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Based on the systemic nature of standard-level deficiencies, related to the Quality Assessment and Performance Improvement (QAPI) Program, the hospital failed to substantially comply with this condition.

The findings include:

The hospital failed to a) have the frequency and detail of data collection for quality indicators specified by the hospital's governing body for two (2) of three (3) indicators reviewed (indicators #1 and #3) and b) break down aggregate data to allow comparison of performance among hospital units covered for one (1) (indicator #1) of three (3) indicators reviewed.

The hospital failed to conduct a quality review for all serious adverse events and implement preventative action for all preventable serious events identified.

The hospital failed to conduct distinct performance improvement projects that are proportional to the scope and complexity of the hospital's services and operation.

The hospital's governing body failed to ensure the quality program involves all hospital departments and services offered and reflects the complexity of services offered. The hospital failed to maintain sufficient evidence of a hospital-wide QAPI program for review by CMS.

Please refer to A-0273, A-0286, A-297 and A-0308 for additional information.

Based on interview and document review, it was determined the facility staff failed to ensure they had a contract with an Organ Procurement Organization (OPO) and an eye bank for the retrieval, processing, preservation and distribution of tissues and eyes. The facility failed to implement a protocol or have a contract related to organ donation.

The findings include:

On 6/2/15 at approximately 3:30 Staff Member #52 was interviewed regarding their contract with an OPO. Staff Member #52 stated, "We don't have a contract with an OPO. I am working on that right now."

Recent death records were reviewed and the medical record(s) for (Patient #21) contained no evidence that an OPO or an eye bank was notified.

Please refer to A-0885, A-0886 and A-887 for additional information.

Based on observations, staff and patient interviews, medical record review and facility document review, there was a systematic failure of the facility to provide medical records that documented the treatment given to patients and the facility staff who provided the services:

Findings include:

I. Ensure that the social work assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) contained sufficient documentation regarding the anticipated role of the social worker in treatment planning and provision of treatment during the patient's hospitalization. Absence of these details adversely affects both the patient's length of hospitalization and a safe and effective re-entry into the community with reduced likelihood of recidivism. (Refer to B108)

II. Document neurological examinations in such a way as to verify the specific testing performed for four (4) of eight (8) active sample patients (A3, A4, B3 and B4). This failure to document specific testing compromises the identification of pathology, which may be pertinent to the current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B109)III. Identify specific interventions to address the individual patient's identified needs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure results in routine generic job description interventions that did not provide focused active treatment for the patients' identified problems. (Refer to B122)

IV. Ensure that registered nurses (RNs) documented specific information about medication education assigned for eight (8) of eight (8) active sample patients ((A1, A2, A3, A4, B1, B2, B3 and B4). (Refer to B124)

V. Provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). There were insufficient structured therapies available for weekends and evenings. In addition, there were no attempts to offer alternative programming for patients who were unable or unwilling to attend groups. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them and potentially delaying their improvement. (Refer to B125)

Based on interview and document review, it was determined the governing body failed to ensure a contract with an Organ Procurement Organization (OPO) and an eye bank was obtained and in effect.

The findings include:

On 6/2/15 at approximately 3:30 Staff Member #52 was interviewed regarding their contract with an OPO (Organ Procurement Organization). Staff Member #52 stated, "We don't have a contract with an OPO. We have a policy but it has not been implemented."

There was also no evidence of a contract with an eye bank.

Based on interview and observation the facility staff failed to ensure medical information related to patients was secured.

The findings include:

On June 2, 2015 at approximately 3:15 P.M. during the tour of the clinic area the eye clinic was observed. Located in an unlocked cabinet in the eye clinic was approximately 375 medical records related to patient's eyes and the purchase of glasses. The medical records dated back to the year 2009.

Staff Member #54 stated, "The records are only about glasses that were purchased for the patient."

Based on interview and document review, it was determined the facility staff failed to ensure a patient (Patient #8) was free of seclusion once there was no danger to the patient or others and or the patient was no longer disruptive on the milieu.

The findings include:

On June 2, 2015 the medical record (MR) of Patient #8 was reviewed. The MR indicated Patient #8 had been placed in seclusion on 6/1/15 at approximately 8:15 P.M. The Seclusion Monitoring Record indicated at 8:45 P.M. Patient #8 was snoring and continued to do so until 9:30 P.M. at which time Patient #8 was released from seclusion. Staff Member #11 stated, "(Name of Patient) should have been released once they were asleep."

Staff Member #2 provided a copy of the policy titled Emergency Use of Seclusion or Restraint (Critical Policy) with an effective date of January 21, 2014 which documents in the section Monitoring Seclusion or Restraint part 2 c readiness for discontinuation of restraint or seclusion, as defined the the conditions for release stated in the physician's order.

The physician's order on Patient #8 MR written on 6/1/15 at 20:49 documented the following, "Seclude for behavior that is Danger to other for up to 4 hours. Verbal order for seclusion was given at 08:15 PM. RN (registered nurse) to release as soon as patient demonstrates behavior that is no longer a Danger to other as evidenced by calm. Place on continuous monitoring. Specific measures to meet the special needs are: Not applicable"

Based on observation, interview and document review it was determined that the hospital staff failed to a) have the frequency and detail of data collection for quality indicators specified by the hospital's governing body for two (2) of three (3) indicators reviewed (indicators #1 and #3) and b) break down aggregate data to allow comparison of performance among hospital units covered for one (1) (indicator #1) of three (3) indicators reviewed.

The findings include:

Three indicators were selected and related data and documentation for the selected indicators was reviewed with Staff Member #2 and #60 on 6/3/15 in the afternoon and continued on 6/4/15 with Staff Member #40 also present.

a) Indicator #1 was the number of employees who received influenza vaccines. All employees were included in the data. Indicator #1 was included in and monitored by the infection prevention plan for fiscal year 2014 (July 1, 2014- June 30, 2015). The infection prevention plan and related documents reviewed failed to specify the frequency and detail of data collection. Indicator #3 is related to the turn around time (TAT) for lab samples sent out to contracted service. All lab tests are included in the data collection. Documents and data reviewed failed to specify the frequency and/or detail of data collection.

Staff Member #2 and #60 were given the opportunity during the review to provide evidence that the governing body had specified the frequency and/or detail of data collection but were unable to provide any evidence related to this matter.

b) Review of data collected for Indicator #1 revealed that aggregated data was not broken down into subsets (i.e. by unit or work area) to allow for comparison of data among all hospital units.

Based on observation, interview and document review it was determined the hospital staff failed to conduct a quality review for all serious adverse events and implement preventative action for all preventable serious events identified.

The findings include:

The surveyor requested and received list of serious adverse events as identified by the hospital, then met with Staff Member #3 who explained the process of event review to the surveyor. Reported events are reviewed and assigned a level of severity by the Staff Member #3. After reviewing the event(s) Staff Member #3 makes the determination as to the need to share the event information with Staff Member #2. At this point the event may be reviewed by the quality department or assigned for review by other individuals or committees as determined by the Quality Management Director and Risk Manager. Staff Member #3 was asked by the surveyor if all serious adverse events were reviewed for quality, he/she stated that events were only reviewed by quality if he/she felt there was the need. Event summaries are shared with the Quality Council but events are not usually reviewed individually. On 6-4-15 the review of serious adverse events was discussed with Staff Members #2 and #60, Staff Staff Member #2 confirmed that all serious events are reviewed by the Risk Manager but not all events have documentation of review for preventable actions (if present) or documentation of the implementation of preventative measures if identified.

Based on observation, interview and document review it was determined that the hospital staff failed to conduct distinct performance improvement projects that are proportional to the scope and complexity of the hospital's services and operation.

The findings are:

On 6-1-15 the surveyor asked Staff Member #2 about the hospital's current performance improvement projects. The surveyor was provided with documentation of two (2) projects, one relating to falls and a Failure Mode Effects Analysis (FMEA) for anticoagulant use. Both projects were labeled 2014. No evidence or list of current projects was provided to the surveyor. No evidence was provided to the surveyor of a performance improvement project or activity related to psychiatric services in this psychiatric hospital.

Surveyor review of facility document entitled "Quality Management Plan (fy15) July 1, 2014" revealed the following: "All departments are responsible for the development and implementation of department level quality and Performance Improvement programs with identified goals and PI activities annually. The following committees are also responsible for developing annual quality and PI programs and goals. Evidence of these programs must be maintained in writing by the chair of the committee or designee. *Pharmacy and Therapeutics *Environment of Care and Safety *Infection Control * Falls Committee". The aforementioned document detailed a list of "Program Goals for FY15". The document failed to contain information detailing data collection, performance improvement projects or plans to achieve those goals. The surveyor was not provided with evidence of departmental quality improvement projects and goals for the fiscal year 2015 as described in the above excerpt from the "Quality Management Plan ... " .

Based on observation, interview and record review it was determined the hospital's governing body failed to ensure the quality program involves all hospital departments and services offered and reflects the complexity of services offered. The hospital failed to maintain sufficient evidence of a hospital-wide QAPI program for review.

The findings are:

On 6-4-15, the surveyor reviewed the information on services offered by the hospital. Information was provided to the surveyor on the Hospital/CAH Data Base Worksheet. The services offered were reviewed with the Staff Member #2 and Staff Member #60. Of the ten (10) services identified as being offered by the facility staff only, the surveyor was provided with evidence of one (1) of the department's involvement in the quality program during the course of the survey (Pharmacy). No further evidence of the involvement of other departments was provided during this review. Evidence of quality assessment of services provided by contract was provided. The hospital has failed to maintain evidence of a hospital-wide QAPI program.

The hospital has failed to reflect the complexity of services offered in performance improvement projects. No evidence was provided to the surveyor of a performance improvement project or activity related to psychiatric services in this psychiatric hospital. When the Quality Management Director was asked about the hospitals' current performance improvement projects on 6-1-15, the surveyor was provided with documentation of two (2) projects, one relating to falls and a Failure Mode Effects Analysis (FMEA) for anticoagulant use. Both projects were labeled 2014.

Based on interview and document review, it was determined the facility staff failed to ensure a registered nurse (RN) supervised and evaluated a patient (Patient #8) to ensure Patient #8 was free of seclusion once there was no danger to the patient or others and or the patient was no longer disruptive on the milieu.

The findings include:

On June 2, 2015 the medical record (MR) of Patient #8 was reviewed. The MR indicated Patient #8 had been placed in seclusion on 6/1/15 at approximately 8:15 P.M. The Seclusion Monitoring Record indicated at 8:45 P.M. Patient #8 was snoring and continued to do so until 9:30 P.M. at which time Patient #8 was released from seclusion. The MR indicated an RN assessed Patient #8 at the time (8:15 P.M.) seclusion was initiated and at 9:30 P.M. the RN documented "resting quietly on mattress at this time. Denies hurting others." There was no evidence Patient #8 had attempted to or hurt anyone prior to seclusion.

Staff Member #11 stated, "(Name of Patient) should have been released once they were asleep."

Staff Member #2 provided a copy of the policy titled Emergency Use of Seclusion or Restraint (Critical Policy) with an effective date of January 21, 2014 which documents in the section Monitoring Seclusion or Restraint part 2 c readiness for discontinuation of restraint or seclusion, as defined the the conditions for release stated in the physician's order.

The physician's order on Patient #8 MR written on 6/1/15 at 8:49 (P.M.) documented the following, "Seclude for behavior that is Danger to other for up to 4 hours. Verbal order for seclusion was given at 08:15 PM. RN (registered nurse) to release as soon as patient demonstrates behavior that is no longer a Danger to other as evidenced by calm. Place on continuous monitoring. Specific measures to meet the special needs are: Not applicable"

Based on interviews and document review, it was determined the facility staff failed to ensure the nursing care plan/treatment plan was kept current and updated with changes as needed for 4 of 34 patients, Patients #21, 22, 23, and 24.

The findings include:

1. A. The medical record (MR) of Patient #21 was reviewed on 6/2/15 and revealed the following:

Patient #21 was admitted on 9/4/13 with the diagnoses of thought disorder, alcohol induced persisting dementia, hypertension and hepatic encephalopathy. Patient #21 expired on 2/20/15. A DNR (Do Not Resuscitate) was signed on 2/11/15 by Patient #21's family. Patient #21's family opted to not have any IV's started on Patient #21. The physician wrote an order on 2/12/15 for a DNR. On 2/12/15 Patient #21 was transported to an acute care facility where Patient #21 remained until 2/16/15. Patient #21 had a physician's order for morphine sulfate 100 mg (milligrams)/5 ml (milliliters) 10 mg by mouth every 6 hours. The order for morphine was discontinued on 2/16/15. Patient #21 was placed on an NPO (nothing my mouth) until seen by the speech therapist. On 2/17/15 the speech therapist recommended thickened liquids and to place Patient #21 in as upright position as possible to administer pureed foods and thickened liquids. Patient #21 was ordered a fentanyl patch 25 mcg (micro grams)/hr every 72 hours. On 2/19/15 Patient #21 was placed back on morphine sulfate 100 mg (milligrams)/5 ml (milliliters) 5 mg by mouth every 4 hours as needed for pain. Patient #21 also had an order for Tylenol suppository 650 mg rectally every 4 hours as needed, for fevers > 100.5.

The MAR (Medication Administration Record) found in Patient #21's MR indicated Patient #21 never received morphine after 2/17/15. On 2/18/15 at 11:30 A.M. Patient #21's fentanyl patch of 12 mcg was discontinued and another fentanyl patch (25 mcg) was not placed until 2/19/15 at 11:20 A.M.

The nurses note on 2/19/15 at 0435 (A.M.) documented Patient #21 "Pt received lying in bed. appeared agitated. Constantly moving extremities. Did not respond to verbal stimuli. Moaned when repositioned for comfort. ADIM (sic) routine ativan. At approx 0330 VS 78/40, 89, 100.6 and 84% on 5 L via mask (concentrator max)., AS NEEDED Tylenol suppository admin. At approx 0430 temp 98.9. Did not respond to verbal stimuli this shift, but did moan when touched or repositioned. Close monitoring continues."

The Problems/Needs List documented on 2/9/15 at 1:45 P.M., a problem (M14) Abdominal pain due to ascites was added. There were no initials or signature by the addition to indicate who wrote the problem. Staff Member #55 stated, "Only physicians add to the problem list. We do not have hospice here, we only offer comfort care." Staff Member #55 was asked to explain comfort care and stated, "We try to keep the O2 stats between 90 and 95%."

The Treatment Plan for Patient #21 did not list M14 Abdominal pain due to ascites.

Hepatic Encephalopathy Written by April Kahn | Published on June 25, 2012Medically Reviewed by Brenda B. Spriggs, MD, MPH, FACP http://www.healthline.com/health/medical-board documented the following:
Hepatic encephalopathy is a deterioration of brain function that is a serious complication of liver disease. In this condition, the liver is not removing toxins from the blood. This results in a buildup of toxins in the bloodstream that can cause brain damage. This condition can be acute or chronic. In some cases, a person with hepatic encephalopathy may become unresponsive and slip into a coma.
Acute hepatic encephalopathy also indicates terminal liver failure.
The exact cause of hepatic encephalopathy is not known. It is brought on by a buildup of toxins in the bloodstream and occurs when the liver fails to function properly.
The liver removes toxic chemicals from the body. These toxins are left over from proteins that are metabolized or broken down for use by various organs in the body. The kidneys change these toxins into safer substances that are then removed from the body through the urine. When the liver is damaged, it is unable to filter out all the toxins. When the kidneys cannot complete this process, toxins build up in the bloodstream. Toxic buildup can damage the organs and nerves.
B. Patient #23's MR was reviewed on 6/3/15. Patient #23 was admitted on 2/27/13 from another facility to this facility as a stepdown and expired on 3/27/13. Patient #23 was diagnosed with schizoaffective disorder, and hypertension. Patient #23 initially refused to have a physical but was seen on 3/13/13 and a limited physical was performed. At that time Patient #23 was diagnosed with vertigo (dizziness). On 3/13/13 Patient #23 had complained of dizziness, vomited and had an unwitnessed fall and denied hitting his/her head. Patient denied being constipated. The physician ordered Maalox 30 cc and assess, continuous 1:1 within 20 feet, vital signs every shift for 5 days, clear liquid diet, Phenergan 25 mg IM every 6 hours PRN (as needed) and H. Pylori every/day(s) starting 3/19/13 X 1.
The MR documented Patient #23 was in bed on 3/15, 18, 19, 20, 21, 23 and on 3/26/13 the physician's note documents' "doing better physically. Attended goals group for the first time in several days. Appropriate in approach." There was no evidence Patient #23 was ever assessed for a possible head injury or neuro checks performed.
Nursing notes documented on 3/14/13 Patient #23 complained of feeling "heavy headed", assisted to bathroom complaining of being dizzy, when lying in bed appears restless, on 3/15/13 Patient #23 sat on the side of the bed briefly and stated, "I gotta lay down." On 3/20/13 the CNA (Certified Nursing Assistant) noted "Client still seems a little unsteady on his/her feet."
There was no evidence on Patient #23's Treatment Plan that the problems of unsteady gait was explored.
Patient #23's autopsy report indicated the cause of death was a nontraumatic intracerebral hemorrhage.


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2. The clinical record for Patient #24 was reviewed on 6-3-15. Patient #24 was admitted on 8-6-14. Review of interdisciplinary notes revealed the patient was often aggressive to staff and others and refusing to be assessed or treated. The patient had malnutrition noted as a problem and addressed in his/her care plan.

Review of records documenting intake of meals and liquids for the period of 9-1-14 to 10-4-14, revealed the last meal accepted by the patient was 9-11-14, after which time all meals were documented as being refused. During this same time period, fluid intake was consistently below 2000 ml for a 24 (twenty-four) hour period. Sixteen (16) of twenty-one (21) days fluid intake was recorded at less than 1000 ml for 24 hrs. The clinical record for Patient #24 failed to reveal an update of the problem list and care plan for malnutrition, the last nutritional note by the dietician was dated 9-12-14 at 12:45 and documented his/her attempt to speak to the patient regarding what food the patient would like.

The nursing note on 10-1014 contained the following "Relatively no significant fluid/nutritional intake in well over 10 days." The clinical record for Patient #24 failed to reveal any addition to the problem list or care plan based on this finding by the nurse. In an interview with Staff Member #16 on 6-3-15, the surveyor asked what his/her expectation would be for the care plan. Staff Member #16 replied that his/her expectation would be that the problem list and care plan would be updated and include a plan for oral care.


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3. Patient # 22 was admitted to the facility on 1/10/11. On 2/3/15, Patient #22 was out with staff at 11:55 a.m. en route to the cafeteria for the lunch meal. It was documented the patient "walked away from staff" and that "[he/she] was not going to the cafeteria". Patient #22 was "redirected with the assistance of (facility) police" and "restricted to the unit". On 2/5/15 it was documented in the "Facility Event Report" that the patient had eloped from the unit twice: at 1330 (1:30 p.m.) and at 1430 (2:30 p.m.). At both instances, it was documented on the patient had been standing at the doorway of the unit and had gotten out the door when a staff member had entered the unit. On both occasions staff were able to "coax" the patient back in to the unit.

Review of the clinical record for Patient #22 revealed no documentation in the "Interdisciplinary Team Notes" that the patient had attempted to elope from the unit on 2/5/15 twice. There was also no documentation updating the patient's care plan of the elopement and any revisions/interventions that were documented regarding these incidents.

On 6/3/15 at 1:30 p.m., Staff #53 stated, "The care plan is usually updated with things like that. I am not sure why it is not on there to address those specific things with the interventions..."

Based on a observations, staff interviews, and record reviews, it was determined the facility staff failed to ensure that drugs were prepared and administered in accordance with the orders of the practitioner responsible for 1 of 34 patients, Patient #30 and #22.

Findings include:

1. The survyeor observed a medication pass on Pod 3 between 8:15 AM and 9:00 AM on 6/3/2015. The MFI observed Staff #32 crush scheduled medications for Patient #30 and administer them in pudding. The surveyor reviewed Patient #30's medical record and medication administration record (MAR) on 6/3/2015, and noted a physician order that Patient #30's medications could be placed in food for administration; however, there was no order to crush pills. When Staff #32 was preparing the medications for administration, he/she stated "(Patient #30) could swallow them, he/she just won't, so we crush them".

2. While reviewing Patient #22's record on 6/4/2015, the surveyor noted an order for Catapres tab (Clonidine) 0.1 mg by mouth two times per day for HBP ( high blood pressure); hold it if SBP (systolic blood pressure) < (less than) 100. The medication was scheduled to be administered daily at 6:00 AM and 6:00 PM. The surveyor noted 21 times between 3/10/2015 and 3/23/2015 when Catapres 0.1 mg was administered to Patient #17 without documentation that a blood pressure was obtained prior to administration, as ordered by the physician.


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Patient #22 had a PRN (when needed) order for a medication which was administered and not documented on the MAR (Medication Administration Record).

Review of the clinical record for Patient #22, who was admitted to the facility on 1/10/11 revealed the patient attempted to elope at 11:55 a.m. while en route with staff to the cafeteria. Documented in the "Interdisciplinary Team Notes" at 12:20 a.m., Patient #22 received 25 mg of Benadryl ( Diphenhydramine hydrochloride- Benadryl is an antihistamine with anticholinergic (drying) and sedative side effects. Nursing Drug Handbook 2014) IM (intramuscular injection). Patient #22 was agitated and insisting that he/she was "not going to the cafeteria".
Further review of the clinical record revealed no documentation on the MAR that Patient #22 had received the intramuscular injection of Benadryl on 2/3/15 at 12:20 a.m.
On 6/3/15 at 2:05 p.m., Staff #53 stated, "All PRN's (as needed medications) must be documented on the MARs" It should have been put there..."

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure radiological reports and vital signs were contained on the current clinical record for 2 of 34 patients in the survey sample. Patient #16 and #17.

The findings included:

1. Patient #16 was admitted to the facility on 2/5/15. The patient had a diagnosis of urinary retention and was seen in consultation by a urologist on 3/19/15 and a renal ultrasound and KUB (x-ray of the kidneys, ureter, and bladder) was recommended. On 3/20/15 it was documented in the clinical record "Per scheduler (name) (Name of physician-urologist) office will do all the scheduling of test for this patient. They are to call (me) with dates and times". Entry signed by Licensed Practical Nurse. On 4/9/15, it was documented that Patient #16 had an appointment for the KUB and Renal ultrasound on 4/14/15 at 10:15 a.m.

The surveyor was unable to locate in the clinical record, any results of the KUB and renal ultrasound.

On 6/2/15, the surveyor requested further information regarding the results of the radiological studies at 3:20 p.m. from Staff # 45.

On 6/3/18 at 4:25 p.m., the surveyor again requested the KUB and ultrasound report at the end of day meeting.

On 6/4/15 at 10:30 a.m., the surveyor was given the test results which had been faxed to the facility on 6/4/15 at 10:24 a.m. Staff # 2 stated the tests should have been on the clinical record in April after the tests were done. "We should have had a copy sent to us..."


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2. The surveyor reviewed Patient #17's record on 6/4/2015 and noted an order for Catapres tab (Clonidine) 0.1 mg (one tenth of a milligram) by mouth two times per day for HBP (high blood pressure); hold it if SBP (systolic blood pressure) < (less than) 100. The surveyor noted 21 times between 3/10/2015 and 3/23/2015 when a blood pressure was not documented prior to administration of Catapres.


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Based on observation, document review and interview the facility staff failed to ensure proper ventilation was maintained in the dirty side of the central supply room where instruments are cleaned and prepared for autoclaving.

The findings include:

On 6/2/15 at approximately 3:15 P.M. the central supply area was inspected. Staff Member #54 explained that instruments such as suture kits are brought to the dirty side of the central supply area where they are cleaned. The Staff Member stated, "The instruments are cleaned with a product called Compliance. We bring the instruments in here (dirty side of central supply) and put them in a basin to soak." Staff Member #54 was asked where the Compliance was stored as there was none in the dirty side of central supply.

Staff Member #54 stated, "We store it in a cabinet in the podiatry clinic because I have no room in here (dirty side of central supply)." Two 1 gallon jugs of Compliance was located in an unlocked cabinet in the podiatry clinic. Both of the jugs was wrapped in a plastic covering with one of the jugs leaking and the covering feeling damp.

Once in the podiatry clinic a metal container sitting on a rolling cart was observed. Staff Member #54 stated, "Those are used clippers the podiatrist has used that are soaking in the Compliance."

The label on the Compliance gallon jug states, "Warnings Compliance is hazardous to humans and animals. Use in a well ventilated area in closed containers."

The Material Safety Data Sheet states Hazardous Ingredients: Hydrogen Peroxide. Other Ingredients: Peracetic Acid. Precautions to be taken in handling and storing: Use in a well-ventilated area.

Based on observation, document review and interview the facility staff failed to ensure they followed their infection control program as it related to transporting cleaned medical instruments from the dirty side of central supply to the clean side of central supply. The staff also failed to maintain refrigerators at proper temperatures for storing medications and biological indicator strips.

The findings include:

On 6/2/15 at approximately 3:15 P.M. the central supply area was inspected. Staff Member #54 explained that instruments such as suture kits were brought to the dirty side of the central supply area where they were cleaned. The Staff Member stated, "The instruments are cleaned with a product called Compliance. I let the instruments soak for about 10 minutes in the Compliance. We bring the instruments in here (dirty side of central supply) and put them in a basin to soak. Once they have been cleaned I cover them with a bath towel and carry them across the hall to the clean side (of central supply). I then wrap them and autoclave them."

Staff Member #54 stated, "Ideally there would be a pass through window here so the instruments would not have to go into the hallway. In the old building we had a pass through window." The hallway connects to a longer hallway used my patients and staff and for transporting supplies.

The table where the cleaned items are wrapped had approximately 20 bags with items in them sitting on the table. Staff Member #54 stated, "I just don't have enough room."

Staff Member #54 was asked to describe what type of equipment is worn when reprocessing clean equipment. Staff Member #54 stated, "When cleaning I wear goggles and an apron. When wrapping I wear shoe covers and a clean gown (disposable paper gown) and when I start to autoclave I add head covers."

The packaging label with the Compliance documented the following:
Directions for sterilization: immersion time of 180 minutes not to exceed 14 days.
Directions for high level disinfection: immersion time of 15 minutes not to exceed 14 days.

On June 1, 2015 at approximately 12:50 P.M. the medication refrigerator on 5C was observed. The temperature in the refrigerator stated 28 degrees Fahrenheit when immediately opened. The same refrigerator was rechecked at 9:00 A.M. on 6/2/15 and was found to be 50 degrees Fahrenheit. The temperature log sheet on the refrigerator documented in the top left corner date (with arrow pointing left to right) and time (with arrow pointing top to bottom) but the time column had degrees listed. A block of degrees ranging from 36 to 45 degrees was highlighted with a comment at the bottom stating this was a range and if a temperature was out of range action was to be taken. None of the temperatures were documented as being out of range.

The refrigerator in the medical clinic was inspected on 6/2/15 at approximately 2 P.M. with Staff Member #57. Staff Member #57 stated, "We have not used our refrigerator since May 31, 2015. We had a couple of temperature out of range back on May 7th and reported them but nothing was done. We had the same problem on the 28th and I moved the medications to the pharmacy refrigerator." Staff Member #57 stated, "We stored flu vaccine, Hep B vaccine, TDAP, TST, eye drops and the biological for central supply in our refrigerator. They are now all in the pharmacy refrigerator."

The temperature log sheet for the medical clinic states "Temperature Range Allowed: 36 - 45 degrees Fahrenheit." The log for the month of May 2015 has the following dates of when the temperature was not in range:
May 1, 3, 7, 13, 16, 19, 22 and 28 all had temperatures of 46°F and on May 21, 26 and 29 the temperatures were below 36°F.
The information on the Biological Indicator Strips state they must be stored between 36 and 75°F and between 30-80% RH (relative humidity).
There was no evidence any of the medications, vaccines or biological were discarded when the temperatures of the refrigerator were out of range.

Based on document review and interview the facility failed to ensure they implemented protocols for organ procurement.

The findings include:

On 6/2/15 at approximately 3:30 Staff Member #52 was interviewed regarding their contract with an OPO (Organ Procurement Organization). Staff Member #52 stated, "We don't have a contract with an OPO. We have a policy but it has not been implemented."

Based on document review and interview the facility failed to ensure they had a contract with an Organ Procurement Organization (OPO).

The findings include:

On 6/2/15 at approximately 3:30 Staff Member #52 was interviewed regarding their contract with an OPO. Staff Member #52 stated, "We don't have a contract with an OPO. I am working on that right now."

Patient #21's medical record was reviewed on 6/2/15. Patient #21 was admitted on 9/4/13 and expired on 2/20/15. There was no evidence in the medical record that an OPO was notified of Patient #21's death.

Based on document review and interview the facility failed to ensure they had a contract with an Organ Procurement Organization (OPO) and an eye bank for the retrieval, processing, preservation and distribution of tissues and eyes.

The findings include:

On 6/2/15 at approximately 3:30 Staff Member #52 was interviewed regarding their contract with an OPO. Staff Member #52 stated, "We don't have a contract with an OPO. I am working on that right now."

Patient #21's medical record was reviewed on 6/2/15. Patient #21 was admitted on 9/4/13 and expired on 2/20/15. There was no evidence in the medical record that an OPO or an eye bank was notified of Patient #21's death.

Based on record review and interview, the facility failed to ensure that the social work assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) contained sufficient documentation regarding the anticipated role of the social worker in treatment planning and provision of treatment during the patient's hospitalization. Absence of these details adversely affects both the patient's length of hospitalization and a safe and effective re-entry into the community with reduced likelihood of recidivism.

Findings include:

A. Record Review

The psychosocial assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (3/18/15), A2 (7/14/14), A3 (5/15/15), A4, (7/19/13), B1 (5/19/15), B2 (3/17/15), B3 (4/9/15) and B4 (5/19/15). This review revealed:

1. Patient A1 was admitted 3/13/15 with a diagnosis of "Schizophrenia, Paranoid Type." In the patient's "Psychosocial Assessment" dated 3/18/15 under the section titled "Summary/Recommendations for Social Work Intervention," the social worker documented a summary of the patient's behaviors and presenting symptoms and wrote the following general statement regarding interventions, "...[S/he] will need stabilization of symptoms to facilitate community placement..." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

2. Patient A2 was admitted 7/14/14 with a diagnosis of "Autistic Disorder, Impulsive Control Disorder." In the "Psychosocial Assessment" dated 7/14/15 under the section titled "Summary/Recommendations for Social Work Intervention," the social worker documented a summary of the patient's behaviors and presenting symptoms and wrote the following general statement regarding interventions, "...[S/he] could benefit from recovery groups and a strict psychiatric medication regiment..." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

3. Patient A3 was admitted 5/14/15 with a diagnosis of "Schizophrenia, Disorganized." In the "Psychosocial Assessment" dated 5/15/15 under the section titled "Summary/Recommendations for Social Work Intervention," the social worker documented a summary of the patient's behaviors and presenting symptoms and wrote the following general statement regarding interventions, "...[S/he] could benefit from further stabilization of symptoms..." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

4. Patient A4 was admitted 7/18/13 with a diagnosis of "Psychotic Disorder, NOS [Not otherwise specified]." In the "Psychosocial Assessment" dated 7/19/13, the social worker documented a summary of the patient's behaviors and presenting symptoms and wrote the following general statement regarding interventions, "Recommended services include med [medication] management, case management, day treatment and SA [substance abuse] services." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization. [Note: The most recent psychosocial assessment was not provided or found in the medical record.]

5. Patient B1 was admitted 5/13/15 with a diagnosis of "Schizoaffective Disorder, Bipolar Type." In the "Psychosocial Assessment" dated 5/19/15 under the section titled "Summary/Recommendations for Social Work Intervention," the social worker wrote the following general statement regarding interventions, "[Patient's name] would benefit from mental health education, medication education, linked with outpatient services and financial benefits." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

6. Patient B2 was admitted 3/13/15 with a diagnosis of "Schizoaffective Disorder." In the "Psychosocial Assessment" dated 3/17/15 under the section titled "Summary /Recommendations for Social Work Intervention," the social worker wrote the following general statement regarding interventions, "[Patient's name] would benefit from mental health education, medication education, linked with outpatient services and financial benefits." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

7. Patient B3 was admitted 4/3/15 with a diagnosis of "Bipolar 1 Disorder..." In the "Psychosocial Assessment" dated 4/9/15 under the section titled "Summary /Recommendations for Social Work Intervention," the social worker documented a summary of the patient's behaviors and presenting symptoms and wrote the following general statement regarding interventions, "[Patient's name] would benefit from being linked with outpatient services upon discharge, legal issues and medication education." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

8. Patient B4 was admitted 3/17/15 with a diagnosis of "Bipolar 1 Disorder, manic with psychotic features." In the "Psychosocial Assessment" dated 5/19/15 under the section titled "Summary/Recommendations for Social Work Intervention," the social worker wrote the following general statement regarding interventions, "[Patient's name] would benefit from obtaining a new living arrangement upon discharge, linked with benefits and mental health education." There were no specific recommendations regarding anticipated social work role(s), which included the individual and/ or group interventions that would be implemented by the social worker during the patient's hospitalization.

B. Staff Interview

In an interview on 6/2/15 at 3:15 p.m. with the Director of Social Work, the psychosocial assessments for Patients A1, A2 and A4 were discussed. He agreed that psychosocial assessments did not contain individual and/or group interventions reflecting what the social worker would do to assist patients during their hospitalization. He stated, "I guess they [social work interventions] are not there."

Based on record review, policy review, and staff interview, the facility failed to document neurological examinations in such a way as to verify the specific testing performed for four (4) of eigh (8) active sample patients (A3, A4, B3 and B4). This failure to document specific testing compromises the identification of pathology, which may be pertinent to the current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions.

Findings include

A. Record Review

1. Patient A3 (admitted 5/14/15) had no neurological completed. It was noted only that the patient "refused" on the History, Physical & Initial Assessment document on 5/14/15. There were no progress notes documenting staff's attempts to complete the neurological examination nor was it listed as a medical problem in the Comprehensive Treatment Plan (dated 5/21/15).

2. Patient A4 (admitted 7/18/13) had a psychiatric evaluation dated 7/19/13, which noted a "cognitive impairment." However, it was noted on 7/18/13 that the patient refused to have a physical examination to assess neurological functioning. On 7/8/14, a physical examination was completed that stated, "Neurological: II-XII intact, normal gait." There was no indication of the specific testing performed. There were no progress notes documenting the patient's continued refusal and staff's attempts to complete the physical examination nor was it listed as a medical problem in the Comprehensive Treatment Plan (dated 1/7/15).

3. Patient B3 (admitted 4/3/15) had no neurological completed. It was noted only that the patient "refused" on the History, Physical &Initial Assessment document on 4/3/15. There were no progress notes documenting staff ' s attempts to complete the neurological examination nor was it listed as a medical problem in the Comprehensive Treatment Plan (dated 4/10/15).

4. Patient B4 (admitted 3/17/15) had no neurological completed. It was noted only that the "client refused" on the History, Physical &Initial Assessment document on 3/17/15. There were no progress noted documenting staff's attempts to complete the neurological examination nor was it listed as a medical problem in the Comprehensive Treatment Plan (dated 3/24/15).

B. Policy Review

Facility Policy 450-011 "History And Physical Examinations For Patients" (dated February 20, 2015) stated, "A history and physical examination will be completed and authenticated, signed, dated and timed in the medical record within 24 hours of admission." It further stated that the examination will include a "neurological examination." Furthermore, it stated that such exams "should be completed at least annually. If unable to complete the neurological examination due to the patient's refusal or condition, the Attending Physician/PCP or designee will complete the examinations prior to the Comprehensive Treatment Conference. Physical examinations not completed at the time of the Comprehensive Treatment Conference due to refusal should be added to the Medical Problem List and must be documented by the Attending Physician or designee with a plan for completion."

This policy further stated, "A patient's refusal of recommended screening tests is to be documented in the medical record weekly for 3 weeks."

C. Staff Interviews

1. On 6/2/15 at 2:45 p.m., the Clinical Director stated, "I see that the neurological exams were not done."

2. On 6/3/15 at 10:30 a.m., Physician 1 stated, "No, we are not charting when examinations are refused and it is not on the Treatment Plans."

Based on record review, document review, and staff interview, the facility failed to identify specific interventions to address the individual patient ' s identified needs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure resulted in routine generic job description interventions that did not provide focused treatment for the patients' identified problems.

Findings include:

A. Record Review

1. Patient A1 (Comprehensive Treatment Plan dated 3/20/15) had the following interventions for the Problem of "thought disorganization" and for the Short Term Goal of "demonstrate improved thought organization":

a. Psychiatrist: "Will prescribe psychotropic medications with consent, titrate as needed, monitor adverse effects and related labs." This was a generic intervention that was nonspecific for this patient.

b. Psychologist: "Will meet with [patient] daily to evaluate progress, educate on mental illness issues, recommend behavioral interventions if needed." This was a generic intervention that was nonspecific for this patient.

c. Nursing: "Will administer all medications as ordered by physicians. Monitor for compliance/effectiveness. Encourage/educate importance in participating in weekly medication education. Encourage participation in scheduled groups, daily showers and putting on clean clothes, oral care twice daily." These were generic interventions that were nonspecific for this patient. The intervention statement regarding medication education lacked a modality (individual or group sessions), a focus of treatment based on the patient's needs, and frequency of contract.

2. Patient A2 (Comprehensive Treatment Plan dated 2/14/15) had the following interventions for the Problem of "Impulse Control" and for the Short Term Goal of "demonstrate management of impulsive behaviors by remaining free of physical aggression":

a. Psychiatrist: "Will order psychotropic medications with consent, titrate as to clinical need, monitor adverse effects and related labs." This was a generic intervention that was nonspecific for this patient.

b. Nursing: "Will administer all medications as ordered, supervise compliance and monitor effectiveness. This was a generic intervention that was nonspecific for this patient. Perform education of medications at a simple level of learning." This was a generic intervention without identification of a modality, focus of treatment based on the patient's need, or frequency of the intervention.

3. Patient A3 (Comprehensive Treatment Plan dated 5/21/15) had the following interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate improved mood stability by having no more than 1 [incident] per week of verbal aggression toward peers and staff for at least 30 days":

a. Psychiatrist: "Will prescribe psychotropic medications with consent, titrate to clinical need, monitor adverse [effects] and related lab work if indicated." This was a generic intervention that was nonspecific for this patient.

b. Nursing: "Will administer all medications, monitor for compliance/effectiveness. Encourage participation in weekly med [education], scheduled groups." This intervention was generic and nonspecific for this patient.

4. Patient A4 (Comprehensive Treatment Plan dated 4/1/15) had the following interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate no acts of physical aggression":

a. Psychiatrist: "Physician will prescribe medication to address psychosis as well as as-needed medication to address agitation. Will monitor for effectiveness and side effects." These interventions were generic and nonspecific for this patient.

b. Nursing: "Will provide medications as prescribed and monitor for adherence." This intervention was generic and nonspecific for this patient.

c. Social Work: "Will provide the full range of discharge planning services in collaboration with the interdisciplinary treatment team. Will meet with [patient] on the unit and continually assess his level of discharge readiness." These intervention were generic and nonspecific for this patient.

d. Rehabilitation Therapy: "Will encourage to attend scheduled groups daily and offer to work with him to develop a schedule that reflects his preferences." This intervention was generic and nonspecific for this patient.

5. Patient B1 (Comprehensive Treatment Plan dated 5/20/15) had the following interventions for the Problem of "disorganized thinking" and the Short Term Goal "Will decrease attempts to force herself on a daily basis out of the door":

a. Psychiatrist: "MD will continue to assess patient and prescribe psychotropic meds to address psychotic behavior, monitor for side effects and educate patient for need of treatment." These interventions were generic and nonspecific for this patient. The intervention regarding educating the patient lacked a modality, a specific focus of treatment based the patient's need, and frequency of contact for the intervention.

b. Nursing: "RN will administer all medications as ordered, monitor for effectiveness and for side effects. Supervise compliance. Encourage to attend/participate in all scheduled groups/treatment." These were generic interventions that were nonspecific for this patient.

c. Social Work: "Will meet with [patient] once a week to assist with discharge planning." This intervention lacked a modality (individual or group sessions) and a focus of treatment based on the patient's discharged need.

6. Patient B2 (Comprehensive Treatment Plan dated 3/20/15) had the following interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will remain free of attempts to elope/leave the unit without permission for 10 consecutive days":

a. Psychiatrist: "MD will continue to adjust psychotropic med regimen to help [patient] calm down and think more clearly, resolve psychotic symptoms. Monitor for side effects." These interventions were generic and nonspecific for this patient.

b. Nursing: "Will administer all medications as ordered. Monitor effectiveness and compliance. Encourage active daily participation in groups and in all scheduled treatment." These were generic interventions that were nonspecific for this patient.

c. Psychology: "Will meet 1:1 weekly for mental health assessment and intervention." This intervention was generic and nonspecific for the individual patient.

d. Rehabilitation Therapy: "Will meet with [patient] to develop a schedule to meet [patient's] needs such as: Mental Health Issues, Managing My Recovery and Medication Education." This intervention was generic and nonspecific for this patient. The intervention statement simply listed interventions without a modality (individual or group sessions), a focus of treatment, and frequency of contact.

7. Patient B3 (Comprehensive Treatment Plan dated 4/10/15) had the following interventions for the Problem of "Severe Mania" and the Short Term Goal "Will respond to prompts to use coping skills to self-calm":

a. Psychiatrist: "MD will continue to adjust psychotropic meds to help resolve psychosis. Monitor for side effects and educate need for treatment." This intervention was generic and the modality and frequency of contact were omitted for the statement regarding educating the patient.

b. Nursing: "Administer medications as prescribed and note any drug side effects." This intervention was generic and nonspecific for this patient.

c. Social Work: "Will meet with [patient] weekly to educate on discharge placement and assist with discharge planning." This intervention lacked a specific focus of treatment based on the patient's discharge needs and a modality (individual or group sessions).

8. Patient B4 (Comprehensive Treatment Plan dated 3/24/15) had the following interventions for the Problem of "Responding to Internal Stimuli" and for the Short Term Goal "Will be able to verbalize at least 3 coping skills during treatment team":

a. Psychiatrist: "Will prescribe antipsychotics, mood stabilizers, monitor response and side effects." This intervention was generic and nonspecific for the individual patient.

b. Nursing: "Will administer all medications as ordered. Monitor effectiveness and for side effects, supervise compliance. Encourage to attend/participate [in] all scheduled groups/treatment." These interventions were generic and nonspecific for the individual patient.

c. Psychology: "Will greet and assess [patient] daily on the unit. Will meet weekly for 1: 1 assessment and intervention regarding medication and mental illness education and assessment of psychiatric well-being." This intervention was generic and nonspecific for the individual patient. The statement educating the patient lacked a focus of treatment based on the patient's need.

d. Social Work: "Will meet with [patient] to assist with discharge needs by completing necessary discharge paperwork and working collaboratively with CSB liaison." This intervention was generic and nonspecific for this individual patient.

B. Document Review

The document, "Eastern State Hospital Plan for Patient Care Services (9/15/13)" under "Treatment Planning" stated, "Specific Goals and objectives are developed and relate to the patient's input regarding their own needs, problems, and strengths."

C. Staff Interviews

1. On 6/2/15 at 2:50 p.m., the Clinical Director said, "I can see that the MD interventions are not specific to the patient."

2. On 6/2/15 at 3:45 p.m., Psychologist 1 stated, "I see that we need to individualize the interventions."

3. On 6/2/15 at 3:15 p.m., the Director of Social work stated, "No, all the interventions are not individualized for the patient."

4. On 6/2/15 at 2:10 p.m., the Director of Nursing said, "I can see that the nursing interventions are not specific for each patient."

Based on record review and interview, the facility failed to ensure that registered nurses (RNs) documented specific information about medication education assigned for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). Specifically, RNs did not consistently document complete information about medication education including non-participation and participation. When the patient participated in sessions, the documentation did not reflect the specific medication(s) discussed and/or information provided at all, and did not consistently document the patient's level of response and behavior during medication education sessions. This failure potentially hampers the treatment team's ability to determine patients' response to active treatment, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

A. Record Review

The Comprehensive Treatment Plans (CTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (3/20/15), A2 (2/14/15), A3 (5/21/15), A4 (1/7/15), B1 (5/20/15), B2 (3/20/15), B3 (4/10/15) and B4 (3/24/15).

This review revealed:

1. Patient A1 had the following nursing intervention regarding medication education: "...Encourage/educate importance in participating in weekly medications..." The "Patient Activity Schedule" which was attached to the CTP showed that Medication Education was scheduled Sunday at 9:30 a.m. A review of treatment notes for May 2015 for this patient revealed that there was no documentation regarding participation or non-participation in medication education found in the medical record. In addition, there was no documentation found in the medical record that noted what would be done to ensure that the patient received this assigned active treatment intervention.

2. Patient A2 had the following nursing intervention regarding medication education: "...Perform education of medications at a simple level of learning." A review of treatment notes for May 2015 for this patient revealed that there were five treatment notes documenting that the patient was sleeping. There was no documentation found in the medical record that noted what would be done to ensure that this patient received the assigned active treatment intervention such as providing the medication at another time or another day.

3. Patient A3 had the following nursing intervention regarding medication education: "Encourage participation in weekly med ed. [medication education]..." A review of the "Medication Education Note" Form for this patient revealed that there were three notes documented in May 2015 reflecting that the patient refused medication teaching. There was no documentation found in the medical record that noted what would be done to ensure that the patient received this assigned active treatment intervention such as providing the medication at another time or another day.

4. Patient A4 had the following nursing intervention regarding medication education: "...Provide patient education regarding the name and purpose of each prescribed medication..." A review of the "Medication Education Note" Form for this patient revealed that there were five notes documented in May 2015 reflecting that the patient was sleeping. There was no documentation found in the medical record that noted what would be done to ensure that the patient received this assigned active treatment intervention such as providing the education at another time or another day.

5. Patient B1 "Medication Education" listed on the "Patient Activity Schedule" which was attached to the CTP showed that Medication Education was scheduled Sunday at 9:30 a.m. However, there was no specific nursing intervention regarding medication education included on this patient's CTP that included the frequency of contact and focus of medication education based on this patient's need. A review of the "Medication Education Note" Form for this patient revealed that there was one note documented in May 2015 reflecting that the patient attended the medication education session but the note did not identify the medications discussed and or information provided.

6. Patient B2 "Medication Education" listed on the "Patient Activity Schedule" which was attached to the CTP showed that Medication Education was scheduled Sunday at 9:30 a.m. However, there was no specific nursing intervention regarding medication education included on this patient's CTP that included the frequency of contact and focus of medication education based on this patient's need. In addition, medication education was assigned to Rehabilitation Services on the CTP, although this intervention was reported to be the responsibility of nursing services. A review of the "Medication Education Note" Form for this patient revealed that there were two notes documented in May 2015 reflecting that the patient attended the medication education session but the treatment note did not identify what medications were discussed and the patient's behavior during the medication session.

7. Patient B3 had "Medication Education" listed on the "Patient Activity Schedule" which was attached to the CTP showing that Medication Education was scheduled Sunday at 9:30 a.m. However, there was no specific nursing intervention regarding medication education included on this patient's CTP that included the frequency of contact and focus of medication education based on this patient's need. A review of the "Medication Education Note" Form for this patient revealed that there were three (3) notes documented in May 2015 reflecting that the patient attended the medication education session and one note showing that this patient refused to attend. The three treatment notes documenting attendance did not identify medications discussed and/or information provided, the patient's level of participation, and behavior during the medication session. The treatment note dated 5/3/15 contained only checks for the criteria on the form and no other comments were documented.

8. Patient B4 had "Medication Education" listed on the "Patient Activity Schedule" which was attached to the CTP showing that Medication Education was scheduled Sunday at 9:30 a.m. However, there was no specific nursing intervention regarding medication education included on this patient's CTP that included the frequency of contact and focus of medication education based on this patient's need. A review of the "Medication Education Note" Form for this patient revealed that there were two (2) notes documented in May 2015 reflecting that the patient attended the medication education session and three notes showing that this patient refused medication education sessions. The one treatment note documenting participation did not identify medications discussed and/or information provided, duration of contact, the patient's level of participation, and behavior during the medication session.

B. Staff Interviews

1. In an interview on 6/2/15 at 11:00 a.m. with RN 1, medication education was discussed. She stated, "A lot of patients are still in bed on Sunday morning and refused. We can't force them to participate."

2. During interview on 6/2/15 at 2:10 p.m. with the Director of Nursing, the "Medication Education Note" Forms for Patients A1, A2, A3 and A4 were reviewed. She agreed that treatment notes regarding medication education should include the medications discussed and/or information provided by the RN. She also acknowledged that the treatment note should include the patient's response to education, level of participation, and understanding, and behavior during the session.

Based on observation, document review, patient interviews, and staff interviews the facility failed to provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). There were insufficient structured therapies available for weekends and evenings. In addition, there were no attempts to offer alternative programming for patients who were unable or unwilling to attend groups. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them and potentially delaying their improvement.

Findings include:

A. Document Review

1. Patient A1 (admitted 3/13/15) was assigned to the following groups on Monday-Friday 10:00 a.m. - 3:00 p.m.: Recovery Group, Stress Management, Tasks and Tunes, Arts and Crafts and Woodworking. The patient attended 4 (45 minute) groups daily on 6/1/15 and 6/2/15. For the month of May 2015, Patient A1 attended 53.50 hours of these groups. There were no specific interventions in the treatment plan to increase participation. There were no groups scheduled after 5:00 p.m. Monday-Friday or on Saturdays. Only the Medication Education was scheduled on Sundays at 9:30 a.m.

2. Patient A2 (admitted 8/11/14) was assigned to the groups: Anger Management, Coping Skills, Directive Group/Current Events and Me and My World on Monday-Friday 10:00 a.m. - 3:00 p.m. The patient attended 1 (45 minute) group on 6/1/15 and 6/2/15. For the month of May 2015, Patient A2 attended 52.75 hours of these groups. There were no specific interventions in the treatment plan to increase participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday or none for the entire day on Saturdays. Only the Medication Education group was scheduled on Sundays at 9:30 a.m.


3. Patient A3 (admitted 5/14/15) was assigned to the groups: Basic Conversation, Good Vibrations, Emotional Awareness, Mind over Mood, Social Skills, Anger Management, Managing My Recovery and Mental Illness Education on Monday-Friday 10:00 a.m. - 3:00 p.m. The patient attended 2 (45 minute) groups on 6/1/15 and 3 (45minute) groups on 6/2/15. For the month of May 2015, Patient A3 attended 0 hours of groups. There were no specific interventions in the treatment plan to increase participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays.

4. Patient A4 (admitted 7/18/13) was assigned to the groups: Tasks and Tunes, Looking/Feeling Good, Healthy Cooking, Wake up with Music, Life Skills, Taking Care of My Body, Money Smart 101 and Symptom Recognition and Management on Monday-Friday 10:00 a.m.-3:00 p.m. The patient attended no groups on 6/1/5 and 6/2/15. For the month of May 2015, Patient A3 attended 15.50 hours of groups. There were no specific interventions in the treatment plan to increase participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays. Only Medication Education group was scheduled on Sundays at 9:30 a.m.

5. Patient B1 (admitted 5/13/15) was assigned the groups: Basic Conversation, Directive Group, Get Out and Stay Out, Social Skills, Good Vibrations, Anger Management and Rhythms of Recovery on Monday-Friday 10:00 a.m.-3:00 p.m. The patient attended 1 (45 minute) group on 6/1/15 and 1 (45 minute) group on 6/2/15. For the month of May 2015, Patient B1 attended 6.50 hours of groups. There were no specific interventions in the treatment plan to increase attendance/participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays. Only Medication Education group was scheduled on Sundays at 9:30 a.m.

6. Patient B2 (admitted 3/13/15) was assigned to the groups: Stress Management, Emotional Awareness, Get Out and Stay Out, Mental Health Issues, Directive Group, Managing My Recovery and Rhythms of Recovery on Monday-Friday 10:00 a.m. - 3:00 p.m. The patient attended 1 (45 minute group) on 6/1/15 and 1 (45 minute) on 6/2/15. For the month of May 2015, Patient B2 attended 31.00 hours of groups. There were no specific interventions in the treatment plan to increase attendance/participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays. Only Medication Education group was scheduled on Sundays at 9:30 a.m.

7. Patient B3 (admitted 4/3/2015) was assigned to the groups: Coping with Life, Directive Group, Emotional Awareness, Intro to legal Issues, Mock courtroom, Basic Conversation, Recovery Planning, Anger Management and Rhythms of Recovery on Monday-Friday 10:00 a.m. - 3:00 p.m. The patient attended 3 (45 minute) groups on 6/1/15 and 2 (45 minute) groups on 6/2/15. For the month of May 2015, Patient B3 attended 42.00 hours of groups. There were no specific interventions in the treatment plan to increase attendance/participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays. Only Medication Education group was scheduled on Sundays at 9:30 a.m.

8. Patient B4 (admitted 3/17/15) was assigned to the groups: Basic Conversation, Stress Management, Mind over Mood, Health and Wellness, Mental Health Issues, Coping skills, Directive Group, Recovery Planning and Anger Management on Monday-Friday 10:00 a.m. - 3:00 p.m. The patient attended no groups on 6/1/15 or 6/2/15. For the month of May 2015, Patient B4 attended 35.50 hours of groups. There were no specific interventions in the treatment plan to increase attendance/participation in groups. There were no groups scheduled after 5:00 p.m. Monday-Friday and none scheduled for the entire day on Saturdays. Only Medication Education group was scheduled on Sundays at 9:30 a.m.

9. The document titled "Eastern State Hospital Plan for Patient Care Services" and dated 9/15/14, under "Active Treatment Program" stated, "It is the philosophy of the Eastern State Hospital Active Treatment program to provide strengths based, recovery oriented treatment based on the input of the patient regarding their needs and preferences, in a manner that will maximize the person's ability to function in the facility and in the community. Referral to and participation in this off- unit program is available to all patients, with services being provided differently only in those rare instances in which a patient cannot be safely managed off of the residential ward." There is no mention of on unit groups, individual work or any alternative programming for patients unable/unwilling to attend off unit groups.

B. Observations

1. On 6/1/15 at 10:30 a.m. on Unit 3 B (census 18 female patients), there were 11 patients on the unit. The patients were seated in chairs talking with each other, talking on the phone and one remained in bed. None were involved in structured groups/activities or engaged in individual work with staff members.

2. During observation on Unit 3A on 6/1/15 at 11:00 a.m., nine (9) patients were escorted to the mall to attend scheduled groups (census 20 male patients). Patient A4 was schedule to attend the "Wii Group" but was found in [his/her] room in bed. Eleven other patients were noted to be either in their room, sitting in the day room, or walk around the unit. Two staff was observed sitting at a table together. This was discussed with RN1 and she stated that some patients were restricted to the unit, some refused to go, and 1 patient was a new patient who would not attend the off-unit program until after 5 working days. She stated that there was no on-unit program to provide active treatment for patients who were unable or unwilling to attend the off-unit program.

3. On 6/1/15 at 2:30 p.m. on Unit 3 B, there were 12 patients on the unit. One remained in bed and the rest were sitting around tables talking with each other and some were coloring. None were involved in structured on unit groups/activities or engaged in individual work with staff members.

4. On 6/2/15 at 10:15 a.m. on Unit 3 B (census 18 females), there were 10 patients on the unit. One patient remained in bed and the others were either on the phone or talking to each other. None were involved in structured groups/activities or engaged in individual work with a staff member.

5. On 6/2/15 at 2:40 p.m. on Unit 3 B, there were 11 patients on the unit. They were in the dayroom or talking on the phone. None were involved in structured groups/activities or engaged in individual work with a staff member.

C. Patient Interviews

1. On 6/1/15 at 10:35 a.m., Patient B 4 stated, "I do not go off the unit to groups. There is nothing to do here."

2. During an interview on 6/1/15 at 1:30 p.m., Patient A4 stated, "I don't go to groups. After breakfast, I sleep or stay in my room."

3. On 6/1/15 at 2:30 p.m., Patient B1 stated, "I don't like the groups. There are no activities on the weekends or in the evenings."

D. Staff Interviews

1. On 6/1/15 at 10:15 a.m., RN 3 stated, "No, we do not have activities on the unit. There are no evening or weekend activities."

2. On 6/1/15 at 10:20 a.m., MHT 1 stated, "The patients that are on the unit can color or talk to each other."

3. On 6/2/15 at 12:30 p.m., the Director of Rehabilitation Therapy stated, "No, we do not provide structured groups in the evenings or on weekends. I am concerned as well about the patients who do not go to off unit groups."

4. On 6/2/15 at 2:10 p.m., the Director of Nursing stated, "There is no individual work or nursing groups conducted on the unit except med education. It could be more formalized. We should meet people where they are."

5. On 6/2/15 at 2:50 p.m., the Clinical Director stated, "No, we do not have groups in the evenings or on weekends. We could do better."

6. On 6/2/15 at 3:15 p.m., the Social Work Director stated, "No, social work does not do groups on the unit."

Based on interview and document review, the Medical Director failed to:

I. Document neurological examinations in such a way as to verify the specific testing performed for four (4) of eight (8) active sample patients (A3, A4, B3 and B4). This failure to document specific testing compromises the identification of pathology, which may be pertinent to the current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B109)
II. Identify specific interventions for the psychiatrist to address individual needs identified for eight (8) of eight (8) active sample patients (A1, A2, A4, B1, B2, B3 and B4). This failure results in routine generic job description interventions that did not provide focused active treatment for the patients' identified problems.

Findings include:

A. Record Review

1. Patient A1 (Comprehensive Treatment Plan dated 3/20/15) had the following psychiatrist intervention for the Problem of "thought disorganization" and for the Short Term Goal of "demonstrate improved thought organization":

Psychiatrist: "Will prescribe psychotropic medications with consent, titrate as needed, monitor adverse effects and related labs." This was a generic intervention that was nonspecific for this patient.

2. Patient A2 (Comprehensive Treatment Plan dated 2/14/15) had the following psychiatrist intervention for the Problem of "Impulse Control" and for the Short Term Goal of "demonstrate management of impulsive behaviors by remaining free of physical aggression":

Psychiatrist: "Will order psychotropic medications with consent, titrate as to clinical need, monitor adverse effects and related labs." This was a generic intervention that was nonspecific for this patient.

3. Patient A3 (Comprehensive Treatment Plan dated 5/21/15) had the following psychiatrist intervention for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate improved mood stability by having no more than 1 [incident] per week of verbal aggression toward peers and staff for at least 30 days":

Psychiatrist: "Will prescribe psychotropic medications with consent, titrate to clinical need, monitor adverse [effects] and related lab work if indicated." This was a generic intervention that was nonspecific for this patient.

4. Patient A4 (Comprehensive Treatment Plan dated 4/1/15) had the following psychiatrist interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate no acts of physical aggression":

Psychiatrist: "Physician will prescribe medication to address psychosis as well as as-needed medication to address agitation. Will monitor for effectiveness and side effects." These interventions were generic and nonspecific for this patient.

5. Patient B1 (Comprehensive Treatment Plan dated 5/20/15) had the following psychiatrist interventions for the Problem of "disorganized thinking" and the Short Term Goal "Will decrease attempts to force herself on a daily basis out of the door":

Psychiatrist: "MD will continue to assess patient and prescribe psychotropic meds to address psychotic behavior, monitor for side effects and educate patient for need of treatment." These interventions were generic and nonspecific for this patient. The statement regarding educating the patient lacked a modality, a specific focus of treatment based the patient's need, and frequency of contact for the intervention.

6. Patient B2 (Comprehensive Treatment Plan dated 3/20/15) had the following psychiatrist interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will remain free of attempts to elope/leave the unit without permission for 10 consecutive days":

Psychiatrist: "MD will continue to adjust psychotropic med regimen to help [patient] calm down and think more clearly, resolve psychotic symptoms. Monitor for side effects." These interventions were generic and nonspecific for this patient.

7. Patient B3 (Comprehensive Treatment Plan dated 4/10/15) had the following psychiatrist interventions for the Problem of "Severe Mania" and the Short Term Goal "Will respond to prompts to use coping skills to self-calm":

Psychiatrist: "MD will continue to adjust psychotropic meds to help resolve psychosis. Monitor for side effects and educate need for treatment." These interventions were generic and the modality and frequency of contact were omitted for the statement regarding educating the patient.

8. Patient B4 (Comprehensive Treatment Plan dated 3/24/15) had the following psychiatrist intervention for the Problem of "Responding to Internal Stimuli" and for the Short Term Goal "Will be able to verbalize at least 3 coping skills during treatment team":

Psychiatrist: "Will prescribe antipsychotics, mood stabilizers, monitor response and side effects." This intervention was generic and nonspecific for the individual patient.

B. Document Review

The document, "Eastern State Hospital Plan for Patient Care Services (9/15/13)" under "Treatment Planning" stated, "Specific Goals and objectives are developed and relate to the patient's input regarding their own needs, problems, and strengths."

C. Staff Interview

In an interview on 6/2/15 at 2:50 p.m., the Clinical Director said, "I can see that the MD interventions are not specific to the patient."

IV. Provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). There were insufficient structured therapies available for weekends and evenings. There were no attempts to offer alternative programming for patients who were unable or unwilling to attend groups. This lack of active therapies results in patients being hospitalized without all interventions for patient recovery being provided to them and potentially delaying their improvement. (Refer to B125)

Based on record review, document review, observation, patient interview and staff interview, the Director of Nursing failed to: (I) Develop individualized nursing interventions that addressed specific patient needs in eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4), (II) Ensure that registered nurses (RNs) documented specific information about medication education assigned for eight (8) of eight (8) active sample patients (Refer to B124), and (III) Ensure that on unit patients were provided alternative, individualized programming throughout weekdays, evenings and weekends for eight (8) of eight (8) active sample patients. (See B125)

Findings include:

I. Nursing Interventions

A. Record Review

1. Patient A1 (Comprehensive Treatment Plan dated 3/20/15) had the following nursing interventions for the Problem of "thought disorganization" and for the Short Term Goal of "demonstrate improved thought organization":

Nursing: "Will administer all medications as ordered by physicians. Monitor for compliance/effectiveness. Encourage/educate importance in participating in weekly medication education. Encourage participation in scheduled groups, daily showers and putting on clean clothes, oral care twice daily." These were generic interventions that were nonspecific for this patient. The intervention statement regarding medication education lacked a modality (individual or group sessions), a focus of treatment based on the patient's needs, and frequency of contract.

2. Patient A2 (Comprehensive Treatment Plan dated 2/14/15) had the following nursing interventions for the Problem of "Impulse Control" and for the Short Term Goal of "demonstrate management of impulsive behaviors by remaining free of physical aggression":

Nursing: "Will administer all medications as ordered, supervise compliance and monitor effectiveness. This was a generic intervention that was nonspecific for this patient. Perform education of medications at a simple level of learning." This was a generic intervention without identification of a modality, focus of treatment based on the patient's need, or frequency of the intervention.

3. Patient A3 (Comprehensive Treatment Plan dated 5/21/15) had the following nursing interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate improved mood stability by having no more than 1 [incident] per week of verbal aggression toward peers and staff for at least 30 days":

Nursing: "Will administer all medications, monitor for compliance/effectiveness. Encourage participation in weekly med [education], scheduled groups." This intervention was generic and nonspecific for this patient.

4. Patient A4 (Comprehensive Treatment Plan dated 4/1/15) had the following nursing intervention for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate no acts of physical aggression":

b. Nursing: "Will provide medications as prescribed and monitor for adherence." This intervention was generic and nonspecific for this patient.

5. Patient B1 (Comprehensive Treatment Plan dated 5/20/15) had the following nursing interventions for the Problem of "disorganized thinking" and the Short Term Goal "Will decrease attempts to force herself on a daily basis out of the door":

b. Nursing: "RN will administer all medications as ordered, monitor for effectiveness and for side effects. Supervise compliance. Encourage to attend/participate in all scheduled groups/treatment." These were generic interventions that were nonspecific for this patient.

6. Patient B2 (Comprehensive Treatment Plan dated 3/20/15) had the following nursing interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will remain free of attempts to elope/leave the unit without permission for 10 consecutive days":

b. Nursing: "Will administer all medications as ordered. Monitor effectiveness and compliance. Encourage active daily participation in groups and in all scheduled treatment." These were generic interventions that were nonspecific for this patient.

7. Patient B3 (Comprehensive Treatment Plan dated 4/10/15) had the following nursing intervention for the Problem of "Severe Mania" and the Short Term Goal "Will respond to prompts to use coping skills to self-calm":

b. Nursing: "Administer medications as prescribed and note any drug side effects." This intervention was generic and nonspecific for this patient.

8. Patient B4 (Comprehensive Treatment Plan dated 3/24/15) had the following nursing intervention for the Problem of "Responding to Internal Stimuli" and for the Short Term Goal "Will be able to verbalize at least 3 coping skills during treatment team":

b. Nursing: "Will administer all medications as ordered. Monitor effectiveness and for side effects, supervise compliance. Encourage to attend/participate [in] all scheduled groups/treatment." These interventions were generic and nonspecific for the individual patient.

B. Document Review

The document, "Eastern State Hospital Plan for Patient Care Services (9/15/13)" under "Treatment Planning" stated, "Specific Goals and objectives are developed and relate to the patient's input regarding their own needs, problems, and strengths."

C. Staff Interview

On 6/2/15 at 2:10 p.m., the Director of Nursing said, "I can see that the nursing interventions are not specific for each patient."

Based on record review and interviews, the Director of Social Services failed to monitor and evaluate the appropriateness of social services. Specifically, the Director of Social failed to:

I. Ensure that the social work assessments of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) contained sufficient documentation regarding the anticipated role of the social worker in the treatment planning and provision of treatment during each patient's hospitalization. Absence of these details adversely affects both the patient's length of hospitalization and a safe and effective re-entry into the community with reduced likelihood of recidivism. (Refer to B108)

II. Ensure that social work interventions on the Comprehensive Treatment Plans for four (4) of eight (8) active sample patients A4, B1, B3 and B4) were individualized to meet specific patient needs. Most social work interventions were generic routine tasks regardless of the different patients' problems and needs. This deficiency potentially hampers the quality and appropriateness of the social services delivered to patients.

Findings include:

A. Record Review

1. Patient A4 (Comprehensive Treatment Plan dated 4/1/15) had the following social work interventions for the Problem of "disorganized thinking" and the Short Term Goal of "Will demonstrate no acts of physical aggression":

Social Work: "Will provide the full range of discharge planning services in collaboration with the interdisciplinary treatment team. Will meet with [patient] on the unit and continually assess his level of discharge readiness." These intervention were generic and nonspecific for this patient.

2. Patient B1 (Comprehensive Treatment Plan dated 5/20/15) had the following social work intervention for the Problem of "disorganized thinking" and the Short Term Goal "Will decrease attempts to force herself on a daily basis out of the door":

Social Work: "Will meet with [patient] once a week to assist with discharge planning." This intervention lacked a modality (individual or group sessions) and a focus of treatment based on the patient's discharged need.

3. Patient B3 (Comprehensive Treatment Plan dated 4/10/15) had the following intervention for the Problem of "Severe Mania" and the Short Term Goal "Will respond to prompts to use coping skills to self-calm":

Social Work: "Will meet with [patient] weekly to educate on discharge placement and assist with discharge planning." This intervention lacked a specific focus of treatment based on the patient's discharge needs and a modality (individual or group sessions).

4. Patient B4 (Comprehensive Treatment Plan dated 3/24/15) had the following social work intervention for the Problem of "Responding to Internal Stimuli" and for the Short Term Goal "Will be able to verbalize at least 3 coping skills during treatment team":

Social Work: "Will meet with [patient] to assist with discharge needs by completing necessary discharge paperwork and working collaboratively with CSB liaison." This intervention was generic and nonspecific for this individual patient.

B. Document Review

The document, "Eastern State Hospital Plan for Patient Care Services (9/15/13)" under "Treatment Planning" stated, "Specific Goals and objectives are developed and relate to the patient's input regarding their own needs, problems, and strengths."

C. Staff Interview

In an interview on 6/2/15 at 3:15 p.m., the Director of Social work stated, "No, all the interventions are not individualized for the patient."