preprinted STGs: "Report and demonstrate effective coping skills for dealing with psychotic symptoms" and "Demonstrate relevant and organized speech."

3. Patient A4's MTP, dated 1/12/18, listed for the problem, "Psychotic Symptoms" as evidenced by "exhibiting paranoid and delusional beliefs," the following non-measurable preprinted STGs: "Be free from speech or behaviors indicative of delusions" and "Report and demonstrate effective coping skills for dealing with psychotic symptoms."

4. Patient A5's MTP, dated 1/3/18, listed for the problem, "Cognitive Deficits" as evidenced by "limited understanding in social situations, poor historian; Hx [history] of successful functioning until 2015," the following non-measurable preprinted STG: "Demonstrate increased independence in ADLs [Activities of Daily Living] / hygiene/self-care."

5. Patient A6's MTP, dated 1/10/18, listed for the problem, "Psychotic Symptoms" as evidenced by "Paranoid," the following non-measurable preprinted STG: "free from speech or behaviors indicative of delusions. Specifically: distrust of others."

6. Patient A7's MTP, dated 9/27/17, listed for the problem, "Anxiety" as evidenced by "discomfort surrounding ideas. Flight of ideas," the following preprinted non-measurable STG: "Demonstrate effective coping and stress reduction skills when anxiety increases."

7. Patient A8's MTP, dated 12/18/17, listed for the problem, "Adaptive Functioning Issues" as evidenced by "difficulty communicating facts about [his/her] personal care and history," the following preprinted non-measurable STG: "demonstrate improvement in Social Skills as evidenced by increased positive interactions with peers and staff."

8. Review of Hospital Policy #MPC 059, revised 11/6/16, revealed a lack of specific requirements necessary for the documentation of the short-term goals on the treatment plans.

C. Interviews

1. In an interview on 1/22/18 at 3:30 p.m., the QA (Quality Assurance) Specialist concurred that short-term goals were not documented in observable, measurable, behavioral language.

2. In an interview on 1 /23/18 at 1:00 p.m., the Medical Director concurred that short-term goals were not documented in observable, measurable, behavioral language.

3. In an interview on 1/23/18 at 1:30 p.m., the Director of Psychology concurred that short-term goals were not documented in observable, measurable, behavioral language.

4. In an interview on 1/23/18 at 2:15 p.m., the Director of Nursing concurred that short-term goals were not documented in observable, measurable, behavioral language.

Based on record review and interviews, the facility failed to document specific treatment modalities/interventions based on the individual needs for six (6) of eight (8) sample patients (A1, A2, A4, A5, A6, and A8). Each goal was accompanied by preprinted treatment modalities describing the specific focus of treatment for each short-term goal. In addition, treatment modalities frequently included routine, generic discipline functions listed as individualized treatment modalities unrelated to the specific patient's short-term goal. This failure to document specific treatment approaches on the MTP interferes with the assurance of consistency of approach to each patient's problem(s).

Findings Include:

A. Specific Patient Findings

1. Patient A1's MTP, dated 12/13/17, listed for the problem "psychotic Sx [symptoms]" as evidenced by "persecutory delusions and paranoia," the STG: "Be free from speech or behaviors indicative of delusions. Specifically talking about paranoia or being followed." The generic Nursing treatment modality for this goal was: "Nursing will ensure the safety of the patient and others." The Social Work generic treatment modality for this goal was: "Social Work staff will coordinate with the treatment team to address hallucinations and/or delusions."

2. Patient A2's MTP, dated 12/18/17, listed for the problem "Psychotic Symptoms" as evidenced by "grandiose delusions, bizarre statements, tangential and [illegible] incoherent speech," the STGs: "Report and demonstrate effective coping skills for dealing with psychotic symptoms" and "Demonstrate relevant and organized speech." The generic Nursing treatment modality for this goal was: "Nursing will ensure the safety of the patient and others." The Rehab Services generic treatment modality was: "Develop rapport, assess attention and evaluated tolerance for future group attendance."

3. Patient A4's MTP, dated 1/12/18, listed for the problems "Psychotic Symptoms" as evidenced by "exhibiting paranoid and delusional beliefs," the STG: "Be free from speech or behaviors indicative of delusions" and "Report and demonstrate effective coping skills for dealing with psychotic symptoms." The unrelated generic Nursing treatment modality for this goal was: "Nursing will ensure the safety of the patient and others."

4. Patient A5's MTP, dated 1/3/18, listed for the problem "Cognitive Deficits" as evidenced by "limited understanding in social situations, poor historian; Hx [history] of successful functioning until 2015," the following STG: "Demonstrate increased independence in ADLs/ hygiene/self-care." The unrelated generic Nursing treatment modalities for this goal was: "Nursing staff will provide the level of basic nursing care needed for the patient's safety while encouraging patient's higher level of function" and "Nursing staff will keep all interactions with the patient pleasant, calm, and reassuring to decrease anxiety."

5. Patient A6's MTP, dated 1/10/18, listed for the problem "Psychotic Symptoms" as evidenced by "Paranoid" the STG: "free from speech or behaviors indicative of delusions. Specifically: distrust of others." The generic Rehab treatment modality for this problem was: "Rehab Services staff will provide Social Skills Group to encourage social interaction; improve listening and interpersonal communication skills; involve patient in directed group discussion about reality-based topics."

6. Patient A8's MTP, dated 12/18/17, listed for the problem "Adaptive Functioning Issues" as evidenced by "difficulty communicating facts about [his/her] personal care and history". The STG: "demonstrate improvement communication as evidenced by improved receptive and expressive language and an increased ability to make needs known." The Rehab Services unrelated treatment modality listed for this goal was; "Rehab Services staff will provide Exercise and Fitness Group to educate patient the benefits of regular exercise and encourage participation in fitness activities."

7. Review of Hospital Policy #MPC 059, revised 11/6/16, revealed a lack of specific requirements necessary for assuring the relevance of the treatment intervention to the treatment goal.

B. Interviews

1. In an interview on 1/22/18 at 3:30 p.m., the QA Specialist concurred that treatment modalities frequently reflected generic discipline functions or were unrelated to the patient's short-term goal.

2. In an interview on 1/23/18 at 1:00 p.m., the Medical Director concurred that treatment modalities frequently reflected generic discipline functions or were unrelated to the patient's short-term goal.

3. In an interview on 1/23/18 at 1:30 p.m., the Director of Psychology concurred that treatment modalities frequently reflected generic discipline functions or were unrelated to the patient's short-term goal.

4. In an interview on 1/23/18 at 2:15 p.m., the Chief Nursing Executive concurred that treatment modalities frequently reflected generic discipline functions or were unrelated to the patient's short-term goal.

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the master treatment plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings Include:

A. Record Review (MTP dates in parentheses)

1. The MTPs for patient A1 (12/13/17), A2 (12/18/17), A3 (4/2/17), A4 (1/12/18), A5 (1/3/18), A6 (1/10/18), A7 (9/22/17), and A8 (12/18/17) failed to identify the names and disciplines of staff persons responsible for specific aspects of care.

2. Review of Hospital Policy #MPC 059, revised 11/6/16, revealed a lack of documentation requirements specifying that the MTP will include the name and discipline of staff providing treatment.

B. Interviews

1. In an interview on 1/22/18 at 3:30 p.m., the QA Specialist concurred that treatment modalities listed did not include the specific staff to implement the modality.

2. In an interview on 1/23/18 at 1:00 p.m., the Medical Director acknowledged that the MTPs identified specific treatment interventions but failed to identify the responsible staff member by name and discipline.

3. In an interview on 1/23/18 at 1:30 p.m., the Director of Psychology concurred that the MTPs lacked treatment modality documentation that specified responsible staff members by name and discipline.

4. In an interview on 1/23/18 at 2:15 p.m., the Chief Nursing Executive concurred with the lack of documentation of a specific staff member responsible for implementing specific treatment modalities.

Based on record review, observation, and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment were provided for five (5) of eight (8) active sample patients (A1, A2, A3, A4, and A5) who were unwilling, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Record Review (date of MTPs in parentheses)

Review of the Master Treatment Plans for Patients A1 (12/13/17), A2 (12/18/17), A3 (4/21/17), A4 (1/12/18), and A5 (1/3/18) revealed that even though these patients were not participating regularly in their assigned groups, this was not addressed in the MTPs nor were alternative treatment modalities identified.

B. Observations

1. On 1/22/18 both Units 1 West and 3 West had a census of 25 patients each. Both Units had basically the same schedules for the entire week. Some groups such as "Exercise & Fitness", "Relaxation", "Open Gym", "Library", and "Alcoholics Anonymous" were open to both units at the same time. On 1/22/18, there were no activities or therapeutic offerings scheduled for the patients on 1 West and 3 West from 9:00 a.m. until 1:15 p.m. when an Exercise Rehab group was offered for both units in the gym. During the time from 10:00 a.m. - 11:30 a.m., Patient A1 was observed in his/her room; Patient A2 was observed in his/her room and later walking the halls, Patients A3 and A4 were observed in their rooms, walking in the halls and watching television and Patient A5 was observed in bed.

2. On 1/22/18 at 1:15 p.m., the activity listed on the Unit schedules for 1West and 3 West was Exercise Fitness. The group was available to all patients who were not restricted to the unit (48 patients not restricted). Eight (8) of the 25 patients on the 1 West and 11 of the patients on 3 West attended the activity. Patient A4 and A5 attended this activity. Patient A1 and A3 were in their rooms. Patient A2 was observed walking the halls. The 17 patients on 1 West and the 14 patients on 3 West who did not attend the group were not involved in any therapeutic or leisure activities. Patients were either in their rooms, walking the halls or watching TV.

3. On 1/22/18 the Unit schedule listed a 3:00 p.m. Computer Lab offered on each of the units and a Relaxation Group, which was open to all patients, was offered in the gym. Five (5) patients from 1 West and three (3) patients from 3 West were observed in the Relaxation group. Four (4) patients were observed in the computer lab (two [2] from each unit). Patients A1, A2, A3, A4 and A5 did not attend either group. The 18 patients on 1 West and the 20 patients on 3 West who did not attend groups were either in their room, walking the halls, sitting in the dayroom or watching television. These patients were not involved in any therapeutic or leisure activities.

4. On 1/23/18 at 9:00 a.m. on 3 West, the scheduled Nutrition Awareness Group did not occur. There were no other therapeutic or rehab groups offered during this time. The 25 patients on 3 West were occupied as follows: 17 were in bed, six (6) were in the dayroom, one (1) was in an assessment and one (1) was at the dentist. Patient A5 was in bed. On 1 West, the 9:00 a.m. Task Skills Group had six (6) patients in attendance (Patients A1, A2, A3 and A4 did not attend.) The 19 patients who were not in the Task Skills Group were occupied as follows: one (1) patient on the treadmill, one (1) patient doing a puzzle alone at a table, three (3) patients were watching TV, three (3) patients were walking the halls, one (1) patient was in an assessment, and ten (10) patients were in bed.

5. On 1/23/18 at 10:00 a.m., a Competency Skills Group and Individual Exercise Session were offered on both 1 West and 3 West. On 1 West, seven (7) patients attended the Competency Skills group and three (3) patients attended the Individual Exercise Session. On 3 West, nine (9) patients attended the Competency Skills group and no patients attended the Individual Exercise Session. Patients A1, A3, A4, and A5 did not attend either group; Patient A2 attended the Individual Exercise Session. The 15 patients on 1 West and the 15 patients on 3 West (one patient at the dentist) who did not attend groups were either in their room, walking the halls, sitting in the dayroom or watching television. These patients were not involved in any therapeutic or leisure activities.

Hospital Document ,"Group Attended/Scheduled by the Specific Client" (undated), provided to the surveyors by the Director of Rehab Therapy, indicated the following attendance records for patients A1, A2, A3 and A4 on Unit 1 West and A5 on Unit 3 West for the time period 1/9/18 to 1/22/18:

Patient A1 attended 2 of the 11 Rehab groups (18%) scheduled for him/her.

Patient A2 attended 5 of the 13 Rehab groups (38%) scheduled for him/her.

Patient A3 attended 1 of the 8 Rehab groups (13%) scheduled for him/her.

Patient A4 attended 5 of the 10 Rehab groups (50%) scheduled for him/her.

Patient A5 attended 7 of the 12 Rehab groups (58%) scheduled for him/her.

C. Interviews

1. In an interview on 1/22/17 at 10:30 a.m., RN1 was asked by the surveyor about the lack of scheduled activities/groups for the patients between 9:00 a.m. and 1:15 p.m. RN1 indicated there were no scheduled activities /therapeutic groups during this time nor were therapeutic alternatives offered to the patients.

2. In an interview on 1/22/18 at 11:00 a.m., Physician 1 acknowledged that there was a lack of therapeutic activities/groups offered to the patients on the unit. Physician 1 further indicated that the lack of structure and/or activities allowed patients to isolate, become more involved in their psychotic thinking processes, and engage with hallucinations without distractions to help them cope with the psychotic thinking.

3. In an interview on 1/22/18 at 1:15 p.m., Psychiatric Tech 2 (PT2) concurred that there was a lack of therapeutic activities for patients and that there was no way, other than encouragement, to force patients to engage in therapeutic offerings.

4. In an interview on 1/22/18 at 3:00 p.m., PT3 was questioned about the lack of activities/therapeutic offerings for patients. PT3 stated that there was not much for patients to do. PT3 further indicated that on weekends he brought in his personal DVD player so that patients would be able to watch some videos.

5. In an interview on 1/22/18 at 3:05 p.m., the QA Specialist concurred with the surveyor that 18 of the 25 patients on 1West were not engaged in any therapeutic offerings and were either in their beds or walking on the hallways.
There were only five (5) 1West patients in the Exercise Group and two (2) others engaged in the Computer Group.

6. In an interview on 1/23/18 at 9:40 a.m., PT1 stated that patients were expected to attend groups. When asked how he would encourage attendance, PT1 stated that he goes to the patients' rooms and asks them if they want to attend group. He further stated that most did not want to attend and preferred to stay in bed.

7. In an interview on 1/23/18 at 1:00 p.m., the Medical Director confirmed surveyor findings regarding a lack of active treatment on the inpatient units.

8. In an interview on 1/23/18 at 1:30 p.m., the Director of Psychology confirmed the need for additional patient therapeutic offering.

Based on record review and interview, the facility failed to ensure that Social Work progress notes were individualized and identified progress towards goals for one (1) of eight (8) sample patients (A8). Specifically the Social Work progress notes for four (4) weeks were identical in wording for patient A8. Failure to accurately document patient progress hinders the treatment team's ability to set goals and can increase patient length of stay.

Findings Include:

A. Record Review

1. Patient A8 was admitted on 12/13/17. The Master Treatment Plan (MTP), dated 12/18/17, identified the problems, "Adaptive Functioning Issues" and "Legal Issues." Review of the Social Work weekly progress notes for 12/26/17, 1/2/18, 1/9/18 and 1/16/18 addressed both problems and were identical in wording. There was no assessment of the patient's current status or progress toward goals, only a rehashing of his resistance to treatment.

2.The policy entitled, "Requirements for Social Work- Medical Record Documentation" undated stated that the progress notes should: "Restate the modalities on the treatment plan, including the number of times per week or month you met", "Patient's response to modalities", "Any additions, deletions, revisions to modalities", and "Discharge plans, placement issues, guardian issues, collateral contacts, etc."

B. Interviews

During interview on 1/23/18 at 2:45 p.m., the Director of Social Work acknowledged that the progress notes were identical and did not address the patient's progress or lack of progress toward goals.

Based on record review and interview, the facility failed to ensure that Nursing Progress Notes complied with hospital policy for one (1) of eight (8) active sample patients (A7). Specifically, the last weekly Nursing Progress Notes for patient A7 was on 12/13/17. There were no weekly notes on the record from 12/13/17-1/22/18. Failure to have nursing progress notes on the record limits the knowledge of the staff regarding patient progress and could increase patient length of stay.

Findings Include:

A. Record Review

1.Review of Patient A7's record revealed that the Nursing weekly progress notes for 12/20/18, 12/27/18, 1/3/18, 1/10/18, and 1/17/18 were not on the record as of the first day of the survey, 1/22/18.

2. The Nursing Policy entitled, "Documentation", reviewed/revised April 2016, stated that the RNs were to assess " ...each client daily for the first 7 days after admission, then weekly." It further stated that "A note is written for each identified problem on the treatment plan for which there is a nursing intervention."

B. Interview

1. During interview on 1/22/18 at 3:10 p.m., the Nurse Manager on 3 West stated that she did not know why the weekly progress notes were not in the record for the past five (5) weeks. During interview on 1/23/18 at 1:15 p.m., the Nurse Manager informed the surveyor that she had called the nurse who was assigned to write the progress notes. The nurse informed the manager that she had written the notes and had copies in her locker at work. The assigned nurse came to the hospital and provided the nurse manager with copies of the progress notes which were then placed on the patient's record. The Nurse Manager did not know what had happened to the original progress notes.

A. Based on record review, observations, and interviews, the Medical Director failed to ensure:

l. The provision of Master Treatment Plans (MTPs) that identified patient-related short-term and long-term goals stated in observable, measurable, behavioral terms for seven (7) out of eight (8) sampled patients (A1, A2, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, leading to patient stays beyond the resolution of the behaviors requiring admission. (Refer to B121)

2. The documentation of specific treatment modalities/interventions based on the individual needs for six (6) of eight (8) sample patients (A1, A2, A4, A5, A6, and A8). Each goal was accompanied by preprinted treatment modalities describing the specific focus of treatment for each short-term goal. In addition, treatment modalities frequently included routine, generic discipline functions listed as individualized treatment modalities unrelated to the specific patient's short-term goal. This failure to document specific treatment approaches on the MTP interferes with the assurance of consistency of approach to each patient's problem(s). (Refer to B122)

3. The documentation of name and discipline of staff persons responsible for specific aspects of care were listed on the master treatment plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

4. The provision of active treatment measures, such as group and/or individual treatment were provided for five (5) of eight (8) active sample patients (A1, A2, A3, A4, and A5) who were unwilling, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

B. Interview

In an interview on 1/23/18 at 1:00 p.m., the Medical Director confirmed surveyor findings regarding documentation of treatment plan regarding short and long-term goals, treatment interventions/modalities, staff signatures and the lack of active treatment on the inpatient units.

Based on record review and interview, the Chief Nurse Executive failed to:

l. Ensure that nursing interventions listed on patients' MTPs addressed individualized patient needs for four (4) of eight (8) active patients (A1, A2, A4, and A5). Instead, the interventions were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency results in a failure to guide nursing staff regarding the specific treatment purpose of each intervention and limits the therapeutic nursing interventions available to patients. (Refer to B122)

2. Ensure that the name and discipline of nursing staff responsible for specific aspects of care were listed on the master treatment plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This practice results in the Chief Nursing Executive's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

3. Ensure that Nursing Progress Notes complied with hospital policy for one (1) of eight (8) active sample patients (A7). Specifically, the last weekly Nursing Progress Notes for patient A7 was on 12/13/17. There were no weekly notes on the record from 12/13/17-1/22/18. Failure to have nursing progress notes on the record limits the knowledge of the staff regarding patient progress and could increase patient length of stay. (Refer to B130)

Findings Include:

l. Generic Nursing Interventions/Modalities

A. Record Review

1. Patient A1's MTP, dated 12/13/17, listed for the problem, "psychotic Sx [symptoms]" as evidenced by "persecutory delusions and paranoia," the STG, "Be free from speech or behaviors indicative of delusions. Specifically talking about paranoia or being followed." The generic Nursing treatment modality for this goal was, "Nursing will ensure the safety of the patient and others."

2. Patient A2's MTP, dated 12/18/17, listed for the problem, "Psychotic Symptoms" as evidenced by "grandiose delusions, bizarre statements, tangential and [illegible] incoherent speech," the STGs, "Report and demonstrate effective coping skills for dealing with psychotic symptoms" and "Demonstrate relevant and organized speech." The generic Nursing treatment modality for this goal was, "Nursing will ensure the safety of the patient and others."

3. Patient A4's MTP, dated 1/12/18, listed for the problems, "Psychotic Symptoms" as evidenced by "exhibiting paranoid and delusional beliefs," the STGs, "Be free from speech or behaviors indicative of delusions" and "Report and demonstrate effective coping skills for dealing with psychotic symptoms." The generic Nursing treatment modality for this goal was, "Nursing will ensure the safety of the patient and others."

4. Patient A5's MTP ,dated 1/3/18, listed for the problem, "Cognitive Deficits" as evidenced by "limited understanding in social situations, poor historian; Hx [history] of successful functioning until 2015," the following STG, "Demonstrate increased independence in ADLs/ hygiene/self-care." The unrelated generic Nursing treatment modalities for this goal was, "Nursing staff will provide the level of basic nursing care needed for the patient's safety while encouraging patient's higher level of function" and "Nursing staff will keep all interactions with the patient pleasant, calm, and reassuring to decrease anxiety."

B. Interview

In an interview on 1/23/18 at 2:15 p.m., the Chief Nursing Executive concurred that treatment modalities frequently reflected generic discipline functions or were unrelated to the patient's short-term goal.