HospitalInspections.org

Based on observation, staff interview and review of maintenance records on 12/19 - 12/20/2022, Granite Hills Hospital failed to construct, install, and maintain the building systems to ensure safety of patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K281 - Illumination of Means of Egress
2. K291 - Emergency Lighting
3. K321 - Hazardous Areas - Enclosure
4. K324 - Cooking Facilities
5. K351 - Installation
6. K712 - Fire Drills
7. K911 - Electrical Systems - Others
8. K917 - Essential Electric - Receptacles
9. K918 - Electrical Systems - Essential Electric System Maintenance and Testing
10. K919 - Other
11.A709 - Life Safety from Fire

As a result of these deficiencies, 42 CFR Subpart CFR 482.41 Condition of Participation: Physical environment was NOT MET.

See K-tags, A701, and A709 for details of the specific findings.

Based on record review and interview the facility failed to ensure a psychosocial assessment was completed for 2 of 29 inpatients (Patients #8 and #10); the facility failed to include an inventory of the patient's strengths and assets that describe personal factors on which to base the treatment plan for 3 of 29 inpatients (Patients #10, #18 and #21); the facility failed to develop and initiate a Master Treatment Plan within 72 hours as defined by policy in 2 (Patients #13 and #30) of 29 inpatients and the facility failed to develop treatment interventions based on the individual needs of the patients for 16 of 29 (Patients #1, #2, #3, #4, #5, #6, #7, #9, #12, #14, #15, #17, #21, #26, #27, and #31) inpatients in a sample of 31 records reviewed.

Findings include:

The facility failed to ensure a psychosocial assessment was completed. See tag A-1625

The facility failed to include an inventory of patient's strengths and assets on which to base the treatment plan. See tag A-1637

The facility failed to develop and initiate a Master Treatment Plan within 72 hours as defined by policy. See tag A-1640

The facility failed to develop treatment interventions based on the individual needs of the patients. See tag A-1643

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality psychiatric treatment.

Based on record review and interview, the facility failed to ensure signed informed consents for Psychotropic medications (used to treat mood, thoughts, behavior or perception) was obtained for 11 of 29 inpatient admissions (Patients #1, #3, #8, #10, #13, #14, #15, #26, #28, #29, #37) receiving Psychotropic medications in a sample of 31 medical records reviewed.

Findings include:

A review of the facility policy titled, "Patient Rights and Responsibilities, ID 11023488", dated 1/13/2022, revealed: "A. Informed Consent: 1. Each patient (or guardian/parent) shall be provided thorough information, as well as time to review or seek additional information, concerning the treatment being proposed to the patient, including: a. The benefits of the proposed treatment and services; b. The way treatment is to be administered or services are to be provided; c. The possible risks or side effects of the proposed treatment and services, including risks or side effects of medication."

A review of Patient #1's medical record revealed an admission date of 12/12/2022 - current inpatient, with a diagnosis of bipolar disorder (manic depression causing extreme mood swings). The medication administration record revealed lurasidone (antipsychotic) was ordered by the psychiatrist on 12/12/2022 and administered 12/12//2022 - 12/20/2022, olanzapine (antipsychotic) ordered on 12/12/2022 and administered 12/12/2022, ziprasidone (antipsychotic) ordered on 12/13/2022 and administered 12/13/2022 - 12/20/2022, and klonopin twice daily as needed (antianxiety) ordered on 12/14/2022 and administered 12/14/2022, 12/16/22, 12/17/2022 and 12/20/2022. There were no signed, written consent forms in the medical record.

A review of Patient #3's medical record revealed an admission date of 10/24/2022 and discharge on 11/09/2022 with a diagnosis of schizophrenia. The record revealed Risperdole (antipsychotic) was ordered by the psychiatrist on 10/25/2022 and administered 10/25/2022, 11/3/2022- 11/09/2022. There was no signed, written consent form for Risperdole in the medical record.

A review of Patient #8's medical record revealed: Olanzapine (antipsychotic) ordered on 10/05/2022 and administered 10/05/2022-10/25/2022, Lorazepam (antianxiety) ordered on 10/19/2022 and administered 10/19/2022, Depakote (mood stabilizer) ordered on 10/08/2022 and administered 10/08/2022-10/09/2022, and Hydroxyzine Pamoate (antianxiety) ordered on 10/12/2022 and administered 10/12/2022-10/18/2022 without signed, written consent forms.

A review of Patient #10's medical record revealed: Mirtazapine (antidepressant) ordered on 10/29/2022 and administered 10/29/2022-11/01/2022 without signed, written consent forms.

A review of Patient #13's medical record revealed an admission date of 12/14/2022 and discharge on 12/21/2022 with a diagnosis of chronic schizophrenia (syndrome of delusions, hallucinations, flatness of affect, poverty of speech or incoherence of speech). The record revealed Quetiapine (antipsychotic) was ordered by the psychiatrist on 12/15/2022 and administered 12/15/2022 - 12/21/2022. There was no signed, written consent form in the medical record.

A review of Patient #14's medical record revealed an admission date of 12/10/2022 - current inpatient, with a diagnosis of paranoid psychosis (symptom of psychosis that involves irrational thoughts and fears that one is being persecuted). The record revealed Aripiprazole (antipsychotic) was ordered by the psychiatrist on 12/11/2022 and administered 12/11/2022 - 12/21/2022, Quetiapine ordered on 12/12/2022 and administered 12/12/2022 - 12/20/2022 and Olanzapine (antipsychotic) ordered PRN (as needed) on 12/13/2022 and administered 12/13/2022 - 12/16/2022. There were no signed, written consent forms in the medical record.

A review of Patient #15's medical record revealed an admission date of 12/08/2022 - current inpatient, with a diagnosis of suicidal ideations with intent. The medication administration record revealed olanzapine (antianxiety) was ordered by the psychiatrist on 12/15/2022 and administered 12/16/2022 - 12/20/2022, lamictal ordered on 12/09/2022 and administered 12/09/22 - 12/20/2022, nortriptyline (antidepressant) ordered on 12/09/2022 and administered 12/09/2022 - 12/20/2022, amphetamine-dextroamphetam (a central nervous system stimulant) ordered on 12/14/2022 and administered 12/14/2022 - 12/21/2022, prazosin (for nightmares) ordered 12/16/2022 and administered 12/16/2022 - 12/20/2022, and diazepam (for anxiety) ordered 12/10/2022 and administered 12/10/2022 - 12/21/2022. Medication consent for olanzapine was signed by patient #15 on 12/20/2022 at 2:00 PM (administered 4 days before consent was signed). There were no signed, written consent forms for lamictal, nortriptyline, amphetamine-dextroamphetam, or diazepam in the medical record.

A review of Patient #26's medical record revealed: "Chlorpromazine (antipsychotic) ordered on 9/29/2022 and administered 9/29/2022-10/6/2022, Quetiapine (antipsychotic) ordered on 9/20/2022 and administered 9/20/2022-9/25/2022, Trazadone (antidepressant) ordered on 9/27/2022 and administered 9/27/2022-10/6/2022 without signed, written consent forms.

A review of Patient #28's medical record revealed: "Aripiprazole (antipsychotic) ordered 10/24/2022 and administered 10/24/2022-10/28/2022, Risperidone (antipsychotic) ordered on 10/28/2022 and administered 10/28/2022-11/15/2022 without signed, written consent forms.

A review of Patient #29's medical record revealed: "Quetiapine (antipsychotic) ordered on 12/4/2022 and administered 12/4/2022-12/5/2022 without a signed, written consent form.

A review of Patient #37's medical record revealed an admission date of 12/13/2022 with a diagnosis of depression and suicidal ideation's, discharged on 12/19/2022. The record revealed mirtazapine (antidepressant) was ordered by the psychiatrist on 12/15/2022 and administered 12/15/2022 - 12/18/2022. There was no signed, written consent form in the medical record.

On 12/21/2022 at 8:35 AM these findings were discussed and confirmed in an interview with Interim DON (Director of Nursing) N when asked about consents for psychotropic medications stated, "Every psychiatric medication that we give requires a consent. It appears that some are missing."




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29963

Based on record review and interview the facility failed to follow their policy to ensure complete documentation in 2 (Patients #23 and #24) of 2 restraint/seclusion medical records reviewed out of 29 inpatient medical records in a sample of 31 records reviewed.

Findings include:

A review of the facility policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion, ID 11022959", dated 1/13/2022, revealed: "3.0 Physician Orders, Consultation, and Evaluation. 3.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. 3.1.2 The physician/LIP (licensed independent practitioner) must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated. 3.1.3 Telephone/verbal orders for restraint/seclusion may be received and recorded by the RN (registered nurse). 3.1.4 The physician shall authenticated the telephone/verbal order within 24 hours....10.0 Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion is important in reducing the use of recurrent restraint/seclusion. The patient and staff participate in a debriefing session following the restraint/seclusion episode...The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode."

A review of Patient #23's medical record revealed an admission date of 8/13/2022 and discharge on 9/9/2022 with a diagnosis of mood disorder (Characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these), rule out bipolar (mental health condition that causes extreme mood swings that include emotional highs (mania) and lows (depression)."

Further review of Patient #23's medical record revealed: "Acute Seclusion/Restraint order on 8/18/2022 at 2:30 AM revealed: Type of Intervention: Seclusion. Reason for Intervention: Imminent danger to others. Patient bumping into staff, throwing things at staff threatening to hurt staff. Placed in seclusion at 2:25 AM and released 2:36 AM. The Seclusion/Restraint Patient Debriefing form is blank."

Further review of Patient #23's medical record revealed: "Acute Seclusion/Restraint order on 8/28/2022 3:33 AM revealed: Type of Intervention: Physical Restraint and Seclusion. Reason for Intervention: Imminent Danger to Self, Imminent Danger to Others; swinging at patients, MHTs (mental health technicians). Telephone order on 8/28/2022 at 3:50 AM, physician signed, but not dated or timed."

Further review of Patient #23's medical record revealed: "Acute Seclusion/Restraint order on 8/28/2022 at 11:12 PM revealed: Type of Intervention: Physical Restraint, Seclusion and Medication/Chemical Restraint: Geodon (antipsychotic) 20 MG IM (intramuscular injection) for severe agitation. Reason for Intervention: Imminent danger to others, swing (Sic) at staff, hit staff, could not be de-escalated. Telephone order on 8/28/2022 at 11:40 PM, signed by a physician on 9/14/2022 at 10:00 AM."

A review of Patient #24's medical record revealed an admission date of 8/9/2022 and discharge on 10/5/2022 with a diagnosis of schizophrenia (mental disorder in which people interpret reality abnormally that may include hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning).

Further review of Patient #24's medical record revealed: "Acute Seclusion/Restraint order on 9/27/2022 at 5:27 PM revealed: Type of Intervention: Seclusion. Reason for Intervention: Imminent Danger to Others, bit a staff member, slapped a staff member with a kitchen tray. Telephone order on 9/27/2022 at 5:27 PM, physician signed, but not dated or timed."

During an interview on 12/21/2022 at 8:30 AM, when asked what is the time frame a physician sign and date verbal/telephone orders for restraints, Interim Director of Nursing (DON) N stated, "24 hours."

Based on interview and record review the facility failed to include all departments of the hospital in the Quality Improvement program in 2 (Environmental Services, Lab) of 12 departments in a total of 12 departments.

Findings include:

Review of the facility policy titled, "Performance Improvement Plan and Policy" #11414772", dated 3/21/2022 revealed: "Purpose: The QAPI (quality assessment performance improvement) program is designed to provide a coordinated, objective and systematic approach to organization-wide performance improvement activities. The program is based upon an integrated and collaborative approach to increase the probability of desired patient outcomes by assessing and improving those governance, managerial, clinical and support processes that most affect patient outcomes..."

In an interview on 12/20/2022 at 8:10 AM with Director of Risk and Quality M, the "Initial QAPI Reporting Schedule" was reviewed. It was observed that Environmental Services and Lab were not included in the reporting schedule. Director M confirmed that they are not currently on the schedule but "should be".

Based on observation, record review, and interview, the nursing staff failed to administer medications according to physician orders in 1 of 29 inpatients receiving medications (Patient #37) and failed to administer court ordered medications in 3 of 4 patients receiving court ordered medications (Patients #2, #8, #12) in a sample of 31 records reviewed.

Findings include:

Record review of policy "Medication Administration Policy, ID 11023405", dated 1/13/2022 revealed: "Medications are administered pursuant to a prescriber's order; to the patient for whom they are ordered; by the route ordered; and at times appropriate to the indication, clinical situation, and needs of the patient." Under Scheduled Medication Dose Administration Times revealed "Medication prescribed for daily, weekly or monthly administration are administered within 2 hours before or after the scheduled dosing time, for a total window that does not exceed 4 hours." Under Missed or Delayed Administration of Scheduled Medications revealed "when medications eligible for a scheduled dosing time are not administered within the defined time period: Document the reason the dose was missed or delayed."

A review of Patient #2's medical record revealed Patient #2 was admitted to the facility involuntarily. Further review of Patient #2's orders revealed, "Prolixin Decanoate, to give 37.5 mg injectable every 2 weeks ... for Schizoaffective disorder, unspecified, court ordered. Start 11/07/22 at 11:00 [AM]." On 11/07/2022, Prolixin Decanoate was documented as, "not administered." Further review of the medication administration record revealed the court ordered medication was not administered until 11/17/2022 at 10:43 AM, 10 days after the medication was ordered. There was no documented evidence as to why the medication was not administered as ordered or that the physician was notified that the medication was not given.

A review of Patient #8's medical record revealed Patient #8 was admitted to the facility involuntarily. "Petition for Medication Order" on 10/11/2022 (no time documented) revealed, "The subject will benefit from psychotropic medications and the undersigned proposes to treat him/her with the following medications... Zyprexa, Haldol, Depakote, Seroquel, Ativan, Lithium, Ziprasidone- oral, or IM (intramuscular) if refused."

Further review of Patient #8's medical record revealed an order for Zyprexa (antipsychotic) to be administered 4 times a day orally starting on 10/08/2022. The physician order did not contain an alternate route of administration (IM) if the patient refused the oral dose as outlined in the court order. Further review of the medication administration record revealed Patient #8 refused oral Zyprexa from 10/09/2022 through 10/25/2022 at least one time a day. There was no evidence found that nursing staff notified the physician of the refusal or obtained orders for alternate route of administration.

Further review of Patient #8's medical record revealed an order for Depakote (mood stabilizer) to be administered one time a day orally starting on 10/08/2022. The physician order did not contain an alternate route of administration (IM) if the patient refused the oral dose as outlined in the court order. Further review of the medication administration record revealed Patient #8 refused oral Depakote from 10/15/2022 through 10/20/2022. There was no evidence found that nursing staff notified the physician of the refusal or obtained orders for alternate route of administration.

Record review of patient #12's medical record revealed patient #12 was a 58 year old admitted under involuntarily status on 9/20/2022 for "attacking others" with the diagnosis of schizoaffective disorder. On 9/23/2022 involuntary medication and treatment order was obtained to administer abilify, haldol, thorazine, and zyprexa to be administered per physician order "po" (by mouth) or "IM" (intramuscularly) "if refused."

Continued review of patient #12's medical record revealed physician order 10/24/2022 at 9:00 PM for haloperidol (Haldol) 10 mg oral at bedtime... IM (intramuscularly) Haldol 5 mg (milligrams) if po is refused". Medication Administration Record on 10/25/2022 at 9:30 PM, 10/28/2022 at 9:37 PM, 10/29/2022 at 9:51, 10/30/2022 at 8:31 PM, 11/03/2022 at 9:24 PM, 11/07/2022 at 10:53, and 11/08/2022 at 9:24 PM revealed "patient refused... Not Administered." There was no evidence found that nursing staff notified the physician of the refusal and no IM injections were given.

Continued review of patient #12's medical record revealed physician order for Aripiprazole (Abilify) tablet 20 mg once daily ordered 10/15/22. Medication Administration Record on 10/22/2022 at 9:45 AM, 11/02/2022 at 12:46 PM, 11/07/2022 at 9:13 AM, 11/09/2022 at 9:59 AM, and 11/20/2022 at 5:49 PM revealed "patient refused" Not Administered." There was no evidence found that nursing staff notified the physician of the refusals. On 11/21/2022 at 8:23 AM revealed "patient refused...Not Administered, says she is not taking pills if she is going to get an injection," and 11/22/2022 at 8:30 am revealed "patient refused... Not Administered, only wants injections." Physician order 11/24/2022 at 12:00 PM revealed "Aripiprazole ER" (extended release) start 11/24/2022 at 12:00 PM and "Intramuscular EVERY THURSDAY." Patient #12 was discharged (Friday) 11/25/2022.

On 12/21/2022 at 2:07 PM during interview with Interim Director of Nursing (DON) N, Director of Risk Management and Performance Improvement M, and Director of Clinical Services O, when asked about the administration of involuntary medications, Director M stated it was "not spelled out" in their medication administration policy and they did not have a policy on administration of court ordered medications. Director O stated it has been a "learning curve" for their staff.

On 12/21/2022 at 3:17 PM during interview with DON N, DON N confirmed the court ordered medications for Patients #2, #8, #12 were "not given" as ordered.

On 12/19/2022 at 10:47 AM during tour of Unit 3, observation of medication room, noted medication cup on a shelf with [Patient #37's] first name written on cup containing one blister pack tablet of hydrochlorothiazide 12.5 mg tablet and one blister pack tablet of lisinopril 20 mg tablet inside of cup.

On 12/19/2022 at 2:40 PM during observation of the medication room, noted the medication cup on a shelf with [Patient #37's] first name written on the cup, with the hydrochlorothiazide and lisinopril tablets inside, was still on the shelf.

On 12/19/2022 at 2:50 PM during interview with Registered Nurse (RN) Z, RN Z stated patient #37 "left." RN Z stated she kept "telling me she was going to take them" but I "should have put them back" into the [medication administration machine] and documented that she "refused them."

Record review of patient #37's medical record revealed patient #37 was a 60 year old admitted under voluntarily status 12/14/2022 for suicidal ideation's and depression with a history of hypertension. Physician order for lisinopril 20 mg and hydrochlorothiazide 12.5 mg by mouth once daily. Medication administration record revealed lisinopril and hydrochlorothiazide was scheduled for 9:00 AM daily. Under lisinopril 12/18/2022 and 12/19/2022 there was no lisinopril documented as been administered. Under hydrochlorothiazide 12/18/2022 under hydrochlorothiazide revealed "Not Administered", 12/19/2022 revealed no documentation of hydrochlorothiazide being administered. There was no documentation of why lisinopril or hydrochlorothiazide were not administered on 12/18/2022 or 12/19/2022.

On 12/21/2022 at 3:17 PM during interview with Float Chief Nursing Officer (CNO) F, when looking at patient #37's medication administration sheets and questioned what the expectations of medication administration are, CNO F confirmed, there should have been documentation that the medications were offered again or "a reason" documented when medications are not administered.




47413

Based on interview and observation the facility failed to address a scheduled drug (narcotics) discrepancy in a timely manner in 1 Omincell (pharmacy dispensing system) (unit 3) in a total of 3 units with Omnicell systems.

Findings include:

During a tour of Unit 3 on 12/19/2022 at 10:45 AM with Pharmacist W and DON (Director of Nursing) N the Omnicell was observed in the medication room. A banner was running across the screen of the Omnicell that read, "Unresolved Discrepancy - please address." When asked what that meant Pharmacist W stated, "It means that the count of one of the scheduled medications is not correct." When asked for the process to correct Pharmacist W stated, the medication count "should be addressed in real time, I run a report every morning to address these issues, it wasn't run over the weekend by the weekend pharmacist, I don't expect him to address discrepancies but it should have been addressed by nursing."

On 12/19/2022 in an interview at 10:50 AM with DON N when asked what the expectation is for nursing to resolved discrepancies DON N stated, and pointed to a sign in the medication room, that read "All discrepancies must be addressed and resolved prior to the nurse leaving at the end of their shift. Nursing should have taken care of it."

Based on interview, observation and record review the facility failed to assure a safe setting for patients by failing to ensure checks of the security of the emergency code cart and defibrillator are completed daily on 2 of 3 inpatient units (unit 1 and 2) in a total of 3 code carts observed.

Findings include:

Review of the "Emergency Medical Equipment Daily Checklist" revealed, "Check each element as indicated and mark with a check if all Emergency Supplies and medications are present, tear away locks are intact... AED (automatic emergency defibrillator) has a green check mark..."

For the occupied units as defined above revealed,
- July 2022 - no checks for 7/17 and 7/22
- August 2022 - no checks for 8/4, 8/18, 8/19, 8/20, 8/23, 8/24, 8/28, 8/29, 8/30, 8/31
- September 2022 - no checks for 9/1, 9/2, 9/3, 9/4, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/22, 9/30
- October 2022 - no checks for 10/5, 10/19, 10/27, 10/28
- November 2022 - facility unable to provide a checklist
- December 2022 - no checks for 12/1 - 12/14

At the time of the tour on 12/19/2022 at 10:30 AM with DON N the emergency code cart was observed to not have an intact lock. This was confirmed with DON N who stated, "It should have a lock on it."

On 12/19/2022 at 10:30 AM in an interview with DON N, DON N stated, "There are no medications in the emergency cart but the expectation is that the cart is locked, checked and documented daily.

Based on record review and interview the facility failed to ensure a dietary consult was obtained to meet the patient's needs in 4 of 29 inpatient admissions (Patient #1, #7, #11, and #12) in a total of 31 medical records reviewed.

Findings include:

Record review of policy "Nutritional Assessment/Consult, ID 11022927", dated 1/13/2022 revealed: "The dietary screen and request for dietary assessments are completed by entering a consult request based on the results of the initial or ongoing Nutritional Screening... Dietitians will follow up with patient based on the results of the nutrition screening." A nutritional consult/assessment will be implemented by the Registered Dietician as indicated and within 72 hours of the consult request or physician order."

Patient #1's medical record revealed patient #1 was involuntarily admitted 12/12/2022. Nursing assessment nutritional screening completed 12/12/2022 at 6:00 PM with boxes checked for Unintentional weight change "gain" written in and nutritionally significant uncontrolled diabetes checked. Nutritional screen notation "If any of the above are identified, a Nutritional Consultation should be obtained" and box in front of "Dietician notification process completed" not checked. There was no dietician consult order or dietician consult documented in patient #1's medical record.

Patient #12's medical record revealed patient #12 was involuntarily admitted 9/20/2022. Nursing assessment nutritional screening completed 9/21/2022 with "not eating or drinking" hand-written in. Dietary Consult ordered 9/22/2022 at 1:40 PM under comments "Not eating or drinking." There was no dietician consult in patient #12's medical record.


29963


Patient #7's medical record revealed patient #7 was involuntarily admitted 11/06/2022. Nursing assessment nutritional screening completed 11/07/2022 at 4:00 PM with boxes checked for Unintentional weight change "loss" written in and BMI > 36 checked. Nutritional screen notation "If any of the above are identified, a Nutritional Consultation should be obtained" and box in front of "Dietician notification process completed" not checked. There was no dietician consult order documented in patient #7's medical record.

Patient #11's medical record revealed patient #11 was voluntarily admitted 11/07/2022. Nursing assessment nutritional screening completed 11/07/2022 at 9:00 PM with the box checked for BMI > 36 checked. Nutritional screen notation "If any of the above are identified, a Nutritional Consultation should be obtained" and box in front of "Dietician notification process completed" not checked. There was no dietician consult order documented in patient #7's medical record.

On 12/21/2022 at 2:45 PM during interview with interim Director of Nursing (DON) N, DON N stated the registered nurse is responsible for putting in the dietary consult and confirmed a dietary consult was not put in or completed for Patients #1, #7, #11, and #12.

Based on interview, observation and record review the facility failed to ensure daily checks of glucose meters and failed to complete daily checks of refrigerator/freezer temperatures on unit refrigerators on 3 of 3 inpatient units (unit 1, 2, and 5) in a total of 12 departments observed.

Findings include:

Review of the "Glucometer Maintenance Log" for Unit 1 and 2 (the units occupied in August - October 2022) revealed the following missing daily checks:
- August 2022 - no checks for 8/5, 8/15, 8/19, 8/20, 8/28, 8/29, 8/30, 8/31
- September 2022 - no checks for 9/1, 9/2, 9/7, 9/8, 9/10, 9/11, 9/12, 9/13
- October 2022 - no checks for 10/18
- November 2022 - (Unit 3 occupancy) - no checks for 11/6, 11/7,11/31
- December 2022 - (Unit 3 occupancy) - no checks for 12/4

Review of the "Patient Nourishment Refrigerator & Freezer Temperature Log" revealed, "Temperatures of patient food refrigerators and freezers are to be monitored and recorded daily..."

Review of the Refrigerator & Freezer Temperature Log for Unit 2 revealed:
-August 2022 - no checks for 8/4, 8/14, 8/15, 8/18, 8/19, 8/20, 8/23/ 8/28, 8/29, 8/30
- September 2022 - no checks for 9/1, 9/2, 9/3, 9/4, 9/7 - 9/13, 9/22
- October 2022 - no checks for 11/5, 11/19, 11/21, 11/26, 11/28
- November and December 2022 - facility unable to provide a checklist

On 12/19/2022 at 10:30 AM in an interview with DON N, DON N stated, "The expectation is that the glucometer is checked daily with the controls. All refrigerators and freezers should be checked and documented on daily. DON N confirmed that the refrigerator and freezer logs had missing dates and "appeared to have not been checked daily."

During a review of facility policy #11023001 dated 01/13/2022 titled, "Refrig Freezer Temp Log" revealed, "All perishable and frozen food must be stored in the freezer or refrigerator until ready for use. To assure freshness of stored food products, the refrigerator and freezer temperature must be checked daily for appropriate temperatures."

Review of the "Patient Refrigerator & Freezer Temperature Log" for Unit 5 revealed the following missing daily checks for December 2022- no checks on 12/7 and 12/16.

At the time of the tour on 12/19/2022 at 10:30 AM, findings of the missing refrigerator checks were discussed and confirmed by Director of Business Development BB who stated, there was some missing documentation.

Based on observation, staff interview and review of maintenance records on 12/19 - 12/20/2022, Granite Hills Hospital failed to construct, install, and maintain the building systems to ensure safety of patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K281 - Illumination of Means of Egress
2. K291 - Emergency Lighting
3. K321 - Hazardous Areas - Enclosure
4. K324 - Cooking Facilities
5. K345 - Fire Alarm System Testing and Maintenance
6. K351 - Installation
7. K712 - Fire Drills
8. K911 - Electrical Systems - Others
9. K917 - Essential Electric - Receptacles
10. K918 - Electrical Systems - Essential Electric System Maintenance and Testing
11. K919 - Other

As a result of these deficiencies, 42 CFR Subpart CFR 482.41(b) Standard: Life safety from fire was NOT MET.

See K-tags for details of the specific findings.

Based on interview, record review, and observation the facility failed to ensure food is dated, labeled, and discarded before the expiration date to ensure food safety in 1 of 3 departments storing food (kitchen), in a total of 12 departments observed; failed to ensure curtains (privacy and shower) are routinely cleaned and disinfected to prevent cross contamination in 1 of 1 staff interview (Supervisor H); failed to ensure the appropriate contact time is performed based on the disinfectants directions for use to ensure patient care areas are appropriately disinfected in 1 of 1 staff interview (Supervisor H); failed to ensure housekeeping staff are thoroughly trained on cleaning technique and competencies are completed to ensure staff are adhering to infection control standards for 4 of 4 housekeeping staff working at the facility (Housekeeper K, J, I, and L).

Findings Include:

Dietary:

Review of Policy 6.13 titled, "Frozen Food" effective 01/13/2022 revealed, "All frozen food must be properly covered, labeled and dated before it is placed in the freezer."

Review of Policy 6.8 titled, "Dry Storage" effective 01/13/2022 revealed the following:
-"Labels are always to be on the outside."
-"All new stock shall be placed in the back of the stock dated earlier."
-"Stored food once removed from the container or package in which it was obtained shall be enclosed in a clean, covered one with the appropriate label."

Review of Policy 6.9 titled, "Refrigerated Storage" revealed, "Date all foods placed in cold storage."

Review of Policy 6.10 titled, "Food and Supply Storage" revealed, "All food storage containers must be marked with item name and date."

Per observations in the Dietary department on 12/20/2022 from 11:30 AM to 1:00 PM the following opened spice containers were not dated with opened date and/or expiration date:
-Cinnamon, White Pepper, Garlic & Herb, Whole Sesame Seeds, Thyme Leaves, Dill Weed, Ground Cumin Seed, Lemon Pepper, Rosemary Leaves, Red Pepper, Onion Powder, Oregano, Paprika, Nutmeg, Celery Salt, Taco Seasoning, and Celery Seed.

Per observations in the Dietary department on 12/20/2022 from 11:30 AM to 1:00 PM the following items were found to be expired:
-10 two pound bags of raisins expired 10/18/2022
-Two 32 ounce Vanilla Yogurt expired 10/20/2022

Per observations during tour of the kitchen with Dietary Manager G, on 12/20/2022 from 11:30 AM to 1:00 PM the following food items were not labeled and/or dated (with expiration and/or date received):
-Large container filled with butter condiments
-Large container filled with cream cheese condiments
-Large jar of Thousand Island dressing
-Frozen steaks in plastic wrap
-Frozen chicken breasts in plastic wrap
-Frozen salmon patties in bags
-Frozen fish in plastic wrap
-Frozen turkey Lunch meat
-Frozen hot dogs
-Frozen Salisbury steaks
-Frozen bratwurst
-Frozen veggie burgers
-Frozen bread sticks
-Frozen chicken strips
-Frozen cookies
-Frozen bags of vegetables (8 yellow squash, 8 peas, 12 cauliflower blend, 16 green beans)
-6 (36 count) eggs
-Pork chops unthawing in the refrigerator
-7 large cans of Tomatoes Picados
-4 large cans of Black Beans
-1 large can of Fruit Cocktail
-3 large cans of Manwich
-Loaf of Bread
-7 bags of large tortilla wraps
-3 bags of cinnamon streusel toppings

Per interview with Dietary Manager G during the tour between 11:00 AM and 1:00 PM Manager G stated that food/spices should be labeled with date opened and/or received date. Per Manager G canned food items should have expiration date on the can from the manufacture, but Dietary Manager G was unable to find an expiration date on the above listed canned food.

Housekeeping:

Review of Policy titled, "Cleaning Schedule" effective date 01/13/2022 revealed the following:
-"It is the policy of (facility) to clean all areas of the facility at proper times to ensure proper cleanliness and infection control. Schedules should be made for each area indicating when particular areas of the facility should be cleaned."
Procedure:
B. Weekly: Shower Curtains

Per interview with Housekeeping Supervisor H on 12/20/2022 at 3:30 PM, Supervisor H stated that the facility does not have of a cleaning schedule for the privacy curtains and shower curtains located in the patient rooms. Per Supervisor H the Privacy curtains should be cleaned as needed and at least quarterly but he/she is unable to provide evidence of this being done.

Review of ECO Neutral Disinfectant E23 manufacturer's directions for use on 12/20/2022 at 11:00 am revealed, "Let solution remain on surface for a minimum of 10 minutes." Review of ECO Neutral Disinfectant directions for use revealed (including not limited to) the following Contact times (amount of time disinfectant needs to be in contact with surface to kill or neutralize the pathogen):

-Human Coronavirus (Covid-19)--1 minute
-HIV-1 (AIDS Virus)--4 minute contact time
-Avian influenza--10 minutes
-Respiratory Syncytical Virus (RSV)--10 minute
-Hepatitis B--10 minutes
-Herpes Simplex Type 1 and Type 2--10 minutes
-Influenza A virus--2 minutes
-SARS (Severe Acute Respiratory Syndrome) associated Coronavirus (SARS)--10 minutes
-Rubella Virus--10 minutes
-Rotavirus--10 minutes
-Adenovirus Type 4 and Type 7--10 Minutes

Per interview with Supervisor H on 12/20/2022 beginning at 10:55 AM, the housekeeping staff use ECO Neutral Disinfectant E23 to clean and disinfect patient care areas/rooms. When asked what the contact/dwell time is for the ECO Neutral Disinfectant to be effective, Supervisor H responded "1 minute". Supervisor H reviewed the above contact times and agreed that 1 minute contact time was not sufficient for disinfection. Supervisor H stated that the facility needs to find a different disinfectant that can disinfect all the pathogens with less contact time. Supervisor H stated that housekeeping staff are taught that the surface contact time should be 1 minute.

Review of Policy titled, "Environmental Cleaning" effective 01/13/2022 revealed the following:
-All environmental services (EVS) (housekeeping) staff and clinical staff will complete infection prevention and control education on hire and annually.
-All EVS staff and appropriate clinical staff will be trained in cleaning techniques.

Per interview with Supervisor H on 12/20/2022 beginning at 10:15 AM Supervisor H stated that housekeeping staff train for 1 week and are given a training packet to review and sign. Supervisor H stated that a competency check off is performed on all housekeeping staff. Per interview with Supervisor H on 12/20/2022 beginning at 3:30 PM, Supervisor H stated that he/she does not have any documented evidence of an orientation, training, and competencies being completed for Housekeeper K, J, I, and L.

Based on record review and interview, the facility staff failed to ensure a psychosocial assessment was completed for 2 of 29 inpatients (Patients #8, #10) in a sample of 31 medical records reviewed.

Findings include:

A review of the facility's policy titled, "Plan for the Provision of Inpatient Care, ID 11023303" dated 1/13/2022, revealed: "D. Psychosocial History: Performed with the individual and, when possible, family members/significant others by Social Services Staff no later then 72 hours and includes a complete family history, interpersonal relationships, medical/psychiatric history, ethnic/cultural and religious issues affecting treatment, abuse hisotry, discharge planning and a summary."

A review of Patient #8's medical record revealed Patient #8 was admitted to the facility on 10/06/2022 for "fighting with [parent]" and "threatening various people." Further review of the medical record revealed no documentation of a psychosocial assessment.

A review of Patient #10's medical record revealed Patient #10 was admitted to the facility on 10/22/2022 for suicidal ideation, suicidal attempt, and psychosis. Further review of the medical record revealed no documentation of a psychosocial assessment.

During an interview on 12/21/2022 at 3:45 PM, the medical record review findings were discussed with and confirmed by Director of Health Information Management EE who stated a psychosocial assessment was required and no documentation of a psychosocial assessment was found for Patient #8 or #10.

Based on record review and interview the facility failed to include an inventory of the patient's strengths and assets that describe personal factors on which to base the treatment plan for 3 of 29 inpatients (Patients #10, #18, #21) in a sample of 31 records reviewed.

Findings include:

A review of the facility policy, titled "Plan for the Provision of Inpatient Care, ID11023303", dated 1/13/2022, revealed: "Assessment and Evaluation Procedures: A. Psychiatric Evaluation:...Includes a history of the present disorder, brief psychiatric history, including history of substance abuse, brief family history, brief medical history, mental status exam, estimate of intellectual functioning memory functioning and orientation, diagnostic impression, strengths and weaknesses, including prompts for an inventory of the individual's assets in a descriptive manner and initial plan of care."

A review of the the facility policy titled, "Interdisciplinary Patient Centered Care Planning, ID 11022911", dated 1/13/2022, revealed: "Policy: It is the policy of Granite Hills Hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions..."
A review of Patient #10's medical record revealed an admission date of 10/22/2022 and discharged on 11/02/2022 with a diagnosis of suicidal ideation and suicidal attempt. Review of the "Master Treatment Plan" revealed no patient assets or strengths documented.

Review of Patient #10's medical record revealed an admission date of 10/22/2022 and discharged on 11/02/2022 with a diagnosis of suicidal ideation and suicidal attempt. Review of the "Master Treatment Plan" revealed no patient assets or strengths documented.

A review of Patient #18's medical record revealed an admission date of 12/05/2022 through present with a diagnosis of psychosis and increased violence toward others. Review of the "Master Treatment Plan" revealed no patient assets or strengths documented.

A review of Patient #21's medical record revealed an admission date of 12/08/2022 through present with a diagnosis of suicidal ideation and suicidal attempt. Review of the "Master Treatment Plan" revealed no patient assets or strengths documented.

During an interview on 12/21/2022 at 8:30 AM, Director of Clinical Services stated, "Patient assets are protective manners in which the Master Treatment Plan is built on. We could do better identifying patient assets."




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Based on medical record review and interview, the facility failed to develop treatment interventions based on the individual needs of the patients for 16 of 29 inpatients (Patients #'s 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, 17, 21, 26, 27, and 37) in a sample of 31 records reviewed. Treatment interventions in the Master Treatment Plan (MTP) listed only routine/generic discipline functions rather than individualized treatment options. This practice has the potential to lead to the failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A review of the facility policy, titled "Plan for the Provision of Inpatient Care", last approved 1/13/2022, revealed: "B. Master Treatment Plan....The plan is based upon the comprehensive assessment of the patient's presenting problems, physical health and emotional/behavioral condition. Comprehensive assessments include but are not limited to the Intake Assessment, Nursing Assessment, Psychosocial Assessment, Psychiatric Evaluation, History and Physical Examination, and Activities Therapy Assessments. The plan will delineate goals and interventions to address the patient's presenting issues and will include the following: 1. Identification of physical, psychological and social problems the individual is experiencing-Prioritization of individual needs and care, and achievable long-term goals of treatment stated in behavioral terms. 2. Measurable short-term goals stated in behavioral terms that will reflect progress toward the goal achievement."

Review of the facility policy titled, "Interdisciplinary Patient Centered Care Planning" #11022911 dated 1/13/2022 under Policy revealed "Each patient's written Treatment Plan must include: ... Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient." Under Procedure revealed "The treatment team will complete the MTP including ... Completion of an individual Problem Sheet" to include "specific patient behavioral manifestations" Interventions will include the "patient-specific focus" for the intervention.

Review of Patient #1's medical record revealed admission on 12/20/2022 - current inpatient, with a diagnosis of bipolar mania and manic behavior (mental health condition causing extreme mood swings). Review of the "Master Treatment Plan" problem list, included "psychosis/mania." Under "Specific Intervention Focus" revealed "social worker will help patient develop coping skills to improve mania and communication," nursing will "distribute medications," and activity therapist will "provide structured groups to promote healthy coping skills and self-care." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #1's care.

Review of Patient #2's medical record revealed an admission date of 11/01/2022 and discharge date of 12/08/2022 with a diagnosis of increased paranoia and aggression. Review of the MTP dated 11/11/2022 revealed short-term goals including the generic, "The patient will comply with all medications as prescribed to help reduce symptoms of psychosis and aggression" with the specific interventions for this goal listed as, "MD will prescribe, monitor and adjust medications." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #2's care.

Review of Patient #3's medical record revealed an admission date of 10/24/2022 and a discharge date of 11/09/2022 with a diagnosis of psychosis and suicide/homicide ideations. Review of the MTP dated 10/26/2022 revealed assets of "supportive mother, healthy, and hard working". Short term goals on the MTP included the generic "Patient will take meds as prescribed." The specific interventions for this goal listed as "Nurse will encourage medication compliance". During review of "Discharge Summary" dated 11/09/2022 revealed, "Patient was a notable behavior issue. Early in stay [s/he] sexually assaulted multiple staff, including a quite serious attack on the phlebotomist. There were concerns for other possible sexually inappropriate and predatory behaviors while [s/he] was on the unit. During [his/her] stay [s/he] was at times antagonistic toward other patients, provoking outburst. [S/he] required agitation PRN's (as needed) during [his/her] stay." The MTP does not have any short/long term goals or specific interventions addressing "sexual assualt or predatory behaviors" as noted in discharge summary. There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #3's care.

Review of Patient #4's medical record revealed an admission date of 10/29/2022 and discharge 11/19/2022 with a diagnosis of paranoia (irrational thoughts and fears that one is being persecuted). Review of the MTP dated 11/1/2022 revealed assests of "Supportive family and has housing". Short term goals on the MTP included the generic "Patient will take all medications prescribed to help reduce paranoia" with the specific interventions for this goal listed as, "MD will prescribe medications to help reduce paranoia" and "RN (Registered Nurse) will encourage med compliance and monitor for safety". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #4's care.

Review of Patient # 5's medical record revealed an admission date of 10/26/2022 and discharge 11/29/2022 with a diagnosis of psychosis. Review of the MTP dated 10/28/2022 revealed assets of "Supportive family, housing and community resources". Short term goals on the MTP included the generic "Pt. (patient) will comply with medications as prescribed to decrease symptoms of psychosis" with the specific interventions for this goal listed as, "MD will prescribe medications, monitor and adjust as needed" and "Nursing will encourage medication compliance and monitor the unit for safety". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #5's care.

Review of Patient #6's medical record revealed an admission date of 11/9/2022 and discharge 11/22/2022 with a diagnosis of paranoia. Review of the MTP dated 11/11/2022 revealed assets of "Group home housing, likes to sing, likes to cook". Short term goals on the MTP included the generic "Patient will cooperate with assessment and administration of medications to improve symptoms" with the specific interventions for this goal listed as, "Psychiatrist will engage patient for medication and symptom management" and "Nursing will educate patient on the importance of med compliance". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #6's care.

Review of Pateint #7's medical record revealed an admission date of 11/06/2022 and a discharge date of 11/28/2022 with a diagnosis of bizarre behaviors and suicidal ideations. Review of the MTP dated 11/09/2022 revealed assets of "physically healthy, personable, good sense of humor". Short term goals on the MTP included "Patient will cooperate with medications as prescribed." The specific interventions for this goal listed as "Nursing will encourage and monitor meds daily." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #7's care.

Review of Patient #9's medical record revealed an admission date of 11/24/2022 and discharge 12/02/2022 with a diagnosis of bipolar (disorder associated with episodes of mood swings) with severe psychosis. Review of the MTP dated 11/27/2022 revealed assets of "healthy and financial support". Short term goals on the MTP included the generic "Pt. will take all medications daily" with the specific interventions for this goal listed as, "MD will adjust medications to help decrease manic symptoms" and "Nursing will monitor behavior and safety on the unit and distribute medication". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #9's care.

Review of Patient #12's medical record revealed admission on 12/08/2022 - current inpatient, with a diagnosis of schizoaffective disorder (includes having false, fixed beliefs, despite evidence to the contrary). Review of the "Master Treatment Plan" problem list, developed on admission 9/23/2022, included "psychosis, HI (homicidal ideation), mania, low mood, lacks self care." Under "Specific Intervention Focus" revealed counselor "will work to engage patient in assessment & education to gain data important to the pt (patient) needs," the psychiatrist "will be engaged daily for engagement & assessment for treatment," nursing will "encourage medication compliance," and the activity therapist will "invite to group... to promote reality orientation." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #12's care.

A review of Patient #14's medical record revealed an admission date of 12/10/2022 - current inpatient, with a diagnosis of paranoid psychosis (symptom of psychosis that involves irrational thoughts and fears that one is being persecuted). Review of the MTP dated 12/12/2022 revealed assets of "Educated and likes to draw". Short term goals on the MTP included the generic "Patient will take medications as prescribed" with the specific interventions for this goal listed as, "MD (medical doctor) will monitor symptoms and prescribe medications" and "Nursing will monitor safety and distribute meds". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #14's care.

Review of Patient #15's medical record revealed admission on 12/08/2022 - current inpatient, with a diagnosis of suicide ideation's with intent, borderline personality disorder, (causes problems functioning in everyday life), OCD (obsessive-compulsive disorder). Review of the "Master Treatment Plan" problem list included "suicidal" and "Fall Risk." Under "Specific Intervention Focus" revealed social worker will "discuss coping skills to help reduce symptoms," "MD will monitor symptoms," activities therapist will "invite to group to address healthy coping strategies" and nursing will "educate" on importance of "medical compliance to help control s/s (signs and symptoms) of SI" (suicide ideation). There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #15's care.

Review of Patient #17's medical record revealed an admission date of 12/9/2022 - current inpatient with a diagnosis of suicidal. Review of the MTP dated 12/12/2022 revealed assets of "connected to services and has a psychiatrist". Short term goals on the MTP included the generic "Patient will take all medications as prescribed daily to help reduce AVH (active visual hallucinations). The specific interventions for this goal listed as "MD will prescribe medications and monitor symptoms" and "Nurse will educate pt. on importance of and compliance to decrease s/s (signs/symptoms) of AVH". There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #17's care.

Review of Patient #21's medical record revealed an admission date of 12/07/2022 and was currently at facility on 12/21/2022 with a diagnosis of suicidal ideation and attempt. Review of the MTP dated 12/16/2022 revealed short-term goals including the generic, "Patient will take all medications prescribed to reduce symptoms of depression" with the specific interventions for this goal listed as, "MD will prescribe, monitor and adjust medications." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #21's care.

A review of Patient #26's medical record revealed an admission date of 9/19/2022 and discharge on 10/6/2022 with a diagnosis of chronic schizophrenia (syndrome of delusions, hallucinations, flatness of affect, poverty of speech or incoherence of speech). Review of the MTP dated 9/20/2022 revealed assets of "supportive mother, involved with CSP (community support program)." Short term goals on the MTP included the generic "Patient will take medications as prescribed" with the specific interventions for this goal listed as, "MD will adjust and monitor medications to reduce depression symptoms" and "Nursing: encourage medication compliance." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #26's care.

A review of Patient #27's medical record revealed an admission date of 10/12/2022 and discharge on 10/21/2022 with a diagnosis of major depressive disorder, severe, recurrent, with psychotic features. Review of the MTP dated 10/14/2022 revealed assets of "stable housing, group home, case managers, family support, guardian." Short term goals on the MTP included the generic "Patient will take medications as prescribed to reduce symptoms of depression" with the specific interventions for this goal listed as, "MD will prescribe, monitor and adjust medications to reduce symptoms of depression" and "Nursing will encourage medication compliance." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #27's care.

Review of Patient #37's medical record revealed admission on 12/13/2022, discharged 12/19/2022 with a diagnosis of suicidal ideation's with intent. Review of the "Master Treatment Plan" problem list included "suicidal ideation" and "Fall Risk." Under "Specific Intervention Focus" revealed "MD will engage pt for discussion to evaluate SI symptoms," "Therapist will engage &/or monitor patient for education on suicidal ideation and coping skills" activity therapist "will invite to scheduled groups to promote healthy coping strategies," nursing will "engage... to support improved medical and MH (mental health) symptoms." There were no patient specific behavioral manifestations or short-term, goal specific interventions, individualized to Patient #37's care.

During an interview on 12/21/2022 at 8:30 AM, Director of Clinical Services stated, "Patient assets are protective manners in which the Master Treatment Plan is built on. We could do better identifying patient assets." When asked if the above assets were incorporated into short and long term goals on each of these patients, Director of Clinical Services stated, "No".



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Based on record review and interview the facility failed to develop and initiate a Master Treatment Plan within 72 hours as defined by policy in 2 (Patient #13 and #30) of 29 inpatients in a sample of 31 records reviewed.

Findings include:

Review of the the facility policy titled, "Interdisciplinary Patient Centered Care Planning" #11022911 dated 1/13/2022 revealed, "Policy: It is the policy of Granite Hills Hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions...Developing the Treatment Plan 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan...4 b. Completion of an individualized Problem Sheet for each active psychiatric or medical problem. The Problem Sheet will include the problem, specific patient behavioral manifestations, long and short term goals with target dates and interventions for each discipline...Interventions will include the action/task, patient specific goals, focus and the name /credentials of the individual responsible for the intervention.

Review of Patient #13's medical record revealed admission on 12/14/2022 with a diagnosis of Chronic Schizophrenia (syndrome of delusions, hallucinations, flatness of affect, poverty of speech or incoherence of speech). The record did not include a Master Treatment Plan as of the morning of 12/19/2022, 120 hours after admission.

On 12/19/2022 at 3:30 PM in an interview with Social Worker V when asked about the Master Treatment Plan for Patient #13 stated, "I don't know why this one is late, it should have been done before the weekend and I guess the Social Worker that worked the weekend was busy and didn't address it. We will be looking at his (the patient's) Treatment Plan today."




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A review of Patient #30's medical record revealed an admission date of 12/7/2022 and discharge on 12/14/2022 with a diagnosis of major depressive disorder, single episode, severe, without psychotic features, and social anxiety disorder. The record did not include a Master Treatment Plan (MTP).

During an interview on 12/21/2022 at 1:30 PM, when asked if the MTP was found for Patient #30, Director of Health Information Mangement EE stated, "No."