HospitalInspections.org

Based on observation, interview and document review, the hospital failed to:

I. Revise the Master Treatment Plans of 2 of 2 active sample patients (D9 and B21) following staff use of chemical restraints. This failure results in Master Treatment Plans that fail to reflect the individual needs of patients as their acuity changes during hospitalization and fails to direct staff in a clear comprehensive manner to reduce a patient's distress. (Refer to B118)

II. Develop and document Master Treatment Plans for 8 of 8 active sample patients (A15, B1, B21, C7, C20, D9 and D11) based on the patient's needs. The short-term treatment goals for these patients were selected from preprinted forms with lists of goals that were not measurable or focused (Refer to B121), and the staff interventions were generic discipline tasks instead of individualized interventions. (Refer to B122). The absence of an integrated, comprehensive treatment plan results in a lack of coordinated and organized treatment.

III. Ensure that active individualized psychiatric care was provided for 3 of 8 active sample patients (B21, D9 and D11). Patient B21 failed to receive the individual 1:1 therapy designated in the treatment plan and remained severely ill while she/he refused needed medications. The treatment team failed to initiate a court order to force medications in a timely fashion. Patients D9 and D11 were admitted with histories of sexual abuse, and they exhibited sexualized behaviors during hospitalization. The treatment team failed to design and implement a treatment plan to appropriately address these issues. These failures result in a safety risk for all patients on the ward and in patients being hospitalized without all interventions for recovery being provided. (Refer to B125)

Based on observation, interview and document review, the facility failed to assure that the Medical Director and Director of Nursing adequately monitored active treatment and took corrective action when patient care required reassessment. Specifically,

I. The Medical Director failed to ensure that: 1) policy and procedures were developed and implemented, specifying the requirement for a review/investigation following patient suicide attempts; 2) psychiatric evaluations included an inventory of patients' assets; 3) Master Treatment Plans specified appropriate goals and interventions, 4) active individualized psychiatric care was provided for all patients; 5) the least restrictive methods were used for external control of patients' aggressive and agitated behaviors; and 6) discharge summaries described the treatment received and patients' status on discharge. (Refer to B144)

II. The Director of Nursing failed to assure that: 1) policy and procedures were developed and implemented, specifying the requirement for a review/investigation following patient suicide attempts during hospitalization; 2) Master Treatment Plans included nursing interventions individualized for patients; 3) the least restrictive methods for external control of aggressive and agitated behavior was used, based on individual patient findings/needs; and 4) nursing staff provided appropriate safety monitoring and supervision for patients while in seclusion. (Refer to B148)

These failures prevent patients from receiving appropriate care and treatment in a safe environment, enabling them to achieve an optimal level of functioning and discharge in a timely manner.

Based on record review and interview, the facility failed to ensure that the Social Work Assessments for 8 of 8 active sample patients (A8, A15, B1, B21, C7, C20, D9 and D11) documented the anticipated role of the Social Worker in treatment and discharge planning. This failure results in a lack of information to formulate social service interventions for patients.

Findings include:

A. Record Review

The "Adult Initial Database/Psycho Social History" was a four page preprinted form completed in hand writing by the assigned social worker. The form had prompts for collection of basic social information to be used in treatment and discharge planning. The last two sections were labeled "Discharge Planning" and "Assessment Summary of Identified Problems and Treatment Recommendations." Each of these sections had several blank lines for staff to fill in. The specific roles for social work in treatment were not identified, and the information written in the discharge plan was very limited.

1. Patient A8 had a Database/Psychosocial completed 6/18/11. The "Discharge Planning" section only said "Patient expected to return home." The "Assessment Summary of Identified Problems and Treatment Recommendations" said "...Recommend GT [group therapy] and IT [individual therapy] to increase motivation for compliance." No further role for the Social Worker (SW) was identified, including assessing the family/home for safety issues.

2. Patient A15 had a Psychosocial Update (2 page form) completed 6/22/11. The "Discharge Planning" section said "Return home. F/U with Dr. [X] within 1 week of discharge." The "Summary of Problems and Treatment Recommendations" were "...Recommend stabilization, medication/illness mgmt [management], stress mgmt. and IT, FT [family therapy], GT." No further role for the Social Worker (SW) was identified, including assessing the reasons the patient had several admissions to the hospital within a short time.

3. Patient B1 had a Database/Psychosocial completed 6/12/11. The "Discharge Planning" section said "Clt. [client] Plans are to move home with his brother that drinks alcohol.[sic]." The "Assessment Summary of Identified Problems and Treatment Recommendations" said "...Recommend IT/GT to increase coping skills and motivate for recovery." No further role for the Social Worker (SW) was identified.

4. Patient B21 had a Database/Psychosocial completed 6/16/11. The "Discharge Planning" section said "Pt. is unreliable historian. Pt. likely to return to her PCH [sic] and see Dr. [Y] for med. mgmt. on d/c." The "Assessment Summary of Identified Problems and Treatment Recommendations" said "...Recommend IT/GT to increase coping skills and increase reality based thinking and behavior." No further role for the Social Worker (SW) was identified.

5. Patient C7 had a Child and Adolescent Initial Database/Psychosocial History completed 6/22/11. The "Discharge Planning" section said "Return home. Return to school in the fall. F/U [follow up] with psychiatrist & outpatient therapy." The "Assessment Summary of Identified Problems and Treatment Recommendations" said "...Recommend med stabilization, IT, FT, GT to increase coping skills, anger management, increase impulse control, increase communication with family." It was unclear what the specific role for the SW was in this generic plan.

6. Patient C20 had a Child and Adolescent Initial Database/Psychosocial History completed 6/29/11. The "Discharge Planning" section said "Return home to family. Followup with doctor within 1 wk of D/C [discharge]." The "Assessment Summary of Identified Problems and Treatment Recommendations" said "...Recommend stabilization, IT, FT and GT." It was unclear what the specific role for the SW was in this generic plan.

7. Patient D9 had a Child and Adolescent Psychosocial Update completed 5/31/11.The Discharge Planning section said "Return home. Return to school. Followup with outpatient psychiatrist and therapist w/in one week of D/C." The Summary of Problems and Treatment Recommendations had no treatment recommendations listed and no role for the SW was identified.

8. Patient D11 had a Child and Adolescent Initial Database/Psychosocial History completed 6/23/11. The "Discharge Planning" section said "Return to placement deemed by CPS. Further education. Followup with outpatient therapist & psychiatrist." The "Assessment Summary of Identified Problems and Treatment Recommendations" stated "...Recommend medication stabilization, IT, FT and GT." It was unclear what the specific role for the SW was in this generic plan.

B. Staff Interview

In an interview on 7/1/11 at 9AM, the Director of Social Work agreed that the psychosocial assessment should be more individualized and that the role of the SW in the assessment should be more specific and complete.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an inventory of patient assets for 5 of 8 active sample patients (A8, B21, C7, D9 and D11). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation.

Findings include:

A. Record Review

The facility's psychiatric evaluation form included a section titled "INVENTORY OF PATIENT'S STRENGTHS/ASSETS." This section of the evaluation had a long list of possible choices with boxes to check. There also were extra lines to elaborate on specific details.

1. Patient A8 had a psychiatric evaluation on 6/15/11. A note said the patient was uncooperative and the STRENGTHS/ASSETS list had nothing checked. On 6/28/11 and 6/29/11, the form was completed as the patient became more cooperative, but again, nothing was checked for STRENGTHS/ASSETS. This is not useful in treatment planning.

2. Patient B21 had a psychiatric evaluation on 6/15/11 which had nothing checked on the STRENGTHS/ASSETS list.

3. Patient C7 had a psychiatric evaluation on 6/20/11 which only had "Family support and involvement" checked on the STRENGTHS/ASSETS list with an illegible word written in next to it. This is of limited use in treatment planning.

4. Patient D9 had a psychiatric evaluation on 5/31/11 with "Family support and involvement" and "Ability to care for self (ADLS)" checked on the STRENGTHS/ASSETS list. This is of limited use in treatment planning.

5. Patient D11 had a psychiatric evaluation on 6/22/11 which had "Family support and involvement" checked on the STRENGTHS/ASSETS list with "family supportive" written in next to it. This is of limited use in treatment planning.

B. Staff Interview

The Medical Director was interviewed on 6/30/11 at 11:20AM. The issue of the range of quality in identifying assets in the psychiatric evaluation was discussed. The Medical Director acknowledged the problem.

Based on interview and record review, the hospital failed to:

I. Revise the Master Treatment Plans of 2 of 2 active sample patients (D9 and B21) following staff use of chemical restraints. Both of these patients were administered combination intramuscular [IM] medications for behavior control. The MTPs were not revised after the use of these medications, documenting the less restrictive interventions to be used prior to future use of these medications. Failure to revise the Master Treatment Plan to address the individual needs of patients as their acuity changes results in lack of direction to staff in providing needed care.

Findings include:

A. Patient D9 was given Haldol 2 mg, Ativan 1mg and Benadryl 25 mg together in an IM injection on 6/8/11 and 6/13/11. As of 6/30/11, the patient's Master Treatment Plan dated 5/30/11 had not been revised.

B. Patient B21 was given Haldol, Ativan and Benadryl together in an IM injection on 6/27/11. As of 6/30/11, the patient's Master Treatment Plan dated 6/14/11 had not been revised.

B. Staff Interviews

1. In an interview on 6/30/11 at 10:30a.m., Physician B4 (primary psychiatrist for patient B21) agreed that the patient's treatment plan was not adequately individualized (revised to reflect the patient's changing needs).

2. In an interview on 7/1/2011 at 9:05a.m., which included a review of the Master Treatment Plan for Patient D9. the Director of Social Work verified that patient's treatment plan did not reflect the patient's specific care needs.

4. In an interview on 7/1/2011 at 10:55a.m., which included a review of the Master Treatment Plan for Patients D9, the Director of Nursing and Assistant Director of Nursing acknowledged that lack of treatment plan revisions to address the patient's needs.

II. Develop and document Master Treatment Plans for 8 of 8 active sample patients (A15, B1, B21, C7, C20, D9 and D11) based on the individual patient's needs. The short-term treatment goals for these patients were selected from preprinted forms with lists of goals that were not measurable or focused (Refer to B121), and the staff interventions were generic discipline tasks instead of individualized interventions. (Refer to B122). The absence of an integrated, comprehensive treatment plan results in a lack of coordinated and organized treatment.

Based on interview and record review, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (A8, A15, B1, B21, C7, C20, D9 and D11). This failure hinders the treatment team's ability to measure change in the patient.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A8 (6/15/11)

a. For the problem, "Thought Disorder," the short-term goal was stated as "Describe 2 coping strategies to utilize while in the hospital." The specific coping strategies were not specified.

b. For the problem, "Violence and Aggression," a non-measurable short-term goal was stated as "Utilize internal controls for violent/aggressive thoughts and/or impulses."

2. Patient A15 (6/14/11)

a. For the problem, "Mood Disorder: Manic," a non-measurable short-term goal was stated as "Verbalize or demonstrate significant reduction in depressive symptoms"

Another short-term goal for this problem was stated as "Describe 2 coping strategies to utilize while in the hospital." The type or focus of the specific coping strategies was not specified.

Another short-term goal was stated as "Describe 2 strategies to decrease/minimize symptoms of mood disturbance." This goal did not state the specific type of mood disturbance symptoms the strategies are to address.

b. For the problem, "Substance Abuse/Addiction, Drugs," a non-measurable short-term goal was stated as "increase knowledge of disease and process of recovery."

3. Patient B1 (6/10/11)

a. For the problem, "Schizoaffective Disorder," a non-measurable short-term goal was stated as "Verbalize or demonstrate significant decrease in depressive symptoms."

Another short-term goal for this problem was stated as "Describe 3 coping strategies to utilize while hospitalized." The type or focus of the specific coping strategies was not stated.

b. For the problem, "Violence and Aggression," a non-measurable short-term goal was stated as "Re-establish sense of hope for self and future."

4. Patient B21 (6/14/11)

For the problem, "Mood Disorder: Manic," a non-measurable short-term goal was stated as "Develop ability to recognize and stabilize early signs of manic behaviors."

Another short-term goal was stated as "Describe 2 strategies to decrease/minimize symptoms of mood disturbance." This goal did not state the specific strategies.

5. Patient C7 (6/20/11)

a. For the problem, "Mood Disorder: Mixed Mood State," non-measurable short-term goals were stated as "Verbalize or demonstrate significant reduction in depressive symptoms" and "Verbalize or demonstrate significant reduction in manic symptoms."

Another short-term goal was stated as "Describe 2 strategies to decrease/minimize symptoms of mood disturbance." This goal did not state the specific strategies.

b. For the problem, "Attention Deficit Disorder/Hyperactivity," non-measurable short-term goals were stated as "Develop the ability to complete a task," "Develop the ability to cope with impulsive behavior" and "Develop 2 skills to follow instruction."

c. For the problem, "Violence and Aggression," a non-measurable short-term goal was stated as "Demonstrate a significant decrease in violent, aggressive, related target behaviors."

d. For the problem, "Substance Abuse/Addition, Drugs," a non-measurable short-term goal was "Acquire necessary skills to maintain long-term sobriety."

6. Patient C20 (6/25/11)

a. For the problem, "Substance Abuse/Addition, Drugs," a non-measurable short-term goal was stated as "Acquire necessary skills to maintain long-term sobriety."

b. For the problem, "Violence and Aggression," non-measurable short-term goals were stated as "Demonstrate a significant decrease in violent, aggressive, related target behaviors," "Utilize internal controls for violent/aggressive thoughts and/or impulses" and "Develop 3 anger management skills."

c. For the problem, "Mood Disorder: Mixed Mood State," a non-measurable short-term goal was stated as "Verbalize or demonstrate significant reduction in depressive symptoms."

Another short-term goal for this problem was stated as "Describe 3 coping strategies to utilize while in the hospital." The specific type or focus of the coping strategies was not stated.

Another short-term goal was stated as "Describe 2 strategies to decrease/minimize symptoms of mood disturbance." This goal did state the specific type of mood disturbance symptoms the strategies are to address.

Another short-term goal was "Resolve any conflict (i.e. family) which may preclude discharge to lesser level of care." The specific discharge conflict to be addressed was not stated.

d. For the problem, "Violence and Aggression," a non-measurable short-term goal was stated as "Utilize internal controls for violent/aggressive thoughts and/or impulses."

7. Patient D9 (5/30/11)

a. For the problem, "Mood Disorder: Manic," a non-measurable short-term goal was stated as "Verbalize or demonstrate significant reduction in manic symptoms."

Another short-term goal for this problem was "Describe 2 coping strategies to utilize while in the hospital." The specific type or focus of the coping strategies was not stated.

Another short-term goal was stated as "Identify 2 high risk behaviors and 3 coping strategies to decrease those behaviors." This goal did not specify the type of high risk behaviors that were to be addressed.

b. For the problem, "Violence and Aggression," non-measurable short-term goals were stated as "Demonstrate a significant decrease in violent, aggressive, related target behaviors"; "Utilize internal controls for violent/aggressive thoughts and/or impulses"; "Re-establish sense of hope for self and future"; "Utilize internal controls for violent/aggressive thoughts and/or impulses" and "Develop 3 anger management skills."

8. Patient D11 (6/21/11)

a. For the problem, "Mood Disorder: Manic," a non-measurable short-term goal was stated as "Verbalize or demonstrate significant reduction in manic symptoms."

Another short-term goal for this problem was stated as "Describe 2 coping strategies to utilize while in the hospital." The specific coping strategies were not identified.

Another short-term goal was stated as "Identify 2 high risk behaviors and 3 coping strategies to decrease those behaviors." This goal did not specify the high risk behaviors or the coping strategies needed.

b. For the problem, "Attention Deficit Disorder/Hyperactivity," non-measurable short-term goals were stated as "Develop the ability to complete a task," "Develop the ability to cope with impulsive behavior," "Develop the ability to listen and follow instruction," "Develop 2 skills to complete task" and "Develop 2 skills to follow instruction."

B. Staff Interview

In an interview on 7/1/11 at 10:30a.m., which included discussion of the treatment plans, the Director of Nursing acknowledged that the some of the short term treatment goals on the patients' treatment plans were not measurable.

Based on interview and record review, the facility failed to

Develop Master Treatment Plans that identified physician (psychiatrist), nursing, social work, and recreation therapy (RT) interventions to address the specific treatment needs of 8 of 8 active sample patients (A.8, A15, B1, B21, C7, C20, D9 and D11). Each Master Treatment Plan included a list of preprinted interventions that were to be used for the patient by entering the "start date" for the listed intervention. The listed interventions were routine, generic discipline functions that lacked an individual focus for treatment. No additional interventions were added. In addition, the MTPs of patients A8, A15 and B1 listed no psychiatrist interventions, and the MTPs for patients C7, C20 and D11 listed no RT interventions. These failures result in Master Treatment Plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A8 (6/15/11)

a. For the identified problem, "Thought Disorder as manifested by agitation, bizarre behaviors/mannerisms, confused, disoriented, labile, impulsive, restless, hyperactive,"

--There were no physician interventions.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." There were no individualized interventions based on patient needs.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization and assess discharge options and readiness" without focus and individualization.

--The same recreational therapy intervention stated as "engage patient in task for at least 15 minutes without the need for re-direction and up to 45 minutes by the time of discharge." This was the same intervention as the one on most patients' treatment plans. There were no individualized interventions based on patient needs.

b. For the identified problem, "Violence and Aggression as manifested by suicidal plan, verbally aggression, argumentative, explosive outbursts, threatening behaviors, suicidal ideation, homicidal threat,"

--There were no physician interventions.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." There were no individualized interventions based on patient needs.

2. Patient A15 (6/14/11)

a. For the identified problem "Medical Impairment -Hypothyroidism,"

--There were no physician interventions.

b. For the identified problem "Medical Impairment -Pain,"

--There were no physician interventions.

--The registered nurse (RN) intervention was listed in generic terms as "monitor VS (vital signs) q4hrs, Q6hrs, Q shift, Daily" with no direction to the nursing staff regarding the patient's needed frequency of vital signs. There were no individualized interventions based on patient needs.

3. Patient B1-Master Treatment Plan initiated on 6/10/11 (completion date unclear):

a. For the identified problem, "Schizoaffective Disorder as manifested by auditory hallucinations, suicidal, fatigue, sleep disturbance,"

--There were no physician interventions.

--The registered nurse (RN) interventions were listed in generic terms as "Standard age specific nursing care; Assess and document presence of psychotic symptoms; Encourage patient to communicate status of symptoms to at lease one staff member per shift; Set limits on inappropriate behaviors beginning with least restrictive measures." There were no specific nursing interventions to direct nursing personnel in the care of the patient on the ward.

--The recreational therapy intervention stated as "engage patient in task for at least 15 minutes without the need for re-direction and up to 45 minutes by the time of discharge" was the same generic intervention listed on most patients' treatment plans. There were no individualized interventions based on the patient's needs.

b. For the identified problem, "Violence and Aggression as manifested by suicidal plan and suicidal ideation."

--There were no physician interventions.

--The registered nurse (RN) interventions were listed in generic terms as "Standard age specific nursing care; safety observations to ensure safety; patient will not harm self or others; assess and document presence of thoughts and behaviors to harm others." There were no specific nursing interventions to direct nursing personnel in the care of the patient on the ward.

4. Patient B21 (6/14/11)

a. For the identified problem, "Manic as manifested by hallucinations, labile, delusions, pressured speech, agitation/irritability, racing thoughts, confrontational, impaired judgment,"

--The Psychiatric intervention was listed in generic terms as "Prescribe medications to improve/stabilize mood" with no individualized focus. ECT was identified as an intervention. According to interview on 6/30/11 at 10:30 a.m. with Physician B4 (primary physician), ECT was not being used for this patient and should not have been on her treatment plan.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 preprinted nursing interventions were listed. All of these interventions were generic with no individualization for the patient.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization"; "assess discharge options" and "provide education on coping strategies for mood disturbance and readiness" without focus and individualization.

--The recreation therapy intervention was listed in generic terms as "engage patient in physical and cognitive activities to learn more effective coping skills" without focus and individualization.

b. For the identified problem "Violence and Aggression manifested as argumentative and suicidal ideation."

--The Psychiatric intervention was listed in generic terms as "prescribe medications to control hostility and/or anger" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 of the generic preprinted nursing interventions were selected. None of these were individualized for the patient.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization" and "aftercare and relapse prevention education and planning" without focus and individualization.

5. Patient C7 (6/20/11)

a. For the identified problem, "Mixed Mood State manifested as sleep disturbance, difficulty making decisions, high risk behaviors, confrontational, impaired judgment."

--The physician intervention was listed in generic terms as "Prescribe medications to improve/stabilize mood" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 generic preprinted interventions were selected. None of these were individualized for the patient.

--The social work interventions were listed in generic terms as "aftercare and relapse prevention education and planning" and "provide education on coping strategies for mood disturbance" with no individualized focus.

--There were no recreation therapy interventions.

b. For the identified problem, "Attention Deficit Disorder/Hyperactivity manifested by easily distracted, easily bored with a task, trouble doing quiet task or activity, impatient,"

--The physician intervention was listed in generic terms as "educate patient/family on positive reinforcement program to reward appropriate behavior" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Eight of the10 generic preprinted interventions were selected. None of these were individualized for the patient.

--There were no recreation therapy interventions.

c. For the identified problem "Violence and Aggression manifested as verbally aggressive, argumentative, explosive outburst, suicidal ideation, and homicidal threat,"

--The physician intervention was listed in generic terms as "prescribe medications to control hostility and/or anger" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 of the generic preprinted interventions were selected. None of these were individualized for the patient.

--There were no recreation therapy interventions.

6. Patient C20 (6/25/11)

a. For the identified problem "Mixed Mood State manifested as anhedonia, feels hopeless/helpless, low energy/fatigue, low self-esteem, lack of interest, and excessive guilt."

--The Psychiatric intervention was listed in generic terms as "Prescribe medications to improve/stabilize mood" with no individualized focus. In addition 4 of the 5 preprinted generic interventions were checked without specifics based on the patient's individual needs.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Nine of the 10 generic preprinted interventions were checked with no specifics based on this patient's individual needs.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization"; "assess discharge options" and "provide education on coping strategies for mood disturbance and readiness" without focus and individualization.

--There were no recreation therapy interventions.

b. For the identified problem "Violence and Aggression manifested as verbally aggressive, argumentative, explosive outburst, threatening behaviors, suicidal ideation, and physical aggression."

--The physician intervention was listed in generic terms as "prescribe medications to control hostility and/or anger" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 of the generic preprinted interventions were selected with no specifics based on this patient's individual needs.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization" and "aftercare and relapse prevention education and planning" without focus and individualization.

--There were no recreation therapy interventions.

7. Patient D9 (5/30/11)

a. For the identified problem "Manic manifested by anxiety, hypersexual, low energy/fatigue, poor hygiene, agitation/irritability, lack of interest, and intrusive,"

--The physician intervention was listed in generic terms as "individual session to monitor, medications effects, side effects and compliance" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Four of the 10 generic preprinted interventions were checked. None of these interventions included specifics based on this patient's individual needs.

--The social work intervention was listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization" without focus and individualization.

--The recreation therapy intervention was listed in generic terms as "engage patient in physical and cognitive activities to learn more effective coping skills" without focus and individualization.

b. For the identified problem "Violence and Aggression manifested as homicidal attempt, explosive outbursts, and homicidal threat,"

--The Psychiatry intervention was listed in generic terms as "prescribe medications to control hostility and/or anger" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Six of the 10 generic preprinted interventions were selected. None of these interventions included specifics based on this patient's individual needs.

--The social work interventions were listed in generic terms as "Identify adaptive coping strategies to utilize during and after hospitalization and aftercare" and "relapse prevention education and planning" without focus and individualization.

8. Patient D11 (6/21/11)

a. For the identified problem "Manic manifested as labile, hypersexual, agitation/irritability, crying spells, and lack of interest."

--The physician interventions were listed in generic terms as "Prescribe medications to improve/stabilize mood" and "individual session to monitor, medications effects, side effects and compliance" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 generic preprinted interventions were selected. None of these generic interventions included specifics based on this patient's individual needs.

--The social work interventions were listed in generic terms as "aftercare and relapse prevention education and planning" and "provide education on coping strategies for mood disturbance" with no individualized focus.

--There were no recreation therapy interventions.

b. For the identified problem "Attention Deficit Disorder/Hyperactivity manifested as easily distracted, does not listen when spoken to, impatient, difficulty focusing, hypersensitive to criticism or disapproval of others,"

--The physician intervention was listed in generic terms as "educate patient/family on positive reinforcement program to reward appropriate behavior" with no individualized focus.

--The registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Nursing interventions identified 5 out of 10 of the preprinted interventions. None of these generic interventions included specifics based on this patient's individual needs.

--There were no recreation therapy interventions.

B. Interview

1. In an interview on 6/30/11 at 10:30a.m., Physician B4 (primary psychiatrist) agreed that the physician interventions on Patient B21's treatment plan were not individualized.

2. In an interview on 6/30/11 at 3:10p.m., Licensed Counselor B7 (patient's therapist) stated that the treatment interventions needed to be individualized for Patient D11.

3. In an interview on 7/1/2011 at 9:05a.m., which included a review of the Master Treatment Plans for Patients D9 and D11, the Director of Social Work verified that the social work interventions were generic and lacked specific and individualized focus to meet the patients' specific care needs.

4. In an interview on 7/1/2011 at 10:55a.m., which included a review of the Master Treatment Plans for Patients B21, D9, and D11, the Director of Nursing and Assistant Director of Nursing verified that individualized nursing interventions to care for patients in the clinical area, including interventions to ensure safety of the patients (other than general monitoring/supervision), were absent in the MTPs.

Based on interview and document review, the facility failed to ensure that active individualized psychiatric care was provided for 3 of 8 active sample patients (B21, D9 and D11). Patient B21 failed to receive the individual 1:1 therapy designated in the treatment plan and remained severely ill while she/he refused needed medications. The treatment team failed to initiate a court order to force medications in a timely fashion. Patients D9 and D11 were admitted with histories of sexual abuse, and they exhibited sexualized behaviors during hospitalization. The treatment team failed to design and implement a treatment plan to appropriately address these issues. These failures result in patients being hospitalized without all interventions for recovery being provided, potentially delaying recovery. Failure to develop an adequate plan to address inappropriate sexual behaviors by patients also places other patients at risk.

Findings include:

A. Patient B21

1. Patient B21 was admitted on 6/14/11 with the diagnosis of "Bipolar Disorder, Recurrent Severe." According to the progress notes, this patient had been "highly agitated, paranoid and delusional since admission." Because of the continuing high acuity level of the patient's symptoms, the patient was unable to attend the regular treatment programming. The patient has also refused many of the prescribed medications.

2. During an interview on 6/29/11 at 2:20, Patient B21 was agitated, hyper-verbal, and verbalized paranoid and grandiose delusions. The patient denied the need for medication, had to be redirected several times during the interview, and made hostile statements about family and staff members. When asked what treatment activities s/he was attending, B21 reported, "I don't attend any of those groups and I've dismissed my therapist because she told me that I had suicidal ideas." Patient B21 reported that s/he had been in and out of hospitals for Bipolar Disorder since 1999.

3. During interview on 6/30/11 at 10:30a.m., Physician B4 (primary physician for Patient B21) stated that the patient refused most medications which prevented administration of adequate types and dosages of medication for the patient's symptoms. Physician B4 stated that Patient B21 had agreed to take Seroquel, but not in dosages appropriate for the presenting symptoms. Physician B4 stated that Patient B21 continued to be paranoid and delusional. Physician B4 stated that the team had not attempted to obtain information about the treatment that Patient B21 had received from other facilities. A process for forcing needed medications had not been initiated; Physician B4 stated, "I plan to obtain a court order to force medications."

4. Patient B21's Master Treatment Plan dated 6/14/11 identified the following interventions to be implemented by the program therapist (social work):

a. "Individual [therapy]: Identify adaptive coping strategies to utilize during and after hospitalization. [1] [1time] weekly."

b. "Group Therapy: Provide education on coping strategies for mood disturbance. [14] [14 times] weekly."

c. "Group Therapy: Provide education on coping strategies to improve frustration tolerance. [14] [14 times] weekly."

5. Group therapy notes revealed that Patient B21 had refused to attend group therapy sessions since admission. Progress notes revealed evidence of only 2 contacts for individual therapy from admission on 6/14/11 to 6/30/11. A therapist note (6/16/11) included the statement, "Pt. [Patient] said (s/he) was firing therapist for telling lies about (him/her)." Another therapist note (6/27/11) stated "Pt [Patient] refused to participate in IT [Individual Therapy]. Pt was angry, paranoid and illogical in thought. Mood and affect were congruent."

6. During an interview on 6/30/11 at 3:00p.m., Patient B21's assigned therapist, LPC B5 [Licensed Counselor] stated that s/he had been "dismissed by the patient." When asked if staff had attempted to provide therapy during the time period between the documented notes (6/16/11 and 6/27/11), LPC B5 stated that she had been on vacation during this time period.

7. During a telephone interview on 7/1/11 at 10:00a.m., RN B10, (a nurse who worked on 3:00-11:00p.m. shift) stated that Patient B21 continued to be delusional and anxious. RN B10 reported that the patient paced the ward, chatted with staff and other patients and frequently became agitated, requiring redirection by the staff. RN B10 expressed concern about whether Patient B21 got enough sleep, reporting that the patient was awake at 11:30 p.m. each evening when RNB10 left the ward. RN B10 stated, "My main concern is [B21's] lack of sleep. I'd like to see [B21] sleep more and be a little less argumentative."

8. A review of Patient B21's Master Treatment Plan revealed that as of 6/30/11, the plan had not been revised even though the patient was too acutely ill to attend group therapy sessions, and was refusing to participate in individual therapy.

B. Patient D9

1. Patient D9 was a 9 year old admitted on 5/30/11 with the diagnosis of Mood Disorder. The history and physical (5/30/11) documented that Patient D9 had been sexually abused.The psychosocial assessment (5/31/11) documented that Patient D9 had experienced a sexual encounter at another hospital.

2. The following RN progress notes were recorded:

6/20/11: "Pt [Patient] has been blurting out inappropriate sexual comments to peers. Pt tried to touch a female peer's chest area. Pt tried to undress in front of staff."
6/22/11: "Pt [Patient] has been blurting out inappropriate comments toward female peers. Pt has been dancing provocatively...had "poor boundaries...sexual acting out in ward...sex talk with peers."
6/23/11: "Pt has been antagonizing peers and has been trying to play with [his/her] private [sic] in front of [his/her] peers."
6/26/11: "Pt exhibits sexual acting out gestures in front of [his/her] peers."
6/29/11: "pt wore tight fitting clothing and was exposing some of [his/her] body parts in the dayroom in front of peers. Pt has been exhibiting poor boundaries with some of the younger kids...Pt remained sexually acting out inappropriately and needed redirection."

3. Review of Patient D9's Master Treatment Plan dated 5/30/11 revealed a failure to clearly address the patient's sexual issues/behaviors. Although "Hypersexual" was listed as a symptom of the problem identified as "Manic," the treatment plan did not include goals or interventions to address the sexual "acting out" behavior, nor was there any revision to the treatment plan addressing the patient's peer relationships on the ward.

C. Patient D11

1. Patient D11 was a 10 year old admitted on 6/21/11 with the diagnosis of "Mood Disorder." The psychiatric evaluation (6/22/11) documented that the patient had a "h/o [history of] sexual abuse. Very agitated at home. Fighting + [and] sexually acting out."
The psychosocial assessment (6/23/11) documented that Patient D11's presenting problem was " Chatting sexually online and drawing sexual pictures." This assessment documented "writes sexual stories...molested by [mother's] boyfriend."

2. The following RN progress notes were recorded:
6/22/11: "Pt [Patient] exhibits poor boundaries with certain females."
6/23/11: "Pt [Patient] have [sic] very poor boundaries with peers and need [sic] constant redirection."
6/25/11: "Exhibits poor boundaries with other peers."
6/27/11: "Pt [Patient] also exhibits poor boundary (sic) with her female peers."

3. Review of Patient D11's medical record revealed an explicit sexual picture and story given to an RN (noted on 6/24/11).

4. In a telephone interview on 6/30/11 at 11:20a.m., Physician B3, the primary attending psychiatrist for Patient D11, stated that Patient D11 "was sexually acting out." When asked how the team was addressing the patient's sexual behaviors (sexual pictures and story given to RN and poor boundaries with other patients) Physician B3 stated, "The individual therapist will address that (sexual issues)." When asked if the physician was aware whether the inappropriate sexual behavior was being addressed by the therapist, Physician B3 stated, "I assumed it was." Physician B3 stated that s/he should give more direction to the team to make sure the patient's issues were clearly addressed.

5. Review of the Master Treatment Plan (6/21/11) revealed a failure to clearly address Patient D11's sexual issues/behaviors. Although "Hypersexual" was listed as a symptom of the problem identified as "Manic," the treatment plan did not include goals or interventions to address this problem. As of 6/30/11, there was no revision of the Master Treatment Plan to specifically address the patient's inappropriate sexual behaviors on the ward.

Based on record review and interview, the facility failed to provide a discharge summary which included a recapitulation of the patient's hospitalization for 4 of 5 discharged patients whose records were reviewed (E1, E3, E4 and E5). The discharge summaries for patients E1 and E4 were incomplete. The summaries for patients E3 and E5 were brief illegible notes. Failure to provide information that identifies effective and/or ineffective treatment strategies during a patient's hospitalization compromises the effective transfer of the patient to future service providers.

Findings include:

A. Record Review

The Discharge Summaries for the 4 patients were on a preprinted form with blank lines after each section. The COURSE OF TREATMENT section had four lines on which to summarize the hospital course.

1. Patient E1: The discharge summary completed on 4/21/11 stated, "Poor historian. Thinking confused + disorganized" on the Course of Treatment lines. This discharge summary lacked any description of what happened during hospitalization.

2. Patient E3: The discharge summary completed on 4/25/11 contained nine illegible words written on the Course of Treatment lines. Thus, the summary provided no useful information for use by future service provider(s).

3. Patient E4: The discharge summary completed on 4/22/11 had "Admitted & meds resumed. Pt. gradually improved and stabilized. Paranoia resolved" written on the Course of Treatment lines. This discharge summary was too brief to be useful for future service providers.

4. Patient E5: The discharge summary completed on 4/22/11 contained nine illegible words written on the Course of Treatment lines. The discharge summary thus provided no useful information for future provider(s).

B. Staff Interview

In an interview on 6/30/11 at 11:20a.m., which included a discussion of the problem of discharge summaries being too brief and illegible, the Medical Director agreed that this was a problem.

Based on record review and interview, the facility failed to ensure that patient discharge summaries contained a summary of the patient's condition on discharge for 4 of 5 patients whose discharge records were reviewed (E1, E3, E4 and E5). This failure results in critical clinical information regarding the patient's level of psychiatric symptomatology and risk not being available to aftercare providers.

Findings include:

A. Record Review

The Discharge Summaries for the 4 patients were on a preprinted form with blank lines after each section. The MENTAL STATUS AT DISCHARGE / TRANSFER section had three lines on which to describe the patient at time of discharge.

1. Patient E1: The discharge summary completed on 4/21/11 had "Mood more (illegible)" written on the MENTAL STATUS AT DISCHARGE /TRANSFER lines. This discharge summary lacked any useful description of the patient at time of discharge.

2. Patient E3: The discharge summary completed on 4/25/11 only stated "Mood & affect stable" written on the MENTAL STATUS AT DISCHARGE /TRANSFER lines. This discharge summary failed to address the patient's suicide risk at the time of discharge, despite the fact that the patient was admitted for suicidality as the presenting problem (noted in the discharge summary section titled Reason for Initial Admission).

3. Patient E4: The discharge summary completed on 4/22/11 stated "Mood and Affect stable, not paranoid" on the MENTAL STATUS AT DISCHARGE/TRANSFER lines. This discharge summary failed to adequately describe the patient's condition at discharge.

4. Patient E5: The discharge summary completed on 4/22/11 contained three illegible words written on the MENTAL STATUS AT DISCHARGE/TRANSFER lines. The discharge summary thus provided no useful information about the patient's condition at discharge.

B. Staff Interview

In an interview on 6/30/11 at 11:20a.m., in which the problem of discharge summaries being too brief and illegible was discussed, the Medical Director agreed that this is a problem.

Based on record review and interview, the Medical Director failed to assure quality and appropriateness of care for patients. Specifically, the Medical Director failed to:

I. Ensure that policy and procedures were developed and implemented, requiring that a review/investigation was completed for 2 of 2 discharged patients (E6 and E7) who attempted suicide during hospitalization, to identify practices, patterns that could have contributed to the events. This failure results in a safety risk for all suicidal patients. In addition, it prevents adequate education of staff to reduce risk of recurrences of suicide attempts.

Findings include:

A. Specific Patient Findings

1. Patient E6

a. E6 was a patient on the adolescent who, according to an incident report (4/5/11) and April and May 2011 Medical Staff minutes, attempted suicide on 4/5/11 by attempting to "choke/strangle self with bed sheets."

b. A nursing progress note dated 4/5/11 stated, "Pt [Patient] tried to choke/strangle self with bed sheets. Pt [Patient] bed sheets taken away from [patient]. Pt [Patient] assessed and pt alert and oriented x3."

c. A nursing progress note dated 4/7/11 at 10:00a.m., written while the patient was in seclusion stated, "[Patient] Placed mattress over door; seclusion room [sic] and being watched through window took [sic] bra and shirt off tied knots [sic] and tried to hang self. Taken down again [physically restrained] and Code White team [called]. Placed on..." The progress note was incomplete and not signed.

d. A physician progress note dated 4/7/11 at 2:00p.m. stated, "Extreme aggression and acting up behavior. Attempted to strangle self."

e. A physician progress note dated 4/8/11 at 10:00a.m. stated, "Was agitated and out of control yesterday. Attempted to kill self. Given emergency meds. [medications]."

2. Patient E7

a. E7 was a patient on the children's unit who, according to an incident report (5/7/11), attempted suicide on 5/7/11 by wrapping "his jacket sleeve tied around his neck, slouched over [sic]." The staff had to put their fingers between the patient's neck and noose to allow air."

b. A memo written by a psychiatric technician was attached to the incident/occurrence report (dated 5/7/11), describing the incident of finding the patient attempting suicide. The note stated, "[Patient] positioned at/by the bathroom door with his jacket sleeve tied around his neck, slouched over. I immediately proceeded to untie the jacket while yelling for assistance (untie consisted of me placing one finger b/w [sic] neck and the jacket noose to allow air."

B. Staff Interview

In an interview on 7/1/2011 at 10:55a.m. with the Director of Nursing and Assistant Director of Nursing, the Director of Nursing stated that the hospital did not require that suicide attempts be investigated. The Director of Nursing also stated that investigations following the suicide attempts by Patients E6 and E7 were not conducted.

II. Ensure that psychiatric evaluations include an inventory of patients' assets for 5 of 8 active patients (A8, B21, C7, D9, and D11). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation. (Refer to B117)

III. Ensure that the Master Treatment Plans of 2 of 2 active sample patients (D9 and B21) were revised following staff use of chemical restraints. Both of these patients were administered combination intramuscular [IM] medications for behavior control. The MTPs were not revised after the use of these medications, documenting the less restrictive interventions to be used prior to future use of these medications. Failure to revise the Master Treatment Plan to address the individual needs of patients as their acuity changes results in lack of direction to staff in providing needed care. (Refer to B118). In addition, the Master Treatment Plans for 8 of 8 active sample patients (A15, B1, B21, C7, C20, D9 and D11) failed to include short-term goals that were measurable and focused (Refer to B121) and included individualized interventions by all disciplines (Refer to B122). The absence of an integrated, comprehensive treatment plan results in a lack of coordinated and organized treatment.

IV. Ensure that active individualized psychiatric care was provided for 3 of 8 active sample patients (B21, D9 and D11). Patient B21 failed to receive the individual 1:1 therapy designated in the treatment plan and remained severely ill while she/he refused needed medications. The treatment team failed to initiate a court order to force medications in a timely fashion. Patients D9 and D11 were admitted with histories of sexual abuse, and they exhibited sexualized behaviors during hospitalization. The treatment team failed to design and implement a treatment plan to appropriately address these issues. These failures result in patients being hospitalized without all interventions for recovery being provided, potentially delaying recovery. Failure to develop an adequate plan to address inappropriate sexual behaviors by patients also places other patients at risk. (Refer to B125)

V. Ensure that procedures/methods for external control of aggressive and agitated behavior are available and appropriately utilized for patients needing these procedures. The facility had high use of chemical restraint (medications usually voluntarily taken). For the months of April, May and June 2011, there was an average of 47 chemical restraints given monthly for an average daily census of 83 patients. In addition, the facility had no policy and procedure in place to support the use of mechanical restraints when needed. This failure exposes patients to potential harm from unnecessary chemical restraint and violates patients' rights to safe treatment in the least restrictive manner possible.

Findings include:

A. During rounds, including observation of the seclusion room on the DAPA [sic] adult ward with the Assistant Director of Nursing on 6/29/11 at 11:30a.m., the Assistant Director of Nursing reported that mechanical restraint was not utilized in this facility. She stated, "It has not been used for many years."

B. During interviews on 6/30/11 at 1:30p.m. and 4:30p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON reported that patients who become aggressive/violent may be held in a physical hold until a chemical restraint may be given. She reported that patients are placed on their side during the physical restraint procedure, but when needed, a prone position is used. She stated, "We never place a patient on their back as they may aspirate." When asked how long the staff can physically hold a patient, she responded, "Children can be held for up to 1 hour, adolescents 2 hours, and the adult patients 4 hours."

The DON and ADON reported that it has been about 13 years since mechanical restraint has been used in this facility. They added, "There are no beds set up (for restraint)." The DON stated that the physicians automatically order "chemical restraints" for their patients.

C. Review of seclusion/restraint log and the patient census (given to the survey team by the Assistant Administrator) revealed the following information:

1. Use of chemical restraints:

a. During April 2011, there were a total of 55 chemical restraints given for an average daily census of 89.8. Eighty-two (82) percent of these were given to children and adolescent patients.

b. During May 2011, there were a total of 55 chemical restraints given for an average daily census of 80.8. Seventy-eight (78) percent of these were given to children and adolescents.

c. During June 2011, there were a total of 30 chemical restraints given for an average daily census of approximately 78.7. At least fifty-seven (57) percent of these were given to children and adolescents.

2. Use of physical restraints/holds and seclusion:

a. During April 2011-3 physical restraints and 6 seclusions.

b. During May 2011-4 physical restraints and 0 seclusions.

c. During June 2011-4 physical restraints and 0 seclusions.

The data documented above shows that chemical restraint (taken voluntarily) is used in large amounts in this facility. The facility also did not accurately document the number of time that physical holds were used in order to administer chemical restraint.

VI. Ensure that the discharge records of 4 of 5 discharged patients (E1, E3, E4 and E5) included an adequate summary of the treatment received in the hospital and the patient's response to treatment (Refer to B133) and contained an adequate description of the patient's condition on discharge (Refer to B135). These failures compromise the effective transfer of the patient's care to future service providers.

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

I. Ensure that policy and procedures were developed and implemented, requiring that a review/investigation was completed for 2 of 2 discharged patients (E6 and E7) who attempted suicide during their hospitalization, to identify practices, patterns that could have contributed to the events. This failure is a safety risk for suicidal patients and prevents adequate education of staff to reduce suicide attempts.

Findings include:

A. Specific Patient Findings

1. Patient E6

a. E6 was a patient on the adolescent unit who, according to an incident report (4/5/11) and medical staff minutes for April and May 2011, attempted suicide on 4/5/11 by attempting to "choke/strangle self with bed sheets."

b. A nursing progress note dated 4/5/11 stated, "Pt [Patient] tried to choke/strangle self with bed sheets. Pt [Patient] bed sheets taken away from [patient]. Pt [Patient] assessed and pt alert and oriented x3."

c. A nursing progress note dated 4/7/11 at 10:00a.m., written while the patient was in seclusion stated, "[Patient] Placed mattress over door; seclusion room and being watched through window took bra and shirt off tied knots and tried to hang self. Taken down again [physically restrained] and Code White team [called]. Placed on..." [sic] The progress note was incomplete and not signed.

c. A physician progress note dated 4/7/11 at 2:00p.m. stated, "Extreme aggression and acting up behavior. Attempted to strangle self."

d. A physician progress note dated 4/8/11 at 10:00a.m. stated, "Was agitated and out of control yesterday. Attempted to kill self. Given emergency meds. [medications]."

2. Patient E7

a. E7 was patient on the children's unit who, according to an incident report (5/7/11), attempted suicide on 5/7/11 by wrapping "his jacket sleeve tied around his neck, slouched over." The staff had to put their fingers between the patient's neck and noose to allow air."

b. A memo written by a psychiatric technician was attached to the incident/occurrence report (dated 5/7/11), describing the incident of finding the patient attempting suicide. The note stated, "[Patient] positioned at/by the bathroom door with his jacket sleeve tied around his neck, slouched over. I immediately proceeded to untie the jacket while yelling for assistance (untie consisted of me placing one finger b/w [sic] neck and the jacket noose to allow air." [sic]

B. Interview

In an interview on 7/1/2011 at 10:55a.m. with the Director of Nursing and Assistant Director of Nursing, the Director of Nursing stated that the hospital did not require that suicide attempts be investigated. The Director of Nursing also stated that investigations following the suicide attempts by Patients E6 and E7 were not conducted.

II. Ensure that nursing staff provided appropriate safety monitoring and supervision for 1 of 2 discharged patients (E6) whose record was reviewed for attempted suicide while hospitalized. This patient was allowed to go into seclusion in clothes that could be used to hang herself after a suicide attempt on the unit. While in the seclusion room, the staff also failed to provide adequate monitoring. The patient placed a mattress against the door and had enough unobserved time to attempt to strangle herself. Inadequate nursing monitoring of patients poses a risk for all hospitalized patients.

Findings include:

A. Patient Findings:

1. E6 was a patient on the adolescent unit who, according to an incident report and medical staff minutes for April and May 2001, attempted suicide on 4/5/11 by "choke/strangle self with bed sheets."

a. A nursing progress note dated 4/5/11 "Pt [Patient] tried to choke/strangle self with bed sheets. Pt [Patient] bed sheets taken away from her. Pt [Patient] assessed and pt alert and oriented x3."

b. A nursing progress note dated 4/7/11 at 10:00a.m. regarding events while the patient was in seclusion stated, "[Patient] Placed mattress over door; seclusion room and being watched through window took bra and shirt off tied knots and tried to hang self. Taken down again [physical hold] and Code White team [called]. Placed on..." [sic] The progress was incomplete and not signed.

B. Interview:

In an interview on 7/1/2011 at 10:55a.m., the Director of Nursing and Assistant Director of Nursing verified that the above incident regarding Patient E6 had not been reviewed/investigated. The Director of Nursing stated that no action had been taken (referring to failure to adequately monitor patient) following the suicide attempts by Patients E6.

III. Provide appropriate counseling and/or disciplinary action for staff following failure to properly monitor and supervise patients. Insufficient monitoring of patients resulted in a sexual encounter between 2 patients on the children's ward (discharged patients E8 and E9). This failure results in a potential recurrence of such incidents and poses a safety risk for all patients on the unit.

Findings include:

A. An incident/occurrence report form documented that on 4/6/11 at 9:30p.m. Patient E8 went across the hallway to Patient E9's bedroom and "attempted to grab [Patient E8's] crotch." The incident report also noted "Pt's [Patient E8] grandmother stated that Patient 8 was molested by a grandfather..."

B. In an interview on 7/1/11 at 10:55a.m., the Director of Nursing stated that she expected nursing personnel to constantly observe the halls when patients are in their rooms during evening and night hours. She verified that there was a "break in the monitoring and supervision" for the child patients. She stated that an investigation identified the staff member was who failed in their assignment (providing adequate monitoring of patients), no individual counseling nor disciplinary action had been done as she did not want to be "punitive."

IV. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (A8, A15, B1, B21, C7, C20, D9 and D11) included nursing interventions that were individualized for patients. The treatment plans included nursing interventions which were routine, generic discipline functions that lacked a specific focus for treatment. The absence of individualized interventions on treatment plans hampers staff's ability to provide individualized care to patients.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A8 (6/15/11)

a. For the identified problem, "Thought Disorder as manifested by agitation, bizarre behaviors/mannerisms, confused, disoriented, labile, impulsive, restless, hyperactive," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." There were no individualized interventions based on patient needs.

b. For identified problem, "Violence and Aggression as manifested by suicidal plan, verbally aggression, argumentative, explosive outbursts, threatening behaviors, suicidal ideation, homicidal threat," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." There were no individualized interventions based on patient needs.

2. Patient A15 (6/14/11)

For the identified problem, "Medical Impairment-Pain," the registered nurse (RN) intervention was listed in generic terms as monitor VS q4hrs, Q6hrs, Q shift, Daily" with no direction to the nursing staff to the frequency of VS. There were no individualized interventions based on patient needs.

3. Patient B1 (6/10/11)

a. For the identified problem, "Schizoaffective Disorder as manifested by auditory hallucinations, suicidal, fatigue, sleep disturbance," the registered nurse (RN) generic interventions were "Standard age specific nursing care"; " Assess and document presence of psychotic symptoms"; "Encourage patient to communicate status of symptoms to at lease one staff member per shift" and "Set limits on inappropriate behaviors beginning with least restrictive measures." There were no specific nursing interventions to direct nursing personnel in the care of the patient on the ward.

b. For the identified problem, "Violence and Aggression as manifested by suicidal plan and suicidal ideation," the generic registered nurse (RN) interventions were "Standard age specific nursing care"; "safety observations to ensure safety" and "assess and document presence of thoughts and behaviors to harm others." There were no specific nursing interventions to direct nursing personnel in the care of the patient on the ward.

4. Patient B21 (6/14/11)

a. For the identified problem, "Manic as manifested by hallucinations, labile, delusions, pressured speech, agitation/irritability, racing thoughts, confrontational, impaired judgment," a generic registered nurse (RN) interventions were "Standard age specific nursing care." All ten preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

b. For the identified problem "Violence and Aggression manifested as argumentative and suicidal ideation," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All ten preprinted generic interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

c. Even though Patient B21 was agitated, paranoid and delusional (as observed in the clinical area at 6/29/11 at 11:30a.m. and during interview on 6/29/11 at 2:30p.m.) and was administered Ativan and Benadryl together in an IM injection on 6/27/11, the patient's MTP did not include any specific nursing interventions to address this issue as of 6/30/11.

5. Patient C7 (6/20/11)

a. For the identified problem, "Mixed Mood State manifested as sleep disturbance, difficulty making decisions, high risk behaviors, confrontational, impaired judgment," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." All 10 of the preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

b. For the identified problem, "Attention Deficit Disorder/Hyperactivity manifested by easily distracted, easily bored with a task, trouble doing quiet task or activity, impatient," a registered nurse (RN) intervention was "Standard age specific nursing care." Eight of the 10 preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

c. For the identified problem "Violence and Aggression manifested as verbally aggressive, argumentative, explosive outburst, suicidal ideation, and homicidal threat," a registered nurse (RN) intervention was listed as "Standard age specific nursing care." All 10 preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

6. Patient C20 (6/25/11)

a. For the identified problem "Mixed Mood State manifested as anhedonia, feels hopeless/helpless, low energy/fatigue, low self-esteem, lack of interest, and excessive guilt," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Nine of the 10 preprinted nursing interventions were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

b. For the identified problem, "Violence and Aggression manifested as verbally aggressive, argumentative, explosive outburst, threatening behaviors, suicidal ideation, and physical aggression," a generic registered nurse (RN) intervention was "Standard age specific nursing care." All 10 preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

7. Patient D9 (5/30/11)

a. For the identified problem, "Manic manifested by anxiety, hypersexual, low energy/fatigue, poor hygiene, agitation/irritability, lack of interest, and intrusive," the registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Five of the 10 preprinted generic nursing interventions were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

b. For the identified problem, "Violence and Aggression manifested as homicidal attempt, explosive outbursts, and homicidal threat," a registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Six of 10 preprinted generic nursing interventions were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

c. Patient D9 was administered Haldol 2 mg, Ativan 1mg, and Benadryl 25 mg together in an IM injection on 6/8/11 and again on 6/13/11. However, as of 5/30/11, the patient's Master Treatment Plan did not include specific nursing interventions to address the patient's behavior necessitating these medications.

8. Patient D11 (6/21/11)

a. For the identified problem "Manic manifested as labile, hypersexual, agitation/irritability, crying spells, and lack of interest," a generic registered nurse (RN) intervention was listed as " Standard age specific nursing care." Ten preprinted generic nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

b. For the identified problem, "Attention Deficit Disorder/Hyperactivity manifested as easily distracted, does not listen when spoken to, impatient, difficulty focusing, hypersensitive to criticism or disapproval of others," a registered nurse (RN) intervention was listed in generic terms as "Standard age specific nursing care." Five of the 10 generic preprinted nursing interventions on the MTP were selected. These interventions lacked specific guidance to nursing staff or individualized needs of the patient.

B. Staff Interview

In an interview on 7/1/2011 at 10:55a.m., which included a review of the Master Treatment Plans for Patients B21, D9, and D11, the Director of Nursing and Assistant Director of Nursing verified that individualized nursing interventions to care for patients in the clinical area, including interventions to ensure safety of the patients (other than monitoring/supervision level), were absent in the Master Treatment Plans.

V. Ensure that procedures/methods for external control of aggressive and agitated behavior are available and appropriately utilized for patients needing these procedures. The facility had high use of chemical restraint (usually voluntarily taken). For the months of April, May and June 2011, there was an average of 47 chemical restraints given monthly for an average daily census of 83 patients. In addition, the facility had no policy and procedure in place to support the use of mechanical restraints when needed. This failure exposes patients to potential harm from unnecessary chemical restraint and violates patients' rights to safe treatment in the least restrictive manner possible.

Findings include:

A. During rounds, including observation of the seclusion room on the DAPA [sic] adult ward with the Assistant Director of Nursing on 6/29/11 at 11:30a.m., the Assistant Director of Nursing reported that mechanical restraint was not utilized in this facility. She stated, "It has not been used for many years."

B. During interviews on 6/30/11 at 1:30p.m. and 4:30p.m. with the Director and Assistant Director of Nursing, the DON reported that patients who become aggressive/violent may be put in a physical hold until a chemical restraint may be given. She reported that patients are placed on their side during the physical restraint procedure, but when needed are held in prone position. She stated, "We never place a patient on their back as they may aspirate." When asked how long the staff can physically hold a patient, she responded, "Children can be held for up to 1 hour, adolescents 2 hours, and the adult patients 4 hours."

C. The DON and ADON reported that it has been about 13 years since mechanical restraint has been used in this facility. They added "There are no beds set up (for restraint)." The DON stated that the physicians have had a "head set" to automatically order chemical restraints for their patients.

D. Review of seclusion/ restraint log and the patient census (given to the survey team by the Assistant Administrator) revealed the following information:

1. Use of chemical restraints:

a. During April 2011, there were a total of 55 chemical restraints given for an average daily census of 89.8. Eighty-two (82) percent of these were given to children and adolescent patients.

b. During May 2011, there were a total of 55 chemical restraints given for an average daily census of 80.8. Seventy-eight (78) percent of these were given to children and adolescents.

c. During June 2011, there were a total of 30 chemical restraints given for an average daily census of approximately 78.7. At least fifty-seven (57) percent of these were given to children and adolescents.

2. Use of physical restraints/holds and seclusion:

April 2011-3 physical restraints and 6 seclusions; May 2011-4 physical restraints and 0 seclusions; June 2011-4 physical restraints and 0 seclusions.