HospitalInspections.org

Based on observation and interview, the hospital failed to ensure that patients have the right to personal privacy. This was evidenced by the hospital's failure to provide psychiatric patients with un-recorded telephone access. Findings:

On 2/01/11 between 1:00 p.m. and 1:10 p.m., observations were made on the acute care psychiatric unit during one of the scheduled "phone times". The Director of Nursing (S2) was present during this observation. Patients were noted to be standing in the hallway outside an office located on the patient care unit. Upon approaching the office, a patient was noted to be setting in a chair on one side of a desk using the telephone and a mental health technician was noted to be setting in a chair on the opposite side of the desk. S2 was interviewed at the time of this observation. S2 reported that patients are allowed to use the telephone on the acute care psychiatric unit during scheduled "phone times". When asked about the presence of a staff member during the patient's telephone conversations, S2 indicated that a mental health technician will accompany the patient at all times during the phone conversation. When asked if there were any recording devices on any of the telephones that patients use, S2 indicated that all hospital telephones are equipped with a recording device. When asked if there have been any patient conversations recorded, S2 explained the purpose for the recording device was not to record patient conversations but stated that he could not guarantee that patient conversations have never been recorded.

The hospital's policy/procedure titled "Telephone" was reviewed. The policy/procedure documents "It is the policy of the Hospital that each patient be assured the right to conduct private conversations with family and friends, to initiate and/or receive calls without undue censorship, and to do so in confidence".

The hospital's admission packet which is provided to patients upon admission to the hospital was reviewed. Review of the patient rights included in this admission packet revealed that the patient has "the right to communicate privately with persons that you choose by mail, telephone, and visits".

The Director of Nursing (S2) was interviewed on 2/01/11 at 3:10 a.m. S2 reviewed the hospital's policy/procedure titled "Telephone" and the patient rights included in the hospital's admission packet. S2 reported that these hospital documents are not being followed as patients have not been allowed the right to communicate privately on the telephone.

Based on record review and interview, the hospital failed to meet the nursing care needs of the patients by failing to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Patient Classification/Acuity System" resulting in the hospital's inability to ensure the safe supervision of patients hospitalized on the acute care psychiatric unit. Findings:

The Clinical Coordinator (S3) was interviewed on 2/02/11 at 8:50 a.m. S3 presented the hospital's policy/procedure titled "Patient Classification/Acuity System". Review of this policy/procedure revealed that the hospital has a system in place to determine the staffing needs of the acute care psychiatric unit based on the needs of the patients hospitalized on the unit. S3 presented the completed "Patient Acuity Worksheet" and the completed "Daily Schedule and Assignments" worksheet for the dates of 1/25/11 through 2/01/11 at the request of the surveyor. Review of the hospital's policy/procedure, the patient acuity worksheets, and the daily schedule and assignments worksheet revealed that the acute care psychiatric unit was understaffed by 1 nursing staff member on the p.m. shift on 1/30/11. Documentation on the "Patient Acuity Worksheet" revealed that there should have been at least 7 FTE's on the p.m. shift on 1/30/11. Documentation on the "Daily Schedule and Assignments" worksheet revealed that the staffing for the p.m. shift on 1/30/11 consisted of 1 RN, 1 LPN, and 4 MHT's for a total of 6 FTE's. Review of the daily census report revealed that there were a total of 28 patients on the acute care psychiatric unit with 2 of the 28 patients being assigned to a 1:1 observational status on the p.m. shift on 1/30/11. S3 confirmed that the acute care psychiatric unit was understaffed by 1 FTE on the p.m. shift on 1/30/11. The Director of Nursing was present during this interview and confirmed that the acute care psychiatric unit was understaffed by at least 1 FTE on the p.m. shift on 1/30/11.

Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care to patients on the acute care psychiatric unit as evidenced by 1) failing to maintain a patient (Patient #7) on a 1:1 observational level as ordered by the licensed practitioner and 2) failing to provide documented evidence to ensure compliance with the ordered observational level for 2 of 7 sampled patients (#3 & #7). Findings:


1. Failing to maintain a patient (Patient #7) on a 1:1 observational level as ordered by the licensed practitioner.

The medical record of Patient #7 was reviewed. Review of the medical record revealed that Patient #7 was admitted to St. James Behavioral Health Hospital on 11/07/10 and discharged on 12/14/10 to long term care facility in which she resided. Review of the Psychiatric Evaluation revealed that Patient #7's Axis I diagnosis was "Dementia with behavioral disturbance". Review of the Risk Assessment for Falls revealed that Patient #7 was assessed to be a High Risk for falls. Review of the multidisciplinary progress notes revealed an entry by S15 (RN) dated 12/13/10 at 2:15 a.m. that read "Tech gets nurse and states Pt rolled out of bed. Assessed Pt noted ? " puncture wound above left eye. Applied 4 X 4 sterile guaze with pressure for 5 minutes". Further review of the multidisciplinary progress notes revealed that the physician was notified and Patient #7 was transferred to Hospital A on 12/13/10 at 2:58 a.m. for "cut above (L) eye". Further review of the multidisciplinary progress notes revealed an entry indicating that Patient #7 returned from Hospital A on 12/13/10 at 9:05 a.m. with sutures to left eye. Further review of the multidisciplinary progress notes revealed an entry indicating that Patient #7 was discharged to the nursing home in which she resides on 12/14/10 at 12:20 p.m. Review of the physicians orders revealed an active observation order for Patient #7 at the time of her rolling out of bed was an order dated 11/23/10 at 2:10 p.m. for "1:1 observation while pt is in in bed only".

The Director of Nursing (S2) was interviewed on 2/07/11 at 10:00 a.m. relating to Patient #7's hospitalizations at St. James Behavioral Health Hospital. S2 reviewed the medical record of Patient #7 and reported that he remembered the patient. S2 reported that Patient #7 did fall during her 11/07/10 through 12/14/10 hospitalization. S2 reported that Patient #7 fell after rolling out of bed on 12/13/10 at approximately 2:15 a.m. S2 reported that Patient #7 was on a 1:1 observational status being observed by S16 (MHT) at the time of her fall. S2 reported that Patient #7 was transferred to Hospital A for treatment of a cut on the left side of her face near her eye. S2 reported that Patient #7 returned on 12/13/11 at approximately 9:00 a.m. with sutures to her injury. S2 reported that Patient #7 was discharged back to the nursing home on 12/14/10. S2 reported that Patient #7 was stable at the time of discharge.

S16 (Mental Health Technician) was interviewed on 2/07/11 at 10:30 a.m. S16 reviewed the medical record of Patient #7 and reported that she did remember the patient. S16 confirmed that she was assigned to conduct the 1:1 observation on Patient #7 on the night shift (7:00 p.m. through 7:00 a.m.) on the p.m. shift that began on 12/12/10. S16 confirmed that Patient #7 fell to the ground after rolling out of bed on 12/13/10 at approximately 2:15 a.m. When asked to explain the events surrounding Patient #7's fall, S16 reported that she was setting in Patient #7's room performing her 1:1 observation of Patient #7 when the roommate of Patient #7 woke up and requested assistance to go to the bathroom. S16 reported that Patient #7 was sleeping at the time of the roommates needing assistance to the bathroom. S16 reported that she was in the process of assisting the roommate to the bathroom when she saw Patient #7 wake up and roll out of bed falling to the floor (breaking the 1:1 observation). S16 reported that Patient #7 hit her head on the bedside shelf.

S15 (Registered Nurse) was interviewed by telephone on 2/07/11 at 4:20 p.m. S15 reported that he works as a PRN nurse for St. James Behavioral Health Hospital. S15 reported that he was the nurse assigned to Patient #7 at the time of her fall on 12/13/11. S15 reported that the mental health technician (S16) approached him and informed him that Patient #7 had fallen after rolling out of bed. S15 reported that S16 told him that she (S16) was assisting Patient #7's roommate to the bathroom when Patient #7 rolled out of bed. S15 reported that Patient #7 hit her head on the bedside table. S15 reported that the physician was notified and Patient #7 was transferred to Hospital A for evaluation and treatment.


2. Failing to provide documented evidence to ensure compliance with the ordered observational level.

The medical record of Patient #3 was reviewed on 2/01/11. This review revealed that Patient #3 is a 21 year old male admitted to the hospital on 1/21/11 with a history of psychosis. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Psychosis, NOS; rule out chronic paranoid schizophrenia". Review of the medical record revealed orders dated 1/21/11 at 1:15 p.m. to place Patient #3 on a 1:1 observational status. Review of the medical record revealed no orders to indicate that the patient was not to be on a 1:1 observational status from 1/21/11 through the date of this record review (2/01/11). Review of the medical record including the Restrictive Management Observation sheets failed to provide evidence to indicate that Patient #3 remained on a 1:1 observational status from 1/21/11 through 2/01/11 as ordered. Review of the Restrictive Management Observation sheet revealed the "Type Management" levels (level of observation) were 1:1 Arms Length, Continuous Visual at 15 ft, Continuous Visual, Other, and 15 Minute Checks. Documentation on the Restrictive Management Observation sheets for the "Type Management" level (level of observation) for Patient #3 was as follows:
1/21/11- "Continuous Visual" circled as the "Type Management" for this date.
1/22/11- "Continuous Visual" circled as the "Type Management" for this date.
1/24/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/25/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/26/11- "Type Management" not identified for this date.
1/27/11- "Continuous Visual" circled as the "Type Management" for this date.
1/28/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/29/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/30/11- "15 Minute Checks" checked as the "Type Management" for this date.
There were a total of 4 Restrictive Management Observation sheets that were not dated. According to the chronological order of the chart, the undated sheets would account for the missing sheets for the dates of 1/23/11 and 1/31/11 but again the sheets were not dated. "15 Minute Checks" was checked off on 2 of the undated sheets. "Type Management" not identified on the other 2 undated sheets.

The Director of Nursing (S2) was interviewed on 2/01/11 at 12:40 p.m. S2 reviewed the Restrictive Management Observation sheets and reported that the observation sheets failed to indicate that Patient #3 was on a 1:1 observational status as ordered. S2 reported that he felt that this was an error in documentation by the mental health technicians indicating that he felt Patient #3 was actually on a 1:1 observational status as ordered even though the medical record did not reflect this.

The medical records of Patient #7 were reviewed. Review of the medical records revealed that Patient #7 was initially admitted to St. James Behavioral Health Hospital on 11/05/10 and discharged to Hospital A on 11/06/10; Re-admitted to St. James Behavioral Health Hospital on 11/07/10 and discharged on 12/14/10 to long term care facility in which she resided.

Review of the medical record for Patient #7's 11/07/10 through 12/14/10 hospitalization revealed that Patient #7 was admitted to St. James Behavioral Health Hospital on 11/07/10. Review of the Psychiatric Evaluation revealed that Patient #7's Axis I diagnosis was "Dementia with behavioral disturbance". Review of the Risk Assessment for Falls revealed that Patient #7 was assessed to be a High Risk for falls. Review of the physicians orders revealed an active order for Patient #7 dated 11/23/10 at 2:10 p.m. for " 1:1 observation while pt is in in bed only". Review of the Restrictive Management Observation sheet revealed the "Type Management" levels (level of observation) were 1:1 Arms Length, Continuous Visual at 15 ft, Continuous Visual, Other, and 15 Minute Checks. Documentation on the Restrictive Management Observation sheets for the "Type Management" level (level of observation) for Patient #7 revealed greater than 10 Restrictive Management Observation sheets that were not dated resulting in the inability of the registered nurse to ensure compliance with the ordered observational level for all days of the patient's hospitalization.

Based on record review and interview, the registered nurse failed to implement and keep current a nursing care plan for 1 of 3 patients (#4) assessed to be a high risk for falls out of a total sample of 7 patients. Findings:

The medical record of Patient #4 was reviewed on 2/01/11 as Patient #4 was assessed to be a High Risk for falls. This review revealed that Patient #4 was admitted to the hospital on 10/13/10 and discharged on 10/27/10. Review of the Psychiatric Evaluation revealed that the patient is an 88 year old male with a history of psychosis and dementia. Review of the History & Physical revealed that Patient #4's medical history included Hypertension, Dementia, Alcohol Abuse and Psychosis. Review of the Risk Assessment for Falls revealed that Patient #4 was assessed to be a High Risk for falls. Review of the Plan of Care revealed a problem titled "Potential for Injury" which documented that the patient will remain free from injury R/T falls while hospitalized. Documentation on the Plan of Care revealed interventions included "Complete falls risk assessment upon admission & place on fall precautions if needed". Review of the group notes and review of the progress notes revealed no documentation to indicate that fall precautions were implemented by the nursing staff and no documentation to indicate the continued need for fall precautions during the patients hospitalization.

The hospital's policies/procedures titled "Fall Precautions" were reviewed. Review of the policy/procedure revealed the fall precautions will include:
? Increased observation of the patient at the frequency specified by physician or nursing orders;
? Assisting the patient in performing ADLs, as indicated;
? Assisting the patient in ambulating, as needed;
? Encouraging the patient to limit fluids after 9:00 p.m.;
? Encouraging the patient to void at bedtime;
? Verbally reminding the patient to seek staff assistance if they need to get out of bed throughout the night;
? Securing a bed with side rails which will remain up throughout the night, as indicated;
? Questioning patients who are found to be awake during night time rounds as to their need for assistance, use of the bathroom, and/or reason for being awake.

The Director of Nursing (S2) was interviewed on 2/01/11 at 9:30 a.m. S2 reviewed the medical record of Patient #4 and confirmed that there was no documentation in the medical record to indicate that fall precautions were implemented by the nursing staff and no documentation to indicate the continued need for fall precautions. S2 indicated that the hospital has recently revised the policy/procedure relating to falls. S2 reported that efforts are underway to improve the quality of care provided to patients who are assessed to be a High Risk for falls.

Based on record review and interview, the hospital failed to ensure that all entries entered into the medical record were dated and/or timed for 2 of 2 patients (#3 & #7) reviewed for the dating/timing of entries out of a total sample of 7 patients. Findings:

The medical record of Patient #3 was reviewed on 2/01/11. This review revealed that Patient #3 is a 21 year old male who was admitted to the hospital on 1/21/11 with a history of psychosis. Review of the Restrictive Management Observation sheet revealed the "Type Management" levels (level of observation) were 1:1 Arms Length, Continuous Visual at 15 ft, Continuous Visual, Other, and 15 Minute Checks. Documentation on the Restrictive Management Observation sheets for the "Type Management" level (level of observation) for Patient #3 was as follows:
1/21/11- "Continuous Visual" circled as the "Type Management" for this date.
1/22/11- "Continuous Visual" circled as the "Type Management" for this date.
1/24/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/25/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/26/11- "Type Management" not identified for this date.
1/27/11- "Continuous Visual" circled as the "Type Management" for this date.
1/28/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/29/11- "15 Minute Checks" checked as the "Type Management" for this date.
1/30/11- "15 Minute Checks" checked as the "Type Management" for this date.
There were a total of 4 Restrictive Management Observation sheets that were not dated. According to the chronological order of the chart, the undated sheets would account for the missing sheets for the dates of 1/23/11 and 1/31/11 but again the sheets were not dated. "15 Minute Checks" was checked off on 2 of the undated sheets. "Type Management" not identified on the other 2 undated sheets.

The medical record of Patient #7 was reviewed. Review of the medical record for Patient #7's 11/07/10 through 12/14/10 hospitalization revealed that Patient #7 was admitted to St. James Behavioral Health Hospital on 11/07/10. Review of the Restrictive Management Observation sheet revealed the "Type Management" levels (level of observation) were 1:1 Arms Length, Continuous Visual at 15 ft, Continuous Visual, Other, and 15 Minute Checks. Documentation on the Restrictive Management Observation sheets for the "Type Management" level (level of observation) for Patient #7 revealed greater than 10 Restrictive Management Observation sheets that were not dated.

The Director of Nursing (S2) was interviewed on 2/01/11 at 12:40 p.m. S2 reviewed the Restrictive Management Observation sheets and confirmed that the sheets were not dated as documented above.

Based on record review and interview, the hospital failed to ensure that all active therapeutic efforts are included in the patients' treatment plan for 2 of 7 sampled patients (#2 & #3) as evidenced by the lack of documentation by the social services representative of the multidisciplinary treatment team. Findings

The medical record of Patient #2 was reviewed on 1/31/11 (Patient #2 was an active patient at the time of this record review). This review revealed that Patient #2 was a 37 year old female admitted to the hospital on 1/13/11 with a history of schizoaffective disorder. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Schizoaffective disorder bipolar type, most recent episode mania". Further review revealed that Patient #2 was admitted for increased psychosis and mania. Review of the Adult Social Assessment (Psychosocial Assessment) revealed that the psychosocial assessment was incomplete as pages 2, 3, 4, 5 and 6 of the psychosocial assessment were left blank. Review of the medical record revealed no documentation to indicate that additional attempts were made by the social worker to complete the psychosocial assessment. Review of the Social Services Progress Notes revealed only one entry which was dated 1/14/11 (no entries by the social worker from 1/14/11 through 1/31/11). Review of the medical record revealed that Patient #2 has been non-compliant with the treatment program as she has refused to attend many group therapy sessions during this hospitalization. Review of the treatment plan revealed no documented evidence to indicate that identified goals and interventions were developed and revised as necessary by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions. In addition, documentation in the medical record failed to provide information relating to the patient's progress and response to treatment interventions.

The medical record of Patient #3 was reviewed on 2/01/11 (Patient #3 was an active patient at the time of this record review). This review revealed that Patient #3 was a 21 year old male admitted to the hospital on 1/21/11 with a history of psychosis. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Psychosis, NOS; rule out chronic paranoid schizophrenia". Review of the medical record revealed orders dated 1/21/11 at 1:15 p.m. to place Patient #3 on a 1:1 observational status. Review of the Adult Social Assessment (Psychosocial Assessment) revealed documentation indicating "Pt unable to answer" with the majority of the psychosocial assessment being incomplete as pages 2, 3, 4, 5 and 6 were incomplete. Review of the medical record revealed no documentation to indicate that additional attempts were made by the social worker to complete the psychosocial assessment. Review of the medical record revealed that Patient #3 has been non-compliant with the treatment program as he physically assaulted another patient on 1/26/11 which resulted in the use of seclusion and has exhibited minimal participation in group therapy sessions at times during this hospitalization. Review of the treatment plan revealed no documented evidence to indicate that identified goals and interventions were developed and revised as necessary by the interdisciplinary treatment team to address Patient #3's physical assault on another patient and/or Patient #3's minimal participation in group therapy sessions.

S7 (Graduate Social Worker) was interviewed on 1/31/11 at 1:40 p.m. S7 reviewed the medical record of Patient #2. S7 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S7 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

S8 (Licensed Professional Counselor) was interviewed on 1/31/11 at 2:00 p.m. S8 reviewed the medical record of Patient #2. S8 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S8 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

Based on record review and interview, the social worker failed to ensure the recording of progress notes that included a precise assessment of the patient's progress in accordance with the original or revised treatment plan. This was noted for 1 of 7 sampled patients (#2). Findings:

The medical record of Patient #2 was reviewed on 1/31/11. This review revealed that Patient #2 is a 37 year old female who was admitted to the hospital on 1/13/11 with a history of schizoaffective disorder. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Schizoaffective disorder bipolar type, most recent episode mania". Further review revealed that Patient #2 was admitted for increased psychosis and mania. Review of the Adult Social Assessment (Psychosocial Assessment) revealed that the psychosocial assessment was incomplete as pages 2, 3, 4, 5 and 6 of the psychosocial assessment were left blank. Review of the medical record revealed no documentation to indicate that additional attempts were made by the social worker to complete the psychosocial assessment. Review of the Social Services Progress Notes revealed only one entry which was dated 1/14/11 (no entries by the social worker from 1/14/11 through 1/31/11). Review of the medical record revealed that Patient #2 has been non-compliant with the treatment program as she has refused to attend many group therapy sessions during this hospitalization. Review of the master treatment plan revealed no documented evidence to indicate that identified goals and interventions were developed and revised as necessary by the interdisciplinary treatment team including the social worker to address Patient #2's non compliance with group therapy sessions. In addition, documentation in the medical record failed to provide information relating to the patient's progress and response to treatment interventions.

S7 (Graduate Social Worker) was interviewed on 1/31/11 at 1:40 p.m. S7 reviewed the medical record of Patient #2. S7 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S7 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

S8 (Licensed Professional Counselor) was interviewed on 1/31/11 at 2:00 p.m. S8 reviewed the medical record of Patient #2. S8 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S8 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

Based on record review and interview, the multidisciplinary team failed to ensure that progress notes contained a precise assessment of the patient's progress in accordance with the original or revised treatment plan. This was noted for 2 of 7 sampled patients (#2 & #3). Findings:

The medical record of Patient #2 was reviewed on 1/31/11. This review revealed that Patient #2 was a 37 year old female admitted to the hospital on 1/13/11 with a history of schizoaffective disorder. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Schizoaffective disorder bipolar type, most recent episode mania". Further review revealed that Patient #2 was admitted for increased psychosis and mania. Review of the Adult Social Assessment (Psychosocial Assessment) revealed that the psychosocial assessment was incomplete as pages 2, 3, 4, 5 and 6 of the psychosocial assessment were left blank. Review of the medical record revealed no documentation to indicate that additional attempts were made by the social worker to complete the psychosocial assessment. Review of the Social Services Progress Notes revealed only one entry which was dated 1/14/11 (no entries by the social worker from 1/14/11 through 1/31/11). Review of the medical record revealed that Patient #2 has been non-compliant with the treatment program as she has refused to attend many group therapy sessions during this hospitalization. Review of the master treatment plan revealed no documented evidence to indicate that identified goals and interventions were developed and revised as necessary by the interdisciplinary treatment team including the social worker to address Patient #2's non compliance with group therapy sessions. In addition, documentation in the medical record failed to provide information relating to the patient's progress and response to treatment interventions.

The medical record of Patient #3 was reviewed on 2/01/11. This review revealed that Patient #3 is a 21 year old male who was admitted to the hospital on 1/21/11 with a history of psychosis. Review of the psychiatric evaluation revealed an Axis I diagnoses of "Psychosis, NOS; rule out chronic paranoid schizophrenia". Review of the medical record revealed orders dated 1/21/11 at 1:15 p.m. to place Patient #3 on a 1:1 observational status. Review of the Adult Social Assessment (Psychosocial Assessment) revealed documentation indicating "Pt unable to answer" with the majority of the psychosocial assessment being incomplete as pages 2, 3, 4, 5 and 6 were incomplete. Review of the medical record revealed no documentation to indicate that additional attempts were made by the social worker to complete the psychosocial assessment. Review of the medical record revealed that Patient #3 has been non-compliant with the treatment program as he physically assaulted another patient on 1/26/11 which resulted in the use of seclusion and has exhibited minimal participation in group therapy sessions at times during this hospitalization. Review of the master treatment plan revealed no documented evidence to indicate that identified goals and interventions were developed and revised as necessary by the interdisciplinary treatment team to address Patient #3's physical assault on another patient and/or Patient #3's minimal participation in group therapy sessions.

S7 (Graduate Social Worker) was interviewed on 1/31/11 at 1:40 p.m. S7 reviewed the medical record of Patient #2. S7 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S7 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

S8 (Licensed Professional Counselor) was interviewed on 1/31/11 at 2:00 p.m. S8 reviewed the medical record of Patient #2. S8 reviewed the Adult Social Assessment (Psychosocial Assessment) and confirmed that the assessment was incomplete in that pages 2, 3, 4, 5 and 6 were left blank. S8 reviewed the master treatment plan and confirmed that there was no documented evidence to indicate that identified goals and interventions were developed and revised by the interdisciplinary treatment team to address Patient #2's non compliance with group therapy sessions.

Based on record review and interview, the hospital failed to ensure that there was a Director of Social Services who monitors and evaluates the quality and appropriateness of social services furnished in the acute care psychiatric hospital. Findings:

Review of the hospital's list of key personnel revealed no evidence to indicate that there was a Licensed Clinical Social Worker (LCSW) functioning as the Director of Social Services.

The Human Resources Director (S9) was interviewed on 2/01/11 at 10:15 a.m. When asked if there was a LCSW (Licensed Clinical Social Worker) serving as the Director of Social Services, S9 reported that there was no current Director of Social Services for the hospital. S9 reported that S10 (LCSW) is currently available to serve as a resource person for the hospital's social services staff. S9 explained that S10 works with the outpatient program but also assist with the hospital's needs when called. S9 reported the previous LCSW (S11) is no longer employed by the hospital stating her last day of employment was on 12/16/10. S9 reported that the S12 (LCSW) is scheduled to begin employment with the hospital on 2/07/11 and indicated that S12 will be the Director of Social Services.