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Based on record review and interview, the facility failed to ensure that registered nurses and social workers adequately documented active treatment interventions listed on the Master Treatment Plan to show detailed and comprehensive information about treatment for five (5) of eight (8) active sample patients (A2, A3, A5, A6 and A7) assigned to registered nurses (RN) and five (5) of eight (8) active sample patients (A1, A2, A4, A7 and A8) assigned to social workers (SW). Also, there were no group treatment notes for active treatment groups listed on the unit schedules assigned to RNs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and assigned to SWs for four of eight active sample patients (A1, A2, A3 and A4). Specifically, documentation associated with assigned individual and group sessions did not consistently include the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the Treatment Plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

1. Nursing Interventions:

a. Interventions in the MTPs - There were no treatment notes found for interventions assigned to nursing in the MTPs. Although most intervention statements failed to identify whether they would be delivered in individual or group sessions, the interventions were reported to be provided in individual sessions. A review of progress notes for one week period revealed that the notes only documented the progress of the patient and failed to document treatment notes at all that reflected the RN met with the patient to provide specific information or teaching. There was no documented evidence showing specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments for the following patients-- Patient A2: "Nursing, with the patient, will engage in 10-15 minute linear conversation once per shift to monitor confusion, disorganized thinking, and reality testing."; Patient A3: "Nursing will engage patient in discussion of current rating of depression sxs and discuss depression management strategies as it relates to suicidal ideation to identify sxs recognition." ;Patient A5: "The nurse will provide teaching and support r/t [relate to] possible coping mechanisms."; Patient A6: "Nursing will provide psychoeducation to the patient during each medication administration about side effects and monitoring desired effects of medications" and for Patient A7: "Nursing will meet with pt [patient] ... and provide education r/t [related to] to managing anxiety without the use of Benzodiazepine."

b. Nursing Groups on the unit schedule

The unit schedule on each unit showed two groups assigned to nurses scheduled on the weekends on the following units: Unit 1 - "Harm Reduc.[Reduction]" on Sundays and "Medication Ed. [Education] and "Stress Reduc." on Saturdays. Unit 2 - "Medication Ed." And "Harm Reduc.[Reduction]" on Sundays and "Medication Ed. [Education] and "Stress Reduc." on Saturdays. Unit 3 - "Stress Reduc.[Reduction]" on Sundays and "Medication Ed. [Education] and "Harm Reduc." on Saturdays. A review of the electronic medical record revealed the two treatment notes were documented for Patient A1 who did not attend and one for Patient A2 who participated in the group. There was no other documented evidence showing that the assigned nursing groups were held.

2. Social Work Interventions:

a. Interventions in the MTPs - There were no treatment notes found for interventions assigned to social workers (SW) in the MTPs. Although most intervention statements failed to identify whether they would be delivered in individual or group sessions, the interventions were reported to be provided in individual sessions. A review of progress notes for one week period revealed that the notes only documented progress of the patient and failed to document treatment notes at all that reflected the SW met with the patient to provide specific information or teaching. There was no documented evidence showing specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if for the following patients.

Patient A1 - "Social Services will prompt patient to engage in a 1-2 minute verbal dialogue daily to encourage reality based thinking, challenge paranoid thought processes, and assess for reduction of AH/Responding to internal stimuli." There were four notes for the week of 3/31/19 through 4/2/19 showing contact with the patient. However, there was no documented evidence that the social worker attempted to encourage reality based thinking or challenged paranoid thought processes.

Patient A2 - "Social Services will facilitate 3 minute conversation daily with patient to challenge delusional thinking and monitor tolerance and ability to process psychotic thought processes." There was no documented evidence that the social worker met with the patient for 3 minutes to challenge delusional thinking.

Patient A4 - "Social Service will meet with [sic] 1:1 daily to assist in reorienting patient to reality and challenge delusional thinking to monitor reduction in psychosis." There was no documented evidence that the social worker met with the patient 1:1 daily to reorient the patient to reality and challenge delusional thinking.

Patient A7 - "Social Service will meet with patient daily to engage in 15 [minutes] reality based conversation to challenge delusions and observe increased organized thinking." There was no documented evidence that the social worker met with the patient daily for 15 minutes to engage in to challenge delusional thinking.

Patient A8 - Social Work Interventions: "Social Service will meet with patient daily 1:1 for 5 minutes to provide reality testing ..." There was no documented evidence that the social worker met with the patient daily for 5 minutes to provide reality testing.

b. Social Work Groups on the unit schedule

The unit schedule on each unit showed that groups titled "Group Therapy" was assigned to social workers on Sundays. A review of the electronic medical record revealed that for the period of 3/27/19 through 4/2/19, there were no group treatment notes were documented for Patients A1, A2, A3, and A4.

B. Interview

1. In an interview on 4/2/19 at 9:30 a.m., the Director of Social Worker did not dispute the findings that there were no group treatment notes for Patients A1, A2, A3, and A4.

2. In an interview on 4/3/17 at 10:00 a.m., with the Director of Nursing, the issue of treatment notes for interventions assigned to nursing were not documented as having been implemented. He did not dispute the findings that the documentation was related to the patients' progress or lack of progress rather than treatment notes showing that RN met with patients in individual or group sessions to provide information or patient teaching.