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

I. Provide adequate nursing monitoring of a hospitalized patient (Death Record D) who was found unresponsive on the morning of 8/13/10 at 5:45 a.m. and pronounced dead upon medical examination. The patient had not received the required "Q15 minute" checks by a Mental Health Technician (MHT) or the required "Q2-hour checks" by an RN or LPN during the night prior to his death. Failure to provide required nursing monitoring of patients poses a risk for repeated serious adverse outcomes for patients, and results in IMMEDIATE JEOPARDY to patient health and safety.

On 9/01/10 at 10:00a.m., a meeting was held with the facility Chief Executive Officer (CEO), Medical Director, and Director of Nursing (DON). At that time they were advised of the findings noted below and that a state of Immediate Jeopardy to patient health and safety exists. (Refer to B125-I)

The facility also failed to:


II. Ensure that active individualized psychiatric care was provided for 3 of 10 active sample patients (#'s 9, 14 and 15) based on their presenting needs. In the case of active sample Patients 9 and 14, there was failure to ensure structured treatment for their specialized treatment needs. In the case of active sample Patient #15, who functioned at low cognitive and social levels, adequate modalities to address his/her problems were not provided. This failure resulted in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125 Section II)

III. Ensure that patients who are admitted and maintained in the facility are appropriate for active psychiatric treatment. Patient #1 was added to the sample because his/her medical/physical conditions precluded participation in active psychiatric treatment. This failure resulted in maintaining this patient in a treatment setting that failed to address his/her specific needs. (Refer to B125 Section III)

IV. Provide necessary evaluation, interpretive services and appropriate treatment for 1 of 1 active patient (#6) who presented with both visual and hearing deficits. In addition, this patient was diagnosed with severe to profound mental retardation. This failure compromised the patient's ability to understand and participate in treatment. (Refer to B125 Section IV)

V. Provide adequate groups/activities on weekends (Saturdays and Sundays) to meet the treatment needs of the patients of patients in the 20-bed unit. This impacted on the patients' ability to move to higher levels of functioning and a less restrictive environment. (Refer to B125 Section V)

Based on record review, document review and interviews, the facility failed to provide adequate medical and nursing leadership to assure identification of deficient practices present in the death of Patient D whose death record was reviewed. The facility failed to conduct a formal investigation of the death, educate and monitor staff, and adopt policies and procedures relevant to the patient's death. This deficient practice results in potential for repeated serious adverse outcomes for patients and IMMEDIATE JEOPARDY to patient safety. (Refer to B144 Part I for findings related to the Medical Director; refer to B148 Part I for findings related to the Director of Nursing)

On 9/01/10 at 10:00a.m., a meeting was held with the facility Chief Executive Officer (CEO), Medical Director, and Director of Nursing (DON). At that time they were advised of the findings noted below and that a state of IMMEDIATE JEOPARDY to patient health and safety exists.

In addition, the facility failed to assure that the Medical Director adequately monitored the development of appropriate individualized treatment modalities on the treatment plans, and the implementation of appropriate treatment to meet patient needs. These deficiencies can result in delays in patient improvement and discharge to appropriate levels of care. (Refer to B144 Parts II-VII)

The facility also failed to assure that the DON adequately monitored nursing services for the identification of appropriate individualized nursing interventions on the treatment plans and the provision of appropriate individualized psychiatric nursing care with changes reflecting change in patient status. The DON also failed to assure that an appropriate room was ready and accessible at all times should a patient require seclusion or restraint. (Refer to B148 Parts II-VI)

Based on record review and interview, it was determined that 5 of 10 active sample patients (6, 7, 9, 11, and 14) did not have an adequate screening neurological examination. This failure to perform and record findings for a neurological exam on admission prevents the facility from detecting treatable neurological conditions. In addition, it prevents the facility from establishing a patient's neurological status at baseline and detecting changes on subsequent reexamination.

Findings include:

A. Record Review

1. Patient 6, admitted 8/12/10 with a diagnosis of Dementia/Psychosis, had a history and physical completed on 8/13/10. The cranial nerve form was present in the chart, but it was blank. No examination of cranial nerves was included in the physical exam.

2. Patient 7, admitted 8/17/10 with a diagnosis of Bipolar Disorder, had a history and physical completed on 8/18/10. The cranial nerve form was present in the chart, but it was blank. The examination noted: "pupils are equal and reactive" and "extra ocular motions are intact." The exam did not contain any other information regarding cranial nerves.

3. Patient 9, admitted 8/9/10 with a diagnosis of Schizophrenia, had a history and physical completed on 8/10/10. The cranial nerve form was present in the chart, but it was blank. The examination noted: "pupils are equal and reactive" and "extra ocular motions are intact." The exam did not contain any other information regarding cranial nerves.

4. Patient 11, admitted 8/27/10 with a diagnosis of Psychotic Disorder/Schizophrenia, had a history and physical completed on 8/28/10. The cranial nerve form was present in the chart, but it was blank.

5. Patient 14, admitted 8/05/10 with a diagnosis of Schizophrenia, had a history and physical completed on 8/05/10. The cranial nerve form was blank. The examination noted: "pupils are equal and reactive" and "extra ocular motions are intact." The exam did not contain any other information regarding cranial nerves.

B. Interview

In an interview on 9/01/10 at 10:30a.m., the Medical Director stated that a neurological exam included completion of a form specifically listing each cranial nerve. When told these forms were blank in the cases of several active sample patients, the Medical Director said the forms "should be filled out."

Based on record review and interview, it was determined that the hospital failed to provide a psychiatric evaluation that included an objective, reproducible estimation of memory functioning for 7 of 10 active sample patient ( 3, 6, 7, 9, 10,14 and 15). This results in failure to identify conditions that impact treatment and can hamper staff's ability to establish appropriate treatment goals.

Findings include:

A. Record Review

1. Patient 3, admitted 8/10/10 with a diagnosis of Dementia/Behavior Disturbance, had a psychiatric examination completed 8/11/10. The mental status examination did not contain any assessment of memory functioning.

2. Patient 6, admitted 8/12/10 with a diagnosis of Dementia/Psychosis, had a psychiatric examination completed on 8/13/10. The mental status examination did not contain any assessment of memory functioning.

3. Patient 7, admitted 8/17/10 with a diagnosis of "Bipolar," had a psychiatric examination completed on 8/18/10. The mental status examination did not contain any assessment of memory functioning.

4. Patient 9, admitted 8/9/10 with a diagnosis of Schizophrenia, had a psychiatric examination completed on 8/10/10. The mental status examination did not contain any assessment of memory functioning.

5. Patient 10, admitted 8/20/10 with a diagnosis of "Bipolar," had a psychiatric examination completed on 8/21/10. The mental status examination did not contain any assessment of memory functioning.

6. Patient 14, admitted 8/05/10 with a diagnosis of Schizophrenia, had a psychiatric examination completed on 8/06/10. The mental status examination did not contain any assessment of memory functioning.

7. Patient 15, admitted 8/18/10 with a diagnosis of Dementia/Behavior Disturbance, had a psychiatric examination completed 8/19/10. The mental status examination did not contain any assessment of memory functioning.

B. Interview

1. In an interview on 9/1/10 at 9:00a.m., RN #3 stated that tests of memory should be found in the psychiatric examination. RN #3 added that, if memory was not in the psychiatric examination, it "probably was not done."

2. In an interview 9/01/10 at 9:45a.m. the Medical Director acknowledged that the sample patients' memory functioning was not tested in a defined, repeatable manner.

Based on interview and document review, the facility failed to ensure that the comprehensive
treatment plans for 4 of 10 sample patients (Patient #'s 6, 9, 14 and 15) included revisions based on patients changes, or lack thereof. This failure impacted on the patients' ability to participate in and benefit from active treatment.

Findings include:

A. Patient #6 was admitted to the facility on 8/12/10. She had hearing and visual deficits and had diagnoses that included Mental Retardation, profound. Review of Patient #6's medical record revealed the following:

1. Even though Patient #6 attended several structured groups, the only activity the patient was able to participate in was the exercise group. Treatment notes documented that the patient required 1:1 assistance to actively participate in this group.

2. Review of the patient's Master Treatment Plan (dated 8/12/10 with review dates of 8/18/10 and 8/27/10) revealed that as of 8/31/10 there was failure to address Patient #6's visual and hearing deficits or her mental retardation, and its impact on her ability to participate in programming.

3. In an interview on 8/31/10 at 11:00a.m., RN #1 verified the above documented findings.

B. Patient #9 was a 41-year-old patient admitted to the facility on 8/9/10 with diagnosis of Schizophrenia:

1. In an interview on 8/30/10 at 10:45a.m., Patient #9 stated that she does not attend any groups/activities. She stated that she spends her time sitting alone in the dayroom (across the hall from the group room).

2. Ward observations on 8/30/10 at 11:00a.m. and on 8/31/10 at 8:50a.m. revealed Patient #9 sitting alone in the dayroom even though groups were being conducted at those times. When approached at those times by the surveyor, she stated that she was not going to go to the groups.

3. Review of Patient #9's medical record revealed the following:

a. Daily treatment notes from 8/11/10 thru 8/28/10 by social work and rehabilitation therapists documented that Patient #9 had refused all treatment groups/activities.

b. Patient #9's Comprehensive Treatment Plan (dated 8/9/10 with review dates of 8/16/10, 8/23/10 and 8/30/10) failed to address the issue of non-compliance with treatment while in the hospital.

4. In an interview on 8/31/10 at 10:40a.m., RN #3 reported that Patient #9 had refused to attend treatment groups. RN #3 stated that the patient was usually in his/her room or pacing the halls. RN#3 also verified that non-compliance with treatment was not addressed in the patient's treatment plan.

C. Patient #14 was a 50 year-old woman admitted to the facility on 8/05/10.

1. Ward observations on 8/30/10 at 10:00a.m. and 10:45 a.m., and 8/31/10 at 8:45a.m. revealed Patient #14 walking by herself in the unit hallway even though groups were being conducted at those times.

2. In an interview on 8/30/10 at 10:00 a.m., the Medical Director acknowledged that Patient #14 "was isolative" and did not attend scheduled groups.

3. Review of Patient #14's medical record revealed the following:

a. Therapeutic group notes dated 8/30/10, 8/27/10, 8/25/10, 8/23/10, 8/20/10, and 8/13/10 indicated that Patient #14 did not attend therapeutic groups on those days.

b. As of 8/31/10 the patient's Comprehensive Treatment Plan (dated 8/5/10 with review dates of 8/12/10, 8/19/10 and 8/26/10) had not been revised to address Patient 14's issue of non-compliance with groups. The treatment plan also did not include appropriate alternatives to group treatment..

D. Patient #15 was an 81-year old patient who was admitted on 8/18/10 with Dementia and Depression.

1. Observations on 8/30/10 from 11:05 to 11:40a.m., during a discussion group conducted for 13 of the 16 unit patients, revealed Patient #15 asleep and snoring during the entire group session.

2. Observations on the adult psychiatric ward on 8/31/10 at 10:35a.m. during a process group on the unit revealed Patient #15 asleep. The patient only briefly responded when asked a question by the group leader.

3. Review of Patient #15's Master Treatment Plan (dated 8/18/10 with review date of 8/25/10) revealed that as of 8/31/10, there was failure to include specific individualized interventions to address his/her impaired cognitive level of functioning.

Based on interview and record review, the facility failed to ensure that the comprehensive treatment plans included physician, nursing, social work, occupational/activity treatment modalities (interventions) that were individualized based on patient needs and abilities for 10 of 10 active sample patients ( #1, 3, 6, 7, 9, 10, 11, 14, 15, and 16) Interventions listed on problem lists for any one named problem were preprinted lists, and identical to one another; the modalities listed were generic treatment and monitoring functions performed by physician, nursing, social work, occupational/activity staff. This resulted in treatment plans that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

The "Problem Lists" presented by the facility for the following patients (dates of treatment plans in parentheses) contained list of generic interventions with checkboxes for the physician, nursing, social service/case management and/or occupational therapy/recreational therapy. Most of the problems focused on medical problems rather than the patient's psychiatric problems. Many of the interventions listed required patients to have a cognitive ability that was beyond their capacity secondary to their specific diagnoses and problems.

1. Patient #1 (8/16/10):

For the identified problem, "spitting food at NH staff," all interventions on the treatment plan form were chosen (checked) for nursing and social work. There were no changes or additions based on the individual patient findings. There were no physician interventions identified for this problem. The list used to choose interventions for the identified problem, "spitting food at NH staff," were those listed on the sheet for the problem "Severe Agitation with Combativeness/Verbal Threats and/or Screaming. The interventions listed for the physician were: "Assess &/or adjust medications daily as needed." "See patient on an individual basis___x week [left blank] for therapy & to assess level of agitation/aggressive behavior." "Monitor and educate regarding precautions, risks, benefits, and side effects of medications." None were checked for the physician.

The interventions listed for Nursing were "Assess for causes of __agitation, __aggression, __escalating behavior, __screaming, __verbal noise [none were checked] q__ [frequency left blank] and record." "Implement guidelines for wandering, screaming, and verbal noises." "Distract with conversation, food, activity, as needed." "Provide for physical needs of fluids, toileting, and pain." "Maintain safe environment to allow for wandering." "Assess milieu q/shift to identify potential safety risks." "Redirect and encourage patient to verbalize feelings as an appropriate way of expressing anger." "Allow verbalization without confrontation or argument." "Encourage expression of feelings in group or 1:1." "Monitor for medication side effects & effectiveness of teaching regarding precautions, benefits and home medication regime." "Provide medication teaching regarding precautions, risks & benefits, reinforcing as needed." "Approach patient calmly & slowly during interactions." "Educate patient/family regarding disease process ___ x's [left blank] week, & as needed." " Implement alternatives to restraint and/or seclusion, (Attach guidelines)." "Implement guidelines for screaming or verbal noises." "Implement guidelines for anger/agitation." All of the interventions for nursing were chosen.

The interventions listed for Social Work/Case Management/Therapist were "Family contact __x's [left blank] for education related to redirection management." (checked) "Meet with patient 1x week to assess mood for agitation and/or aggressive behavior." (checked) " Provide_SW__ Group 5 days/week for LOS [length of stay]." (checked ) "Coordinate discharge placement, aftercare and community resources." (checked) "Develop written behavioral contract with_______. [Left blank]" "Develop written behavioral contract with_____." (not checked). These interventions were generic and not individualized based on patient's needs.

For the identified problem, "Fall Risk," all nursing interventions on the treatment plan
Form were chosen (checked) without additions or changes based on the patient's
individual needs. The interventions listed for Nursing were "Place on fall precautions." "Frequent toileting." "Obtain orthostatic blood pressure as ordered by physician ___x___/" [left blank] "Implement Close Observation." "Assess patient's gait while ambulating." "Encourage use of hand rails." "Assess need for PT consult as indicated by patient status." "Instruct in use of safe slippers & shoes." "Assess for medication related to gait & ambulatory problems every waking shift." "Communicate fall precautions on census board." "Instruct patient not to get up without assistance, as needed." "Assess need for safety devices." "Provide nursing group or individual instruction related to falls prevention." "Encourage all activities to distract from napping." "Teach use of safety devices." "Monitor for medication side effects & effectiveness of teaching regarding precautions, benefits, and home medication regime."

For the identified problems, "Diabetes," "Congestive Heart Failure," and "Chronic Obstructive Pulmonary Disease," there were no identified physician interventions. Interventions for nursing were identical for all patients with these problems identified; for the lists of nursing interventions for each problem, see the other patient findings which follow.

2. Patient #3: 80 year old male patient with a diagnosis of Dementia/Behavioral Problems. (treatment plan dated 8/10/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Disruption in cognitive operations and activities," preprinted interventions listed for the physician were: "Assess &/or adjust medications daily as needed." "See patient on an individual basis for supportive therapy & to assess behavior and treatment progress." "Monitor therapeutic medication levels." "Physician to order medications and monitor for effectiveness and/or side effects daily." None were checked.

For the identified problem, "Disruption in cognitive operations and activities," preprinted interventions listed for Nursing were "1:1 contact every shift while awake to allow expression of feelings." "Monitor for medication side effectiveness of teaching regarding precautions, benefits and home medication regime." "Monitor hours sleep each right (sig) & document." "Monitor environment & reduce loud noises & increased stimulus during night." "Instruct patient to avoid caffeine & tobacco in evening." "Monitor weight Monday, Wednesday, and Friday (per phy. Order)." "Monitor meal percentage every meal & document." "Encourage___increase/___decrease [neither chosen] fluid/caloric intake each waking shift." "Request nutritional assessment per screening." "Direct patient out of room to program & social activities each shift while awake." "Assess ADL's every shift." "Provide set-up for hygiene tasks." "Educate patient and family disease process x1, reassure each shift and/or as needed." All items were checked; these items were generic and not individualized for the patient.

For the identified problem, "Disruption in cognitive operations and activities," preprinted interventions listed by Social Services/Case Management were "See patient ___ [left blank] week for support & education regarding patients disease process, encourage expression of feelings & identification of needs." "Assess mood & behavior/ [sic]" "Group 5days/week for education, process & support related to patients disease process." "Use reminiscence therapy in group." "Use cognitive therapy in group." "Meet 1x week with family for support & education regarding diagnosis, recovery, & relapse prevention. Assist patient with discharge needs & community resources." "Coordinate discharge placement, aftercare & community resources." "Education group 1x week on topics such as grief, depression, community resources, self-esteem." All of these were checked; all are generic.

For the identified problem, "Disruption in cognitive operations and activities," preprinted interventions listed by Occupational Therapy/Recreation/Activity Therapy that were checked were: "Provide leisure skills group &/or 1 [sic], ___ [left blank] x week to increase leisure inventory & coping skills." "Provide activity to decrease agitation in group &/or 1:1 setting, as needed to increase tolerance." "Provide exercise/gross motor skills 3 days per week to reroute energy into appropriate activities." "Provide stress management group 1x/week to increase coping skills." "Approach in a calm manner." These were all generic modalities.

For the identified problem, "Diabetes," the intervention listed for the Physician was "Physician to assess and/or adjust diabetic medications daily and/or __." [left blank] This was not checked, and no other intervention was listed.

For the identified problem, "Diabetes," interventions listed for Nursing were "Monitor blood sugars at least q. day and teach patient how to do own blood sugars if indicated." "Administer medications as ordered." "Monitor and teach for signs and symptoms of hyper/hypoglycemia." "Monitor and teach diet management." "Teach foot care." There was a "squiggly line" running down the check box column, indicating all were relevant. These were all generic modalities.

For the identified problem, "Hypertension," the intervention listed for the Physician was "Physician to assess and/or adjust anti-hypertension medications daily and/or__." [left blank] This was not checked, and no other modality was listed.

For the identified problem, "Hypertension," interventions listed for Nursing were "Assess patient every shift for signs of increased blood pressure daily and/or as needed." "Monitor blood pressure every shift and/or as needed and document." "Give anti-hypertensive as ordered every shift and monitor for effectiveness and/or side effects." "Provide medication teaching times one, reinforcing as needed." "Educate patient in disease process and risk factors, including smoking, dietary, obesity, etc." There was a "squiggly line" running down the check box column, indicating all were relevant. These were all generic interventions.

For the identified problem, "Fall Risk," the interventions listed for the Physician were "Order Physical Therapy or Occupational Therapy consult." "Order durable medical equipment." " Monitor and educate regarding precautions, risks, benefits, and side effects of medications." None of these generic interventions were checked.

For the identified problem, "Fall Risk," the interventions listed for Nursing were identical to those for Patient #1 above.

For the identified problem, "Fall Risk," the interventions listed for Occupational Therapy/Recreation/Activity Therapy were: "Assess barriers to exercise activities due to falls risk." "Teach fall prevention techniques to increase safety." "Provide useful activities to decrease restlessness and wandering." "Functional Assessment." None of these generic interventions were checked.

3. Patient #6: 76 year old blind, deaf and mentally delayed female with a diagnosis of Dementia. (Treatment plan date 8/12/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for the physician were Identical to those for Patient #1 above. None were checked.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Nursing were identical to those for Patient #1 above. None were checked.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed by Social Work/Case Management/Therapist were identical to those for Patient #1 above.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming." interventions listed by Occupational Therapy/Recreation/Activity Therapy were "Provide leisure skills group &/or______________, ____ x week to increase leisure inventory & coping skills." (not checked) "Provide activity to decrease agitation in group &/or 1:1 setting, as needed to increase tolerance/" (checked) "Provide exercise/gross motor skills __2_ days per week to reroute energy into appropriate activities." (checked) "Provide stress management group___x week to increase coping skills." (not checked) "Provide opportunities for patient to express feelings daily, letting patient know he/she can ventilate anger and frustration in a socially acceptable manner." (not checked) "Encourage use of journal when appropriateness as a way to vent anger." (not checked) "Approach in a calm manner." (checked) These interventions were generic and not individualized,

For the identified problem, "Fall Risk," the interventions listed for the Physician were identical to those on the plan of patient #3 cited above. None of these were checked.

For the identified problem "Fall Risk," the interventions listed by Nursing were identical to those listed for patient #3 cited above. All of these generic interventions were checked, and the blanks were not filled in.

For the identified problem, "Fall Risk," the interventions listed by Occupational Therapy/Recreation/Activity Therapy were identical to those listed for patient #3 cited above. None of these were checked.

4. Patient #7:72 year old male with a diagnosis of Bipolar Disorder (treatment plan date 8/17/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," the interventions listed for the physician were identical to those for patient #6 cited above. None were checked.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Nursing were identical to those for patient #6 cited above. No blanks were filled in; none of the interventions were checked, although there were 2 nurse's signatures next to "Name/Discipline."

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Social Work/Case Management/Therapist were identical to those for patient #6 cited above. There were 5 interventions checked; "develop a behavioral contract" was not. All were generic.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed by Occupational Therapy/Recreation/Activity Therapy were an identical list to that of patient #6. Five items were checked. Not checked were "Provide opportunities for patient to express feelings daily, letting patient know he/she can ventilate anger and frustration in a socially acceptable manner;" nor "Encourage use of journal when appropriate as a way to vent anger.

For the identified problem, "Fall Risk," the interventions listed for the Physician were the same as for the patients with "Fall Risk" problems cited above. None of these were checked.
For the identified problem, "Fall Risk," the interventions listed by Nursing were the same as the lists for "Fall Risk" for the patients cited above. There was a "squiggly line" running down the check box column, indicating all were chosen; all were generic nursing interventions.

For the identified problem, "Fall Risk," the interventions listed by Occupational Therapy/Recreation/Activity Therapy were the same as for the patients cited above. None of these were checked but there were 2 signatures by a "COTA" and a "RT."

For the identified problem, "Hypertension," the intervention listed for the Physician was identical to the list for the patient cited above with the problem of "Hypertension." This was not checked, but there was a signature next to "Responsible Person," which was illegible.
For the identified problem, "Hypertension," interventions listed by Nursing were the same as those for the patient with Hypertension cited above. All were checked; all were generic.

For the identified problem, "Diabetes," the intervention listed for the Physician was the same as for the patient with Diabetes listed above. This was not checked, but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Diabetes," interventions listed for Nursing were the same as for the patient cited above. Four items were checked: "Monitor blood sugars at least q.day and teach patient how to do own blood sugars if indicated." "Administer medications as ordered." "Monitor and teach for signs and symptoms of hyper/hypoglycemia." "Monitor and teach diet management." "Teach foot care.", "Administer medications as ordered" was blacked out with "diet control" written next to it.

For the identified problem, "Anemia," interventions listed for the Physician were "Assess patient's status related to Anemia daily &/or as needed & order medications as needed." "Assess patient's response to medications daily &/or as needed." These interventions were generic and not individualized for this patient. These were not checked, but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Anemia," interventions listed by Nursing were "Assess for signs and symptoms related to Anemia each shift &/or as needed." "Administer medications as ordered by the physician & assess for effectiveness & side effects each shift." "Monitor labs as ordered by MD and report as indicated." "Procedures as ordered by MD__." "Stools for occult blood [sic] if ordered." "Monitor vitals signs q.shift." These were all checked. These interventions were generic and not individualized for this patient.

5. Patient #9: 41 year old female with a diagnosis of Schizophrenia ( treatment plan dated 08/09/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Psychotic Symptoms: Delusional Thoughts," interventions listed for the Physician were "Assess &/or adjust medications 7x/week or as needed." "See patient on an individual basis ___x/week [left blank] for therapy & to assess level of delusional thinking." "Assess for severity of impairment in daily functioning." "Monitor for social withdrawal/isolation." "Monitor for irrational beliefs." "Monitor and educate regarding precautions, risks, benefits, and side effects of medications." None of these generic interventions was checked, but there was a signature next to "Name" which was illegible.

For the identified problem, "Psychotic Symptoms: Delusional Thoughts," interventions listed for Nursing were "Assess for signs and symptoms of delusional thinking every shift." "Assess for delusional thoughts and allow expression of feelings & fears each waking shift." "Provide explanation of all procedures when performed, unit rules x1, reinforcing as needed." "Monitor for medication side effects and effectiveness of teaching regarding precautions, benefits, and home medication regime." "Assess patient for appropriate observation level daily." "Provide short, frequent, contacts for support, reality testing, and redirection each shift & as needed." All of these were checked. These interventions were generic and not individualized for this patient.

For the identified problem, "Psychotic Symptoms: Delusional Thoughts," interventions listed for Social Work/Case Management/Therapist were "See patient__1_x week for trust building; approach patient in a non-threatening manner, providing positive affirmation and reassurance." "Groups 5_ days/week for support & education regarding delusions, recovery & relapse prevention." "Assess patient's ability to interact with peers as it relates to delusional thoughts." "Family meetings &/or contact for support & education regarding diagnosis, discharge needs, and community resources." "Provide reality testing in 1:1 and/or group setting." All were checked. These interventions were generic and not individualized for this patient.

For the identified problem, "Psychotic Symptoms: Delusional Thoughts," interventions listed for Occupational Therapy/Recreation/Activity Therapy were "Provide reality testing in OT group &/or 1:1 settings___days/week." [left blank] "Redirect patient from delusional thinking in group setting back to structured activities as appropriate." "Provide structured group activities with functional outcomes _2_ x/week to decrease delusional thinking." "Provide social skills opportunities to increase appropriate interactions in group & meals." These interventions were all generic and not individualized for this patient. None of these interventions were checked yet there were 2 signatures, 1 from "COTA" and 1 from " RT."

For the identified problem, "Fall Risk," the interventions listed for the Physician were as noted above. None of these were checked, but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Fall Risk," the interventions listed by Nursing were the same as above. There were checks next to all of the interventions. These were all generic and not individualized for this patient.

For the identified problem, "Fall Risk," the interventions listed for Occupational Therapy/Recreation/Activity Therapy were the same as above. These interventions were generic and not individualized. None of these were checked but there were 2 signatures, by a "COTA" and a "RT."

For the identified problem, "Hypertension," the intervention listed for the Physician was the same as above. This was not checked but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Hypertension," interventions listed for Nursing were the same as above. The first 3 items on the list were checked. They are all generic nursing interventions.

6. Patient # 10: An 81 year old female with a diagnosis of Bipolar (treatment plan dated 08/20/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for the physician were the same as noted above. None were checked, but there was a signature next to "Responsible Person," which was illegible.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for Nursing were the same as above. All were checked, these were all generic and not individualized for this patient.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for Social Services/Case Management were the same as noted above. All were checked, these were all generic and not individualized for this patient.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for Occupational Therapy/Recreation/Activity Therapy were the same as for the patients cited above. Five of the seven interventions were checked: "Provide leisure skills group &/or 1[sic]__, ___x (left blank)week to increase leisure inventory & coping skills." "Provide activity to decrease agitation in group &/or 1:1 setting, as needed to increase tolerance." "Provide exercise/gross motor skills 3 days per week to reroute energy into appropriate activities." "Provide stress management group 1x/week to increase coping skills." "Approach in a calm manner." These were generic.

For the identified problem, "Hypertension," the intervention listed for the Physician was the same as noted above. This was not checked, but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Hypertension," interventions listed by Nursing were the same as noted above. These were generic and not individualized for this patient. All items were checked.

For the identified problem, "Fall Risk," the interventions listed for the Physician were the same as above. These were generic and not individualized for this patient. None of these were checked, but there was a signature next to "Responsible Person," which was illegible.

For the identified problem, "Fall Risk," the interventions listed by Nursing were the same as noted above. These were generic and not individualized for this patient. There were checks next to all of the interventions.

For the identified problem, Fall Risk," the interventions listed by Occupational Therapy/Recreation/Activity Therapy were generic and not individualized for this patient. None of these were checked but there were 2 signatures by a "COTA" and a "RT".

7. Patient #11: A 54 year old female with a diagnosis of Schizophrenia (treatment plan dated 08/27/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for the physician were the same as noted above. Neither was checked, but there was a signature next to "Name;" it was illegible.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Nursing were the same as noted above for the same problem. These were generic and not individualized for this patient. None were checked, there was no signature.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Social Work/Case Management/Therapist were the same as noted above for the same problem; these were generic and not individualized for this patient. There were no interventions checked and there was no signature.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Occupational Therapy/Recreation/Activity Therapy were the same as noted above for the same problem. These were generic and not individualized for this patient. There were no items checked; there was a signature which was illegible.

For the identified problem, "Fall Risk," the interventions listed for the Physician were the same as noted above for the same problem; these were generic and not individualized for this patient." None of these were checked and there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Fall Risk," the interventions listed by Nursing were the same as above for this problem; these were all generic and not individualized for this patient. There were checks next to all of the interventions.

For the identified problem, "Fall Risk," the interventions listed by Occupational Therapy/Recreation/Activity Therapy were the same as above for this problem, these were all generic and not individualized for this patient. None of these were checked yet there was a signature by a "RT."

For the identified problem, "Chronic Obstructive Pulmonary Disease (COPD)," the interventions listed for the Physician were "Assess and provide medication to relieve symptoms daily." "Review risks, benefits, & alternatives to treatment modalities with patient/family." Neither of these were checked, but there was signature next to "Responsible Person" which was illegible.

For the identified problem, "Chronic Obstructive Pulmonary Disease (COPD)," the interventions listed for Nursing were "Assess & record breath sounds, respiratory rate, coughing ability & sputum production for baseline & ________________. [left blank]" "Instruct patient/family x1 and as needed regarding pursed-lip breathing & effective coughing." "Educate patient/family regarding adjusting activities". All were checked; all are generic nursing tasks.

For the identified problem, "Chronic Obstructive Pulmonary Disease (COPD)," in a section titled: "Respiratory Therapist", there was nothing listed, nor a signature.

8. Patient #14: A 50 year old female with a diagnosis of Schizophrenia (treatment plan dated 08/05/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for the physician were the same as above for the same problem; these were not individualized for this patient. No items were checked.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Nursing were the same as above for the same problem; these are generic and not individualized for this patient. All were checked.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed for Social Work/Case Management/Therapist the same as above for the same problem; these are generic and not individualized for this patient.

For the identified problem, "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," interventions listed by Occupational Therapy/Recreation/Activity Therapy were the same as above for the same problem; these are generic and not individualized for this patient.

For the identified problem, "Anemia," interventions listed for the Physician were the same as noted for the same problem above. These were not checked, but there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Anemia," interventions listed for Nursing were the same as for the same problem listed above All but the last item ("Monitor vitals signs q.shift") was checked. These were generic, the blank on the sheet was not filled in. and these were not individualized for this patient.

For the identified problem, "Imbalanced Nutrition," the interventions listed for the Physician were "Assess & adjust medications as needed." "order labs as indicated." These were generic and not individualized for this patient. These were not checked, but there was a signature by "Responsible Person" which was illegible.

For the identified problem, "Imbalanced Nutrition," the interventions listed for Nursing were "Monitor lab values as ordered by physician." "Observe for changes in mental status." "Monitor vital signs." "Monitor weight Monday, Wednesday, Friday or as ordered by physician." "dietary consult as ordered__________. [left blank]" "document patients nutritional intake daily." "educate patient and family regarding the need for nutrition intake." "monitor medication side effects and effectiveness of teaching regarding precautions, benefits, and home medication regime." These were generic and not individualized for this patient. All of these were checked. .

For the identified problem, "Fall Risk," the interventions listed for the Physician were the same as above for the same problem. None of these were checked; there was a signature next to "Responsible Person" which was illegible.

For the identified problem, "Fall Risk," the interventions listed by Nursing were the same as above for the same problem; these were generic and not individualized for this patient. There were checks next to all of the interventions.

For the identified problem, "Fall Risk," the interventions listed for Occupational Therapy/Recreation/Activity Therapy were "the same as above for the same problem; these were generic and not individualized for this patient. None of these were checked but there were 2 signatures by a "COTA" and a "RT."


9. Patient #15: An 81 year old male with a diagnosis of Dementia/Behavioral (treatment plan dated 08/18/10). The treatment plan failed to identify the focus of the interventions, based on the specific needs of the patient.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for the physician were the same as above for the same problem; these were generic and not individualized for this patient None were checked.

For the identified problem, "Disruption in cognitive operations and activities," interventions listed for Nursing were the same as above for the same problem; these were generic and not individualized for this patient. All were checked.

For the identified problem, "Disruption in cognitive operations and activities," interventions lis

Based on record review, document review and interview, the facility failed to:

I. Provide adequate nursing monitoring of a hospitalized patient (Death Record D) who was found unresponsive on the morning of 8/13/10 at 5:45a.m. and pronounced dead upon medical examination. The patient had not received the required "Q15 minute" checks by a Mental Health Technician (MHT) or the required "Q2-hour checks" by an RN or LPN during the night of his death. Failure to provide required nursing monitoring of patients poses a risk for repeated serious adverse outcomes for patients, and results in IMMEDIATE JEOPARDY.
On 9/01/10 at 10:00a.m., a meeting was held with the facility Chief Executive Officer (CEO), Medical Director, and Director of Nursing (DON). At that time they were advised of the findings noted below and that a state of Immediate Jeopardy to patient health and safety exists.
In addition, the facility failed to:

II. Provide individualized psychiatric treatment for 3 of 10 active sample patients (#'s 9, 14 and 15) based on their presenting needs. In the case of active sample Patients 9 and 14, there was failure to ensure structured treatment for their specialized treatment needs. In the case of active sample Patient #15 who functioned at low cognitive and social levels, adequate modalities to address his/her problems were not provided. This failed practice results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement.

III. Ensure that patients who are admitted and maintained in the facility are appropriate for active psychiatric treatment. Patient #1 was added to the sample because of medical/physical conditions that clouded her sensorium enough to prevent participation in active psychiatric treatment. The only behavioral problem listed on the treatment plan was not in evidence. This failure results in patients being hospitalized in a treatment setting that cannot address their specific needs.

IV. Provide adequate evaluation, interpretive services, and appropriate treatment for active sample patient #6 who presented with both visual and hearing deficits. In addition, this patient was diagnosed with severe to profound mental retardation. This failure compromises the patient's ability to understand and participate in treatment.

V. Provide adequate groups/activities on weekends (Saturdays and Sundays) to meet the treatment needs of patients in the 20-bed unit. This hinders patients' ability to move to higher levels of functioning and less restrictive environment.

Findings include:

I. Failure to provide adequate nursing monitoring of Patient D: (Death Record D)

A. Record Review

Patient D, whose death record was reviewed, was a 62 year-old man admitted to the hospital on 8/05/10 with diagnoses including "Psychotic Disorder NOS," "Mental Retardation," and "Abnormal EKG." On 8/13/10 at 5:45a.m., nursing staff found the patient cold and unresponsive. Upon medical examination, the patient was pronounced dead. Review of nursing documentation revealed that a Registered Nurse (RN) had last documented a check on the patient at 9:00 p.m. on 8/12/10. Review of mental health tech (MHT) documentation revealed that a MHT had last documented a check on the patient at 4:30 a.m. on 8/13/10.

B. Policy Review

The facility's "Nursing Rounds" policy, effective 8/23/04, states the following in the Policy Section (b): "Rounds are made q15 checks by MHT and q 2 hours by the RN and LPN." The policy also states under Procedures Section (e) "The staff member must enter the room to observe the condition of the patient and verfify [sic] the patient is in his/her bed and breathing normally."

C. Staff Interview
1. In an interview on 8/31/10 at 8:30a.m., the Medical Director stated that on the day of Patient D's death (8/13/10), he arrived at the facility at 6:35a.m. and found the patient cold and in full rigor mortis. He stated that in his opinion, staff could not have checked on the patient for several hours.

2. In an interview with the Director of Nursing and Chief Executive Officer on 8/31/10 at 12:00p.m., the DON stated that RN #8 (the nurse providing care to Patient D on the night the patient expired) had observed the patient from outside the door during his/her supervision rounds, but had not entered the patient's room to "inspect the patient," nor had she documented according to policy.

II. Failure to provide individualized treatment for active sample patients 9, 14 and 15

A. Specific Patient Findings

1. Patient #9

a. Patient #9 was 41-year-old patient admitted to the facility on 8/9/10 with diagnosis of Psychosis Disorder NOS.

b. In an interview on 8/30/10 at 10:45a.m., Patient #9 stated that she does not attend any groups/activities. She stated that she spends her time sitting alone in the dayroom (across the hall from the group room).

c. Ward observations on 8/30/10 at 11:00a.m. and on 8/31/10 at 8:50a.m. revealed Patient #9 sitting alone in the dayroom even though groups were being conducted at those times. When approached at this these times by the surveyor, she stated that she was not going to go to the groups.

d. Review of Patient #9's medical record revealed the following:

e. Daily treatment notes from 8/11/10 thru 8/28/10 by social work and rehabilitation therapists documented that Patient #9 had refused all treatment groups/activities.

f. Patient #9's Master Treatment Plan (dated 8/9/10 with review dates of 8/16/10, 8/23/10 and 8/30/10) failed to address the issue of non-compliance with treatment while in the hospital.

g. In an interview on 8/31/10 at 10:40 a.m., RN #3 reported that Patient #9 had refused to attend treatment groups. RN #3 stated that the patient was usually in his/her room or pacing the halls. RN#3 also verified that non-compliance with treatment was not addressed in the patient's treatment plan.

2. Patient #14

a. Patient #14 was a 50 year-old woman admitted to the facility on 8/5/10.

b. Ward observations on 8/30/10 at 10:00a.m. and 10:45a.m., and 8/31/10 at 8:45a.m. revealed Patient #14 walking by herself in the unit hallway even though groups to which all patients go were being conducted at those times.

c. In an interview on 8/30/10 at 10:00 a.m., the Medical Director acknowledged that Patient #14 "was isolative" and did not attend groups.

d. Review of Patient #14's medical record revealed the following:

1). Therapeutic group notes dated 8/30/10, 8/27/10, 8/25/10, 8/23/10, 8/20/10, and 8/13/10 indicated that Patient #14 did not attend group.

2). As of 8/31/10 the patient's Master Treatment Plan (dated 8/5/10 with review dates of 8/12/10, 8/19/10 and 8/26/10) did not address Patient 14's issue of non-compliance with groups. The treatment plan also did not include appropriate alternatives to group treatment.

3. Patient #15

a. Patient #15 was an 81-year old patient who was admitted on 8/18/10 with Dementia and Depression.

b. Observations on 8/30/10 from 11:05 to 11:40a.m. during a discussion group conducted for 13 patients revealed Patient #15 asleep and snoring during the entire session.

c. Observations of the adult psychiatric ward on 8/31/10 at 10:35a.m. during a process group revealed Patient #15 asleep. The patient only briefly responded when asked a question by the group leader.

d. Review of Patient #15's Master Treatment Plan (dated 8/18/10 with review date of 8/25/10) revealed failure to include specific individualized interventions to address his/her impaired cognitive level of functioning.

III. Severe medical/physical conditions that prevented participation in active psychiatric treatment

A. Patient #1 was a 78-year old female admitted to the facility on 8/16/10 from a nursing home due to agitation, yet as the assessments, notes and observations below reveal, there was no evidence of a psychiatric condition requiring treatment during the patient's stay, but rather serious medical problems requiring care.

B. The patient's History and Physical exam (dated 8/17/10) documented that she [Patient #1] was admitted after treatment in a general hospital for exacerbation of congestive heart failure and pneumonia. "Cardiopulmonary: ...shortness of breath...edema." "Physical: ...She is wheelchair bound with nasal O2 [oxygen]...Lungs: Has bilateral basal crackles posteriorly."

C. The psychiatric evaluation (dated 8/17/10) documented the patient's diagnoses as Depressive disorder associated with medical condition, possibly dementia with behavioral disturbance, possible delirium from medications (Xanax, Benadryl). Her medical diagnoses were listed as "Obesity, heart disease, intolerance of Penicillin and Quinine, sleep apnea, possible hypothyroidism, history of cerebrovascular (sic) accident." The psychiatric evaluation stated "She has a pacemaker. She has...diabetes, lung disease, heart failure..." "We will hold her Lasix for hypotension. (Blood pressure 91/49 this morning). I will see if I can get her on her CPAP [Continuous Positive Airway Pressure machine]."

D. The treatment plan listed the behavioral problem requiring inpatient treatment as "Spitting at NH [Nursing Home] staff." There were no physician interventions for this problem, and the nursing and social work interventions were generic lists without specificity. She was to attend groups along with all other patients. See B122 for the list of interventions.

E. Observation of a discussion group on the adult psychiatric ward on 8/30/10 at 11:05 a.m. conducted by a rehabilitation therapy worker for 13 patients on the unit, found Patient #1 asleep during the entire group session. The patient was in a reclining position in wheel chair with nasal oxygen. She had labored breathing and edematous legs and was non-responsive when the leader called the patient by name and "shook" her.

F. Observation of a process group on the adult psychiatric ward conducted by the Director of Social Work for 14 active patients on 8/31/10 at 10:35a.m., revealed Patient #1 asleep during the entire group session. She was in a reclining position in wheel chair with nasal oxygen. She had edematous legs.

G. During an observation on 8/31/10 at 8:25a.m. in the Unit dayroom, Patient #1 was reclining asleep in wheelchair with nasal oxygen. When the surveyor called the patient by name, and touched her arm, the patient was non-responsive other than briefly opening her eyes.

H. A review of Physician Notes in Patient #1's medical record revealed the following:

1. Note dated 8/19/10: "renal failure, heart failure, poorly controlled diabetes, possible dementia, sleep apnea." "I will hold her Remeron since she is in renal failure...I will reduce her potassium since she is in renal failure and on both Zestril and Aldactone. She needs her CPAP [Continuous Positive Airway Pressure machine] at night."

2. Note dated 8/20/10: "I cannot really understand [patient's] speech. It is like her mouth is full of saliva and she chooses not to swallow."

3. Note dated 8/24/10: "Now she is on IM Lasix. Her glucose on her blood sample was only 50. Her BNP [B-type natriuretic peptides] is still up at 695. The nurse noted her legs jerked at night."

I. A review of Registered Nurse Notes in Patient #1's medical record revealed the following:

1. Admission note on 8/16/10 at 9:55p.m.: "Resp. [respirations] 22, some coarse rhonchi & [and] occas [occasional] exp [expiration] wheeze noted...requires assistance c/ [with] transfers & ADLS [and activities of daily living skills] and is incontinent of B&B [bowel and bladder]. Has 3+ edema RLE [right leg extremity] and 2+ edema LLE [left leg extremity]...Skin assessment reveals 1.0cm x 0.2cm x 0.2mm wound to coccyx, moist rash to bil [bilateral] groin, thighs and under breasts."

2. Note on 8/28/10 at 7:30a.m.: "Has BLE [bilateral leg edema] edema (2+). Drowsy. Oriented x1 (person only). Hard to awaken c/ [with] verbal stimulation but awaken easily c/ [with] tactile stimulations...Has productive cough c/ [with] frothy white sputum. Crackles auscultated...Pt [Patient] is total care c/ [with] ADLS [activities of daily living]."

3. Note on 8/28/10 at 11:00p.m.: "O2 [Oxygen] (unreadable word) per NC [nasal catheter] via O2 [oxygen] concentrator...Requires turning q [every] 2 hours...She has been sleeping c/ [with] snoring respirations between turnings."

J. A Treatment Team Conference Note on 8/19/10 documented that the meeting was attended by Patient #1's daughter and that the psychiatrist reported that "the patient's heart was failing and that she was having issues with her diabetes." The note also said that the psychiatrist also reported that on "morning rounds this morning, the patient was mumble (sic) and was difficult to understand."

K. Review of Activity Therapy Notes in Patient #1's medical record revealed the following:

1. Note on 8/1910: "The patient answers open-ended questions 5% of the time...The patient with slurred speech 90% of the time."

2. Note on 8/26/10: "The patient has no [sic] attended any activity therapy groups this charting period secondary to the patient not feeling well...The patient very lethargic."

IV. Failure to provide evaluation, interpreter services and appropriate treatment for Patient #6

A. Patient #6 was 76-year-old female admitted to the facility on 8/12/10 with diagnoses of Mood Disorder NOS and Mental Retardation, profound:

B. Observation of a group session led by a rehabilitation therapist on 8/30/10 from 11:05a.m. to 11:35a.m. revealed 13 patients attending the group, including patient #6. Patient #6 was rocking, making random movements with her arms, and frequently looking from one side of her chair to the other. At times she made "startled response movements." There was no behavior presented by the patient that indicated any understanding of the group session or that s/he was aware of where she was at that time.

C. During an attempted interview on 8/30/10 at 11:50a.m., Patient #6 did not respond verbally or non-verbally to the surveyor's queries. The patient looked in the direction of a staff member in a bright red uniform standing nearby and patted him on the arm.

D. Review of Patient #6's medical record revealed the following:

1. Even though Patient #6 attended several structured groups, the only activity the patient was able to participate in was the exercise group. Treatment notes document that the patient required 1:1 assistance to actively participate in this group.

2. Review of the patient's Master Treatment Plan (dated 8/12/10 with review dates of 8/18/10 and 8/27/10) as of 8/31/10 revealed failure to address Patient #6's visual and hearing deficits or her mental retardation

E. In an interview on 8/31/10 at 11:00a.m., RN #1 verified the above documented findings. RN #1 stated that s/he had not heard Patient #6 say anything, but has attempted to use sign language. RN #1said that staff are unaware of the severity of Patient #6's visual or hearing deficits. S/he also stated that Patient #6 has not had a visual or hearing evaluation since being admitted to the facility. RN #1 added " I guess the doctor would have to order and evaluation." RN#1 stated that an interpreter has not been used for the evaluation or treatment of Patient #6.

F. Review of the medical record failed to reveal evidence that an interpreter was contacted as of 8/31/10.

V. Failure to provide adequate groups/activities on weekends (Saturdays and Sundays):

Staff Interviews

A. In an interview on 8/31/10 about 10:10a.m., the CEO reported that the facility's structured groups/activities are minimal due to loss of a Rehabilitation staff member about 3-4 months ago.

B. In an interview on 8/31/10 at 10:00 a.m., RN #1 reported that there are usually no formal groups for the patients on week-ends. S/he related that the patients "go on passes, see movies, have longer visiting hours and go outside, if possible."

C. In an interview on 8/31/10 at 3:30p.m., the Director of Social Work (supervisor of Rehabilitation Services) stated that week-end (Saturday and Sunday) groups and activities are minimal due to a position vacancy. S/he acknowledged that the facility has not considered alternative methods for providing week-end coverage (while the hospital is attempting to fill the vacancy) other than having a prn staff member work on the week-end when that person is available.

Based on record review, document review and interview, the Medical Director failed to assure adequate medical and psychiatric care to patients. Specifically, the Medical Director failed to:

I. Assure that, following the death of a patient D in the facility, an adequate review of the circumstances of the death was performed, and that corrective actions were taken to assure that those areas of staff failures identified were adequately addressed in a timely manner to assure ongoing patient safety. This failure resulted in IMMEDIATE JEOPARDY to patient health and safety.
Findings include:

A. Record Review

1. Patient D, whose death record was reviewed, was a 62 year-old man admitted to the hospital on 8/05/10 with diagnoses including "Psychotic Disorder NOS," "Mental Retardation," and "Abnormal EKG." On 8/13/10 at 5:45a.m., nursing staff found the patient cold and unresponsive. Upon medical examination, the patient was pronounced dead. Review of nursing documentation revealed that a Registered Nurse (RN) had last documented a check on the patient at 9:00p.m. on 8/12/10. Review of mental health tech (MHT) documentation revealed that a MHT had last documented a check on the patient at 4:30a.m. on 8/13/10.

2. The surveyors reviewed the incident report file supplied by the facility. No incident review was found relating to Patient D's death.

B. Policy Review

The facility's "Nursing Rounds" policy, effective 8/23/04, states the following in the Policy Section (b): "Rounds are made q15 checks by MHT and q 2 hours by the RN and LPN." The policy also states under Procedures Section (e) "The staff member must enter the room to observe the condition of the patient and verfify [sic] the patient is in his/her bed and breathing normally."

C. Staff Interview

1. In an interview on 8/31/10 at 8:30a.m., the Medical Director stated that on the day of Patient D's death (8/13/10), he arrived at the facility at 6:35a.m. and found the patient cold and in full rigor mortis. He stated that in his opinion, staff could not have checked on the patient for several hours.

2. During an interview on 8/31/10 at 12:00p.m., the DON and CEO both stated that the facility did not have a death review policy and had not conducted a formal death review for expired Patient D. They also stated that the facility does not have a policy related to sentinel incidents, although there is a practice of filling out incident reports. The CEO and DON stated that they believed an incident report had been filled out for the patient D's death; however, both the CEO and DON acknowledged that no incident report could be found.

3. In an interview on 9/01/10 at 9:45a.m., the Medical Director stated that the facility did not have a formal policy to review patient deaths. He stated that in the case of patient D, he had concerns that he expressed to the DON. When asked if he was comfortable with whether or not his concerns were addressed, he said: "There wasn't anything I could do about it."

In addition, the Medical Director failed to:

II. Ensure that the comprehensive treatment plans for 4 of 10 sample patients (Patient #'s 6, 9, 14 and 15) included revisions based on patients changes, or lack thereof. This failure impacted on the patients' ability to participate in active treatment. (Refer to B118)

III. Assure that individualized interventions were developed and documented on the Master Treatment Plans of 10 of 10 active sample patients (#'s 1. 3, 6, 7, 9, 10, 11, 14, 15 and 16). The treatment plans were completed on a form with preprinted lists of problems and related possible interventions; most of the interventions were generic guidelines. This failure hinders the provision of individualized and consistent, focused treatment. (Refer to B122)

IV. Assure that individualized psychiatric care was provided for 3 of 10 active sample patients (#9, 14 and 15) based on their presenting needs. In the case of active sample Patients 9 and 14, there was failure to ensure structured treatment for their specialized treatment needs. In the case of active sample Patient #15, who functioned at low cognitive and social levels, adequate modalities to address his problems were not provided. This failed practice results in patients being hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B125-II)

V. Assure that patients who are admitted and maintained in the facility are appropriate for active psychiatric treatment. Patient #1 added to the sample, had multiple medical/physical conditions that prevented participation in active psychiatric treatment, and did not exhibit the psychiatric symptoms listed on the treatment plan and requiring psychiatric inpatient care. This failure results in patients being hospitalized in a treatment setting that is not appropriate to address their specific needs. (Refer to B125-III)

VI. Provide adequate interpreter services and appropriate treatment for active sample patient #6, who presented with both visual and hearing deficits. In addition, this patient was diagnosed with severe to profound mental retardation. This failure compromises the patient's ability to understand and participate in treatment. (Refer to B125-IV)

VII. Provide adequate groups/activities on weekends (Saturdays and Sundays) to meet the treatment needs of patients in the 20-bed unit. This hinders patients' ability to move to higher levels of functioning and less restrictive environment. (Refer to B125-V)

Based on interview and document review, the Director of Nursing failed to monitor and assure adequate nursing care to patients at the facility. The DON failed to:

I. Assure adequate nursing monitoring of Patient D (Death Record D) who was found unresponsive on the morning of 8/13/10 at 5:45a.m. and pronounced dead upon medical examination. The patient did not receive the required "q15 minute" checks by a Mental Health Technician (MHT) or the required "q2-hour" checks by an RN or LPN during the night prior to his death. The DON also failed to ensure that Registered Nurses and Mental Health Technicians received adequate training regarding the correct monitoring and documentation of patient safety rounds following the death of Patient D. Failure to provide required nursing monitoring of patients poses a risk for repeated serious adverse outcomes for patients, and resulted in IMMEDIATE JEOPARDY.

Findings include:

A. Record Review

Patient D was a 62 year old man admitted to the hospital on 8/05/10 with diagnoses including "Psychotic Disorder NOS," "Mental Retardation," and "Abnormal EKG." On 8/13/10 at 5:45a.m., nursing staff found the patient cold and unresponsive. Upon medical examination, the patient was pronounced dead. Review of nursing documentation revealed that a Registered Nurse (RN) had last documented a check on the patient at 9:00p.m. on 8/12/10. Review of mental health tech (MHT) documentation revealed that a MHT had last documented a check on the patient at 4:30a.m. on 8/13/10.

B. Policy Review

The facility's "Nursing Rounds" policy, effective 8/23/04, states the following in the Policy Section (b): "Rounds are made q15 checks by MHT and q 2 hours by the RN and LPN." The policy also states under Procedures Section (e) "The staff member must enter the room to observe the condition of the patient and verfify [sic] the patient is in his/her bed and breathing normally."

C. Staff Interviews
1. In an interview on 8/31/10 at 8:30a.m., the Medical Director stated that on the day of Patient D's death (8/13/10), he arrived at the facility at 6:35a.m. and found the patient cold and in full rigor mortis. He stated that in his opinion, staff could not have checked on the patient for several hours.

2. In an interview with the Director of Nursing and Chief Executive Officer on 8/31/10 at 12:00p.m., the DON stated that RN #8 (the nurse providing care to Patient D on the night the patient expired) had observed the patient from outside the door during his/her supervision rounds, but had not entered the patient's room to "inspect the patient," nor had she documented according to policy.

3. In an interview with the Director of Nursing and Chief Executive Officer on 8/31/10 at 12:00 p.m., the DON stated that she had conducted 1:1 training with RN #8. However, the DON could not produce documentation of such training. The DON had no documented plan to train other RNs, and she acknowledged that she had not yet taken any action on this training. The DON also stated that on 8/16/10, she conducted a training review of q15 minute checks with the MHT who provided care to Patient D on the night the patient expired. However, the training sheet provided by the DON did not address nursing policy section on Procedures (e), stating that staff must verify patient breathing.

D Additional Record Review

1. Review of RN #8's documentation flow sheets of patient monitoring for 3 of 7 nights that RN #8 worked since Patient D's death (8/13/10) revealed the following deficiencies for 2 of 2 patients reviewed (sample Patients #'s 7 and 15):

Patient #7: [8/21/10] status of patient, including respirations not noted at 6:00 a.m.
Patient #15:

a. [8/20/10] respirations not noted at 12:00a.m., 2:00a.m., and 4:00a.m.
b. [8/21/10] status, including respirations, not noted at 4:00a.m. and 6:00a.m..
c. [8/22/10] respirations not noted at 6:00a.m.

2. Review of the Mental Health Technician #9's signed documentation training record
of 8/16/10 and titled: "Competency For Taking Blood Pressure Appropriately and Documentation for Q.15 Minutes Checks Appropriately," revealed an absence of review for the assessment of breathing as required by policy.

In addition, the DON failed to assure that:

II. Treatment plans included individualized nursing interventions for 10 of 10 active sample patients (#'s 1, 3, 6, 7, 9, 10, 11, 14, 15 and 16). Treatment plans were completed on a form with preprinted lists of possible nursing interventions for each listed problem; most of the interventions were generic nursing tasks rather than being based on individual patients' assessed needs. In some instances, no nursing interventions were chosen for listed problems. This failure hampers nursing staff's ability to provide focused treatment.

Findings include:

A. Record Review (dates of MTPs in parentheses)

1. Patient #1 (8/16/10): For the identified problems, "spitting food at NH staff," and "Fall Risk," all preprinted nursing interventions on the treatment plan form were chosen (checked). There were no changes or additions to the preprinted lists based on the individual patient findings.

2. Patient #3 (8/10/10): For identified problems "Disruption in cognitive operations and activities"; "Diabetes"; "Hypertension" and "Fall Risk," all of the preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings. Refer to B122 for the list of interventions related to each problem category.

3. Patient #6(8/12/10): For identified problem "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," there were no interventions identified by nursing. For the identified problem "Fall Risk," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

4. Patient #7(8/17/10): For the identified problem "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," no nursing interventions were identified. For identified problems, "Fall Risk," "Hypertension" and "Anemia," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

5. Patient #9(08/09/10): For identified problems "Psychotic Symptoms: Delusional Thoughts" and "Fall Risk," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

6. Patient # 10(08/20/10): For identified problems "Disruption in cognitive operations and activities" and "Fall Risk," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

7. Patient #11(08/27/10): For the identified problem "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," no nursing interventions were identified. For identified problems, "Fall Risk" and "Chronic Obstructive Pulmonary Disease (COPD)," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

8. Patient #14(08/05/10): For identified problems "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," "Fall Risk" and "Imbalanced Nutrition," all nursing interventions on the treatment plan form were identified without individualization based on the patient findings.

9. Patient #15(08/18/10): For identified problems "Disruption in cognitive operations and activities" and "Fall Risk," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

10. Patient #16(08/09/10): For the identified problem "Severe Agitation with Combativeness/Verbal Threats and/or Screaming," "Hypertension" and "Altered Tissue Perfusion," all preprinted generic nursing interventions on the treatment plan form were chosen without individualization based on the patient findings.

B. Interviews

1. In an interview on 09/01/10 at 10:00a.m., regarding the nursing interventions checked on the sample patients' treatment plans, the Director of Nursing (DON) stated "The nurses are probably not able to complete them all; they should not check them all."

2. In an interview on 08/31/10 at 9:30a.m., regarding nursing involvement in the treatment planning process, RN #3 stated, "The nurse doesn't really do anything with them (referring to the Treatment Plans); the social worker decides what is needed and fills them in, we just follow what she says."

III. Ensure that active individualized psychiatric care was provided for 3 of 10 active sample patients (#'s 9, 14 and 15) based on their presenting needs. In the case of active sample Patients 9 and 14, there was failure to ensure structured treatment for their specialized treatment needs. In the case of active sample Patient #15, who functioned at low cognitive and social levels, adequate modalities to address his/her problems were not provided. This failure resulted in patients being hospitalized without all interventions for recovery being provided in a timely fashion, delaying improvement. (Refer to B125 Section II)

IV. Provide necessary evaluation, interpretive services and appropriate treatment for 1 of a sample of 1 active patient (#6) who presented with both visual and hearing deficits. In addition, this patient was diagnosed with severe to profound mental retardation. This failure compromised the patient's ability to understand and participate in treatment. (Refer to B125 Section IV)

V. Ensure that nursing services are provided in accordance with safe, acceptable standards of nursing practice related to the use of Seclusion and Restraint. The Seclusion and Restraint room was neither readily accessible nor sanitary. This failure results in an environment which is unprepared for an emergency in which the need for seclusion or restraint may be necessary.

Findings include:

A. Interview:

1. In an interview on 08/30/10 at 11:45a.m., when asked to open the Seclusion and Restraint Room, RN #1 stated "I don't have a key."

2. In an interview on 08/30/10 at 11:45 a.m., when asked to use her key to open the Seclusion and Restraint Room, RN #2 stated "I don't have one either."

3. In an interview with the DON on 08/30/10 at 12:00 p.m., when asked to use her key to open the Seclusion and Restraint Room, the DON stated "I have too many keys and don't keep those on my key ring; I ' m sure one of the nurses has one."

B. Document Review:

The facility's policy for Restraints and Seclusion, # 09.001 dated: 08/25/04, states the following on page 11, Section M: "The only item allowed in the seclusion room is a floor mat. At no time will any furniture, fixtures, or any other items except for the floor mat on which a patient can stand be placed in the seclusion room."

C. Observations:

On 08/30/10 at 12:10p.m., the Seclusion and Restraint room was observed. The following conditions were noted:

a. There were two dead cockroaches on the floor.

b. The Seclusion Room had a wooden restraint bed bolted to the floor. This is against the facility's S/R policy (cited above in item B) which states that at no time will there be any furniture, fixtures, or any other items in the Seclusion Room except for a floor mat. An attempt to move the restraint bed was not successful.

c. There were Velcro restraints tied to the Seclusion Room bed. The DON and the CEO were asked how quickly the room could be ready for a patient who might need to be secluded. The CEO replied "5 minutes." A demonstration of an attempt to remove the restraints lasted beyond 5 minutes and was unsuccessful. At this time, the CEO stated, "I would get a pair of scissors and cut them off."