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Based on observation, record review , and interview the hospital failed to ensure the rights of two of two patients (Patient #16, and #22) to receive care in a safe setting.

1) Patient #16 was observed in close vicinity and access to a metal domino box that could be broken in pieces and used for self harm. Patient #16 had been hospitalized with 62 self-inflicted cuts to his lower arms requiring sutures.

2) Patient #22 was on suicide precautions and was allowed to watch a movie with gun violence on television as part of the therapeutic milieu and treatment.

Findings included:

1) Observations on the hospital's 4th floor adult unit on 11/16/15 at 1055 reflected a metal domino box in an unlocked cabinet located in the unit's dining room. It was accessible to patients.

Hospital Personnel #26 acknowledged the open cabinet and stated it was "usually locked and Techs [mental health technicians] have a key." Hospital Personnel #26 put the domino box back in the cabinet at that time.

Patient #16 was observed in the dining room in close vicinity to the unlocked cabinet 11/16/15 at approximately 1057. The patient had his left and right lower arm covered with a dressing and stated he had cut himself "62 times."

Record review of Patient #16's Intake Assessment dated 11/14/15 at 1950 reflected that the patient had multiple risk factors for suicide and self harming behavior. The patient had been admitted from an acute care hospital with 37 stitches on his left forearm and 25 stitches on his right forearm. Patient #16 had cut himself with a razor prior to admission.

Physician Admission Orders dated 11/14/15 at 2015 placed Patient #16 on Suicide/Self-Harm precautions.

Physician History and Physical Examination dated 11/16/15 at 1330 noted the patient had "bilateral forearm lacerations" which were "self-inflicted." The cuts required sutures.

Patient #16's Interdisciplinary Treatment Plan dated 11/14/15 at 2200 reflected as "Problem #1" that the patient had a potential for self-harm because he had attempted to cut on both of his forearms. Patient #16 felt hopeless and stated he was "tired of the same stuff every day."

Physician Progress Note dated 11/16/15 at 1330, approximately two and a half hours after surveyor observation of Patient #16, noted the patient felt "guilty, depressed, withdrawn." The physician changed Patient #16's diagnosis to severe Major Depressive Disorder.

Nursing documentation dated 11/16/15 reflected the patient felt hopeless and was withdrawn during the 0700 to 1900 shift. His group participation was minimal.

On 11/16/15 at approximately 1630 Hospital Personnel #1 was interviewed. Hospital Personnel #1 stated the metal dominos box did not belong on the unit.

Hospital Policy GBH.NURS.031 titled "Management of Contraband" and dated 09/2015 reflected that "all metal items" were considered contraband.

2) Observations in the hospital's Activity Room on 11/16/15 at 1105 reflected that Patient #22 and two other unidentified patients were watching a show on television where one person used a gun on another person.

Record review of the document labeled Daily Patient checklist reflected Patient #22 was on suicide precautions.

Hospital Personnel #1 stated on 11/18/15 at approximately 1400 that the patients had watched "Gun Smoke," an "old show from the fifties."

Based on record review, interview, and document review the facility failed to develop and document comprehensive multidisciplinary treatment plans formulated on the individual needs of the patients for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5) and six (6) of 10 discharged patients (D2, D3, D4, D6, D7 and D8). Patient treatment plans were completed by the admitting RN, rather than by their treatment team and patients were asked to sign their treatment plans prior to the psychiatrist completing the psychiatric evaluation, the social worker completing the psychosocial assessment and prior to the treatment team meeting. Failure to include all assessments when developing treatment plans does not allow for an integrated multidisciplinary treatment plan, potentially compromising patient care by not meeting the individualized needs of the patient.

FINDINGS INCLUDE:

RECORD REVIEW

1. Patient A1 was admitted on 11/14/15. The psychiatric evaluations dated 11/15/15 documented the diagnoses, "Major Depressive Disorder; Sedative Hypnotic/Anxiolytic D/O [Disorder] severe; Cannabis use Disorder, sustained remission; Sedative/Hypnotic/Anxiolytic Withdrawal." The Master Treatment Plan revealed the patient signature dated 11/14/15 at 10:00 PM, the day prior to the completion of psychiatric evaluation (dated 11/15/15 at 12:25 AM) and the psychosocial assessment (dated 11/15/15 at 2:07 PM).

2. Patient A2 was admitted on 11/15/15. The psychiatric evaluation dated 11/16/15 documented the diagnoses of "Bipolar 1 Disorder, depressed, severe, recurrent without psychotic features; PTSD [Post Traumatic Stress Disorder]; ADHD [Attention Deficit Hyperactivity Disorder] combined." The Master Treatment Plan revealed the patient signature on 11/16/15 at 10:30 AM prior to the completion of the psychiatric evaluation (dated 11/16/15 at 11:50 AM) and the psychosocial assessment (dated 11/16/15 at 12:30 PM).

3. Patient A3 was admitted on 11/12/15. The psychiatric evaluation dated 11/13/15 documented the diagnoses of "Alcohol use Disorder, severe with alcohol induced anxiety disorder, occurring drug withdrawal; Major Depressive Disorder, severe, recurrent without psychotic features." The Master Treatment Plan revealed the patient signature on 11/12/15 at 9:15 AM. The psychiatric evaluation was dated 11/13/15 at 3:30 PM and the psychosocial assessment was dated 11/13/15 at 2:55 PM.

4. Patient A4 was admitted on 11/4/15. The psychiatric evaluation dated 11/5/15 documented the diagnoses of "Alcohol use Disorder, severe; Major Depressive Disorder, recurrent without psychotic features." The Master Treatment Plan revealed the patient signature on 11/4/15 (no time listed). The psychiatric evaluation was dated 11/5/15 (no time listed) and the psychosocial assessment was dated 11/5/15 at 11:22 AM.

5. Patient A5 was admitted on 11/15/15. The psychiatric evaluation dated 11/16/15 documented the diagnoses of "Bipolar 1 Disorder, depressed type, severe recurrent with psychotic features; Anxiety Disorder NOS." The Master Treatment Plan revealed the patient signature dated 11/15/15 (no time listed). The psychiatric evaluation was dated 11/16/15 at 1:25 PM and the psychosocial assessment was dated 11/16/15 at 3:25 PM.

6. Patient D2 was an inpatient from 9/23/15-10/1/15. The psychiatric evaluation dated 10/11/15 documented the diagnoses, "MDD [Major Depressive Disorder], recurrent, severe w/out [without] psy. [psychotic] features; Anxiety d/o [disorder], unspecified; Cannabis use d/o [disorder], severe." The Master Treatment Plan revealed the patient signature dated 10/10/15 at 8:08 AM. The psychiatric evaluation was dated 10/11/15 at 11:15 AM and the psychosocial assessment was dated 10/12/15 at 11:41 AM.

7. Patient D3 was an inpatient from 10/11/15-10/15/15. The psychiatric evaluation dated 10/11/15 documented the diagnoses, "MDD, recurrent/severe w/out psy.[psychotic] features; Stimulant (amphetamine type) use d/o, severe; Stimulant w/d [withdrawal]." The Master Treatment Plan revealed the patient signature dated 10/11/15 at 5:00 AM. The psychiatric evaluation was dated 10/11/15 at 11:45 AM and the psychosocial assessment was dated 10/13/15 at 4:10 PM.

8. Patient D4 was an inpatient from 10/7/15-10/12/15. The psychiatric evaluation dated 10/8/15 documented the diagnoses, "Alcohol Use Disorder, opiate use disorder; GAD [Generalized Anxiety Disorder]; Alcohol Induced Aggressive Disorder; Alcohol w/d [withdrawal]; Opiate w/d." The Master Treatment Plan revealed the patient signature dated 10/7/15 at 12:55 PM. The psychiatric evaluation was dated 10/8/15 at 12:30 PM and the psychosocial assessment was dated 10/28/15 at 3:11 PM (error-date should have been 10/8/15 per the Director of Clinical Services).

9. Patient D6 was an inpatient from 10/14/15-10/15/15. The psychiatric evaluation dated 10/15/15 at 10:30 AM documented the diagnoses, "Alcohol Use Disorder, severe, Stimulant Use Disorder, severe." The Master Treatment Plan revealed the patient signature dated 10/14/15 at 10:27 AM. The psychiatric evaluation was dated 10/15/15 at 10:30 AM. The psychosocial assessment was not completed since the patient was discharged prior to 72 hours.

10. Patient D7 was an inpatient from 10/12/15-10/16/15. The psychiatric evaluation dated 10/13/15 documented the diagnosis, "Major Depression, severe, recurrent." The Master Treatment Plan revealed the patient signature dated 10/12/15 (no time documented). The psychiatric evaluation was dated 10/13/15 at 11:15 AM. The psychosocial assessment was dated 10/14/15 at 12:07 PM.

11. Patient D8 was an inpatient from 10/5/15-10/10/15. The psychiatric evaluation dated 10/6/15 documented the diagnoses, "Bipolar Disorder, depressed, severe, recurrent with psychotic features; stimulant use disorder; opiate use disorder." The Master Treatment Plan revealed the patient signature dated 10/5/15 at 6:25 PM. The psychiatric evaluation was dated 10/6/15 at 1:00 PM. The psychosocial assessment was dated 10/6/15 at 10:45 AM.

INTERVIEWS:

1. In interview on 11/16/15 at 2:00 PM, Social Worker 2 (SW2) acknowledged that Patient A2 had signed his/her treatment plan prior to the completion of both the psychiatric evaluation and the psychosocial assessment. The patient signed his/her treatment plan prior to the treatment team meeting, which is held to formulate a plan based on all the assessments.

2. In interview on 11/17/15 at 1:00 PM, Registered Nurse 1 (RN1) confirmed that RNs have the patient sign the treatment plan on admission.

3. In interview on 11/17/15 at 1:25 PM, SW1 stated that the treatment plans are already signed by the patient when she reviews the plan with the patient.

DOCUMENT REVIEW

Review of the policy, "Treatment Planning" number GBH.GC.017, effective 9/2015, revealed that the Social Worker was to obtain the patient's signature on the Master Treatment Plan. "The therapist/Social Worker is responsible for discussing the treatment plan with the patient or designating a member of the treatment team to do so. After the treatment plan is reviewed with the patient/family, the patient/family is to sign the appropriate areas."

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for five (5) of five (5) active patients. (A1, A2, A3, A4 and A5). Lack of patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment.

FINDINGS INCLUDE:

RECORD REVIEW:

1. Patient A1 admitted 11/14/15 had listed on the Master Treatment Plan (dated 11/14/15) for the problem, "Potential for Self Harm", the short term goal, "Patient will not harm self while in hospital." A goal unrelated to the problem was "Pt [patient] will sleep for 6 -8hrs/night for three (3) consecutive days."

2. Patient A2 admitted 11/15/15 had listed on the Master Treatment Plan (dated 11/15/15) for the problem, "Excessive anxiety", the short term goal, "Patient will identify triggers and or warning signs."

3. Patient A3 admitted 11/12/15 had listed on the Master Treatment Plan (dated 11/12/15) for the problem, "Potential for Self Harm", the short term goal, "Patient will not harm self while in the hospital."

4. Patient A4 admitted 11/4/15 had listed on the Master Treatment Plan (dated 11/4/15) for the problem, "Out of Contact with Reality", the short term goal, "Patient will not attempt to harm self or others due to hallucinations/delusions/paranoia."

5. Patient A5 admitted 11/15/15 had listed on the Master Treatment Plan (dated 11/15/15) for the problem, "Alteration in mood Depressed", the short term goal, "Patient will identify a positive coping skill for depression."

INTERVIEWS:

1. In an interview on 11/17/15 at 9:00 AM, the Director of Social Work confirmed that the short term goals on the Master Treatment Plans were not listed in observable, measurable, behavioral terms.

2. In an interview on 11/17/15 at 2:00 PM, the Director of Nursing and the Consulting Director of Nursing concurred that the short term goals on the Master Treatment Plans were not listed in observable, measurable terms.

Based on record review and interview, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5). Interventions listed on treatment plans were preprinted. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than individualized patient specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve identified goals.

FINDINGS INCLUDE:

RECORD REVIEW:

1. Patient A1, admitted 11/14/15, on the Master Treatment Plan dated 11/14/15 had for the short term goal, "Patient will not harm self while in hospital", the following interventions:
"Physician assessment to assess mood, mental status, and effectiveness of medications" and "RN assessment to determine suicidality, mood, and patient perception of [sic]."

2. Patient A2 ,admitted on 11/15/15, on the Master Treatment Plan dated 11/15/15 had for the short term goal, "Patient will not harm self while in the hospital", the following interventions:

"Physician assessment to assess mood, mental status, and effectiveness of medications" and "RN assessment to determine suicidality, mood, and patient perception of [sic]."

3. Patient A3, admitted 11/12/15, on the Master Treatment Plan dated 11/12/15 had for the short term goal, "Patient will not harm self while in the hospital", the following interventions:

"Physician assessment to assess mood, mental status, and effectiveness of medications" and "RN assessment to determine suicidality, mood, and patient perception of [sic]."

4. Patient A4, admitted 11/4/15, on the Master Treatment Plan dated 11/4/15 had for the short term goal, "Patient will not attempt to harm self or others due to hallucinations/delusions/paranoia", the following interventions:

"Physician assessment to assess mood, mental status, and effectiveness of medications" and " RN assessment to determine suicidality, mood, and patient perception of [sic]."

5. Patient A5, admitted 11/15/15, on the Master Treatment Plan dated 11/15/15 had for the short term goal, "Patient will identify a positive coping skill for depression", the following interventions:

"Physician assessment to assess mood, mental status, and effectiveness of medications" and " RN assessment to determine suicidality, mood, and patient perception of [sic]."

INTERVIEWS

1. In an interview on 11/17/15 at 9:00 AM the Director of Social Work confirmed that the treatment interventions listed on the Master Treatment Plans were not individualized and frequently generic job description functions rather than individualized patient specific interventions.

2. In an interview on 11/17/15 at 2:00 PM, the Director of Nursing and the Consulting Director of Nursing concurred that that the treatment interventions listed on the Master Treatment Plans were not individualized and frequently generic job description functions rather than individualized patient specific interventions.

Based on record review, interview , and document review, the medical director failed to ensure:

1. The development and documentation of comprehensive multidisciplinary treatment plans formulated on the individual needs of the patients for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5) and six (6) of 10 discharged patients (D2, D3, D4, D6, D7 and D8). Patient treatment plans were completed by the admitting RN, rather than by their treatment team and patients were asked to sign their treatment plans prior to the psychiatrist completing the psychiatric evaluation, the social worker completing the psychosocial assessment and prior to the treatment team meeting. Failure to include all assessments when developing treatment plans does not allow for an integrated multidisciplinary treatment plan, potentially compromising patient care by not meeting the individualized needs of the patient. (See B118)

2. The development of Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for five (5) of five (5) active patients. (A1, A2, A3, A4 and A5). Lack of patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment (See B121).

3. The identification in the MTP specific treatment interventions/modalities to address the identified patient problems for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5). Interventions listed on treatment plans were preprinted. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than individualized patient specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve identified goals. (See B 122)

INTERVIEW

1. In an interview on 11/18/15 at 10:00 AM the findings related to the treatment planning process, the Master Treatment Plan document lacking individualized patient specific short term goals, and the Master Treatment Plans containing non-individualized generic discipline functions were discussed. He concurred with these findings.

Based on record review and interview, the Director of Nursing failed to identify in the MTP specific nursing interventions to address the identified patient problems for five (5) of five (5) active sample patients (A1, A2, A3, A4 and A5). Interventions listed on the treatment plans were preprinted. The nursing interventions listed were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention and limits the therapeutic nursing interventions available to patients.

FINDINGS INCLUDE

RECORD REVIEW:

1. Patient A1, admitted 11/14/15, on the Master Treatment Plan dated 11/14/15 had for the short term goal, "Patient will not harm self while in hospital", the nursing intervention, "RN assessment to determine suicidality, mood, and patient perception of [sic]."

2. Patient A2, admitted on 11/15/15, on the Master Treatment Plan dated 11/15/15 had for the short term goal, "Patient will not harm self while in the hospital ", the nursing intervention, "RN assessment to determine suicidality, mood, and patient perception of [sic]."

3. Patient A3, admitted 11/12/15, on the Master Treatment Plan dated 11/12/15 had for the short term goal, "Patient will not harm self while in the hospital", the nursing intervention, "RN assessment to determine suicidality, mood, and patient perception of [sic]."

4. Patient A4, admitted 11/4/15, on the Master Treatment Plan dated 11/4/15 had for the short term goal, "Patient will not attempt to harm self or others due to hallucinations/delusions/paranoia", the nursing intervention, "RN assessment to determine suicidality, mood, and patient perception of [sic]."

5. Patient A5, admitted 11/15/15, on the Master Treatment Plan dated 11/15/15 had for the short term goal, "Patient will identify a positive coping skill for depression", the nursing intervention, "RN assessment to determine suicidality, mood, and patient perception of [sic]."

INTERVIEWS

1. In an interview on 11/17/15 at 2:00 PM, the Director of Nursing and the Consulting Director of Nursing concurred that that the nursing interventions listed on the Master Treatment Plans were not individualized and frequently generic nursing job description functions rather than individualized patient specific interventions.