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Based on observation and staff interview, the facility staff failed to ensure each patient's right to receive care in a safe setting as evidenced by: cracked plastic on some bathroom doors exposing sharp edges, broken/cracked Plexiglass/safety glass in a seclusion room which exposed sharp edges, and 3 (three) desks in the "classroom" which had broken corners exposing sharp edges. There was also a sink with the laminate top broken which exposed a sharp edge. Also, three mattresses in seclusion room areas were torn and unable to be disinfected properly and on 2 (two) of 2 (two) restraint-ready beds, the leather restraints were lying on the floor. One patient refrigerator was observed to be in need of cleaning.


The findings included:

During the tour of the facility on 4/28/14 at 12:30 p.m., the survey team observed the following:
Rooms 166, 167, 169, 237, 243, 245, and 315 had broken plastic on the bathroom doors which exposed sharp edges and were a safety risk/hazard for the patients. Room 315 had a sink with the laminate broken exposing a sharp edge.

In the area designated as the "classroom" there were three (3) desks with the upper corners which were broken revealing a sharp edge which was a safety hazard for the patients.

In the #1 seclusion room on the Child/Adolescent Unit, there was cracked/broken Plexiglass/safety glass on the window which created sharp edges and was a safety risk/hazard for the patients. The staff stated this room had been used in the past two months.

During the tour, Staff #3 and #4 were present and observed the above with the survey team. Staff #3 stated the facility was working on a design for new bathroom doors but they had not been approved yet.

Further observation revealed that in 2 (two) of 4 (four) seclusion room areas, 3 (three) mattresses were observed to have rips/tears in the covering which exposed the inner material of the mattress. This prevented the mattress from being able to be properly cleaned/disinfected by the facility staff. Staff # 3 and #4 were present during the tour and also observed the condition of the mattresses. Staff #3 stated the mattresses would be removed and replaced.

Two (2) of two (2) restraint-ready beds in the seclusion areas were also observed to have the leather restraints attached to the bed, but lying on the floor. Staff #4 stated the beds were "ready" for a patient if needed.

At approximately 1:30 p.m., the patient refrigerator on the "ITP" (intensive treatment program) unit was observed to be in need of cleaning. There was food debris scattered inside and a dried white material on the top of the glass shelving. When the survey team inquired as to who was responsible for cleaning the refrigerator, Staff #4 stated "housekeeping" but "the staff on the unit should be checking and cleaning it as necessary". Further inquiry with the staff on the unit revealed there was not an "assignment" for cleaning of the refrigerator by the unit staff.

On 4/28/14 at the end of day wrap-up with Staff # 1 (one) through #4 (four) at 5:00 p.m., the survey team discussed the findings and observations.

Based on observation and staff interview, the facility staff failed to ensure the environment was maintained in a safe manner for the patients. There was cracked plastic on some bathroom doors exposing sharp edges, broken/cracked Plexiglass/safety glass in a seclusion room which exposed sharp edges, and 3 (three) desks in the "classroom) which had broken corners exposing sharp edges. There was also a sink with the laminate top broken which exposed a sharp edge.

The findings included:

During the tour of the facility on 4/28/14 at 12:30 p.m., the survey team observed the following: Rooms 166, 167, 169, 237, 243, 245, and 315 had broken plastic on the bathroom doors which exposed sharp edges and were a safety risk/hazard for the patients. The sink laminate in room 315 was broken exposing a sharp edge.

In the area designated as the "classroom" there were three (3) desks with the upper corners which were broken revealing a sharp edge which was a safety hazard for the patients.

In the #1 seclusion room on the Child/Adolescent Unit, there was cracked/broken Plexiglass/safety glass on the window which created very sharp edges and was a safety risk/hazard for the patients. The staff stated this room had been used in the past two months.

During the tour, Staff #3 and #4 were present and observed the above with the survey team. Staff #3 stated the facility was working on a design for new bathroom doors but they had not been approved yet.

On 4/28/14 at 5:00 p.m., the survey team discussed the observations/findings with Staff #1 through #4. Staff #1 stated they were working on getting all new doors for the patient bathrooms but the doors had not been approved yet.

Based on observation and staff interview, the facility staff failed to ensure the provision of a sanitary environment in 2 (two) of 4 (four) seclusion room areas, and one patient care area. Three mattresses in seclusion room areas were torn and unable to be disinfected properly and on 2 (two) of 2 (two) restraint -ready beds, the leather restraints were lying on the floor. One refrigerator was observed to be in need of cleaning.

The findings included:


During the tour of the facility conducted 4/28/14 at approximately 12:30 p.m. by the survey team, it was observed that in 2 (two) of 4 (four) seclusion room areas, 3 (three) mattresses were observed to have rips/tears in the covering which exposed the inner material of the mattress. This prevented the mattress from being able to be properly cleaned/disinfected by the facility staff. Staff # 3 and #4 were present during the tour and also observed the condition of the mattresses. Staff #3 stated the mattresses would be removed and replaced.

Two (2) of two (2) restraint-ready beds in the seclusion areas were also observed to have the leather restraints attached to the bed, but lying on the floor. Staff #4 stated the beds were "ready" for a patient if needed.

At approximately 1:30 p.m., the patient refrigerator on the "ITP" (intensive treatment program) unit was observed to be in need of cleaning. There was food debris scattered inside and a dried white material on the top of the glass shelving. When the survey team inquired as to who was responsible for cleaning the refrigerator, Staff #4 stated "housekeeping" but "the staff on the unit should be checking and cleaning it as necessary". Further inquiry with the staff on the unit revealed there was not an "assignment" for cleaning of the refrigerator by the unit staff.

On 4/28/14 at the end of day wrap-up with Staff # 1 (one) through #4 (four) at 5:00 p.m., the survey team discussed the findings and observations.

Based on facility document review, medical record review, facility staff interviews the facility failed to provide psychosocial assessments for eight (8) of 8 active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) that included conclusions and recommendations for social work roles that could be utilized during the treatment and discharge planning for the patients. This failure of documentation of conclusion and recommendations has the potential to compromise team planning for treatment and discharge for each individual patient and potentially delay discharge.

Findings include:

A. DOCUMENT REVIEW:

Hospital policy and procedure "Biopsychosocial Assessment and Reassessment" "Policy 300.91": dated 9/13 lists the required contents of the biopsychosocial assessment and does not require the documentation of conclusions and recommendations within the text of the assessment.

B. RECORD REVIEW

1. The following biopsychosocial assessments for Patient G1 dated 1/22/14, Patient G2 dated 3/20/14, Patient G3 dated 3/21/14, Patient G4 dated 3/21/14, Patient G5 dated 3/13/14, Patient G6 dated 3/19/14, G7 dated 3/23/14, and G8 dated 2/21/14 failed to contain documented social services conclusions, formulations, and recommendations for treatment and discharge planning.

C. INTERVIEWS

1. In an interview on 3/25/14 the Director of Social Services concurred that the policy for social services assessments did not require documentation of conclusions or recommendations for treatment. He indicated the information obtained by social service personnel was to be transmitted verbally at the treatment team meeting. He also concurred that conclusions and recommendations were not documented in the social service evaluations.

2. In an interview on 325/14 at 9:00 AM the Director of Nursing and the Chief Executive Officer agreed that conclusions and recommendations were not present in the social service assessments.

Based on facility document review, medical record review, and facility staff interview the facility failed to provide a psychiatric evaluation that included the personal assets on which to base a meaningful treatment plan in eight (8) of eight (8) medical records reviewed (G1, G2, G3, G4, G5, G6, G7, and G8). The failure to identify patients assets has the potential to impair the treatment team's ability to choose treatment modalities that best utilize the patients attributes in therapy.

A. DOCUMENT REVIEW

1. Page 15 of the Hospital Policy "Organization Policy Riverside Behavioral Health Center Recommended General Medical Staff " dated May 18, 2012 lists the areas for inclusion in the psychiatric assessment, however does not note the requirement of listing assets within the psychiatric assessment.

B. RECORD REVIEW

1. Review of the following psychiatric evaluations for Patient G1 dated 1/19/14, Patient G2 date 3/18/14, G3 dated 3/19/14, G4 dated 3/19/14, G5 dated 3/13/14, G6 dated 3/19/14, G7 dated 3/21/14 and G8 dated 2/24/14 noted the absence of a listing of patient assets within the content of the psychiatric evaluations.

C. INTERVIEWS

1. In an interview on 3/26/14 at 9:00 AM the Director of Nursing and the Chief Executive Officer concurred that admission psychiatric assessments failed to contain a listing of patient assets.

2. In an interview on 3/26/14 at 9:45 AM the Medical Director concurred that the psychiatric assessments did contain a listing of patient assets.

Based on facility document review, medical record review and facility staff interview the facility failed to provide Master Treatment Plans (MTPs) that included short-term goals and interventions specifically addressing individualized patient needs for eight (8) of eight (8) sample patients. (G1, G2, G3, G4, G5, G6, G7 and G8). Specifically the short-term goals were the same regardless of the identified problem. Interventions were the same or slightly reworded for all sample patients. Failure to address patient needs in an individualized treatment plan has the potential to delay the patients' response to treatment and/or risk recidivism in the patients' longer term treatment.

Findings include:

A. Document Review

"The Interdisciplinary Treatment Planning Inpatient/Residential Policy" #300.46 revised date: 08/2008 stated "Each patient/resident admitted to the hospital has a written, individualized treatment plan."

B. Record Review [date of MTP in brackets]

1. Regardless of the identified problem on the MTP, all sample patients (G1 [1/19/14], G2 [3/17/14], G3 [3/18/14], G4 [3/18/14[, G5 [3/12/14], G6 [3/18/14], G7 [3/20/14] and G8 [2/20/14]) all had the short-term goals, "Compliance with prescribed medication daily", "Actively participate in groups", "Family will participate in treatment", and "Patient will participate in daily sessions with the psychiatrist to assess response to treatment."

2. Patients G1 [1/19/14], G2 [3/17/14], G3 [3/18/14] and G4 [3/18/14] all had the problem "Psychotic Thought Process" identified on the MTP. For this problem, all four (4) patients had the short-term goals listed in B118 (B) (1). All four (4) patients had the following interventions to address the goals: (Nursing) "Administer medications as ordered daily", (Group Art Therapy) "To provide 45 minute art therapy groups three times weekly with various therapeutic activities and discussion and encourage at least 65% attendance in order to help pt improve reality based thinking", (Social Work Group Therapy) "Pt. will be encouraged to (for Patients G2 and G4 it states' attend therapy group for a minimum of 15 minutes' for Patients G1 and G3 it states 'to participate in group') process his/her thoughts and feelings related to his/her psychosis in a therapeutic environment. Pt. will be educated about psychoses, adaptive coping skills, medications, and community based services to prevent relapse", (Recreation Therapy) "To encourage Recreation Therapy attendance and participation in either expressive therapy, fitness or relaxation groups at least once per day for 40 minutes to help improve reality based thinking", (Physician) "Psychiatrist will assess patient daily for response to therapeutic modalities" and (Social Work) "Family Involvement".

2. Patients G5 [3/12/14], G7 [3/20/14] and G8 [2/20/14] all had the problem "Depression" identified on the MTP. For this problem, all three (3) patients had the short-term goals listed in B118 (B) (1). All three (3) patients had the following interventions to address the goals: (Nursing) "Administer medications as ordered" and (Social Work) "Family Involvement".

3. Patient G6 [3/18/14] had the problem "Mania" identified on the MTP. For this problem, the short-term goals were those listed in B118 (B) (1). For the problem "Mania", the interventions listed were (Nursing) "Administer medications as ordered daily", (Group Art Therapy) "To provide 50 minute art therapy groups three times weekly with various therapeutic activities and discussion and encourage at least 80% attendance in order to help pt stabilize mood and develop safe coping skills as an alternative to drugs/alcohol" and "Psychiatrist will assess patient daily for response to therapeutic modalities".

C. Interview

In interview on 3/26/14 at 9:00 a.m., the Director of Nursing and the Chief Executive Officer both stated that they were aware the short-term goals and interventions were not individualized and were the same for most patients.

Based on facility document review, medical record review and facility staff interview the facility failed to provide Master Treatment Plans (MTPs) that included short-term goals stated in measureable, patient focused terms for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors.

Findings include:

A. Document Review

"The Interdisciplinary Treatment Planning Inpatient/Residential Policy" # 300.46 revised date: 08/2008 stated "The plan contains both short and long term goals that are specific, measurable, and address identified problems."

B. Record Review

1. Patient G1 was admitted on 1/19/14. The MTP dated 1/19/14 for the problem "Psychotic Thought Process" had the short-term goal, "Actively participates in groups and interacts daily." For the problem "Altered Health" the short-term goal was "Maintain/improve health status while hospitalized."

2. Patient G2 was admitted on 3/17/14. The MTP dated 3/17/14 for the problem "Psychotic Thought Process" had the short-term goals, "Family will participate in treatment" and "Actively participates in groups and interacts daily."

3. Patient G3 was admitted on 3/18/14. The MTP dated 3/18/14 for the problem "Psychotic Thought Process" had the short-term goals, "Family will participate in treatment" and "Actively participates in groups and interacts daily."

4. Patient G4 was admitted on 3/18/14. The MTP dated 3/18/14 for the problem "had the short-term goals," "Family will participate in treatment" and "Actively participates in groups and interacts daily."

5. Patient G5 was admitted on 3/12/14. The MTP dated 3/12/14 for the problem "Depression" had the short-term goal, "Actively participates in groups and interacts daily."

6. Patient G6 was admitted on 3/18/14. The MTP dated 3/18/14 for the problems "Mania" and "Alcohol and/or Substance Abuse" had the same short-term goals, "Actively participates in groups and interacts daily."

7. Patient G7 was admitted on 3/20/14. The MTP dated 3/20/14 for the problem "Alcohol and/or Substance Abuse" had the short-term goal, "Hydration/Nutrition will be maintained and will meet metabolic needs" and "Safe detoxification/no complications daily."

8. Patient G8 was admitted on 2/20/14. The MTP dated 2/20/14 for the problem "Altered Health" had the short-term goal, "Maintain/improve health status while hospitalized."

C. Interview

In interview on 3/24/14 at 1:20 p.m., the Director of Nursing stated that she and the Nurse Manager had discussed treatment plan goals and had identified that they were not always measureable and that they were working on correcting that.

Based on medical record review and facility staff interview the facility failed to develop Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) that included individualized nursing interventions with a specific purpose and focus. Many of the listed nursing interventions were generic monitoring or routine nursing functions with identical wording for all patients with similar problems. Failure to clearly describe specific nursing modalities on patients' MTPs can hamper nursing staff's abilities to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed.

Findings include:

A. Record Review

1. Patient G1's MTP dated 1/19/14 identified the problem "Psychotic Thought Process." The nursing intervention for this problem was "Encourage daily group attendance participation."

2. Patient G2's MTP dated 3/17/14 identified the problem "Psychotic Thought Process." The nursing intervention for this problem was "Encourage daily group attendance participation."

3. Patient G3's MTP dated 3/18/14 identified the problem "Suicide Risk." The nursing intervention for this problem was "Precaution: Suicide Monitor Q (every) 10 minutes."

4. Patient G4's MTP dated 3/18/14 identified the problem "Psychotic Thought Process." The nursing intervention for this problem was "Encourage daily group attendance participation."

5. Patient G5's MTP dated 3/12/14 identified the problem "Depression." The nursing intervention for this problem was "Encourage daily group attendance participation." For the identified problem "Suicide Risk" the nursing intervention was "Precaution: Suicide Monitor Q 10 minutes."

6. Patient G6's MTP dated 3/18/14 identified the problem "Mania." The nursing interventions for this problem were "Administer medications as ordered" and "Encourage daily group attendance participation".

7. Patient G7's MTP dated 3/20/14 identified the problem "Alcohol and/or Substance Abuse." The nursing interventions for this problem were "Encourage adequate nutrition intake daily" and "Encourage daily group attendance participation."

8. Patient G8's MTP dated 2/20/14 identified the problem "Suicide Risk." The nursing intervention was "Precaution: Suicide Monitor Q 10 minutes."

B. Interview

In interview on 3/25/14 at 10:45 a.m. the Director of Nursing stated that she and the Nurse Manager had discussed how the nursing interventions were not individualized and were routine, expected nursing interventions.

Based on facility document review, medical record review, and facility staff interview the Medical Director failed to ensure the following:

The provision of a psychiatric evaluation that included the personal assets on which to base a meaningful treatment plan in eight (8) of eight (8) medical records reviewed (G1, G2, G3, G4, G5, G6, G7, and G8). The failure to identify patients assets has the potential to impair the treatment team's ability to choose treatment modalities that be4st utilize the patients attributes in therapy. (Refer to B117)

The development of a Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) that included individualized interventions with a specific purpose and focus. Many of the listed interventions were generic monitoring or routine functions with identical wording for all patients with similar problems. Failure to clearly describe specific modalities on patients' MTP's can hamper staff's abilities to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed. (Refer to B118)

Based on facility document review, medical record review and facility staff interview the Director of Nursing failed to ensure that the facility developed Master Treatment Plans for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) that included individualized nursing interventions with a specific purpose and focus. Many of the listed nursing interventions were generic monitoring or routine nursing functions with identical wording for all patients with similar problems. Failure to clearly describe specific nursing modalities on patients' MTPs can hamper nursing staff's abilities to provide treatment based on individual patient needs and may result in patients not receiving the full range of treatment needed.

Findings include:

A. Record Review

1. Patient G1's MTP dated 1/19/14 identified the problem "Psychotic Thought Process". The nursing intervention for this problem was "Encourage daily group attendance participation".

2. Patient G2's MTP dated 3/17/14 identified the problem "Psychotic Thought Process". The nursing intervention for this problem was "Encourage daily group attendance participation".

3. Patient G3's MTP dated 3/18/14 identified the problem "Suicide Risk". The nursing intervention for this problem was "Precaution: Suicide Monitor Q (every) 10 minutes".

4. Patient G4's MTP dated 3/18/14 identified the problem "Psychotic Thought Process". The nursing intervention for this problem was "Encourage daily group attendance participation".

5. Patient G5's MTP dated 3/12/14 identified the problem "Depression". The nursing intervention for this problem was "Encourage daily group attendance participation". For the identified problem "Suicide Risk" the nursing intervention was "Precaution: Suicide Monitor Q 10 minutes".

6. Patient G6's MTP dated 3/18/14 identified the problem "Mania". The nursing interventions for this problem were "Administer medications as ordered" and "Encourage daily group attendance participation".

7. Patient G7's MTP dated 3/20/14 identified the problem "Alcohol and/or Substance Abuse". The nursing interventions for this problem were "Encourage adequate nutrition intake daily" and "Encourage daily group attendance participation".

8. Patient G8's MTP dated 2/20/14 identified the problem "Suicide Risk". The nursing intervention was "Precaution: Suicide Monitor Q 10 minutes".

B. Interview

In interview on 3/25/14 at 10:45 a.m. the Director of Nursing stated that she and the Nurse Manager discussed how the nursing interventions were not individualized and were routine, expected nursing interventions.