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Based on document review and interview, the facility failed to notify the attending physician of restraint or seclusion initiation for 6 of 24 (N21, N23, N27-N30) medical records (MR)reviewed.

Findings:

1. Policy 702.31, Seclusion and Restraint, revised/reapproved 1/16, indicated on page 5:
A. the LIP/QRN: Contacts the Attending Physician or designee to discuss the evaluation of the patient, the need for other interventions or treatments and the need to continue or discontinue the S/R.
B. this needs to be done as soon as possible after completing the One Hour Face to Face Medical & Behavioral Evaluation but no longer than 30 minutes after the evaluation is completed.

2. Review of medical records confirmed:
A. N21's MR indicated on 1/21/16 at 1331 hours for physical restraint was ordered by MD 3. N21's attending physician was MD 1. N21's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/21/16 at 1415 hours. N21's MR indicated on 1/21/16 at 1810 hours for physical restraint was ordered by MD 4 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/21/16 at 1820 hours. N21's MR indicated on 1/23/16 at 0855 hours for physical restraint was ordered by MD 2 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/23/16 at 0915 hours.
B. N23's MR indicated on 1/23/16 at 0836 hours for physical restraint was ordered by MD 2. N23's attending physician was MD 1. N23's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/23/16 at 0930 hours.
C. N27's MR indicated on 1/20/16 at 1820 hours for physical restraint was ordered by MD 5. N27's attending physician was MD 1. N27's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/20/16 at 1825 hours. N27's MR indicated on 1/21/16 at 1510 hours for physical restraint was ordered by MD 5 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/21/16 at 1600 hours. N27's MR indicated on 1/22/16 at 1337 hours for physical restraint was ordered by MD 7 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 1/22/16 at 1410 hours.
D. N28's MR indicated on 2/14/16 at 1100 hours for physical restraint was ordered by MD 2. N28's attending physician was MD 1. N28's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/14/16 at 1135 hours.
E. N29's MR indicated on 2/19/16 at 1020 hours for physical restraint was ordered by MD 3. N29's attending physician was MD 1. N29's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/19/16 at 1035 hours. N29's MR indicated on 2/21/16 at 1425 hours for physical restraint was ordered by MD 5 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/21/16 at 1500 hours.
F. N30's MR indicated on 2/10/16 at 1640 hours for physical restraint was ordered by MD 3. N30's attending physician was MD 1. N30's MR lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/10/16 at 1710 hours. N30's MR indicated on 2/11/16 at 0945 hours for physical restraint was ordered by MD 6 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/11/16 at 1010 hours. N30's MR indicated on 2/12/16 at 1913 hours for physical restraint was ordered by MD 2 and lacked documentation that MD 1 was notified within 30 minutes of completion of the face to face medical and behavioral evaluation on 2/12/16 at 2000 hours.

3. Staff P4 (Chief Nursing Officer/Director of Clinical Services) was interviewed on 4/27/16 at approximately 0930 hours and confirmed attending physician notification for emergency intervention order/initiation for physical restraints had not been documented and confirmed staff are to follow policy and procedure for seclusion and restraint.

Based on document review and interview, the quality assessment and performance improvement (QAPI) program failed to measure, analyze and track 1 of 3 quality indicators (indicator #3) within the past 4 quarters.

Findings:

1. Review of the document titled Performance Improvement Plan 2015 and the document titled Performance Improvement Plan 2016 indicated the following:
a. III. Goals and Objectives. 7. To annually evaluate the adequacy of the Performance Improvement (PI) Program based on systematic collection of data...
b. V. Measurement/Monitoring: The Hospital uses a systemic collection of quantifiable data about both processes and outcomes over time or at a single point in time.
c. VI. Assessment/Analysis 1. Selected data is aggregated, formatted and analyzed to turn information into data for decision making. 4. Data analysis may result in: a. Continued monitoring...b. Intensive assessment... 5. Quality control of data collection and interpretation is used to monitor data content and to ensure timely and effective data collection.
d. VII. Improve 13. Determine frequency and intensity of data collection... 15. Annually evaluate functioning level of the committee and the PI Plan and determine opportunities for improvement.
e. Attachment 2 of the 2015 plan indicated the following as an indicator to monitor: STAT (urgent) Report; All STATs reported and reviewed per procedures and forms in policy...Use of STAT Medication. Specific summary reports provided to Leadership and PI/S/RM (performance improvement/safety/risk management) team monthly. Summaries reviewed quarterly by Physicians.

2. Review of PI documents from 4/2015 to 4/2016 indicated the following:
a. Meeting minutes were documented as handwritten notes on documents titled PI Meeting Agenda with the following agenda dates: April 15, 2015, April 25, 2015, May 20, 2015, June 17, 2015, July 30, 2015, August 25, 2015, September 23, 2015, October 21, 2015, December 16, 2015, February 3, 2016 and February 25, 2016 and meeting minutes were documented on the document titled Performance Improvement dated March 30, 2016.
b. PI documents lacked documentation of STAT Reports being measured, analyzed or tracked at any time in the past 4 quarters.

3. On 4/27/16 at 4:00 pm, A11, Director of Performance Improvement, indicated the facility did not have documentation of measuring, analyzing or tracking the PI selected indicator for STAT Reports.

Based on document review and interview, the governing board (GB) failed to ensure that the QAPI (quality assessment and performance improvement) program included all services and all departments of the hospital for 2 services (Alcohol and/or Drug Services and Psychiatric-Child/Adolescent) in the past 4 quarters.

Findings:

1. Review of Governing Board Bylaws indicated the following: 9.5 Performance Improvement: The GB shall require the Medical Staff and each of the Hospital departments or services to implement and report on mechanisms for monitoring and evaluating the quality of patient care... The Bylaws were approved 3/15.

2. Review of the documents titled Performance Improvement (PI) Plan 2015 and the attached PI selected indicators, Performance Improvement Plan 2016 and 2016 PI Indicators lacked documentation of alcohol and/or drug services or psychiatric child/adolescent services being included in the program.


3. Review of PI documents from 4/2015 to 4/2016 indicated the following:
a. Meeting minutes were documented as handwritten notes on documents titled PI Meeting Agenda with the following agenda dates: April 15, 2015, April 25, 2015, May 20, 2015, June 17, 2015, July 30, 2015, August 25, 2015, September 23, 2015, October 21, 2015, December 16, 2015 and February 3, 2016 and meeting minutes were documented on documents titled Performance Improvement dated February 26, 2016 and March 30, 2016.
b. PI meeting documents lacked documentation of alcohol/drug services or psychiatric child/adolescent services being report on or reviewed in the past 4 quarters.

4. On 4/26/16 at 3:15 pm, A1, Chief Executive Officer, indicated the PI committee reports did not include alcohol and drug services nor separation of child/adolescent services from adult psychiatric services.

Based on document review, observation and interview, the facility failed to ensure unauthorized personnel could not gain access to patient records for 6 of 6 (N34-N39) medical records (MR) observed in an unsecure area.

Findings:

1. Policy 1000.01, Confidentiality of Information, revised/reapproved 01/16 indicated on page 1:
A. any information of any kind pertaining to a patient or the patient's family is treated as strictly confidential. This includes any information that might be obtained through conversation, documentation, computerization, mail system, witnessed or innuendo.
B. employees share information concerning patient only with authorized persons. No unauthorized person may receive information, including family.
C. all patient documents are maintained in a secure area with only authorized personnel access.

2. While on tour of facility on 4/27/16 at approximately 0945 hours, in the presence of staff P9 (Registered Nurse [RN]), 6 patient medical records were observed on the upper counter of the nursing station area of the youth unit, accessible to unauthorized persons.

3. Staff P9 was interviewed on 4/27/16 at approximately 0945 hours and confirmed 6 patient medical records were placed in an unsecure area on the upper counter of the nursing station and confirmed the medical records were accessible to unauthorized persons and persons not involved with the patients' care.

Based on observation, document review and interview, the facility failed to ensure 1 of 1 outpatient reception offices open to the corridor was provided with an electrically supervised automatic smoke detection system, failed to ensure 3 of 8 exit accesses were provided with handrails, failed to include the use of the kitchen range hood fire suppression system in relation to kitchen fire extinguishers for 1 of 1 written fire safety plans for the facility in the event of an emergency, failed to document activation of the fire alarm system for first and second shift fire drills conducted between 6:00 a.m. and 9:00 p.m. for 3 of 4 quarters, failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop, failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 35 of 35 residents and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

Findings:

1. Observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16 noted the Outpatient Reception Office was not provided with an electrically supervised automatic smoke detection system and is open to the corridor due to the adjoining Outpatient Waiting Area is open to the corridor. The Outpatient Reception Office is open to the corridor due to the adjoining Outpatient Waiting Area has no corridor door and a three foot by four foot wide set of nonrated sliding glass doors was in the separation wall of the reception office from the waiting area. The automatic sprinkler system observed in the reception office was not equipped with quick response sprinklers and is not arranged and located to allow continuous direct supervision by the facility staff from a nurse station or similar space.

2. In interview at the time of the observations, the Director of Plant Operations stated outpatients have customary access to the waiting area and acknowledged the Outpatient Reception Office area is open to the corridor and is not provided with an electrically supervised automatic smoke detection system.

3. Observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16 noted the Dining Room exit discharge, Outpatient corridor exit discharge and the south exit discharge each led to the public way and had a portion of the exit discharge constructed as a ramp. The Outpatient exit discharge had a twenty foot sloping ramp sidewalk section with a twelve inch rise over the length of the ramp which was not provided with handrails. The Dining Room exit discharge had a fifteen foot sloping ramp sidewalk section with a sixteen inch rise over the length of the ramp which was not provided with handrails. The south exit discharge had a ten foot sloping ramp sidewalk section with a one foot rise over the length of the ramp which was not provided with handrails.

4. In interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned three exit discharge ramps to the public way were not provided with handrails.

5. Review of "Emergency Operations Plan: Fire Plan" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16 indicated the written fire safety plan for the facility did not address the use of the kitchen range hood fire suppression system in relationship with the use of the kitchen K class fire extinguisher. Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire safety plan did not address the use of the range hood suppression system in relationship with the use of the K Class fire extinguisher.

6. Observation with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16 noted a portable K Class fire extinguisher was located in the kitchen and a placard was conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.

7. Review of "Fire Drill Report" and "Bloomington Hospital - Healthcare Peer Review Report" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16 noted the following:
a. documentation for first shift fire drills conducted on 12/17/15 at 10:00 a.m. and on 02/23/16 at 9:30 a.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned first shift fire drill documentation stated, respectively, "Simulated" and "Drill was simulated."
b. documentation for the second shift fire drill conducted on 04/08/15 at 4:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned second shift fire drill documentation stated "simulated grease fire."

8. In interview at the time of record review, the Director of Plant Operations acknowledged documentation for the aforementioned first and second shift fire drills conducted after 6:00 a.m. but before 9:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal.

9. Observation with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16 noted the emergency generator lacked a remote shut off device.

10. In interview at the time of observation, the Director of Plant Operations acknowledged the emergency generator was rated over 100 horsepower and verified there was no remote shut off device for the emergency generator.

11. Review of "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16 indicated the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is the authority having jurisdiction and the building owner.

12. In interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH and the building owner.

13. Review of "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16 indicated the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction.

14. In interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

Based on document review, observation and interview, the infection control officer failed to implement facility policies regarding control of infections and communicable diseases in one of one laundry which services the two inpatient units of the facility.

Findings:

1. Review of Routine Cleaning Procedures, Policy No. 309.05, last reviewed 4/2015, indicated:
Section 18 MEDICATION ROOMS:
Nursing will be responsible for these areas
DAILY:
2. Dust sills, ledges, and other horizontal building and furniture surfaces. Use a disposable cloth dampened with germicidal detergent solution.
3. Spot clean walls, door facings, column, and other surfaces to remove hand prints, smudges, and other obvious soil. Use a cloth and germicidal detergent from a spray bottle.
7. Vacuum traffic patterns of carpeted floors.

2. On 4/27/2016 at 1100 hours, staff member NA12 indicated:
Usually we do not have the time to do cleaning of the medication room.

3. On 4/25/2016, at 1100 hours, the medication room was toured. It contained two medication carts, each with a slotted medication tray sitting on top of them. Both carts appeared to be dirty, with dust and smudges. Both medication trays appeared to be dirty and the slots where medication cups are placed had dust and spilled liquid in them.
The carpeted floor was dusty and had scraps of paper debris on it.
On 4/27/2016 at 1045 hours, the medication room was re-examined and there appeared to be no change from 4/25/2016.

4. Review of Routine Cleaning Procedures, Policy No. 309.05 indicated:
Section 22. LAUNDRY ROOMS (Washer/Dryers)
4. Washers and Dryers will be disinfected with quaternary disinfectant or bleach product daily by housekeeping.
5. Washers and Dryers will be disinfected with quaternary disinfectant or bleach product after clothing wash of, or diagnosed of, communicable disease or illness by Nursing staff.

5. Cleaning and Sanitation of Washing Machines and Dryers; a document posted in the laundry room, indicated:
1) Procedure:
Clothes washers should self sanitize during each use with the proper use of approved commercial washing powder. To insure that the washer and dryer units are properly sanitized, the facility will utilize the following procedure:
Patient-use washers and dryer units will be disinfected and sanitized on a scheduled basis.
The following checklist should be utilized to document washer and dryer sanitation and inspection:
(No document present.)

6. On 4/27/2016 at 1530 hours, staff members NA14 and NA15, housekeepers, were interviewed. Both housekeepers indicated:
That they clean the washers one time daily, using a bleach cycle. No approved commercial detergent is used; however, for each patient load, Tide is the detergent used for washing patients' clothes. We don't use any checklist for documentation of the daily disinfection.

7. On 4/25/2016 at 1410 hours, while touring the patient units, the laundry room was observed. Tide was the detergent in the laundry room for use for washing clothes. Neither the labeling on the bottle or Material Safety Data Sheet (MSDS) information indicted that Tide is an approved commercial detergent. There was no checklist in the laundry room for daily disinfection of the washing machine.

Based on interview and document review, the facility failed to ensure that patient care was under the supervision of a physician for six (6) of eight (8) active sample patients (B9, B14, B15, and B18). This deficiency results in the diagnosis and treatment of patients not being directed by a physician.

Findings include:

A. Record Review

1. Patient B9

a. Patient B9 was a 14 year old admitted 4/3/16. The Psychiatric Evaluation stated that Patient B9 "tried to kill himself by taking an overdose of medications..." The "Diagnostic Impression" was "Dysthymia with suicidal ideation."

b. The History and Physical Examination dated 4/4/16 was completed by a family nurse practitioner without documentation that the examination had been supervised or reviewed by a physician.

c. A review of the "Physician Orders" from 4/3/16 to 4/26/16 revealed only orders by clinical nurse specialists and nurse practitioners for the treatment of medical and psychiatric conditions including medications. No physician orders were documented except for a telephone order for admission (not authenticated by a physician) and orders for observation and as needed medications by on call covering physicians. No attending physician orders or countersignatures of clinical nurse specialist and nurse practitioner orders to indicate supervision of treatment were documented.

d. A review of the "Psychiatric Progress Notes" from 4/5/16 to 4/26/16 revealed only notes written by clinical nurse specialists and nurse practitioners except for notes by on call covering physicians on the weekend days of 4/9/16, 4/16/16, 4/17/16, and 4/23/16. No attending physician notes or countersignatures of clinical nurse specialist or nurse practitioner notes, to indicate supervision of treatment, were documented.

2. Patient B14

a. Patient B14 was a 16 year old admitted 4/6/16. The Psychiatric Evaluation dated 4/7/16 (no time indicated) stated that Patient B14 "was admitted for suicidal ideation, possible suicide attempt." The "Diagnostic Impression" was "Depressive episode." The Psychiatric Evaluation was completed by a nurse practitioner without documentation that the evaluation had been supervised or reviewed by a physician.

b. The History and Physical Examination dated 4/7/16 was completed by a family nurse practitioner without documentation that the examination had been supervised or reviewed by a physician.

c. A review of the Master Treatment Plan dated 4/8/16 revealed no documented involvement of a physician in the development, review, or implementation of the treatment plan.

d. A review of the "Physician Orders" from 4/6/16 to 4/26/16 revealed only orders by clinical nurse specialists and nurse practitioners for the treatment of medical and psychiatric conditions including medications. No physician orders were documented except for a telephone order for admission (not authenticated by a physician) and orders for observation and as needed medications by on call covering physicians. No attending physician orders or countersignatures of clinical nurse specialist and nurse practitioner orders to indicate supervision of treatment were documented.

e. A review of the "Psychiatric Progress Notes" from 4/6/16 to 4/26/16 revealed only notes written by clinical nurse specialists and nurse practitioners except for notes by on call covering physicians on the weekend days of 4/9/16, 4/17/16, and 4/23/16. No attending physician notes or countersignatures of clinical nurse specialist or nurse practitioner notes, to indicate supervision of treatment, were documented.

3. Patient B15

a. Patient B15 was a 13 year old admitted 4/15/16. The Psychiatric Evaluation dated 4/16/16 at 6:17 p.m. stated that Patient B15 "was brought in with a suicidal ideation with a plan to cut, auditory hallucinations telling [her/him] harm to [sic] [her/himself] and homicidal ideations with plan to hurt [her/his] father." The psychiatric diagnoses were "Major depressive disorder, single episode, with psychotic features" and "Unspecified anxiety."

b. The History and Physical Examination dated 4/15/16 was completed by a family nurse practitioner without documentation that the examination had been supervised or reviewed by a physician.

c. A review of the Master Treatment Plan dated 4/18/16 revealed no documented involvement of a physician in the development, review, or implementation of the treatment plan. The area of the Master Treatment Plan designated for the "Psychiatrist" was signed by a clinical nurse specialist.

d. A review of the "Physician Orders" from 4/15/16 to 4/26/16 revealed only orders by clinical nurse specialists and nurse practitioners for the treatment of medical and psychiatric conditions including medications. No physician orders were documented except for a telephone order for admission and orders for observation and as needed medications by on call covering physicians. No attending physician orders or countersignatures of clinical nurse specialist and nurse practitioner orders to indicate supervision of treatment were documented.

e. A review of the "Psychiatric Progress Notes" from 4/15/16 to 4/26/16 revealed only notes written by clinical nurse specialists and nurse practitioners a note documented by a covering physician on the weekend day of 4/23/16. No attending physician notes or countersignatures of clinical nurse specialist or nurse practitioner notes, to indicate supervision of treatment, were documented.

4. Patient B18

a. Patient B18 was a 14 year old admitted 3/28/16. The Psychiatric Evaluation stated that Patient B18 "was admitted for cutting [her/his] wrist and suicide gesture, often verbalizing suicidal ideations and gestures." The "Diagnostic Impression" was "mood disorder, unspecified."

b. The History and Physical Examination dated 3/29/16 was completed by a family nurse practitioner without documentation that the examination had been supervised or reviewed by a physician.

c. A review of the Master Treatment Plan dated 3/30/16 revealed no documented involvement of a physician in the development, review, or implementation of the treatment plan. The space designated for the "Psychiatrist" was signed by a nurse practitioner.

d. A review of the "Physician Orders" from 3/28/16 to 4/26/16 revealed only orders by clinical nurse specialists and nurse practitioners for the treatment of medical and psychiatric conditions including medications. No physician orders were documented except for a telephone order for admission (not authenticated by a physician) and orders for observation and as needed and immediate medications by on call covering physicians. No attending physician orders or countersignatures of clinical nurse specialist and nurse practitioner orders to indicate supervision of treatment were documented.

e. A review of the "Psychiatric Progress Notes" from 4/3/16 to 4/26/16 revealed only notes written by clinical nurse specialists and nurse practitioners except for notes by on call covering physicians on the weekend days of 4/9/16, 4/16/16, 4/17/16, and 4/23/16. No attending physician notes or countersignatures of clinical nurse specialist or nurse practitioner notes, to indicate supervision of treatment, were documented.

B. Staff Interview

1. During an interview with CNS 1 on 4/26/16 at 4:00 p.m., she stated that she was responsible for the psychiatric care for children and adolescents admitted to both the Child and the Adolescent units including Patients B9, B14, B15, and B18. She stated that she was supervised by the Medical Director but that the Medical Director did not directly evaluate these patients or directly supervise the care. She stated that the Medical Director provided supervision by reviewing the medical record documentation for five percent of the discharged patients for whom she provided the psychiatric assessment and treatment. CNS 1 stated that the Medical Director did not supervise or review the care that she provided for active patients.

2. During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he stated that he was the supervising physician for Patients B9, B14, B15, and B18. He acknowledged that neither he nor another physician reviewed these medical records, participated in treatment planning, or evaluated these patients. He stated that he did not directly supervise the care of active patients and only reviewed a sample of discharged medical records for the care provided by the clinical nurse specialist and nurse practitioners.

C. Document Review

The "Rules and Regulations of the Medical Staff " dated 2/11/16 stated the following: "The supervising physician [of the Advanced Practice Provider] is required to personally evaluate the patient on new admissions and consults with 24 hours and cosign the initial History and Physical or Consultation. At the time of discharge, it is the duty of the Attending Psychiatrist to see that the record is complete, state his/her final diagnosis, and sign the record... Treatment orders involving only psychological treatment given by Allied Health Professionals shall be authenticated by the responsible Psychiatrist...Each active staff Psychiatrist with hospitalized patients will conduct a treatment planning meeting at least weekly.

The Attending Physician shall be held responsible for overseeing Psychiatric Evaluations and for preparing a complete medical record for each patient. The Attending Physician will be responsible for dictation of the discharge summary within 30 days after discharge. Every patient admitted must be seen and progress notes written daily by the Attending Physician during his or her hospitalization. Patients may be seen by Allied Health Professionals...However, this does not preclude the requirement that the Attending Physician must see the patient six of 7 days."

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

I. Provide a physical examination, including a descriptive neurological examination, for one (1) of eight (8) active sample patients (A6) who refused the initial physical examination. The absence of this patient information compromises accurate diagnosis and potential care for primary neurological or secondary medical illnesses or conditions contributing to the psychiatric illness. (Refer to B109)

II. Ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for two (2) of eight (8) active sample patients (B9 and B14). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment of psychiatric illnesses. (Refer to B 110)

III. Ensure that the Master Treatment Plan for one (1) of eight (8) active sample patients (C4) was revised when the patient failed to participate in the prescribed treatment and required multiple restraints and seclusion. The Master Treatment Plan was not revised to provide alternative treatment modalities when the patient refused or was unable to participate in the group therapies and following multiple episodes of restraints and seclusion. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 III.)

IV. Develop Master Treatment Plans that identified physician, nursing and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A3, A7, B7, B9, B14, B15, B18 and C4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. (Refer to B122)

V. Substantiate a diagnosis documented on the Master Treatment Plan for one (1) of eight (8) active sample patients (B14). The presence of an unsubstantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment. (Refer to B120)

VI. Assess and treat the psychiatric problems for one (1) of eight (8) active sample patients (C4) who had a reported history of traumatic brain injury, seizure disorder, and cognitive deficits. These conditions were not assessed by the facility. Patient C4 was unable, unwilling, or not motivated to attend assigned treatment groups and required multiple restraints and seclusion. The failure to assess significant clinical conditions and address the lack of participation in assigned treatment modalities by the patient negates the clinical effectiveness of the patient ' s treatment goals, potentially delaying improvement. (Refer to B125)

VII. Ensure that progress notes by the physician were recorded for four (4) of eight (8) active sample patients (B9, B14, B15, and B18) who were assigned to the clinical nurse specialist. This failure to communicate the patient's medical and psychiatric progress prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric and medical conditions and from assisting in arranging after care referrals. (Refer to B126)

VIII. Ensure that progress notes by social workers contained information about patient progress towards treatment goals and safe discharge planning for eight (8) of eight (8) sample patients (A2, A4, A9, A12, B2, B4, B7, and B9). This failure impedes the treatment team's ability to assess or evaluate the patient's response to the treatment plan. (Refer to B128)

IX. Ensure that discharge summaries included a brief summary of the patient's condition on discharge including psychiatric, physical, and functional condition for three (3) out of five (5) discharged patients (D1, D4, and D5). This deficiency results in a failure to communicate in a timely manner patients' psychiatric condition and discharge recommendations to providers providing follow-up care. (Refer to B135)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for 7 of 8 sample patients (A3, A6, B7, B9, B14, B15, and C4). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include an evaluation of psychosocial issues, conclusions and recommendations, or a description of the social worker's role in treatment and discharge planning: Patient A3 (4/16/16), Patient A6 (4/20/16), Patient B7 (4/7/16), Patient B9 (4/5/16), Patient B14 (4/8/16), Patient B15 (4/16/16), and Patient C4 (4/8/16).

B. Staff Interview

During an interview with the Director of Social Work on 4/26/16 at 2:30 p.m., she acknowledged that the Psychosocial Assessments for Patients A3, A6, B7, B9, B14, B15, and C4 lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment or discharge planning.

Based on record review and interview, the facility failed to provide a physical examination, including a descriptive neurological examination, for one (1) of eight (8) active sample patients (A6) who refused the initial physical examination. The absence of this patient information compromises accurate diagnosis and potential care for primary neurological or secondary medical illnesses or conditions contributing to the psychiatric illness.

Findings include:

A. Record Review

Patient A6 was admitted 4/20/16. The History and Physical Examination form dated 4/20/16 at 9:05 a.m. stated "refusing exam." The medical record, reviewed on 4/26/16 at 9:30 a.m., did not document a completed physical examination, including a descriptive neurological examination, or attempts to approach the patient to perform the examination after the initial refusal of the examination.

B. Interview

During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he acknowledged that there was no documentation of attempts to perform a physical examination after the attempt at admission. He stated the medical provider should have approached the patient daily in an attempt to complete the physical examination.

C. Policy Review

The facility policy "Medical History and Physical Examination," policy number 701.07, reviewed 1/16, stated "If the patient refuses the exam, the patient will be re-approached within an appropriate time frame." The definition of "an appropriate time" frame was not specified in the policy.

Based on record review and interview, ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for two (2) of eight (8) active sample patients (B9 and B14). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment of psychiatric illnesses.

Findings include:

A. Record review

1. Patient B9 was admitted 4/3/16. The psychiatric evaluation dated 4/5/16 at 12:03 a.m. included the diagnosis of "Dysthmia with suicidal ideation." The only "HPI [history of present illness]" documented was "Positive for numerous suicide attempts and patient stating consistently that [s/he] does not want to go home and that if [s/he] does, [s/he] will kill [her/himself] again." The only medical history documented was "Patient is smaller than stated age." The only developmental history documented was "Patient was a normal vaginal delivery according to the write-up by the practitioner and no negative notes were noted." The only social history documented was "Patient is very obviously does not get along with most people seems to be withdrawn and introverted." The only "Abuse History" documented was "Patient states that [s/he] has been shut down for over a year because [s/he] is not to be trusted for stealing money out of [her/his] mother's wallet. According to [her/him] [s/he] has no privileges. [S/he] does not go anywhere. [S/he] does not do anything but read."

2. Patient B14 was a 16 year old admitted 4/6/16. The psychiatric evaluation dated 4/7/16 (no time indicated) included the diagnosis of "Depressive episode." The only "HPI [history of present illness]" documented was "Pt [patient] admitted to Meadows adolescent unit with plan to OD [overdose] with recent superficial cutting last night." The only psychiatric history documented was "Previous Residential Tx [treatment] at [facility] in Kanas [sic] Missouri for 15 month program in June 2015 at 13 yo [years old]. For lying, stealing. Eventually eloped." The only medical history documented was "NKDA [no know drug allergy]. Allergy to Bee stings, "height, weight, vital signs, and body mass index," "Age 7 ear surgery unknown why," and "PCP [primary care provider] [name]."

B. Staff Interview

During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he acknowledged that the Psychiatric Evaluations for Patient B9 and Patient B14 did not contain sufficient information to justify psychiatric diagnoses and treatment.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 8 of 8 active sample patients (A3, A6, B7, B9, B14, B15, B18, and C4) included an inventory of specific patient assets or personal factors on which to base the treatment plan or which are useful in therapy. Failure to identify personal patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient.

Findings include:

A. Record Review

The following Psychiatric Evaluations (dates in parentheses) failed to include specific patient assets that could be used in treatment planning and documented only the following as " Strengths: "

Patient A3 (4/16/16): " The patient is in treatment. " " The patient is employed. "

Patient A6 (4/20/16): " [S/he] has a good outpatient team with [name] at [another facility] who [s/he] needs to follow their directions, but does not always do so. "

Patient B7 (4/6/16): [S/he] is basically healthy and does have support by [her/his] aunt. [S/he] still interacts with [her/his] mom, with visits, but dad lives in California and has not seen [her/him] for a couple of years, but does feel that they still support [her/him].

Patient B9 (4/5/16): " Are patient is vocal about [her/his] suicidality and also plan [sic]. "

Patient B14 (4/6/16): No patient assets were identified.

Patient B15 (4/16/16): " The patient is intelligent and gets physical health [sic]. "

Patient B18 (3/29/16): " Include physically healthy and average intelligence. "

Patient C4 (4/8/16): " Strengths are that [s/he] has average-to-above-average intelligence and is currently physically healthy. "

B. Staff Interview

During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he acknowledged that the psychiatric evaluations for these patients did not include specific patient assets to be used in treatment planning.

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

I. Substantiate a diagnosis documented on the Master Treatment Plan for one (1) of eight (8) active sample patients (B14). The presence of an unsubstantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment. (Refer to B120)

II. Develop Master Treatment Plans that identified physician, nursing and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A3, A7, B7, B9, B14, B15, B18 and C4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment. (Refer to B122)

III. Ensure that the Master Treatment Plan for one (1) of eight (8) active sample patients (C4) was revised when the patient failed to participate in the prescribed treatment and required multiple restraints and seclusion. The Master Treatment Plan was not revised to provide alternative treatment modalities when the patient refused or was unable to participate in the group therapies and following multiple episodes of restraints and seclusion. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

Patient C4

1. Patient C4 was admitted on 4/7/16. The Psychiatric Evaluation dated 4/8/16 included the diagnoses of "Persistent mood disorder, unspecified," "Depressive disorder, unspecified," "History of traumatic brain injury," "Headaches," and "History of seizures."

2. The Master Treatment Plan dated 4/11/16 identified the psychiatric problem as "Aggressive Behavior with Suicidal Ideations." The interventions and modalities listed on patient C4's Master Treatment plan included: "Family Therapy" "1-2x/45 min. [minutes]/week," "Medication Education" by the nursing staff and physician, "Assess [Patient C4's] response and any side effects to prescribed medication: clonidine" by the physician, "Educate [Patient C4] regarding purpose, actions, risks & side effects of Seroquel" by the physician, "Provide praise to [Patient C4] for reduction and/or elimination of staff-directed time outs" by the nursing staff, "Provide re-direction with [Patient C4] when early warning signs of aggression are observed," "Expressive Therapy" by recreation therapy staff, and "Assist [Patient C4] in developing a safety plan to prevent aggressive/violent behaviors with family and peers" by the social work staff once prior to discharge. Other interventions listed on the Master Treatment Plan were psychoeducational groups provided by mental health technicians and "Milieu Mgmt [management]" provided "As Needed."

3. The medical record from 4/7/16 to 4/25/16 documented that Patient C4 attended only eight (8) out of 10 Expressive Therapy groups. The family therapy intervention was not documented during this period. Documentation of the "Psychotherapy/Process" group conducted by "Therapy/Social Work" (not included on the Master Treatment Plan) documented that Patient C4 only attended 11/19 group sessions.

4. The medical record from 4/7/16 to 4/25/16 documented that Patient C4 was physically restrained on 4/16/16 at 6:23 p.m., 4/18/16 at 9:38 a.m. and 8:18 p.m., 4/19/16 at 9:50 a.m. 8:03 p.m., and 8:15 p.m., on 4/20/16 at 10:20 a.m., and 6:06 p.m., 4/22/16 at 9:21 a.m., 4/23/16 at 12:55 p.m., and 4/24/16 at 6:04 p.m. and secluded on 4/20/16 at 3:22 p.m.

5. The Master Treatment Plan for Patient C4 on 4/26/16 indicated no revisions had been made to the Master Treatment Plan or to the interventions to address the needs of Patient C4 despite not participating in therapies and continued need for multiple restraints and seclusion.

Based on record review and interview, the facility failed to substantiate a diagnosis documented on the Master Treatment Plan for one (1) of eight (8) active sample patients (B14). The presence of an unsubstantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment.

Findings include:

A. Record Review

1. The Master Treatment Plan dated 4/8/16 documented the addition of a diagnosis of "Reactive Attachment Disorder" on 4/14/16.

2. The Psychiatric Evaluation dated 4/6/16 and Psychiatric Progress Notes from 4/6/16 to 4/26/16 did not document the presence of signs and symptoms or diagnostic criteria to justify a diagnosis of reactive attachment disorder.

B. Staff Interview

1. During an interview with CNS 1, the psychiatric provider for Patient B14, on 4/26/16 at 4:00 p.m., when asked about documentation to substantiate a diagnosis of reactive attachment disorder, she stated "I probably didn't write that [documentation to substantiate the diagnosis]." She stated the justification for the diagnosis was only Patient B14's "history of abuse and neglect," "cutting [her/himself]," and "doesn't connect to anyone." CNS one (1) stated that Patient B14 did not have a previous diagnosis of reactive attachment disorder despite an age of 16 years old and history of extensive psychiatric treatment.

2. During an interview with the Medical Director, who was also the supervising physician for CNS 1, on 4/27/16 at 12:30 p.m., he stated that he had not interviewed Patient B14 but stated that "we need data" to substantiate a diagnosis of reactive attachment disorder.

Based on interview and record review, the facility failed to develop Master Treatment Plans that identified physician, nursing and social work staff interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (A3, A7, B7, B9, B14, B15, B18 and C4). The interventions were routine, generic discipline functions that lacked any focus for individualized treatment.

Findings

A. Record Review:

Review of the sample patients' Master Treatment Plans revealed that the plans included generic physician, social work and nursing interventions for the listed problems of "Psychosis NOS-Suicidal ideation", "depression and suicidal ideation", "Aggressive behavior with suicidal ideations", and depression with psychosis". The interventions were the same for each patient having one or more of these identified problems

1. For problem "Psychosis NOS-Suicidal Ideation with Previous Attempt" Patient A3 MTP dated 4/16/16 interventions stated:

Physician: "Assess patient response to any side effects to prescribed Zyprexa 5 X 1 wk."

Social Work: "Assist patient in exploring Hallucinations/Delusion and distinguishing from reality. Identify current conversations with staff and others from delusional thinking. Identify concrete objects from hallucinations 1-2 x weekly".

Nursing: "Educate patient regarding the benefits of taking Zyprexa for control of psychosis and suicidal thoughts 1-2 x 1 wk".

2. For the Problem "Psychosis NOS-Suicidal Ideation with Plan and Previous Attempt" Patient A6 MTP dated 4/20/16 interventions stated:

Physician: "Assess patients [sic] response and any side effects to prescribed Seroquel XR, 5x 1wk".

Social Work: "Assist patient in exploring Hallucination/Delusions and distinguishing from reality. Ref. Command Hallucinations to kill himself and others, 1 -2 x weekly". "Assist patient to connect his underlying emotions that led to thoughts of self-harm. Low self-esteem (mood/emotions), Self-defeating statements (thoughts) 1-2 x weekly".

Nursing: "Assess patient daily for signs or symptoms of anxiety and allow time to process feelings of anxiety".

3. For the problem "Psychosis with Suicidal Ideation" Patient B7 MTP dated 4/5/16 interventions stated:

Physician: "Asses (patient's name) response and side effects to prescribed medication: melatonin, Seroquel, Prozac 5x/week".

Social Worker: "Help (patient's name) to identify stressors & circumstances that trigger suicidal thoughts 1x/week".

Nursing: "Encourage (patient's name) to use new coping skills to manage anxiety and suicidal ideations, as needed". "Provide praise immediately when coping skills are used to prevent an aggressive act or verbal outburst, as needed". "Educate (patient's name) re: the benefits of taking medication(s): melatonin, Seroquel and Prozac for control of anxiety and suicidal ideation, daily during med pass". "Provide re-direction with (patient's name) when early warning signs of aggression are observed, as needed".

4. For the problem "Depression and suicidal ideation" Patient B9 MTP dated 4/3/16 interventions stated:

Physician: "Assess (patient's name) response and any side effects to prescribed medications: Abilify 5x /week". "Educate (patient's name) regarding purpose, actions, risk & side effects of Effexor, 1x per week & as needed".

Social Work: "Help (patient's name) to identify stressors & circumstances that trigger suicidal thoughts, 2x/week". "Assist (patient's name) in developing a safety plan with family to prevent depression and increasing suicidal ideation, 1x 24 hours prior to discharge".

Nursing: "Educate (patient's name) re: the benefits of taking medication(s): Abilify for control of depression, anxiety, and suicidal ideation, daily during med pass". "Educate (patient's name) regarding symptoms of depression and importance of compliance with treatment". "Provide praise to (patient's name) for reduction and/or elimination of staff-directed time out, as needed". "Provide re-direction with (patient's name) when early warning signs of depression or observed, as needed".

5. For problem: "Depression with suicidal ideation" Patient B14 MTP dated 4/8/16 interventions stated:

Physician: No intervention on the plan.

Social work: No intervention on the plan.

Nursing: "Assist patient to connect underlying emotions with depression and suicidal thoughts, and present them in family session". Encourage patient to use new coping skills to manage depression/suicidal ideations, as needed". Provide praise immediately when coping skills are used to prevent depression, suicidal thoughts, or making poor choices, as needed". "Role play with patient on how to manage stresses with peers &/or staff in the milieu, 2x/week".

6. For problem "Depression with Psychosis" Patient B15 MTP dated 4/15/16 interventions stated:

Physician: No intervention on plan

Social Work: "Help (patient's name) share with her family what her needs are when she/he gets home, 1-2x week".

Nursing: "Educate patient regarding the benefits of taking Seroquel for control of psychosis and depression 1-1x/week". "Assess patient's response and any side effects to prescribed Seroquel, 5x/week".

7. For problem: "Depression with Suicidal Ideation" Patient B18 MTP dated 3/28/16 interventions stated:

Physician: "Assess patient's response and any side effects to prescribed medication: Seroquel".

Social work: "Assist patient to connect underlying emotions with worry and anxiety". "Help patient to identify triggers for depression and suicidal ideations and to recognize early warning signs".

Nursing: "Encourage patient to use new coping skills to manage depression/suicidal ideations". "Provide praise immediately when coping skills are used to prevent depression, suicidal thoughts, or making poor choices". "Role play with patient on how to manage stresses with peers &/or staff in the Milieu". "Educate patient re: the benefits of taking medication(s): Seroquel for control of suicidal thoughts and behaviors". "Provide praise to patient for reduction and/or elimination of staff-directed time outs". "Provide re-direction with patient when early warning signs of depression are observed".

8. For problem: "Aggressive Behavior with Suicidal Ideations" Patient C4 MTP dated 4/7/16 interventions stated:

Physician: "Assess patient's response and any side effects to prescribed medication: Clonidine". "Educate (patient's name) regarding the purpose, action, risks and side effects of Seroquel."

Social work: "Assist (patient's name) to connect underlying emotions with angry and violent outbursts in family session.

Nursing: "Educate (patient's name) re: the benefits of taking medication(s): Clonidine for the control of aggressive thoughts and behaviors". "Provide praise to (patient' name) for reduction and/or elimination of staff-directed time outs". "Provide re-direction with (patient's name) when early warning signs of aggression are observed".

C. Interviews:

1. In the interview on 4/27/16 at 10:25 a.m. with the Director of Nursing, nursing interventions on the sample patients MTP's were discussed. The Director of nursing agreed that the interventions are routine nursing staff duties. She stated, that the new format for the MTP was implemented 4/13/16 and there will be much improvement in the weeks to come.

2. In the interview on 4/27/16 at 12:30 with the Medical Director the physician's interventions on the MTP was discussed. The medical director agreed with the findings that the interventions were generic and stated "somebody put them in for the doctors".

3. In the Interview on 4/26/16 at 2.30 p.m. the Director of Social work was asked about the social work interventions on the sample patient's MTP, she agreed with the finding and stated "they need to be more individualized".

Based on record review and interview, the facility failed to assess and treat the psychiatric problems for one (1) of eight (8) active sample patients (C4) who had a reported history of traumatic brain injury, seizure disorder, and cognitive deficits. These conditions were not assessed by the facility. Patient C4 was unable, unwilling, or not motivated to attend assigned treatment groups and required multiple restraints and seclusion. The failure to assess significant clinical conditions and address the lack of participation in assigned treatment modalities by the patient negates the clinical effectiveness of the patient's treatment goals, potentially delaying improvement.

Findings include:

A. Record Review

Patient C4

The Psychiatric Evaluation dated 4/8/16 stated that Patient C4 was an 11 year old admitted 4/7/16 due to "depression, mood instability, and suicidal ideations" and "self-harm." Diagnoses included "Persistent mood disorder, unspecified," "Depressive disorder, unspecified," "History of traumatic brain injury," "Headaches," and "History of seizures." The "Significant Medical History" included that Patient C4 "did have a traumatic brain injury at age 6. [S/he] was in a car accident. [S/he] has a history of seizures in the past." "Strengths and Limitations" included "average-to-above average intelligence."

The medical record from 4/7/16 to 4/25/16 indicated that Patient C4 was physically restrained on 4/16/16 at 6:23 p.m., 4/18/16 at 9:38 a.m. and 8:18 p.m., 4/19/16 at 9:50 a.m. 8:03 p.m., and 8:15 p.m., on 4/20/16 at 10:20 a.m., 3:22 p.m., and 6:06 p.m., 4/22/16 at 9:21 a.m., 4/23/16 at 12:55 p.m., and 4/24/16 at 6:04 p.m.

1. Traumatic Brain Injury and Seizure Disorder

a. Referral information in the medical record that was faxed to the facility on 4/8/16 at 2:28 p.m. including the discharge summary from an admission to an outside facility dated 3/9/16 at 9:46 a.m. stated that Patient C4 "was in a MVA [motor vehicle accident] when 6 [years old] and was in a coma for 3 days. Reported TBI [traumatic brain injury]...Use to have seizures both before and after the accident." The history and physical examination at the outside facility dated 3/11/16 stated "school records indicate [Patient C4] has borderline intellectual functioning." The "Care Team Child Consult" dated 4/7/16 stated that Patient C4 reported "she blacked out at school today and does not remember why [s/he] acted out at school, per pt. [patient]." The "Medical History" and "Provisional Diagnosis" included "TBI (traumatic brain injury)."

b. The Interdisciplinary Master Treatment Plan dated 4/11/16 stated "Medical Diagnosis" as "Seizures" and "Hx [history] of TBI." For the problem of "Seizures," the only intervention was "Encourage patient to report any seizure activity or suspected activity" to be implemented by nursing staff. For the problem of "Hx of TBI," the only intervention was "educate patient of safety importance and concussive symptoms."

c. Psychiatric Progress Notes from 4/9/16 to 4/25/16 did not document further assessment of possible traumatic brain injury or seizure disorder except for a Physician Order dated 4/20/16 at 10:10 a.m. that stated "Pt to be transferred to general hospital ASAP [as soon as possible]. Rule out seizure disorder." The Psychiatric Progress Note by MD 1 dated 4/21/16 at 7:34 p.m. stated "Around 3:00, [his/her] agitation worsened and again Zyprexa 10 mg IM was given with no improvement in her symptoms, at which time an order was placed for her to be sent to [medical facility] for a neurological condition to be ruled out such as temporal lobe epilepsy or other undiagnosed neurological condition." The information from the outside emergency department dated 4/21/16 in the medical record only included general patient discharge information about acute traumatic brain injury. No information was documented in the medical record concerning the evaluation and recommendation from the emergency department. No documentation of the facility's assessment of traumatic brain injury or seizure disorder or the possible contribution of these disorders to Patient C4's behaviors and treatment was present in the medical record.

2. Cognitive Function

a. Referral information in the medical record that was faxed to the facility on 4/8/16 at 2:28 p.m. including a history and physical examination at an outside facility dated 3/11/16 stated "school records indicate [Patient C4] has borderline intellectual functioning."

b. A consultation by the Medical Director dated 4/22/16 at 4:57 p.m. stated "intelligence appeared to be low average" and "capacity for activities of daily living is impaired that [s/he] is not really able to take care of herself." This consultation stated "disabilities [of] reading, writing, math and ability to comply with usual requests."

c. The Interdisciplinary Master Treatment Plan dated 4/11/16 did not include consideration of cognitive limitations in the treatment interventions.

d. Psychiatric Progress Notes from 4/9/16 to 4/25/16 did not document assessment of possible cognitive limitations or the possible presence of specific learning difficulties. No documentation in the medical record indicated Patient C4 was referred by psychological testing to assess intellectual functioning or the presence of specific learning disabilities.

3. Eating Behaviors

The Physician Orders on 4/8/16 at 11:40 a.m. written by a family nurse provider stated "Bulemia Protocol" and "Ensure [after] meals if patient vomits up meal." Psychiatric Progress Notes from 4/9/16 to 4/25/16 did not document further assessment of a possible eating disorder or monitoring of eating behaviors.

4. Active Treatment

1. The Therapeutic Group Notes from 4/8/16 to 4/25/16 indicated that Patient C4 attended only 16 of 20 Art Therapy and Activity Therapy groups and only 11/19 Therapy/Social Work Groups during the hospitalization. A review of the medical record indicated no individual therapy sessions except with the social worker on 4/8/16 for fifteen minutes.

2. The medical record from 4/8/16 to 4/25/16 did not document alternative treatments to group therapy such as individual therapy or behavioral therapy.

B. Patient Interview

During an interview with Patient C4 on 4/26/16 at 11:15 a.m., when asked about her treatment in the facility, Patient C4 stated "basically, no treatment because I'm on 1:1 observation." Patient C4 stated that s/he didn't remember seeing her/his assigned social worker and had only seen her/his physician twice since admission.

C. Staff Interview

1. During an interview with the Director of Social Work, who was also the assigned social worker for Patient C4, on 4/26/16 at 2:30 p.m., she stated that she thought Patient C4 would benefit from individual therapy. She acknowledged that no individual therapy was documented the medical record.

2. During an interview with MD 1, attending psychiatrist for Patient C4, at 4/27/16 at 11:00 a.m., MD1 stated that she was not aware that Patient C4 had a history of traumatic brain injury, seizures, purging, and cognitive deficits. MD 1 stated that she was not aware that Patient C4 had been hospitalized previously and stated that she had not reviewed the referral information in the medical record. MD 1 initially stated that she referred Patient C4 to an emergency department on 4/20/16 for "cardiac monitoring" because Patient C4 had received frequent doses of haloperidol intramuscularly. MD 1 later stated that she referred Patient C4 to the emergency department because she wanted to "rule out seizures because of [her/his] uncontrollable behavior, even with meds." MD 1 stated that the emergency department "just sent [her/him] back." MD 1 stated that she was not aware of the findings and recommendations of the emergency department. MD 1 stated that she was not aware that referring information indicated that Patient C4 had borderline intellectual functioning. MD 1 stated that she had not reviewed or discussed the consultation by the Medical Director on 4/22/16 in which he felt the patient had "low average" intelligence and "disabilities [of] reading, writing, math and ability to comply with usual requests." When asked about psychological testing, she stated "we can't get IQ [intelligence quotient] testing here" and that testing "wasn't available" for specific learning disabilities. MD 1 stated that she was not aware that Patient C4 had a reported history of bulimia and was placed on a "bulimia protocol." MD 1 acknowledged that the treatment plan for Patient C4 had not been revised despite Patient C4's lack of participation in group interventions and multiple episode restraints and seclusion.

3. During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he acknowledged that MD 1 should be aware and appropriately assess Patient C4's history of traumatic brain injury, seizures, cognitive limitations, and bulimia. He acknowledged that no alternative interventions were documented when Patient C4 did not attend groups or to address multiple episodes of restraint and seclusion. The Medical Director acknowledged that these issues could potentially impact the care and treatment of Patient C4.

Based on record review and interview, the facility failed to ensure that progress notes by the physician were recorded for four (4) of eight (8) active sample patients (B9, B14, B15, and B18) who were assigned to the clinical nurse specialist. This failure to communicate the patient's medical and psychiatric progress prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric and medical conditions and from assisting in arranging after care referrals.

Findings include:

A. Record Review

1. Patient B9 was admitted on 4/3/16. The "Psychiatric Progress Notes" from 4/5/16 to 4/26/16 revealed only status notes written by on call covering physicians on the weekend days of 4/9/16, 4/16/16, 4/17/16, and 4/23/16. No physician notes were documented by a physician responsible for the patient's care.

2. Patient B14 was admitted on 4/6/16. The "Psychiatric Progress Notes" from 4/5/16 to 4/26/16 revealed only status notes written by on call covering physicians on the weekend days of 4/9/16, 4/17/16, and 4/23/16. No physician notes were documented by a physician responsible for the patient's care.

3. Patient B15 was admitted on 4/15/16. The "Psychiatric Progress Notes" from 4/15/16 to 4/26/16 revealed only one note written by a covering physician on a weekend day, 4/23/16. No physician notes were documented by a physician responsible for the patient ' s care.

4. Patient B18 was admitted on 3/28/16. The "Psychiatric Progress Notes" from 3/28/16 to 4/26/16 revealed only status notes written by on call covering physicians on the weekend days of 4/9/16, 4/17/16, and 4/23/16. No physician notes were documented by a physician responsible for the patient's care.

B. Staff Interview

During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he stated that he was the supervising physician for the psychiatric provider for Patients B9, B14, B15, and B18. He stated that he had not documented progress notes in these medical records.

Based on record review and staff interview, the facility failed to ensure that progress notes by social workers contained information about patient progress towards treatment goals and safe discharge planning for eight (8) of eight (8) sample patients (A2, A4, A9, A12, B2, B4, B7, and B9). This failure impedes the treatment team's ability to assess or evaluate the patient's response to the treatment plan.

Findings include:

A. Record Review

The medical records for the following patients did not document progress notes by the social worker addressing the patients' progress toward social work goals or discharge planning: Patients A2, A4, A9, A12, B2, B4, B7, and B9.

B. Staff interview

During an interview with the Director of Social Work on 4/26/16 at 2:30 p.m., she acknowledged that there were no progress notes addressing the patients' progress toward social work goals or discharge planning.

Based on record review and staff interview, the facility failed to ensure that discharge summaries included a brief summary of the patient's condition on discharge including psychiatric, physical, and functional condition for three (3) out of five (5) discharged patients (D1, D4, and D5). This deficiency results in a failure to communicate in a timely manner patients' psychiatric condition and discharge recommendations to providers providing follow-up care.

Findings Include:

A. Record Review

The "Discharge Summary" (dates in parentheses) for the following patients did not include a brief summary of the patient's condition on discharge including psychiatric, physical and functional condition: Patient D1 (3/18/16), and Patient D4 (3/3/16), and Patient D5 (3/3/16).

B. Staff Interview

During an interview with the Medical Director on 4/27/16 at 12:30 p.m., he acknowledged that these discharge summaries did not include a brief summary of the patient's condition on discharge including psychiatric, physical and functional condition.

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

I. Ensure that the Medical Director monitored and took the needed corrective actions to:

A. Provide a physical examination, including a descriptive neurological examination, for one (1) of eight (8) active sample patients (A6) who refused the initial physical examination. "The absence of this patient information compromises accurate diagnosis and potential care for primary neurological or secondary medical illnesses or conditions contributing to the psychiatric illness." (Refer to B109)

B. Ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for two (2) of eight (8) active sample patients (B9 and B14). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment of psychiatric illnesses. (Refer to B 110)

C. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (A3, A6, B7, B9, B14, B15, B18, and C4) included an inventory of specific patient assets or personal factors on which to base the treatment plan or which are useful in therapy. Failure to identify personal patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B 117)

D. Ensure that the Master Treatment Plan for one (1) of eight (8) active sample patients (C4) was revised when the patient failed to participate in the prescribed treatment and required multiple restraints and seclusion. The Master Treatment Plan was not revised to provide alternative treatment modalities when the patient refused or was unable to participate in the group therapies and following multiple episodes of restraints and seclusion. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 III)

E. Substantiate a diagnosis documented on the Master Treatment Plan for 1 of 8 active sample patients (B14). The presence of an unsubstantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment. (Refer to B120)

F. Ensure that Master Treatment Plans included specific interventions to be carried out by psychiatrists to address patient treatment needs for eight (8) of eight (8) active sample patients (A3, A6, B7, B9, B14, B15, B18 and C4). The listed interventions for psychiatric providers on the Master Treatment plans were stated as generic, discipline functions or absent. This failure results in a lack of interventions provided or supervised by a psychiatrist to provide treatment, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)

G. Based on medical record review and interview the facility failed to assess and treat the psychiatric problems for one (1) of eight (8) active sample patients (C4) who had a reported history of traumatic brain injury, seizure disorder, and cognitive deficits. These conditions were not assessed by the facility. Patient C4 was unable, unwilling, or not motivated to attend assigned treatment groups and required multiple restraints and seclusion. The failure to assess significant clinical conditions and address the lack of participation in assigned treatment modalities by the patient negates the clinical effectiveness of the patient's treatment goals, potentially delaying improvement. (Refer to B125)

H. Ensure that progress notes by the physician were recorded for four (4) of eight (8) active sample patients (B9, B14, B15 and B18) who were assigned to the clinical nurse specialist. This failure to communicate the patient's medical and psychiatric progress prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric and medical conditions and from assisting in arranging after care referrals. (Refer to B126)

I. Ensure that discharge summaries included a brief summary of the patient's condition on discharge including psychiatric, physical, and functional condition for three (3) out of five (5) discharged patients (D1, D4 and D5). This deficiency results in a failure to communicate in a timely manner patients' psychiatric condition and discharge recommendations to providers providing follow-up care. (Refer to B135)

J. Ensure that the Director of Nursing provided adequate oversight to ensure quality nursing services. (Refer to B148)

K. Provide adequate numbers of nursing personnel, including Registered Nurses (RN) on the day, evening and night shifts for Adult patient care unit. Frequently there is only one RN and one Mental Health Tech (MHT) assigned to the day, afternoon and night shifts. This staffing pattern results in the unit being left without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for brief or extended periods of time during each shift. Also when the one (1) MHT is off the unit for lunch, escort etc. the RN is then only staff to monitor and supervise the patients. This creates a potential safety risk for the patients and remaining staff on the unit. (Refer to B150)

L. Ensure that the Director of Social Work provided adequate oversight to ensure quality social work services. (Refer to B152)

Based on interview and record review, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Provide a physical examination, including a descriptive neurological examination, for one (1) of eight (8) active sample patients (A6) who refused the initial physical examination. "The absence of this patient information compromises accurate diagnosis and potential care for primary neurological or secondary medical illnesses or conditions contributing to the psychiatric illness." (Refer to B109)

II. Ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for two (2) of eight (8) active sample patients (B9 and B14). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment of psychiatric illnesses. (Refer to B 110)

III. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (A3, A6, B7, B9, B14, B15, B18 and C4) included an inventory of specific patient assets or personal factors on which to base the treatment plan or which are useful in therapy. Failure to identify personal patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B 117)

IV. Ensure that the Master Treatment Plan for one (1) of eight (8) active sample patients (C4) was revised when the patient failed to participate in the prescribed treatment and required multiple restraints and seclusion. The Master Treatment Plan was not revised to provide alternative treatment modalities when the patient refused or was unable to participate in the group therapies and following multiple episodes of restraints and seclusion. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118 III)

V. Substantiate a diagnosis documented on the Master Treatment Plan for one (1) of eight (8) active sample patients (B14). The presence of an unsubstantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment. (Refer to B120)

VI. Ensure that Master Treatment Plans included specific interventions to be carried out by psychiatrists to address patient treatment needs for eight (8) of eight (8) active sample patients (A3, A6, B7, B9, B14, B15, B18 and C4). The listed interventions for psychiatric providers on the Master Treatment plans were stated as generic, discipline functions or absent. This failure results in a lack of interventions provided or supervised by a psychiatrist to provide treatment, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)

VII. Assess and treat the psychiatric problems for one (1) of eight (8) active sample patients (C4) who had a reported history of traumatic brain injury, seizure disorder, and cognitive deficits. These conditions were not assessed by the facility. Patient C4 was unable, unwilling, or not motivated to attend assigned treatment groups and required multiple restraints and seclusion. The failure to assess significant clinical conditions and address the lack of participation in assigned treatment modalities by the patient negates the clinical effectiveness of the patient's treatment goals, potentially delaying improvement. (Refer to B125)

VIII. Ensure that progress notes by the physician were recorded for four (4) of eight (8) active sample patients (B9, B14, B15, and B18) who were assigned to the clinical nurse specialist. This failure to communicate the patient's medical and psychiatric progress prevents the treatment team from monitoring progress or deterioration in the patient's psychiatric and medical conditions and from assisting in arranging after care referrals. (Refer to B126)

IX. Ensure that discharge summaries included a brief summary of the patient's condition on discharge including psychiatric, physical, and functional condition for three (3) out of five (5) discharged patients (D1, D4, and D5). This deficiency results in a failure to communicate in a timely manner patients' psychiatric condition and discharge recommendations to providers providing follow-up care. (Refer to B135)

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

I. Ensure nursing interventions were included in the Master Treatment Plans (MTPs) based on the individual needs of eight (8) of eight (8) active sample patients (A3, A6, B7, B9,B1, B15, B18 and C4). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery. (Refer to B122)

II. Provide adequate numbers of nursing personnel, including Registered Nurses on al three tours of duty (day, Evening and night) for the Adult Patient care unit. The staffing pattern hindered on-going monitoring and supervision of the patients and oversight of the MHT's functions due to lack of sufficient numbers of staff and frequent absence of the RN from unit resulting in a potential safety risk for patients and staff. (Refer to B150)

Based on observation, interview and document review, the Nursing Director failed to staff adequate numbers of nursing personnel, including Registered Nurses (RN) on the day, evening and night shifts for the Adult patient care unit. Frequently there is only one RN and one Mental Health Tech (MHT) assigned to the day, afternoon and night shifts. This staffing pattern results in the unit being left without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for brief or extended periods of time during each shift. Also when the one (1) MHT is off the unit for lunch, escort etc. the RN is then only staff to monitor and supervise the patients. This creates a potential safety risk for the patients and remaining staff on the unit.

Findings include:

A. Specific Findings:

The Adult patient care unit is an 11-bed acute admission unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (4/25/16) revealed that there was a census of 10 patients - one (1) patient was on seizure precaution, one (1) on detox protocol and nine (9) patients needed escort to meals off the units, one (1) patient was potentially assaultive, nine (9) patients were low risk for suicide, one (1) patient on assault precautions and six (6) constantly demand staff time and 10 were on every 15 minutes checks.

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for nine (9) days including the first day of the survey (4/25/16), revealed that the day shift, evening shift and night shifts for eigth (8) of the nine (9) days was staffed with one RN and one MHT. There was no evidence that a replacement staff of similar classification was assigned for coverage when the assigned nursing staff were required to leave the unit for meals, breaks, patient's escorts, off unit programs etc., This pattern of staffing do not provide for sufficient number of nursing personnel on the unit for on-going monitoring and supervision of the patients.

B. Observation

1. During rounds on the Adult Patient care unit on 4/25/16 at approximately 11:50 a.m. the current census was 11 patients there was 1 RN who was also the charge nurse on the day shift and two (2) MHT assigned. There was four admissions the night before and two discharges in process. The RN was very busy answering the phone, doing medication, assessments and documenting in the charts etc. At about 2.14 pm the RN left the unit to escort a patient that was being discharge to the front of hospital for transportation, RN returned at 2:43. The RN is assigned to lead the nursing group scheduled to begin at 2:45p.m. and end at 3:30 p.m. The RN was off the unit leading the nursing group from 2:58 to 3:44 pm. During these periods of times there was no RN on the unit to monitor and supervise the patient and staff.

C. Interview

In an interview with Adult unit Charge nurse on 4/25/16 at 12:15 p.m. staffing patterns for the unit was discussed. She stated the staffing is based on census and for nine (9) patients and less there is one (1) RN and one (1) MHT, 10 patients one (1) RN and two (2) MHT and 12 patients and above two (2) RN and two (2) MHT. When asked about work performance based on current level of staffing she stated that "current level of staffing makes it difficult to get everything done". She also stated the Residential Treatment Care (RTC) unit RN though not physically present on the Adult unit will be called by the MHT's for assistance if needed during the absence of the RN.

2. In an interview on 4/26/16 at 12:05 P.M., with the RN Manager for all the units, the staffing for the Adult patient care unit was discussed. She stated that when the census is below 12 there is only one (1) RN assigned on the day and evening shifts. Regarding coverage when the regular RN is absence from the unit, she stated the nurse on RTC units floats over to replace the nurse for lunch, they try to schedule the RN on the adult unit lunch while the patients on the RTC unit is at lunch and if not possible the RN Manager will try to cover the unit. When asked if there are times when there are no RN on the Adult patient care unit, she responded, "unfortunately this do happen, yes there are times when there is no RN on the unit".

3. In the interview on 4/27/16 at 10.25 a.m., with the DON the pattern of staffing the Adult acute unit with one (1) RN and1MHT for census of nine (9) and below was discussed. She states "We have not have a problem". When asked if there time when the unit have no RN on the unit? She stated it is possible but it should not be because the RTC RN is to come to the unit for coverage when the assigned RN is not there on the day and afternoon shifts. On the night shift one of the RNs on the youth unit will release the night shift nurse for breaks. She also stated the "RN will monitor the unit if the MHT is gone for their meal".

Based on record review and staff interview, the Director of Social Work failed to:

I. Assure that social work staff provided social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (A3, A6, B7, B9, B14, B15, B18 and C4). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that Master Treatment Plans included specific interventions to be carried out by social work staff to address patient treatment needs for eight (8) of eight (8) active sample patients (A3, A6, B7, B9, B14, B15, B18 and C4). The listed interventions for social work providers on the Master Treatment Plans were stated as generic, discipline functions or absent. This failure results in a lack of interventions provided by the social worker to provide treatment, potentially delaying patient improvement and discharge from the hospital. (Refer to B122)

III. Ensure that progress notes by social workers contained information about patient progress towards treatment goals and safe discharge planning for eight (8) of eight (8) sample patients (A2, A4, A9, A12, B2, B4, B7 and B9). This failure impedes the treatment team's ability to assess or evaluate the patient's response to the treatment plan. (Refer to B128)

Interview

During an interview with the Director of Social Work on 4/26/16 at 2:30 p.m., she stated that she did not monitor psychosocial assessments, treatment planning, or discharge planning performed by social work staff.