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Based on document review and interview, the hospital failed to ensure the Medical Alert Physician responders from the host hospital that provided Code Response services for inpatients of the survey hospital were accountable to its Governing Body (See tags A46 and A93), and failed to maintain a list of all contracted services, including the scope and nature of services provided for 3 of 14 contracted services (biomedical engineering, IC consultant services & medical transcription) (See tag A85)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that the Governing Body was responsible for the hospital.

Based upon document review and interview, the Governing Body and Medical Staff failed to maintain its agreement and develop, approve, and maintain policies and procedures for ordering and obtaining Radiology Services at the survey facility for one occurrence (see tag A 529).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Radiology Services provided quality health care in a safe environment.

Based on document review and interview, the facility failed to provide a qualified Infection Control Officer (See tag A748) and failed to ensure the QAPI (Quality Assurance and Performance Improvement) program addressed any problems identified by the IC (infection control) program (See tag A756).

The cumulative effects of the above resulted in the facilities inability to ensure an active Infection Control Program was in place.

Based on observation, record review and interview, the facility failed to ensure that active individualized psychiatric care was provided for three (3) of eight (8) active sample patients (5, 8, and 9). There was a failure to provide structured treatment for these patients' specialized treatment needs. These patients functioned at low cognitive and social functioning levels, yet adequate modalities to address their problems were not provided. The failure to ensure active treatment results in the patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125)

Based on document review and interview, the survey hospital failed to ensure the Medical Alert Physician responders from the host hospital that provided Code Response services for inpatients of the survey hospital were accountable to its Governing Body by maintaining their Medical Staff membership and privileges in accordance with the survey hospital's Medical Staff Bylaws for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital indicated the following: "3.3 [the host facility] shall provide and pay for the provision of the following additional services for the benefit of the Leased Premises... Code Response Team (Tenant and [host hospital] shall follow the [host hospital] Cardiopulmonary Emergency (Medical Alert) policy, and [host hospital] shall ensure the code cart located on the Leased Premises is stocked with appropriate supplies and equipment..."

2. Review of the survey facility's policy/procedure titled Deterioration of the Patient's Medical Condition Requiring Medical Interventions (approved 10-13) indicated the following: "For medically compromised patients, staff are to call a "medical alert" by dialing 911 for the operator, while at the same time, another staff member is notifying the attending, or on-call Psychiatrist of the change in the patient's condition. Then the decision is made by the House Doctor on the "Medical Alert" team with the IP (inpatient) Psychiatrist, or on-call Psychiatrist, to send the patient to the [host hospital's] ER (Emergency Room) for evaluation and treatment per Doctor's order..."

3. Review of the survey facility's Medical Staff Bylaws (approved 9-12) indicated the following: "Article 4 Categories of the Medical Staff. Only those individuals who satisfy the qualifications and conditions for appointment to the Medical Staff contained in the Credentialing Policy are eligible for appointment to one of the following categories... 4.2 Consulting Staff (A) Qualifications. The Consulting Staff shall consist of practitioners of recognized professional ability and expertise that provide a service that is not available on the Active Staff, and who are appointed to the Active Staff at another hospital or facility where they are currently practicing."

4. Review of a list of 15 Credentialed Medical Staff Physicians provided by the Quality Analyst, staff A3 failed to indicate any host hospital's Medical Alert Physicians, or "House Doctors" were appointed to the Medical Staff at the survey facility.

5. On 11-15-17 at 1540 hours, the Human Resources Specialist, staff A14 and the Quality Analyst, staff A3 confirmed the list of Medical Staff was composed of providers who were actively involved with patients of the survey hospital impatient facility or affiliated outpatient services and did not include any [host hospital] House Doctors or Medical Alert Physicians.

6. On 11-15-17 at 1255 hours, the Vice President of Clinical Services, staff A1 confirmed the facility had failed to ensure any host hospital "House Doctors" responding to a Medical Alert were appointed to the Medical Staff of the survey facility in the event of a patient emergency.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided for 3 of 14 contracted services (biomedical engineering, IC consultant services & medical transcription).

Findings include:

1. Review of the list of contracted services lacked documentation indicating a provider for biomedical engineering, IC (infection control) or medical transcription.

2. Review of maintenance documentation and service agreement documentation indicated the following: biomedical engineering, IC consultant services and medical transcription were provided by the host hospital.

3. On 11-15-17 at 1230 hours, the Quality Analyst, staff A3 confirmed that the list of contracted services lacked the indicated services and had not been maintained.

Based on document review and interview, the survey hospital failed to ensure the Medical Alert Physician responders from the host hospital that provided Code Response services for inpatients of the survey hospital were accountable to its Governing Body by maintaining their Medical Staff membership and privileges in accordance with the survey hospital's Medical Staff Bylaws for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital indicated the following: "3.3 [the host facility] shall provide and pay for the provision of the following additional services for the benefit of the Leased Premises... Code Response Team (Tenant and [host hospital] shall follow the [host hospital] Cardiopulmonary Emergency (Medical Alert) policy, and [host hospital] shall ensure the code cart located on the Leased Premises is stocked with appropriate supplies and equipment..."

2. Review of the survey facility's policy/procedure titled Deterioration of the Patient's Medical Condition Requiring Medical Interventions (approved 10-13) indicated the following: "For medically compromised patients, staff are to call a "medical alert" by dialing 911 for the operator, while at the same time, another staff member is notifying the attending, or on-call Psychiatrist of the change in the patient's condition. Then the decision is made by the House Doctor on the "Medical Alert" team with the IP (inpatient) Psychiatrist, or on-call Psychiatrist, to send the patient to the [host hospital's] ER (Emergency Room) for evaluation and treatment per Doctor's order..."

3. Review of the survey facility's Medical Staff Bylaws (approved 9-12) indicated the following: "Article 4 Categories of the Medical Staff. Only those individuals who satisfy the qualifications and conditions for appointment to the Medical Staff contained in the Credentialing Policy are eligible for appointment to one of the following categories... 4.2 Consulting Staff (A) Qualifications. The Consulting Staff shall consist of practitioners of recognized professional ability and expertise that provide a service that is not available on the Active Staff, and who are appointed to the Active Staff at another hospital or facility where they are currently practicing."

4. Review of a list of 15 Credentialed Medical Staff Physicians provided by the Quality Analyst, staff A3 failed to indicate any host hospital's Medical Alert Physicians, or "House Doctors" were appointed to the Medical Staff at the survey facility.

5. On 11-15-17 at 1540 hours, the Human Resources Specialist, staff A14 and the Quality Analyst, staff A3 confirmed the list of Medical Staff was composed of providers who were actively involved with patients of the survey hospital impatient facility or affiliated outpatient services and did not include any [host hospital] House Doctors or Medical Alert Physicians.

6. On 11-15-17 at 1255 hours, the Vice President of Clinical Services, staff A1 confirmed the facility had failed to ensure any host hospital "House Doctors" responding to a Medical Alert were appointed to the Medical Staff of the survey facility in the event of a patient emergency.

Based on document review and interview, the facility failed to ensure all patients and/or their representatives were provided with notice of patient rights including notice of privacy practices and current QIO (Quality Improvement Organization) contact information for Medicare patient concerns for 4 of 4 MR (medical records) reviewed (Patients #7, 10, 11 & 12).

Findings include:

1. Review of the [facility] Health Services Consent for Treatment form 10795 indicated the following: "Acknowledgement of Receipt of Notice of Privacy Practices: ...I do [vs] do not (Please circle) acknowledge that I have read and/or obtained a copy of [the facility] Health Services Notice of Privacy Practices."

2. Review of the Consent for Treatment for Patients #7, 10, 11 & 12 lacked documentation indicating each patient read and/or obtained a copy of [the facility] Health Services Notice of Privacy Practices.

3. On 11-16-17 at 0930 hours, the Quality Analyst, staff A3 and the Administrative Assistant, staff A4 confirmed the 4 MR (#7, 10, 11 & 12) lacked the indicated documentation.

4. During a tour of the inpatient unit on 11-16-17 at 1200 hours, in the company of the Vice President of Clinical Services, staff A1, the Clinical Secretary, staff A11 was requested to provide a copy of the Notice of Privacy Practices as indicated on the Consent for Treatment form.

5. On 11-16-17 at 1200 hours, the Clinical Secretary, staff A11 confirmed they were not aware of a "Notice of Privacy Practices" to be provided at the time of patient registration and confirmed a copy was not available on the unit at the time of the request.

6. Review of the Patient Rights and Responsibilities notice failed to indicate the current Medicare QIO contact information.

7. On 11-15-17 at 1005 hours, the Quality Analyst, A3 confirmed the contact information for the Medicare QIO was incorrect and confirmed the notice had not been maintained.

Based on document review and interview, the facility failed to maintain its policies and ensure the process for responding to complaints clearly indicated when a complaint must be addressed as a grievance for one occurrence.

Findings include:

1. Review of the policy/procedure Patient/Visitor Complaints and Grievances Policy & Procedure (approved 4-10) indicated the following: "The following definitions will apply... Patient Grievance - A formal or informal written or verbal complaint that is made 1) directly to [the survey hospital] / the unit, or indirectly through a representative of an affiliated organization, by a patient, or the patient's representative, when a patient issue or complaint cannot be resolved promptly by staff present... If, however, the issue is referred to a staff on the unit and the issue can be resolved at that moment, then it is not a Patient Grievance..." The policy/procedure lacked documentation indicating all written complaints, all allegations of abuse and neglect, all issues related to the Hospital's compliance with the CMS Hospital Conditions of Participation, and all Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 are always considered a grievance.

2. On 11-15-17 at 1015 hours, the Quality Analyst, A3 confirmed the policy/procedure lacked documentation indicating the specified circumstances or criteria when a complaint must be addressed as a grievance.

Based on document review and interview, the QAPI (Quality Assurance and Performance Improvement) program failed to maintain documentation of IC (infection control) surveillance and reporting activities for 6 of 6 quarters in 2016 and 2017.

Findings include:

1. The policy/procedure Infection Control Plan of Service (approved 5-08) indicated the following: "The (facility) Hospital Infection Control Committee (ICC) is responsible for identifying, prioritizing and addressing the risks for acquiring and transmitting infections within the population being served... [and]... Maintain appropriate surveillance, data analysis and reporting activities to control or prevent the spread of healthcare associated infections."

2. Review of the QAPI and IC committee meeting documentation for 5/25/16, 8/24/16, 11/30/16, 2/22/17, 5/24/17 and 8/23/17 indicated the following: "... Geropsych Agenda... B) Infection Control meeting..." and lacked documentation indicating any IC program surveillance activity was reported and reviewed by the committee.

3. On 11-16-17 at 0925 hours, the Quality Analyst, staff A3 and the Administrative Assistant, staff A4 confirmed the QAPI meeting minutes lacked documentation of IC program activity.

Based on document review and interview, the governing body failed to ensure that the quality assessment and performance improvement (QAPI) program assessed all departments and services including contracted services at the facility for 4 of 14 contracted services (biomedical engineering, diagnostic radiology, IC (infection control) consulting, and respiratory therapy services).

Findings include:

1. The policy/procedure Quality Management Plan (approved 5-08) indicated the following: "[The] Quality Assessment and Improvement Plan covers all patient care and support services of (the facility) Hospital."

2. Review of the QAPI committee minutes for 11/30/16, 2/22/17, 5/24/17 and 8/23/17 lacked documentation indicating the services of biomedical engineering, diagnostic radiology, IC consulting, or respiratory therapy were evaluated and reviewed.

3. On 11-15-17 at 1230 hours, the Quality Analyst, staff A3 confirmed the indicated services were not being reviewed by the QAPI program.

Based on document review and interview, the Medical Staff failed to follow and ensure its Medical Staff Bylaws were periodically reviewed and approved for one occurrence.

Findings include:

1. Review of the Medical Staff Bylaws (approved 9-12) indicated the following: "Article 5 Medical Director... 5.3 Duties... The Medical Director is responsible for the following... (7) assisting with the review, at least every three years, [of] the Bylaws, policies, Rules and Regulations and associated documents of the Medical Staff..."

2. Review of the Medical Staff Bylaws (approved 9-12) failed to indicate review and approval within the last 3 years.

3. On 11-14-17 at 1400 hours, the Quality Analyst, staff A3 confirmed that the Medical Staff Bylaws lacked documentation of review and approval within the last 3 years and no other documentation was available.

Based on document review and interview, the Director of Nursing (P52) failed to provide quality of care to all patients by emailing staff with times that they could not call the psychiatrists for admission orders for 1 facility.

Findings Included:

1. Telephone interview on 11/16/17 at approximately 4:00 pm with P61 (current night shift nurse) confirmed receipt of email instructing nursing not to call the psychiatrists for admission orders between 11:30 pm and 6:00 am.

2. Interview with P53 on 11/16/17 at approximately 4:10 pm confirmed existence of named email; requested a copy and received.

3. Email to staff on 06/29/17 at 8:52 pm indicates "When a need is not emergent, please save your items to be addressed (including admit orders) to be addressed outside of sleep hours (generally before 2300 and after 0600)."

4. Email to staff then forwarded to Medical Director and other physicians/NP on 06/29/17 at 9:55 pm.

5. Unable to speak with P52 (Director of Nursing) due to not present on last day of survey.

Based on personnel record review, policy and procedure review and interview, the facility failed to provide training of personnel in 13 of 13 employee department orientation (N1, N2, N3, N4, N5, N6, N7, N8, N9, N10, N11, N12 and N13); 12 out of 13 employee annual competencies (N1, N2, N3, N5, N6, N7, N8, N9, N10, N11, N12 and N13); and 3 out of 10 in point of care training (N1, N11, and N12).

Findings Include:

1. Review of 13 personnel files lacked documentation of department orientation on all 13 records reviewed.

2. Review of 13 personnel files lacked documentation of annual competencies (psych skills, blood draws) in 12 of 13 records (N4 had competencies).

3. Request for policy and procedure made on 11/14/17 at 12:45 pm and 11/15/17 at 11:45 am; both requests made to P52, Director of Nursing. Not received by the end of survey.

3. Interview with P52 on 11/15/17 at 11:45 am confirms lack of knowledge of any policy specific for department orientation and does not know where the nursing staff competencies are located. "That was before I came."

Based on document review and interview, the facility failed to provide training of personnel in 13 of 13 employee department orientations (N1, N2, N3, N4, N5, N6, N7, N8, N9, N10, N11, N12 and N13); 12 out of 13 employee annual competencies (N1, N2, N3, N5, N6, N7, N8, N9, N10, N11, N12 and N13); and 3 out of 10 in point of care training (N1, N11, and N12).

Findings Include:

1. Review of personnel files (N1, N2, N3, N4, N5, N6, N7, N8, N9, N10, N11, N12 and N13) lacked documentation of department orientation.

2. Review of personnel files (N1, N2, N3, N5, N6, N7, N8, N9, N10, N11, N12 and N13) lacked documentation of annual competencies (psych skills, blood draws).

3. Request for policy and procedure made on 11/14/17 at 12:45 pm and 11/15/17 at 11:45 am; both requests made to P52, Director of Nursing. Not received by the end of survey.

3. Interview with P52 on 11/15/17 at 11:45 am confirms lack of knowledge of any policy specific for department orientation and does not know where the nursing staff competencies are located. "That was before I came."

Based upon document review and interview, the Governing Body and Medical Staff failed to develop or identify and approve, maintain and periodically review all policies and procedures for the safe and appropriate ordering, storage, dispensing, administering, and disposal of medications at the survey facility for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital indicated the following: " ...[The host hospital] shall provide Pharmacy Services to [the survey hospital] that comply with all the requirements set forth in 410 IAC 15-1.5-7. Notwithstanding the preceding, [the host hospital] Pharmacy Services to provide [the survey hospital] an appropriate selection or formulary of medications available for prescribing or ordering as determined by [the host hospital] Pharmacy and Therapeutics Committee, control of preparation and dispensing of medication, and a secure automated dispensing system, which is kept supplied by [the host hospital] Pharmacy Services. Consultative Services of a Pharmacist ("RPh") provided to [the survey hospital] as requested by [the survey hospital] subject to availability on a non-stat/non-emergent basis."

2. Review of the survey facility policy/procedure titled Pharmacy Services Policy (approved 10-15) indicated the following: "...[the survey hospital] leases its Pharmacy Services from [the host hospital]. As part of the Service Contract, [the survey hospital] receives those services outlined in the Pharmacy Services sections of IAC 410 and IAC 440, as well as CMS and Joint Commission regulations, from [the host hospital]. The formulary and pharmacy manual is maintained on the [host hospital] intranet and is accessible by [the survey hospital] unit staff for reference.

3. On 11-15-17 at 1545 hours, the Quality Analyst, staff A3 confirmed the Pharmacy Services Policy failed to identify the specific pharmacy services policies or procedures approved for use by the facility and no other documentation was available.

4. Review of the survey facility policy/procedure titled Nursing Procedures (approved 7-15) indicated the following: "As part of its contractual agreements with [the host hospital], [the survey hospital] utilized equipment and services from [the host hospital] such as IV equipment... pharmacy, and others... Therefore, [the survey hospital] uses [the host hospital] nursing procedures and training for staff wherever practicable (sic) and [the survey hospital] staff are directed to those policies and procedures and have on-line access.

5. On 11-15-17 at 1545 hours, the Quality Analyst, staff A3 confirmed the Nursing Procedures policy failed to identify the specific nursing services policies or procedures approved for use by the facility and no other documentation was available.

Based upon document review and interview, the Governing Body and Medical Staff failed to maintain its agreement and develop, approve, and maintain policies and procedures for ordering and obtaining Radiology Services at the survey facility for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital lacked documentation indicating the host hospital provided Radiology Services to the survey hospital as ordered by a member of Medical Staff of the survey hospital.

2. On 11-15-17 at 1230 hours, the Quality Analyst, staff A3 confirmed that the list of contracted services lacked the indicated service and had not been maintained.

3. Review of the Policies and Procedures Table of Contents for the survey hospital lacked documentation indicating any Radiology Services policies and/or procedures were available.

4. On 11-16-17 at 1510 hours, the Vice President of Clinical Services, staff A1 confirmed that mobile radiology equipment from the host facility comes onto the inpatient unit of the survey hospital to perform chest x-rays, etc. and indicated that patients are typically "discharged" from the inpatient unit (per the request of an unidentified staff(s) associated with the host facility) and transported to the host facility radiology department by the survey facility staff for medical imaging. After medical imaging is performed, the patient is transported back to the survey facility inpatient unit and "readmitted" using the same chart unless the patient needed to be admitted to the host facility for ongoing medical care.

5. On 11-16-17 at 1525 hours, the Vice President of Clinical Services confirmed that no radiology policy/procedures or process description for obtaining medical imaging from the host facility was available.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on record review with the Maintenance Director and Vice President on 11/14/17 at 11:33 a.m., there was no monthly inspection of the wet sprinkler system's gauges and valves available for review. During an interview at the time of record review, the Maintenance Director stated no monthly checks of the sprinkler system's gauges or valves were recorded.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled utility rooms was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect staff and up to 16 on the third floor.

Findings include:

Based on observations during a tour of the facility with the Maintenance Director and Vice President on 11/14/17 at 12:40 p.m., the soiled utility room, which contained over 64 gallons of soiled linen, was not equipped with a self-closing device. Based on interview at the time of observations, the Maintenance Director agreed the room contained soiled linen and the door was not equipped with a self-closer.

Based on document review and interview, the facility failed to provide a qualified Infection Control Officer.

Findings Include:

1. During entrance conference on 11/14/17 at approximately 10:00 am, Vice-President of Clinical Services (P50), confirmed that P57 was the Infection Control nurse, but not present due to vacation and that P52 would be the back up.

2. Review of P52, Director of Nursing personnel file lacked documentation of any infection control training.

3. Review of P57 personnel file indicates not responsible for facility infection control per job description; page 1, Infection Control Functions: "1. Serves as the Meridian Infection Control Coordinator for the entire organization with the exception of the hospital".

4. Interview with P57 on 11/16/17 at 10:30 am confirms not infection control officer for facility.

5. Interview with P50 on 11/16/17 at 11:30 am confirmed that P57 was not infection control officer for the facility.

Based upon document review and interview, the Governing Body and Medical Staff failed to develop or identify and approve, maintain and periodically review all policies and procedures for ordering, furnishing, and documenting physical, occupational and speech therapy services at the survey facility for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital indicated the following: "...[The host hospital] to provide [the survey hospital] patients with physical therapy, occupational therapy and speech therapy services as ordered by a Physician on [the survey hospital] Medical Staff on a non-stat/non-emergent basis."

2. Review of the Policies and Procedures Table of Contents for the survey hospital lacked documentation indicating any rehabilitation services, or physical, occupational or speech therapy policies were available for review.

3. On 11-15-17 at 1545 hours, the Quality Analyst, staff A3 confirmed no host hospital rehabilitation services or physical, occupational or speech therapy policies or procedures were approved for use by the facility and no other documentation was available.

Based upon document review and interview, the Governing Body and Medical Staff failed to develop or identify and approve, maintain and periodically review all policies and procedures for ordering, administering, and documenting respiratory therapy services at the survey facility for one occurrence.

Findings include:

1. Review of the Lease Agreement (approved 5-17) between the survey hospital and the host hospital indicated the following: "...[The host hospital] shall provide Respiratory Care Services to [the survey hospital] that comply with all the requirements set forth in 410 IAC 15-1.6-7. Notwithstanding the preceding, [the host hospital] Respiratory Department shall provide [the survey hospital] patients with respiratory care services as customarily provided within [the host hospital] as ordered by a Physician on [the survey hospital] Medical Staff on a non-stat/non-emergent basis."

2. Review of the survey facility policy/procedure titled Respiratory Care Policy (approved 6-15) indicated the following: "...[the survey hospital] leases its Respiratory Care Services from [the host hospital]. As part of the Service Contract, [the survey hospital] receives those services outlined in the Respiratory Care Services sections of IAC 410 and IAC 440, as well as CMS and Joint Commission regulations, from [the host hospital]. The [host hospital] Respiratory Care policies and procedures are available on the Intranet system which can be accessed by [the survey hospital] staff on the care unit, and are followed by [the survey hospital] staff.

3. On 11-15-17 at 1545 hours, the Quality Analyst, staff A3 confirmed the Respiratory Care Services Policy failed to identify the specific respiratory therapy services policies or procedures approved for use by the facility and no other documentation was available.

Based on record review and interview, the facility failed to ensure that the Psychosocial Assessments identified the specific role and responsibility of this discipline in discharge planning for eight (8) of eight (8) active sample patients (1, 3, 5, 6, 7, 8, 9, and 10). As a result, specific social work recommendations regarding discharge planning were not described for the treatment team.

Findings include:

A. Record Review

1. In patient 1's Psychosocial Assessment, dated 10/27/17, the Discharge Plan stated: "Patient will return to [name of facility] in Tipton, IN."---"Patient will take prescribed medications. Patient will participate in discharge planning."

2. In patient 3's Psychosocial Assessment, dated 11/6/17, the Discharge Plan stated: "Once stabilized, pt. [patient] will return to Sugar Creek. [S/he] will deny suicidal and homicidal ideation. [S/he] will not exhibit physical aggression for at least 3 days prior to discharge. [S/he] will take medications as directed, attend group clinical sessions, and engage in individual clinical sessions with focus on healthy coping skills, anger management and depression."

3. In patient 5's Psychosocial Assessment, dated 9/15/17, the Discharge Plan stated: "Patient will return to [name of state hospital]. Patient will attend group and individual therapy. Patient will take prescribed medications. Patient will participate in discharge planning."

4. In patient 6's Psychosocial Assessment, dated 11/11/17, the Discharge Plan stated: "Once stabilized, patient will return to [name of facility]. Patient should not exhibit physical aggression for at least three (3) days prior to discharge. Patient should comply with medication recommendations and physical care as patient requires assistance with ADLs [Activities of Daily Living] and other tasks."

5. In patient 7's Psychosocial Assessment, dated 11/10/17, the Discharge Plan stated: "Once stabilized, pt. will discharge home with OP [Outpatient] services scheduled and further resources/recommendations." "Pt will not endorse suicidal ideation, plan, or intent. [S/he] will participate in resources. Pt. will be able to identify at least three (3) healthy coping strategies to implement during times of anxiety and/or stress."

6. In patient 8's Psychosocial Assessment, dated 11/13/17, the Discharge Plan stated: "Patient will have reduced hallucinations to a point that is manageable as OP [Outpatient]. Patient will be compliant with medication recommendations while on inpatient and agree to continue medication and other treatment recommendations post discharge."

7. In patient 9's Psychosocial Assessment, dated 11/10/17, the Discharge Plan stated: "Patient will not exhibit physical aggression for at least three (3) days prior to discharge. [S/he] will communicate with staff and peers effectively and appropriately"---"Upon stabilization, [s/he] will return to Providence."

8. In patient 10's Psychosocial Assessment, dated 11/8/17, the Discharge Plan stated: "Once stable, pt will return to [name of facility]"---"Pt. will not exhibit sexually inappropriate behavior for at least three (3) days prior to discharge."

None of the above Psychosocial Assessments described the specific role of the social worker in discharging.

B. Interviews

1. In an interview on 11/14217 at 1:43 p.m., the lack of the role of social worker in discharge planning on the Psychosocial Assessments was discussed with SW1. She felt that mentioning of where patients were being discharged to after leaving the facility in the Psychosocial Assessment was enough to assume that the social worker would be responsible for carrying out this task.

2. In an interview on 11/16/17 around 12:40 p.m., the lack of the specific role of social workers on their assessments was discussed with the Director of Social Work. He did not dispute the findings.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an inventory of specific personal assets that could be used in treatment for eight (8) of eight (8) active sample patients (1, 3, 5, 6, 7, 8, 9, and 10). This failure to identify assets impairs the treatment team's ability to choose treatment modalities that utilize patient's attribute in the therapy provided.

Findings:

A. Record Review

The admission Psychiatric Evaluations (dates of review in parenthesis) for the following active sample patients did not contain specific personal assets which could be useful in treatment:

1. The following Psychiatric Evaluations (dates of evaluations in parenthesis) did not list any assets: patient 1 (10/6/16), patient 3 (11/5/17), patient 5 (9/14/17), patient 6 (11/11/17), patient 8 (11/12/17), patient 9 (11/9/17), and patient 10 (11/8/17).

2. Patient 7 (11/9/17) listed the assets as "supportive family, no substance use." These two assets were not personal attributes the patient could use while hospitalized.

B. Interview

In an interview on 11/15/17 around 3:30 p.m., the lack of personal assets on the Psychiatric Evaluations was discussed with MD1. He agreed with the findings.

Based on interview and record review, the facility failed to ensure that Master Treatment Plans (MTPs) included deficient outcome patient goals for eight (8) of eight (8) active sample patients (MTPs dates in parentheses): Patient 1 (10/26/17); Patient 3 (11/5/17); Patient 5 (9/14/17); Patient 6 (11/13/17; Patient 7 (11/13/17); Patient 8 (11/13/17); Patient 9 (11/13/17): and Patient 10 (11/13/17). Goals were stated in non-measurable terms and did not identify or delineate specific outcome behaviors for patients. Patients' treatment compliance was listed as patient goals. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure the change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1. Patient 1

For the problem, "confused Thoughts/Behaviors," a non-measurable long-term goal was stated as "Think clearly enough to be able to return to normal activities for 2 days."

Non-measurable short-term goals were "Fears will decrease to a level that does not cause severe distress" and "Patient will have less episodes of paranoia and hallucinations."

A treatment compliance statement was listed as a short-term goal: "Pt. (Patient) will participate in Recreation Therapy Group daily x 5 days/week to increase self-awareness."

2. Patient 3

For the problem, "Aggressive behavior," a treatment compliance statement was listed as a short-term goal: "Pt. (Patient) will attend Recreation Therapy Group daily x 5 days/week to increase socialization and communication skills as behavior allows."

3. Patient 5

For the problem, "Hyperactive Behavior," a non-measurable short-term goal was listed as "Manic behavior decreased to baseline."

A patient treatment compliance statement was listed as a short-term goal: "Pt. (Patient) will participate in Recreation Therapy Group daily x 5 days/week to increase socialization as behavior."

A non-measurable short-term goal was listed as "Patient will have decreased episodes of manic behavior."

4. Patient 6

For the problem, "Threatening- Violent Behavior," a non-measurable short-term goal was stated as "Tolerate everyday frustrations/conflicts /s (without) temper outburst, threats or insults."

A patient treatment compliance statement was listed as a short-term goal: "Pt. (Patient) will attend 1 Recreation Therapy Group daily x 5 days/week to increase self-awareness as behavior allows."

5. Patient 7

For the problem, "Suicidal Thoughts," a patient treatment compliance statement was listed as a short-term goal: "Pt. (Patient) will attend Recreation Therapy Group daily x 5 days/week to increase coping strategies."

6. Patient 8

For the problem, "confused thoughts + behaviors," the long-term goal was a non-measurable statement: "Achieve clear thinking and reduced paranoia." A non-measurable short-term goal was "Fears will decrease to a level that does not cause severe distress."

Patient treatment compliance statements were listed as short-term goals: "Pt. [Patient] will participate in group recreational therapy 1 group daily x 5 days/week to improve coping skills" and "Pt. [Patient] will attend 1 Recreation Therapy Group daily x 5 days/week to increase self-awareness."

7. Patient 9

For the problem, "violent/threatening behavior," a patient treatment compliance statement was listed as a short-term goal: "Pt. [Patient] will attend 1 Recreation Therapy Group daily x 5 days/week to decrease aggression."

8. Patient 10

For the problem, "Aggression + sexually inappropriate behavior," a non-measurable short-term goal was stated as "Pt. [Patient] will communicate appropriately and will not (illegible) sexual preoccupation at least 5 days prior to D/C [Discharge]."

A patient treatment compliance statement was listed as a short-term goal: "Pt. [Patient] will attend 1 Recreation Therapy Group daily x 5 days/week to increase self-awareness."

B Interview

During an interview, with a review of treatment plans, on 11/15/17 at 10:00 a.m., the Director of Nursing (DON) and the Director of Social Work verified the above findings.

Based on observation, interview, and record review, the facility failed to develop and document individualized treatment interventions with specific purpose and focus based on the needs of eight (8) of eight (8) sample patients (Master Treatment Plan dates in parentheses): Patient 1 (10/26/17); Patient 3 (11/5/17); Patient 5 (9/14/17); Patient 6 (11/13/17; Patient 7 (11/13/17); Patient 8 (11/13/17); Patient 9 (11/13/17); and Patient 10 (11/13/17). Treatment plans lacked physician interventions and failed to list interventions to guide nursing personnel in the care of patients presenting with violence toward self or others. In addition, patient behaviors were listed as staff interventions. This deficiency results in a failure to provide a basis for accurate implementation, evaluate treatment provided, and to plan revisions based on individual patient needs and findings.

Findings include:

A. Record review

1. The treatment plans of all eight (8) patients (1, 3, 5, 6, 7, 8, 9, and 10) failed to include physician interventions, including prescribed medications.

2. Nursing, social work, and therapeutic recreation interventions:

1. Patient 1

For the problem, "confused Thoughts/Behaviors," a generic role function was listed as a nursing intervention: "Medications as prescribed." There were no specific nursing interventions to address this patient's confusion in the clinical area.

A generic statement was listed as a Therapeutic Recreation intervention: "Express needs appropriately daily."

A patient behavior was listed as a therapeutic recreation intervention: "Follow directions to decrease agitation and anxiety daily."

Patient's treatment compliance expectations were listed as social work interventions: "Pt. [Patient] will participate in indiv+ (individual and) group therapy," "Pt. [Patient] will take medication as prescribed by doctor," and "Pt. [Patient] will participate in d/c [discharge] planning if able."

2. Patient 3

For the problem, "Aggressive behavior," there were no specific nursing interventions to guide nursing personnel in the monitoring and prevention of aggressive behaviors in the clinical area. Only nursing care guidelines were listed: "Allow control over aspects every [sic] day routine," "Provide positive feedback for proper behavior" and "Approach in a calm confident behavior."

Patient 's treatment compliance was listed as social work interventions: "Engage in up to three (3) wkly [weekly] ind [individual] clinical sessions to ensure appropriate (illegible word)," "Participate in up to three (3) weekly grp (group) sessions on anger management + healthy coping." A generic social work intervention was listed as "Assist with D/C [discharge] planning return [sic] to SNF [skilled nursing facility]."

Patient behaviors were listed as therapeutic recreation interventions: "Express self without aggressive behavior daily," "Verbalize emotions clearly and appropriately daily," and "Interact with others without aggressive behaviors daily."

3. Patient 5

For the problem, "Hyperactive Behavior," generic nursing interventions were listed as "Group therapy 3x week" and "Med [Medication] compliance." Even though this patient was observed on 11/14/17 at 11:10 a.m. and at 1:45 p.m. to be agitated (continually walking around the unit) and hallucinating (talking to him/herself), there were no specific nursing interventions to address these behaviors.

Patient behaviors and treatment compliance were listed as therapeutic recreation interventions: "Express self clearly and slowly daily," Attend unit leisure activities daily," and "Obtain 1:1 monitor and support weekly."

Patient treatment compliance was listed as social work interventions: "Pt. (Patient) will attend indiv + [individual and] group therapy," "Pt. [Patient] will take medication as prescribed," and "Pt. [Patient] will participate in d/c [discharge] planning if able."

4. Patient 6

For the problem, "Threatening- Violent Behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Not be allowed to harm self, others, property." There were no specific nursing interventions to guide nursing personnel in specific monitoring and prevention of aggressive behaviors in the clinical area.

Patient treatment compliance was listed as social work interventions: "Pt. [Patient] will participate in up to 3 weekly groups to increase socialization," "Engage in up to 3 weekly indiv [individual] sessions to practice healthy coping when agitated," and "As able, assist /w [with] D/C [Discharge] planning - D/C back to nursing home."

Patient behaviors were listed as therapeutic recreation interventions: "Express self and needs without aggression daily," "Engage in unit activities without aggressive behaviors daily," and Obtain 1:1 monitor [sic] and support weekly."

5. Patient 7

For the problem, "Suicidal Thoughts," nursing care guidelines were listed as interventions: "Offer emotional support for patient" and "Pt. (patient) to express feelings appro (appropriate)." There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of suicidal behaviors in the clinical area.

Patient 's treatment compliance was listed as social work interventions: "Attend up to three (3) wkly [weekly] groups on health coping + depression," "Engage in up to 3 weekly ind (individual) sessions to enhance emotional support." "A generic social work intervention was listed as "Assist with D/C [discharge] planning -D/C home, set up OP [Out Patient]."

Patient behaviors were listed as therapeutic recreation interventions: "Identify emotions and triggers daily." "Identify coping skills daily" and "Express 0 self-harm daily."

6. Patient 8

For the problem, "confused thoughts + behaviors," nursing care guidelines were listed as interventions: "Provide reassurance + support when fearful," "Provide positive feedback for proper behavior," and "Offer short, concise explanations,"

A generic nursing intervention was stated as "Assist with D/C [Discharge] planning-return to home."

Patient behaviors were listed as therapeutic recreation interventions: "Express self clearly daily," Identify stressors daily," and "Obtain 1:1 monitor and support weekly."

7. Patient 9

For the problem, "violent/threatening behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Provide positive feedback for proper behavior." There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of violent, threatening behaviors in the clinical area.

Patient 's treatment compliance was listed as social work interventions: "Attend up to three (3) groups wkly [weekly] on healthy coping + symptom awareness" and "Engage in up to three (3) weekly ind [individual] sessions to socialize w/ [with] therapist."

A generic social work intervention was stated as "As able, assist w/ [with] D/C [Discharge] planning-return to NH [Nursing Home]."

Patient behaviors were listed as therapeutic recreation interventions: "Identify stressors daily," Express self without threats daily" and "Obtain 1:1 monitor and support weekly."

8. Patient10

For the problem, "Aggression + sexually inappropriate behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Offer opportunity for gross motor activity."

There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of aggression and sexual behaviors in the clinical area.

Patient 's treatment compliance was listed as social work interventions: "Attend up to three (3) wkly grps [weekly groups] to (illegible) socialization" and "Engage in up to three (3) weekly individual sessions to (illegible) appropriate communications."

A generic social work intervention was stated as, "As able, assist w/ [with] D/C [Discharge] planning-return to (illegible name)."

Patient behaviors were listed as therapeutic recreation interventions: "Identify behaviors and coping skills daily," "Express self without sexual inappropriate behaviors daily, and "Follow redirection without aggressions daily."

B. Interview

During an interview, with a review of treatment plans, on 11/15/17 at 10:00 a.m., the DON and the Director of Social Work verified the above findings.

Based on observation, record review, and interview, the facility failed to ensure that active individualized psychiatric care was provided for three (3) of eight (8) active sample patients (5, 8, and 9). There was a failure to provide structured treatment for these patients' specialized treatment needs. These patients functioned at low cognitive and social functioning levels, yet adequate modalities to address their problems were not provided. The failure to ensure active treatment results in the patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement.

Findings include:

A. Patient 6

1. Patient 6 was admitted on 11/10/17. The Psychiatric Evaluation, dated 11/11/17, documented: "An 87 year old [male/female] presenting with depression with increased agitation, bizarre behavior, and psychosis beyond [his/her] baseline. Writer met with CLT [Client] who was lying in bed. CLT was completely unoriented [sic] apart from knowing [his/her] birthdate. CLT demonstrated paralysis on [his/her] left side and largely spoke incoherently. CLT repeatedly mumble that [s/he] needed to use the bathroom but didn't because [s/he] didn't have shoes on. Per records and CLT's nurse, CLT was aggressive upon arrival to ED [sic], likely out of confusion, and had to be sedated with Haldol. Nurse reported CLT has been calm and compliant since and is in a posey vest. Writer spoke in person with CLT's daughter, [name of daughter] who reported baseline is to be unoriented. However, [name of daughter] reported her [father/mother] has been increasingly agitated and acting bizarrely [i.e. stating [s/he] wants to burn the house down by using a screwdriver, throwing food on the porch and denying it]. [Name of daughter] also reported her [father/mother] has appeared delusional lately, much more than normal [i.e. paranoid belief that people are trying to poison [him/her] with [his/her] medication or food, belief that [his/her] [husband/wife] is cheating on [him/her], belief that the police gave [him/her] a gun to protect [him/herself]."

2.The patient was observed going up and down the hallway in his/her wheelchair while a chaplain group was being conducted in the dayroom around 10:40 a.m. The patient did not attend the group in the dayroom.

3. There were no specific groups listed on patient 6's Master Treatment Plan, dated 11/17/17.

4. A review of group notes for the period of 11/13 - 11/14/17 [no times of groups listed] showed that patient 6 did not attend most of the therapeutic groups held on the unit as follows:

- 11/13/17 - "Pt participating in group. Pt was pleasant and interactive with dog and handler."

- 11/13/17 - "Pt in day area. Pt pleasant and responded to questions, but answered often one word. Pt. smiled and then began to drift off to sleep, struggling to remain awake."

- 11/13/17 - "Due to lack of pt participation, group was cancelled for today. Pt. unavailable due to testing and did not attend group."

- 11/13/17 - "Pt. unavailable due to meeting with nurse practitioner and did not attend group at this time."

- 11/14/17 - "Pt did not participate in group. Pt will continue to be encouraged to participate in future sessions."

- 11/14/17 - "Pt. did not participate in group. Pt. will continue to be encouraged to participate in future sessions. Pt. complained of burning in throat and nursing staff notified."

- 11/14/17 - "Pt was invited to group. Pt declined. Pt seeking help for burning throat. Nursing staff notified. Pt did not attend group at this time."

- 11/14/17 - "Pt was invited to group. Pt declined. Pt did not attend group at this time."

5. The Precaution Checklist sheet (for every 15 minute checks of patient's location on the unit) showed the following location of patients during the groups on the unit:

- 11/03/17 - 8:00 a.m. - "Community meeting" - "Pt out on unit."

- 9:30 a.m. - "TR (Therapeutic recreation)" - "Pt. out on unit."

- 3:30 p.m. - "Social work group" - Pt "sitting idly."

- 6:00 p.m. - "Group opportunity" - Pt. "out on unit."

6. In an interview on 11/15/17 at 12:30 p.m. with MD1 who was covering for patient 6's physician who was covering for patient 6's physician who was away from the facility at this time, the lack of the patient not attending many groups was discussed. MD1 agreed that nursing staff should provide 1:1 [one to one] with the patient as an alternative to this patient not attending groups.

B. Patient 8

1. Patient 8 was admitted on 11/12/17. The Psychiatric Evaluation, dated 11/12/17, documented: "The patient is a 75 year old white [male/female], who was admitted on Geropsych Unit due to having headache and hallucinations. [S/he] had been off [his/her] medications. [S/he] does not believe in taking medications. [S/he] states [s/he] lives with [his/her] nephew in [his/her] brother's house. [S/he] states that [s/he] was working and was unable to work, so [s/he] got upset and was unable to lay down and rest, so [s/he] started feeling pretty weak. [S/he] talked to [his/her] nephew, who brought [him/her] to the ER [emergency room], and [s/he] was admitted to the Psych Unit. [S/he] denied any hallucinations or paranoia. [S/he] has a history of Schizoaffective Disorder, depressive type; unspecified anxiety disorder; and borderline intellectual functioning. [S/he] reports going off the road, walking, and picking up stuff and burning them. [S/he] reports being picked up by police twice. [S/he] had services at Meridian Health Services in the past. Right now [s/he] states [his/her] headache is gone, [s/he] is feeling better, mood is better. [S/he] denies any hallucinations or paranoia. [S/he] denies any suicidal or homicidal ideations."

2. The patient was observed on 11/14/17 around 10:30 a.m. in bed with head covered with a blanket during the Chaplain Group being held at that time in the Dayroom.

3. The patient's Master Treatment Plan, dated 11/12/17, did not contain any specific groups listed as yet since [s/he] was a new admission.

4. A review of group notes for the period of 11/13/17 - 11/14/17 (no times of groups listed) showed that patient 8 did not participate in most of the Therapeutic Recreation Groups held on the unit as follows:

- 11/13/17 - "Pt was asleep and did not participate at this time. Pt will continue to be encouraged to attend in future groups"

- 11/13/17 - "Due to lack of pt participation, group was cancelled for today. Pt struggled to engage and respond, not typical of pt."

- 11/13/17 - "Pt was asleep and did not participate at this time. Pt will continue to be encouraged to attend future groups."

- 11/13/17 - "Pt initially expressed interest in group and left room to go to day area. Pt was unsteady on [his/her] feet and stated [s/he] was woozy due to medicine." "Pt assisted to change in day area. Pt fell asleep and was unresponsive when attempts were made to awaken pt to visit therapy dog." "Pt did not actively participate in group at this time."

- 11/14/17 - 'Pt was invited to group. Pt declined. Pt did not attend group at this time."

- 11/14/17 - "Pt unavailable due to meeting with [name of person] and did not attend group at this time."

- 11/14/17 - "Pt did not participate in group. Pt will continue to be encouraged to participate in future sessions."

- 11/14/17 - "Pt was invited to group. Pt declined. Pt did not attend group at this time."

- 11/14/17 - "Pt was lying in bed at time of encounter where writer had observed that pt has spent significant time. Writer did not observe pt in Dayroom however did see pt walk towards activity room during group time."

5. The "Precaution Checklist Sheet (for every 15 minute check)" showed the following location of patients during the groups on the unit:

- 11/12/17 - 9:30 a.m. - "Group Opportunity" - "Pt was in bathroom."

- 11/12/17 - 3:30 p.m. - "Social Work Group" - "Pt resting, sleeping."

- 11/12/17 - 6:00 p.m. - "Group Opportunity" - "Pt was resting, sleeping."

- 11/13/17 - 9:30 a.m. - "TR Group - "Pt was resting, sleeping."

- 11/13/17 - 10.00 a.m. - "Pet Therapy" - "Pt was resting, sleeping."

- 11/13/17 - 10:30 a.m. - "Social Work Group" - "Purposeful activity."

- 11/13/17 - 2:30 p.m. - "TR Group" - "Pt was resting, sleeping."

- 11/13/17 - 3:30 p.m. - "Social Work Group" - "Purposeful activity."

- 11/13/17 - 6:00 p.m. - "Group Opportunity" - Out on unit."

6. In an interview on 11/15/17 at 12:30 p.m. with the physician (MD1) covering for patient 8's physician who was away from the facility during the survey, the lack of the patient not attending many groups was discussed. MD1 agreed that nursing staff should provide 1:1 with the patient as an alternative to this patient not attending groups.

C. Patient 9 was a 61-year old patient admitted on 11/10/17

1. According to the psychiatric evaluation (11/10/17), Patient 9 had "hx [history] of Major Neurocognitive Disorder" and was admitted to this facility due to "physical aggression." This assessment documented that the patient had an "established hx [history] of Dementia with vascular etiology."

2. On 11/14/17 at 11:10 a.m. and 1:45 p.m. and on 11:15/17 at 9:00 a.m. and 10:30 a.m. Patient 9 was observed sitting in a wheelchair recliner in the dayroom usually watching television. During an interview at 11:10 a.m., when asked if s/he was going to attend the 1:00 a.m. group, Patient 9 responded, "No." When asked how s/he spent his/her time in the hospital, Patient 9 responded, "Sitting and watching TV."

3. During an interview on 11:15 17 at 11:30 a.m. RN 1 and SW 2 reported that Patient 9 sits in dayroom most of the day. They reported that s/he has refused to attend groups. RN 1 reported that nursing staff is not meeting with Patient 9 other than to assess and monitor and care for physical needs. SW 1 reported that she meets individually with Patient 9 two to three times weekly to "talk about coping skills." Review of progress notes related to these individual sessions revealed that SW 2 met with Patient 9 on 11/13/17 and 11/14/17. According to the progress notes, these meetings addressed Patient 9's "discharge."

4. Review of Patient 9's comprehensive treatment (9/13/17) revealed that this patient is assigned to attend "up to 3 groups wkly [weekly] on health coping + symptom awareness." The only individual sessions are those reported above by the social worker stated as "Engage in up to 3 wkly [weekly] ind [individual] sessions to socialize w/ [with] therapist." Based on Patient 9's low cognitive abilities the focus of the assigned groups and individual sessions are likely beyond this patient cognitive level of understanding.

5. Even though Patient 9 was not attending groups and was not able to cognitively participant in his/her assigned treatment, the treatment plan had not been revised as of 1:00 p.m. on 11/15/17.

Based on record review and interview, the Medical Director failed to ensure

1. that Psychiatric Evaluations included an inventory of specific personal assets that could be used in treatment for eight (8) of eight (8) active sample patients (1, 3, 5, 6, 7, 8, 9, and 10). This failure to identify assets impairs the treatment team's ability to choose treatment modalities that utilize patient's attribute in the therapy provided. (Refer to B117)

2. that Master Treatment Plans (MTPs) included deficient outcome patient goals for eight (8) of eight (8) active sample patients (MTPs dates in parentheses): Patient 1 (10/26/17); Patient 3 (11/5/17); Patient 5 (9/14/17); Patient 6 (11/13/17; Patient 7 (11/13/17); Patient 8 (11/13/17); Patient 9 (11/13/17); and Patient 10 (11/13/17). Goals were stated in non-measurable terms and did not identify or delineate specific outcome behaviors for patients. Patients' treatment compliance was listed as patient goals. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure the change in the patient consequent to treatment interventions. (Refer to B121)

3. the development and documentation of Individualized Treatment Interventions with specific purpose and focus based on the needs of eight (8) of eight (8) sample patients (Master Treatment Plan dates in parentheses): Patient 1 (10/26/17); Patient 3 (11/5/17); Patient 5 (9/14/17); Patient 6 (11/13/17; Patient 7 (11/13/17); Patient 8 (11/13/17); Patient 9 (11/13/17); and Patient 10 (11/13/17). Treatment plans lacked physician interventions and failed to list interventions to guide nursing personnel in the care of patients presenting with violence toward self or others. In addition, patient behaviors were listed as staff interventions. This deficiency results in a failure to provide a basis for accurate implementation, evaluate treatment provided, and to plan revisions based on individual patient needs and findings. (Refer to B122)

4. that active individualized psychiatric care was provided for three (3) of eight (8) active sample patients (5, 8, and 9). There was a failure to provide structured treatment for these patients' specialized treatment needs. These patients functioned at low cognitive and social functioning levels, yet adequate modalities to address their problems were not provided. The failure to ensure active treatment results in the patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125)

Based on interview and document review, the Director of Nursing (DON) failed to meet the educational or on-going consultation and/or training requirements necessary for her administrative position as Executive Nurse within this facility. This hindered direction for the nursing department and the level of care provided by nursing personnel.

Findings include:

Review of the Director of Nursing's resume and interview on 11/14/17 at 3:00 p.m. revealed that she had a Bachelor of Science in Nursing. She reported that she does not currently have ongoing the consultation with a nurse with a Master's degree in Psychiatric/Mental Health or sufficient on-going training programs directly related to nursing care delivered in this facility.

Based on observation, interview and document review, the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that master treatment plans included sufficient nursing interventions to care for the individual needs of patients:

Findings include:

1. Patient 1

For the problem, "confused Thoughts/Behaviors," a generic role function was listed as a nursing intervention: "Medications as prescribed." There were no specific nursing interventions to address this patient's confusion in the clinical area.

2. Patient 3

For the problem, "Aggressive behavior," there were no specific nursing interventions to guide nursing personnel in the monitoring and prevention of aggressive behaviors in the clinical area. Only nursing care guidelines were listed: "Allow control over aspects every (sic) day routine," "Provide positive feedback for proper behavior" and "Approach in a calm confident behavior."

3. Patient 5

For the problem, "Hyperactive Behavior," generic nursing interventions were listed as "Group therapy 3x week" and "Med [Medication] compliance." Even though this patient was observed on 11/14/17 at 11:10 a.m. and at 1:45 p.m. to be agitated (continually walking around the unit) and hallucinating (talking to him/herself), there were no specific nursing interventions to address these behaviors.

4. Patient 6

For the problem, "Threatening- Violent Behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Not be allowed to harm self, others, property." There were no specific nursing interventions to guide nursing personnel in specific monitoring and prevention of aggressive behaviors in the clinical area.

5. Patient 7

For the problem, "Suicidal Thoughts," nursing care guidelines were listed as interventions: "Offer emotional support for patient" and "Pt. [patient] to express feelings appro [appropriate]." There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of suicidal behaviors in the clinical area.

6. Patient 8

For the problem, "confused thoughts + behaviors," nursing care guidelines were listed as interventions: "Provide reassurance + support when fearful," "Provide positive feedback for proper behavior," and "Offer short, concise explanations,"

A generic nursing intervention was stated as "Assist with D/C [Discharge] planning-return to home."

7. Patient 9

For the problem, "violent/threatening behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Provide positive feedback for proper behavior." There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of violent, threatening behaviors in the clinical area.

8. Patient10

For the problem, "Aggression + sexually inappropriate behavior," nursing care guidelines were listed as interventions: "Approach in calm confident manner," "Offer short concise explanations," and "Offer opportunity for gross motor activity." There were no specific nursing interventions to guide nursing personnel in the specific monitoring and prevention of aggression and sexual behaviors in the clinical area.

B Interview

During an interview, with a review of Master Treatment Plans, on 11/15/17 at 10:00 a.m., the DON verified the above findings.

II. Ensure that active individualized psychiatric treatment was provided for 3 of 8 active sample patients (6, 8 and 9). There was a failure to provide structured treatment for these patients' specialized treatment needs. These patients functioned at low cognitive and social functioning levels, yet adequate modalities to address their problems were not provided. The failures to ensure active treatment resulted in the patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125.)

Based on information from the CEO during the entrance conference on 11/10/17 around 9:40 a.m., he stated that the facility failed to have available psychological services to meet the needs of the patients. Without access to such services the differential diagnosis of certain psychiatric conditions, especially major neurocognitive disorders as defined in DSM-5 is less accurate than it needs to be in order to permit specific interventions, including neuroimaging and specific pharmacotherapy.

Based on document review and interview, the Chief Executive Officer, the Medical Staff and the Director of Nursing failed to ensure the QAPI (Quality Assurance and Performance Improvement) program addressed any problems identified by the IC (infection control) program for 6 of 6 quarters in 2016 and 2017.

Findings include:

1. The policy/procedure Infection Control Plan of Service (approved 5-08) indicated the following: "The (facility) Hospital Infection Control Committee (ICC) is responsible for identifying, prioritizing and addressing the risks for acquiring and transmitting infections within the population being served... Maintain appropriate surveillance, data analysis and reporting activities to control or prevent the spread of healthcare associated infections... [and]... Provide for effective implementation of policy..."

2. Review of the QAPI and IC committee meeting documentation for 5/25/16, 8/24/16, 11/30/16, 2/22/17, 5/24/17 and 8/23/17 indicated the following: "...Geropsych Agenda... B) Infection Control meeting..." and no other documentation provided for review indicated any IC surveillance was conducted or any problems identified by IC surveillance and/or data analysis were reported and addressed by the IC or QAPI committee.

3. On 11-16-17 at 1045 hours, the Vice President of Clinical Services, staff A1 confirmed the QAPI and IC meeting minutes lacked documentation indicating any IC problems were presented and addressed and no other documentation was available.