HospitalInspections.org

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

I. Develop Master Treatment Plans (MTPs) in a timely manner for 1 of 1 active sample patients (A5) and 2 selected non-sample patients (B2 and B20) who were hospitalized fewer than seven days. The facility did not develop MTPs for patients who had a length of stay less than seven days, which was approximately 50% of the patient population. For these patients, a preprinted "Initial Treatment Plan," completed by the RN at the time of admission and reviewed by the treatment team within 4 days, was used throughout the hospitalization. This plan was not individualized for the patient. Failure to develop timely comprehensive treatment plans results in lack of guidance to staff in providing appropriate treatment. (Refer to B118- I)

II. Revise the Master Treatment Plans of 2 of 8 active sample patients (B10 and B11) after the use of physical restraint. Neither of these patient's MTPs was updated to address the less restrictive measures to be used by staff to control the problematic behavior and provide safety. Failure to do needed revisions of treatment plans results in patients being hospitalized without a plan that adequately reflects their current treatment needs, potentially delaying improvement and discharge. (Refer to B118-II)

III. Provide Master Treatment Plans for 7 of 8 active sample patients (A2, A14, A23, B6, B10, B11 and B12) that identified individualized treatment interventions to address the patients' presenting problems and treatment goals. The Master Treatment Plans (MTPs) contained generic and routine functions for nursing and the physician, with little differentiation between what interventions would be carried out by which discipline. The frequency of staff contact with patients and the modality for the interventions (individual or group sessions) also was not specified for registered nurses and/or physicians on the MTPs of 5 of 8 active sample patients (A2, A23, B6, B11 and B12). There were no social worker interventions on the MTPs for 5 of 8 active sample patients (A2, A14, A23, B6 and B11) and no activity therapy interventions on the MTPs of 6 of 8 active sample patients (A2, A14, A23, B10, B11and B12). These failures can result in patients not receiving coordinated multidisciplinary treatment. (Refer to B118-III)

IV. Provide active treatment for 5 of 8 active sample patients (A2, A14, A23, B10 and B11) who did not regularly participate in unit activities or their scheduled group treatment. The facility, also failed to provide structured active treatment for all patients, including 8 of 8 active sample patients (A2, A5, A14, A23, B6, B10, B11 and B12) from 8a.m. until 1:15p.m. daily. During this time, patients were observed sitting idly on the unit or sleeping in their rooms (Refer to B125-I). In addition, the facility failed to develop and document adequate interventions to address multiple occurrences of self injurious behavior and episodes of restraint of 1 of 8 active sample patients (B11). (Refer to B125-II). These deficient practices potentially delay patient's improvement and their subsequent discharge.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for 6 of 8 active sample patients (A2, A5, A14, A23, B10 and B11). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapeutic endeavors.

Findings include:

A. Record Review

1. Patient A2: The Psychiatric Evaluation dated 6/22/2011 stated for assets "Patient has family members."

2. Patient A5: The Psychiatric Evaluation dated 6/24/2011 had no assets described.

3 Patient A14: The Psychiatric Evaluation dated 5/27/2011 stated for assets "Previous treatment, good medical health, willing to accept treatment."

4. Patient B6: The Psychiatric Evaluation dated 8/31/2010 had no assets described.

5. Patient B10: The Psychiatric Evaluation dated 6/15/2011 stated "Patient apparently does have a place to stay, income and supportive family."

6. Patient B12: The Psychiatric Evaluation dated 5/20/2011 stated "Apparently she has been able to stay out of the hospital for the last seven years."

B. Staff Interview

In an interview on 6/28/2011 at approximately 1:00p.m., the Clinical Director was shown the findings listed above. The Clinical Director agreed that these comments were not descriptive of patient attributes that could be utilized in therapeutic endeavors.

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

I. Develop Master Treatment Plans (MTPs) in a timely manner for 1 of 1 active sample patient (A5) and 2 selected non-sample patients (B2 and B20) who were hospitalized for less than 7 days. The facility did not develop MTPs for patients who had a length of stay less than seven days, which was approximately 50% of the patient population. For these patients, a preprinted "Initial Treatment Plan," completed by the RN at the time of admission and reviewed by the treatment team within 4 days, was used throughout the hospitalization. This plan was not individualized for the patient. Failure to develop timely comprehensive treatment plans results in lack of guidance to staff in providing appropriate treatment.

Findings include:

A. Staff Interviews

1. In an interview with the Assistant Superintendent of Quality Management on 6/27/11 at approximately 9:05a.m., the treatment planning process used by the facility was discussed. The Assistant Superintendent of Quality Management reported that about 50% of the patient population is discharged within 5 days. He stated that the Initial Treatment Plan was completed on admission and that an Initial Treatment Plan Review was done within 72 hours of admission. He stated these plans were used to cover the patient's care until a Master Treatment Plan was developed 7 days after admission.

2. In an interview on 6/28/11 at approximately 4:15p.m., the Director of Hospital Services for Tennessee's Department of Mental Health acknowledged that Master Treatment Plans were not developed for patients who have a length of stay less than seven days. She stated that clinical assessments were expected to be completed by 72 hours of admission, and that the Master Treatment Plan was completed within seven days after admission. She noted that if the treatment team determines that the patient's length of stay will be more than seven days, the Master Treatment Plan could be initiated prior to seven days.

B. Policy Review

The facility's "Policy No. 2.31.00: Treatment Planning," states under the section "Initial Treatment Plan": "Treatment planning shall begin at admission, with the initiation of the Initial Treatment Plan, including the Diagnosis page, by the admitting physician." Under the heading "Initial Treatment Plan Review," the policy says, "The Interdisciplinary Treatment Team shall meet to review the Initial Treatment Plan no later than the 4th day following the day of admission..." Under the section "Master Treatment Plan," the policy states, "The Interdisciplinary Treatment Team shall meet again no later than the 7th day following the day of admission to develop the Master Treatment Plan... The Interdisciplinary Treatment Team shall determine which problems are prioritized for active treatment based on their relative significance and the patient's estimated length of stay."

C. Specific Patient Findings

1. Patient A5 (admitted 6/23/11)

a. The preprinted initial treatment plan for the patient was signed by the admitting and attending physicians and registered nurse on 6/23/11 and by the patient on 6/24/11. The psychiatric evaluation dated 6/24/11 stated, "...His [patient's] presenting symptoms include unusual ideation...He has psychotic symptoms and persecutory delusions...he is responding to voices." The treatment plan listed the Problem Category "High Risk Behavior/Psychiatric Symptoms" with no symptoms checked. There were no interventions checked for the psychiatrist. The following preprinted generic interventions were checked: "Nursing:" "Administer medications and monitor for effectiveness" and "Provide designated level of observation/supervision to assess for possible antecedents of high risk behaviors." Social Services: "Meet with the patient to provide a complete preliminary assessment." Activity Therapy: "Orient patient to treatment program"; "Complete Adjunctive Therapy Assessment"; "Assign patient to appropriate treatment activities" and "Facilitate patient involvement/participation in treatment activities." There were no revisions on the initial plan at the 4th day review. There was no MTP developed for the patient to guide staff in delivering individualized active treatment during the hospitalization.

b. During an observation on 6/27/11 at 1:25p.m. on unit Chota 4, sample patient A5 was attending a group titled "Anger Management" and conducted by RT2. The "Weekly Treatment Schedule" had two sessions circled for the patient at this time period -- "Co Triggers" and "Anger Management" Neither of these groups were on the patient's treatment plan, There also was also no expected behavioral outcome on the treatment plan that staff could use to evaluate the patient's response to the groups.

c. In an interview on 6/27/11 at approximately 1:55p.m., RT2 was not able to provide any information about what brought Patient A5 to the hospital. RT2 also was not able to explain why Patient A5 had two sessions circled on his Weekly Treatment Schedule for the same time period.

d. During an observation on 6/28/11 at 1:20p.m. on unit Chota 4, Patient A5 attended a group titled "Co Stages of Grief." The Weekly Treatment Schedule had two sessions circled for the patient at this time period -- "Co Relapse Prevention" and "Co Stages of Grief." Neither group was on the patient's treatment plan. There also was no expected behavioral outcome on the plan that staff could use to evaluate the patient's response to these groups.

e. In an interview on 6/27/11 at approximately 3:55p.m. Patient A5 stated he had attended a treatment team meeting but that he did not remember the treatment program being discussed. When asked about the Weekly Treatment Schedule, Patient A5 stated, "I did not get a copy of the schedule."

2. Patient B2 (admitted 6/25/11)

a. The preprinted initial treatment plan for this patient was signed by a physician and registered nurse on 6/25/11, by the social worker on 6/26/11, and by another physician and Patient A2 on 6/28/11. The plan listed the Problem Category: "High Risk Behavior/Psychiatric Symptoms" with no documented symptoms. The following preprinted generic interventions were checked: Psychiatrist: "Prescribe psychotic meds & monitor efficacy." Nursing: "Administer medications and monitor for effectiveness"; "Provide designated level of observation/supervision to assess for possible antecedents of high risk behaviors"; "Intervene immediately at the onset of any high risk behavior utilizing individualized approaches developed by the MD and the treatment team in order to protect the individual patient as well as other patients and staff." Social Services: "Meet with the patient to provide a complete preliminary assessment" and "Contact family/significant others; provide supportive counseling to patient." Activity Therapy: "Orient patient to treatment program"; "Complete Adjunctive Therapy Assessment"; "Assign patient to appropriate treatment activities" and "Facilitate patient involvement/participation in treatment activities." There was no MTP for the patient that identified the treatment priorities to guide staff in delivering individualized active treatment during the hospitalization.

b. During an observation at a treatment team meeting on 6/28/11 at 9:10a.m., Psychiatrist 2 interviewed patient B2 and discussed the decision to discharge the patient that day. Team Coordinator I had the patient sign the "Initial Treatment Plan" form and discharge paperwork during the meeting. The treatment plan was not discussed with the patient.

3. Patient B20 (admitted 6/23/11)

a. The preprinted initial treatment plan for this patient was developed on 6/23/11, and was reviewed by the team on 6/27/11. The patient "refused" to sign the form. The following routine discipline functions were checked: Psychiatrist: "Meet w/Patient to assess mental status, evaluate current risk/seriousness of high risk behavior, access [sic] mental status & response to treatment"; "Prescribe psychotic meds & monitor efficacy" and "order Special Diet."Nursing: "Provide designated level of observation/supervision to assess for possible antecedents of high risk behaviors." Social Services: "Meet with the patient to provide a complete preliminary assessment"; "Contact family/significant others" and "Provide supportive counseling to family/significant others." Activity Therapy: "Orient patient to treatment program"; "Complete Adjunctive Therapy Assessment"; "Assign patient to appropriate treatment activities" and "facilitate patient involvement/participation in treatment activities." There was no MTP that identified the treatment priorities to guide staff in delivering individualized active treatment during the hospitalization.

b. During an observation at a treatment team meeting on 6/28/11 at 9:10a.m., patient B20 was interviewed by Psychiatrist 2. The Initial Treatment Plan, Initial Treatment Plan Review, and the Weekly Treatment Schedule were not discussed during the treatment team meeting.

c. In an interview on 6/29/11 at approximately 10:30a.m., RN1 stated that this patient had been discharged on 6/28/11. At the time of discharge, the patient only had an Initial Treatment Plan and an Initial Treatment Plan Review. There was no MTP that identified the treatment priority determined by the interdisciplinary team and included individualized active treatment interventions that were planned for the patient during the hospitalization.

II. Revise the Master Treatment Plans of 2 of 8 active sample patients (B10 and B11) after the use of physical restraint. Neither of these patients' MTPs was updated to address the less restrictive measures to be used by staff to control the patient's problematic behavior and provide safety. Failure to do needed revisions of treatment plans results in patients being hospitalized without a treatment plan that adequately reflects the patients' treatment needs, potentially delaying improvement and discharge.

Findings include:

A. Patient B10

1. Patient B10 was admitted 6/15/11. A review of the medical record revealed that the patient required a physical restraint on 6/22/11.

2. The Master Treatment Plan for Patient B10, dated 6/22/11, listed the following interventions: "PSW [psychiatric social worker] will meet with the patient and request signatures as needed for discharge planning; Staff will provide instruction in basic health practices and hygiene; and Staff will prompt pt [patient] with needed ADLs bathing, feeding, grooming, incontinent care, medication supervision and any needed personal care."

3. As of 6/27/11 (beginning of survey) the MTP had not been revised to address the patient's behavior that required the physical restraint of 6/22/11, nor did it document the techniques staff would use in an attempt to de-escalate the patient before making the decision to apply physical restraints in the future.

4. The facility's policy for Treatment Planning: "Policy No. 2.31.00", dated "December 2009," states the following under "Section V. Policy; E: The treatment planning process...:" "Master Treatment Plan Reviews may be also conducted when indicated, between regularly scheduled reviews. These Master Treatment Plan Reviews may be precipitated by a change in the patient's condition..."

B. Patient B11

1. Patient B11 was admitted 11/29/07. The facility's "Adult Program Summary of Program Wide Incidents May 28, 2011 thru June 26, 2011 "revealed that Patient B11 had 8 incidents of "Self-Injurious Behavior" during this time period.

2. The facility's documentations for "Seclusion/Restraint" for the 30 day time frame, May 29, 2011 to June 27, 2011, disclosed that Patient B11 had 3 episodes of physical restraint and 1 episode of mechanical restraint during this time period.

3. The Master Treatment Plan for Patient B11, last revised on 6/3/11, listed the following interventions: "Staff will intervene immediately and appropriate [sic] should the pt [patient] endorse or how any self-harming behaviors; Staff will appropriately intervene to protect the patients well-being and offer information and direction on coping skills to circumvent self-harm."

4. As of 6/27/11 (beginning of survey), the treatment plan had not been revised/updated to reflect the patient's current condition and need for the physical/mechanical restraints. The plan also failed to outline a specific behavioral plan that staff could use to ensure the consistency and effectiveness of the treatment approach, and to prevent the future use of restraint.

5. Patient B11's current Master Treatment Plan of 6/3/11 was reviewed with the Acting DON who stated, "This (the MTP) will not be updated until 7/3/2011." When asked if there had been any written modifications to the MTP or any note in a MTP review regarding needed changes in treatment approaches for this patient, the Acting DON replied "No, the Treatment Plan has not been modified."

6. In an interview on 6/28/2011 at 9:35a.m., the Director of Hospital Services for the Department of Mental Health was asked to review Patient B11's current Master Treatment Plan (dated 6/3/11). After the review, she agreed that the patient's treatment plan did not include any revisions that addressed the use of mechanical and/or physical restraints, nor were there descriptions of different treatment modalities to address these issues.

7. The facility's policy for Physical Restraint: "Policy No. 2.37.00", dated "January 2010", states the following under "Section VI: Procedures and Responsibilities; Section E: Treatment Team Responsibilities": "If a patient requires multiple episodes of seclusion and/or restraint, the behaviors necessitating the use of seclusion and/or restraint should be addressed on the patient's treatment plan."

8. The facility's policy for Mechanical Restraint: "Policy No.2.46.00", dated "June 2010", states the following under "Section VI: Procedures and Responsibilities; E: Treatment Team Responsibilities": "If a patient requires multiple episodes of seclusion and/or restraint, the behaviors necessitating the use of seclusion and/or restraint should be addressed on the patient's treatment plan."

9. The facility's policy for Treatment Planning: "Policy No. 2.31.00", dated "December 2009", states the following under "Section V. Policy; E: The treatment planning process...:" "Master Treatment Plan Reviews may be also conducted when indicated, between regularly scheduled reviews. These Master Treatment Plan Reviews may be precipitated by a change in the patient's condition..."

III. Ensure that the Master Treatment Plans of 7 of 8 active sample patients (A2, A14, A23, B6, B10, B11 and B12) identified individualized treatment interventions to address patients' presenting problems and treatment goals. The Master Treatment Plans (MTPs) contained generic and routine functions for nurses and physicians, with little differentiation between what interventions would be carried out by which discipline. The frequency of staff contact with patients and the modality for the interventions (individual or group sessions) also was not specified for registered nurses and/or physicians on the MTPs of 5 of 8 active sample patients (A2, A23, B6, B11 and B12). There were no social worker interventions on the MTPs for 5 of 8 active sample patients (A2, A14, A23, B6 and B11) and no activity therapy interventions on the MTPs of 6 of 8 active sample patients (A2, A14, A23, B10, B11 and B12). These failures can result in patients not receiving coordinated interdisciplinary treatment. (Refer to B122-I)

IV. Ensure that treatment sessions listed on the "Weekly Treatment Schedule" and attended by 3 of 8 active sample patients (A23, B6 and B12) were included on the patients' Master Treatment Plans. The treatment schedules also had multiple groups assigned to a given patient for the same 45 minute time periods, reflecting the uncoordinated treatment planning. Treatment plans that do not reflect an integrated approach to treatment can delay patients' recovery. (Refer to B122-II)

V. Ensure that the name of staff responsible for interventions was listed on the Master Treatment Plans (MTPs) of 7 of 8 active sample patients (A2, A14, A23, B6, B10, B11 and B12). The MTPs for these patients only listed the discipline, not the name of the person responsible for each intervention. This practice results in lack of staff accountability for planned interventions. (Refer to B123)

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

I. Ensure that the Master Treatment Plans of 7 of 9 active sample patients (A2, A14, A23, B6, B10, B11 and B12) identified individualized treatment interventions to address patients' presenting problems and treatment goals. The Master Treatment Plans (MTPs) contained generic and routine functions for nursing and the physician, with little differentiation between what interventions would be carried out by which discipline. The frequency of staff contact with patients and the modality for the interventions (individual or group sessions) also was not specified for registered nurses and/or physicians on the MTPs of 5 of 8 active sample patients (A2, A23, B6, B11 and B12). There were no social worker interventions on the MTPs for 5 of 8 active sample patients (A2, A14, A23, B6 and B11) and no activity therapy interventions on the MTPs of 6 of 8 active sample patients (A2, A14, A23, B10, B11 and B12). These failures can result in patients not receiving coordinated interdisciplinary treatment.

II. Ensure that treatment sessions listed on the "Weekly Treatment Schedule" and attended by 3 of 8 active sample patients (A23, B6 and B12) were included on the patients' Master Treatment Plans. The treatment schedules also had multiple groups assigned to a given patient for the same 45 minute time periods, reflecting the uncoordinated treatment planning. Treatment plans that do not reflect an integrated approach to treatment can delay patients' recovery.

Findings include:

I. Failure to Individualize MTP Interventions

A. Record Review

The Master Treatment Plans (MTPs) or most recent revisions of the treatment plans for the following sample patients were reviewed (dates of plans/revisions in parentheses): A2 (3/11/11), A14 (6/3/11), A23 (6/24/11), B6 (6/2/11), B10 (6/22/11), B11 (6/3/11) and B12 (5/24/11).

1. Seven patients had the following generic and routine discipline functions listed: [Note: Most MD and RN interventions were not differentiated by discipline]

a. Patients A2 and A23: RN and MD interventions: "Staff will intervene immediately and appropriately should the patient endorse violence or attempt to harm others." "MD will review and adjust medications as needed. MD will meet daily with patient to assess medications, note any side effects and make any necessary changes."

b. Patient A14: RN and MD intervention: "Staff will observe patient for evidence of psychosis and intervene with appropriate medical interventions." "Staff will observe patient for evidence of audio or visual hallucination and intervene with appropriate medical interventions." "Staff will observe patient for evidence of improved self-care."

c. Patient A23: RN and MD intervention: "Staff will interact and observed patient for clarity of thought, speech and evidence of responding to internal stimuli and note patients progress in the chart on a daily basis."

d. Patient B6: RN and MD interventions: "Staff will monitor and assess client for psychotic symptoms and document observations daily." "MD and tx [treatment] team will meet daily with pt [patient] to assess psychotic thinking and to help with problem solving to help reduce her level of stress."

e. Patient B10: SW Intervention - "PSW [Psychiatric Social Worker] will meet with the patient and request signatures as needed for discharge planning." Nursing Intervention - "...Staff will prompt pt [patient] with needed ADL's, Bathing, feeding, grooming, incontinent care, medication supervision and any needed personal care."

f. Patient B11: MD and Nursing Interventions: "Staff will intervene immediately and appropriate [sic] should the pt. [patient] endorse or show any self-harming behaviors" and "Staff will appropriately intervene to protect the patients [sic] well-being..."

g. Patient B12: MD and Nursing Interventions: "Staff will engage pt. [patient] in conversation to encourage pt [patient] to respond and allow staff to assess pt.'s [patient's] current level of reality and comprehension." "MD will review meds daily with the patient and make changes as needed for effectiveness."

2. Five patients had the following intervention with no frequency of contact and/or no specified modality (individual or group):

a. Patient A2: RN and MD intervention: "Staff will educate patient on skills and tools to utilize to deal with feelings of anger on a daily basis."

b. Patient A23: RN and MD intervention: "Staff will educate patient on alternative to aggression and allow discussion and encouragement as needed."

c. Patient B6: MD interventions: "MD will meet daily with patient to provide supportive therapy and medication management."

d. Patient B11: MD and Nursing Intervention: "Staff will...offer the patient information and direction on coping skills to circumvent self-harm."

e. Patient B12: MD and Nursing Intervention: "MD and Nursing will educate the pt. [patient] on her medication and mental illness."

3. Five patients (A2, A14, A23, B6 and B11) had no social worker interventions on the Master Treatment Plan for the identified patient problem.

4. Six patients (A2, A14, A23, B10, B11 and B12) had no activity therapy interventions on the Master Treatment Plan for any of the identified patient problems.

B. Staff Interview

1. In an interview on 6/27/11 at approximately 11:35a.m. with RN1 & RN2, the treatment plan of Patient B6 was reviewed. RN1 acknowledged the treatment plan contained routine nursing functions. RN1 also acknowledged that the plan did not specify whether the intervention would be delivered in individual or group sessions.

2. In an interview on 6/28/11 at approximately 11:00a.m. with the Director of Activity Therapy, the treatment plans for A23, B6 and B12 were reviewed. The Director of Activity therapy acknowledged that there were no activity therapy and social work interventions on the master treatment plans.

3. In an interview on 6/29/11 at 10:50a.m. with the Acting DON, the sample patient's MTPs were discussed, including the problem of overlapping MD and nursing interventions. In response to the question of why the nursing staff was assigned to interventions that were within the scope of practice for the MD, the Acting DON stated that it probably was a typo.

II. Failure to include Groups Attended on the MTP

A. Observations

1. Patient B6 was observed participating in a self awareness group on 6/27/11 from 3:20p.m. to 3:40p.m. The "Weekly Treatment Schedule" showed that the "Self Awareness" group was scheduled for the patient at 3:15p.m. However, this group was not listed on the patient's MTP.

2. Patient B12 was observed participating in a self awareness group on 6/27/11 from 3:20p.m. to 3:40p.m. The "Weekly Treatment Schedule" showed "Self Awareness" scheduled for the patient at 3:15p.m. However, this group was not listed on the patient's MTP.

3. Patient A23 was observed participating in a one to one session on 6/28/11 from 1:40p.m. to 1:50p.m. The "Weekly Treatment Schedule" for Patient A23 showed "Relapse Prevention" and "Medication Education" scheduled at 1:15p.m. Neither the 1:1 session nor these groups were listed on the patient's MTP. The Relapse Prevention session was conducted by SW1 who stated that Patient A23 was the only patient attending the group. SW1 stated that she was not aware of what problems brought Patient 23 to the hospital and that she had not read the patient's chart.

B. Record Review

1. The Master Treatment Plans (MTPs) (or the most current revision of the treatment plan) for the following sample patients were reviewed (dates of plans/revisions in parentheses): A2 (3/11/11), A14 (6/3/11), A23 (6/24/11), B6 (6/2/11), B10 (6/22/11), B11 (6/3/11), and B12 (5/24/11). The review revealed that the groups listed on the patients' "Weekly Treatment Schedules" and/or attended by patients A23, B6 and B12 were not included on their MTPs.

2. The "Weekly Treatment Schedule" for Patients A23, B6 and B12 showed that 17 to 28 sessions were scheduled weekly for these patients. On 6/27/11, the following treatment sessions were scheduled but not listed on the patients' MTPs:

a. Patient A23 was assigned to: "Co Triggers" and "Anger Management" scheduled at 1:15p.m.; "Co Relapse Prevention," "Family Tree of Addiction," and "Recovery Management" scheduled at 2:15p.m.; and "Self Defeating Behavior" scheduled at 3:15p.m.

b. Patient B6 was assigned to: "Stress Management" at 1:15p.m.; "Wellness" at 2:15p.m.; and "Self-Awareness" at 3:15p.m.

c. Patient B12 was assigned to: "Stress Management" at 1:15p.m.; "Recovery Management" at 2:15p.m.; and "Self Awareness" at 3:15p.m.

C. Staff Interview

1. During an interview on 6/27/11 at appropriately 11:15a.m., the Weekly Treatment Schedule for Patient A23 was reviewed with RT1. When asked about the multiple sessions on the patient's schedule, RT1 stated, "I don't know why the patient is assigned to more than one group at the same time."

2. In an interview on 6/28/11 at approximately 11:00a.m., the Director of Activity Therapy stated, "The weekly treatment schedule should be referenced on the treatment plan by [noting] - See Treatment Schedule."

Based on record review and interview, the facility failed to ensure that the name of staff responsible for interventions was listed on the Master Treatment Plan (MTPs) of 7 of 8 active sample patients (A2, A14, A23, B6, B10, B11 and B12). The MTPs listed only the discipline, not the name of the person responsible for each intervention. This practice results in lack of staff accountability for planned interventions.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) or most current revisions of the treatment plan for the following sample patients were reviewed (dates of plans/revisions in parentheses): A2 (3/11/11), A14 (6/3/11), A23 (6/24/11), B6 (6/2/11), B10 (6/22/11), B11 (6/3/11), and B12 (5/24/11). The review revealed that for 7 of the 8 sample patients (A2, A14, A23, B6, B10, B11 and B12), the name of the person responsible for the listed interventions was not recorded on the treatment plans.

B. Staff Interviews

1. In an interview on 6/28/11 at 2:55p.m. with the Acting Director of Nursing (DON), the Master Treatment Plans of Patients A23, B6 and B12 were reviewed. The Acting DON acknowledged that the name of the person responsible for interventions was not included on the Master Treatment Plan. The Acting DON stated that since they were not sure what nurse would be available to do the intervention, they decided to just put "RN" instead of a name.

Based on observation, interviews, and medical record and document review, it was determined that the facility failed to:

I. Provide active treatment for 5 of 8 active sample patients (A2, A14, A23, B10 and B11) who did not regularly participate in scheduled programming. These patients were observed sitting idly on the unit or sleeping in their rooms instead of attending unit activities and/or assigned group treatment. The facility also failed to provide structured active treatment for all patients, including 8 of 8 active sample patients (A2, A5, A14, A23, B6, B10, B11 and B12) from 8:00a.m. until 1:15p.m. daily. These failures potentially delay patients' improvement their timely discharge.

II. Develop and document active treatment interventions that addressed the multiple self injurious behaviors and episodes of restraint for 1 of 8 active sample patients (B11). This deficient practice results in patients being hospitalized without all interventions for recovery being provided, potentially delaying their improvement.

Findings include:

I. Failure to provide active treatment

A. Specific Patient Findings

1. Patient A2

a. A2 was admitted on 2/21/2011 with the diagnoses "Schizophrenia paranoid chronic" and "Intermittent Explosive Disorder."

b. On 6/27/2011 at 10:30a.m., the patient was found on the Unit asleep in his bed.

c. In an interview on 6/27/2011 at 11:30a.m. with RN3 and Patient A2, the patient was asked to describe what he had been doing earlier that day. He said "I ate breakfast; I ate lunch and read some magazines." He stated he had not been in any group activities because "There are no groups in the morning." The patient's account was confirmed by RN3 who also stated "He [patient A2] is paranoid. He doesn't like to be around people." RN3 also stated that the patient was eating meals in his room.

d. In an interview on 6/28/2011 at 8:50a.m., Patient A2 was found in the Unit hallway. He reported that he had had his breakfast and his medications. He stated he did not know what else he would be doing for the rest of the morning. (See Document Review below for the findings with respect to Unit activities from 8a.m. to 1:15).

e. Review of the medical record for Patient A2 revealed that for the week prior to the survey (6/20/2011 to 6/26/2011), the patient had attended 3 of the 32 possible therapy groups selected for him on his Weekly Treatment Schedule, which was dated 5/19/2011 (one month earlier). Of the 3 groups that he had attended, one had not been selected for him. The Adjunctive Therapy Director confirmed this finding on 6/28/2011 at 11:50a.m.

f. In an interview on 6/28/2011 at 9:05a.m., Psychiatrist1 was asked about the treatment of Patient A2. Psychiatrist1 stated that the goal was to "transfer the patient to the Sub acute Unit when there is a bed available." When asked how a patient in Acute Care and not participating in scheduled activities would be a candidate for a less structured setting, Psychiatrist1 replied "There is not a lot we can do. I had a patient refuse to go to groups for a year until we changed his meds."

2. Patient A14

a. A14 was admitted 5/27/2011 with the diagnosis "Schizoaffective Disorder."

b. On 6/27/2011 at 1:10p.m., the patient was observed in his room lying on his bed.

c. In an interview on 6/27/2011 at 1:15p.m., patient A14 explained to the surveyor that he was in bed because "I'm tired, my head aches, but mostly just tired." When asked to describe what he had been doing earlier that day he replied, "I ate lunch, I ate breakfast. That is about it." The only group selected on the "Weekly Treatment Schedule" for this patient on this date was a 10a.m. "On Unit Activity." He was asked to describe what that was. He replied "Shoot pool. Play ping pong."

3. Patient A23

a. A23 was admitted on 6/19/11. His Psychiatric Evaluation dated 6/19/2011 reported that he was diagnosed with "Bipolar Affective Disorder- Most Recent Episode Mixed and Polysubstance Dependence." The "Weekly Treatment Schedule" showed 28 sessions per week assigned to the patient.

b. During an observation on 6/27/11 at 1:20p.m., Patient A23 was found sleeping on the sofa in the dayroom. He/she was scheduled to attend the "Co Triggers" or the "Anger Management" group, scheduled for 1:15p.m.

c. During an observation on 6/27/11 at approximately 2:45p.m., the surveyor made patient rounds with two MHTs [Mental Health Technician]. During the rounds, the "Patient Checklist" showed 23 patients were on the unit. Among these patients, 6 patients were in bed including Patient A23; 8 patients were in the dayrooms (3 in Green Dayroom and 5 in the Orange Dayroom) and 5 patients were participating in a group in the group room. There were three "off unit" groups and one "on unit" group scheduled for 2:15p.m. According to RT1, these groups were generally held for 45 minutes. Thus, most of the patients, including patient A23, did not attend any of these groups.

d. Review of Patient A23's Master Treatment Plan dated 6/24/11 revealed listed interventions for only the registered nurse and the physician. The following intervention was assigned to both the RN and the physician: "Staff will educate patient on alternatives to aggression and allow discussion and encouragement as needed." There was no documentation found in the patient's medical record that this education was provided by the RN or MD.

e. Review of the "Weekly Treatment Schedule" for Patient A23 revealed that the patient was assigned to: "Co Triggers" and "Anger Management" scheduled at 1:15p.m.; "Co Relapse Prevention," "Family Tree of Addiction," and "Recovery Management" scheduled at 2:15p.m.; and "Self Defeating Behavior" scheduled at 3:15p.m. Patient A23 did not participate in any of these sessions on 6/27/11.

f. Review of the "Group Treatment Absentee Record" for 6/20/11 to 6/26/11 and the medical record of patient A23 revealed that the patient only attended 6 of the 19 group sessions that he/she could have attended.

g. A review of the sessions attended (documented on the "Treatment Intervention Note" form) revealed that on 6/24/11 at 1:15p.m., the patient attended "Medication Education." The form had "None" checked for "Participation; Interaction with others; and Attention/Concentration." On 6/24/11 at 2:15, the "Treatment Intervention Note" documented that the patient attended a "Recovery Management" session with "None" checked for "Participation; Interaction with others; and Attention/Concentration."

h. In an interview on 6/28/11at 1:50p.m. with SW1, the treatment program for Patient A23 was discussed. SW1 stated that, in addition to the groups above (see item g), Patient A23 had attended one other "Co-Occurring Disorder Group." When asked about the patient's lack of participation in groups and if alternative sessions were provided, SW1 stated, "I don't know about alternative interventions..."

4. Patient B10

a. B10 was admitted 6/15/2011. The psychiatric diagnosis was "Psychotic Disorder NOS."

b. In an interview on 6/27/2011 at 2:25p.m. (12 days after the patient's admission), Patient B10 told the surveyor, "I haven't been to group so far. I went to one today. I didn't know they had them before today."

c. In an interview on 6/27/2011 at 2:40p.m., the Director of Activity Services was asked to review patient B10's attendance at the 25 group sessions listed on her "Weekly Treatment schedule." The Director of Activity Services noted that the patient had only attended 1 assigned group during the week of 6/20/11 to 6/26/11. The Director of Activity Services also acknowledged that there had been no revision of the treatment plan of 6/22/2011 to address the patient's non-participation in treatment.

5. Patient B11

a. B11 was admitted 11/29/2007. The annual Psychiatric Evaluation dated 11/04/2010 listed diagnoses as a "Mood Disorder NOS (Not Otherwise Specified) and a Personality Disorder NOS with borderline and antisocial features."

b. During an observation on 6/27/2011 at 2:05p.m., the patient was found asleep in her room. She was on a 1 to 1 observational status with MHT1 (Mental Health Technician) watching her from the doorway to the room.

c. During an observation on 6/28/2011 at 1:15p.m., the patient was found in her room, lying on her bed and covered with a bed sheet. The patient was on 1 to1 observational status with MHT2. The patient's roommate was also lying awake on her bed.

d. In an interview on 6/27/2011 at 2:10p.m., Patient B11 was asked what changes she would like to see in her treatment. She replied, "The therapy. I would like more therapeutic activities and more to keep the patients occupied."

B. Document Review

A review of the "Weekly Schedule" for patients on the 2 Units of the hospital's distinct part showed that the daily schedule of structured events started at 6a.m. and listed the following activities: "Breakfast"; at 8a.m. "Outdoor Break"; at 10a.m. "On Unit Activity", "Juice or Coffee & Phone calls," then "Lunch", and "Medications if ordered." The structured group therapies began at 1:15p.m. on both units. The groups were scheduled for 45 minute time periods throughout the afternoon.

II. Failure to develop and document alternatives to restraint

Patient B11 was admitted 11/29/2007. The annual Psychiatric Evaluation dated 11/04/2010 listed diagnoses as a "Mood Disorder NOS (Not Otherwise Specified) and a Personality Disorder NOS with borderline and antisocial features."

A. On 6/29/2011 at 9:07a.m. the Acting Director of Nursing (DON) provided the facility's "Adult Program Summary of Program Wide Incidents May 28, 2011 Thru June 26, 2011." The document revealed that Patient B11 had 8 incidents of "Self-Injurious Behavior" during this time period.

B. The facility's documentations for "Seclusion/Restraint" for the 30 day time frame, May 29, 2011 to June 27, 2011, disclosed that Patient B11 had 3 episodes of physical restraint and 1 episode of mechanical restraint during this time period.

C. Patient B11's current Master Treatment Plan (MTP) dated 6/3/2011 was reviewed with the Acting DON who stated, "This (the MTP) will not be updated until 7/3/2011." When asked if there had been any written modifications to the MTP or any note in a MTP review regarding needed changes in treatment approaches for this patient, the Acting DON replied "No, the Treatment Plan has not been modified."

D. In an interview on 6/28/2011 at 9:35a.m., the Director of Hospital Services for the Department of Mental Health was asked to review Patient B11's current Master Treatment Plan (dated 6/3/2011). After the review, she agreed that the treatment plan did not include any changes that reflected the use of mechanical and/or physical restraints for the patient, nor were there descriptions of different treatment modalities to address these events.

E. The facility's policy for Physical Restraint: "Policy No. 2.37.00", dated "January 2010", states the following under "Section VI: Procedures and Responsibilities; Section E: Treatment Team Responsibilities": "If a patient requires multiple episodes of seclusion and/or restraint, the behaviors necessitating the use of seclusion and/or restraint should be addressed on the patient's treatment plan."

F. The facility's policy for Mechanical Restraint: "Policy No.2.46.00", dated "June 2010", states the following under "Section VI: Procedures and Responsibilities; E:Treatment Team Responsibilities": "If a patient requires multiple episodes of seclusion and/or restraint, the behaviors necessitating the use of seclusion and/or restraint should be addressed on the patient's treatment plan."

G. The facility's policy for Treatment Planning: "Policy No. 2.31.00", dated "December 2009", states the following under "Section V. Policy; E: The treatment planning process...:" "Master Treatment Plan Reviews may be also conducted when indicated, between regularly scheduled reviews. These Master Treatment Plan Reviews may be precipitated by a change in the patient's condition..."

Based on observation, medical record review, patient and staff interview and facility policy review, it was determined that the Clinical Director failed to:

I. Ensure that Psychiatric Evaluations contained a description of patient assets for 6 of 9 active treatment patients (A2, A5, A14, B6, B10 and B12). This failure can result in staff not utilizing positive patient attributes in treatment endeavors. (Refer to B117)

II. Ensure that Master Treatment Plans were developed in a timely manner for 1 of 1 active sample patients (A5) and 2 selected non-sample patients (B2 and B20) who were hospitalized fewer than seven days. The facility did not develop MTPs for patients who had a length of stay less than seven days, which was approximately 50% of the patient population. For these patients, a preprinted "Initial Treatment Plan," completed by the RN at the time of admission and reviewed by the treatment team within 4 days, was used throughout the hospitalization. This plan was not individualized for the patient. Failure to develop timely comprehensive treatment plans results in lack of guidance to staff in providing appropriate treatment. (Refer to B118- I)

III. Assure that the Master Treatment Plans of 2 of 8 active sample patients (B10 and B11) were revised/updated after the use of physical restraint. Neither patient's MTP was updated to address the less restrictive measures to be used by staff to control the problematic behavior and provide safety. Failure to do needed revisions of treatment plans results in patients being hospitalized without a plan that adequately reflects their current treatment needs, potentially delaying discharge. (Refer to B118-II)

IV. Ensure that the Master Treatment Plans of 7 of 9 active sample patients (A2, A14, A23, B6, B10, B11 and B12) identified individualized treatment interventions to address patients' presenting problems and treatment goals. The Master Treatment Plans (MTPs) contained generic and routine functions for nurses and physicians, with little differentiation of what interventions would be carried out by which discipline. The frequency of staff contact with patients and the modality for the interventions (individual or group sessions) also was not specified for registered nurses and/or physicians on the MTPs of 5 of 8 active sample patients (A2, A23, B6, B11 and B12). There were no social worker interventions on the MTPs for 5 of 8 active sample patients (A2, A14, A23, B6 and B11) and no activity therapy interventions on the MTPs of 6 of 8 active sample patients (A2, A14, A23, B10, B11 and B12). These failures can result in patients not receiving coordinated multidisciplinary treatment. (Refer to B118-III)

V. Provide active treatment for 5 of 8 active sample patients (A2, A14, A23, B10 and B11) who did not regularly participate in unit activities or their scheduled group treatment. The facility, also failed to provide structured active treatment for all patients, including 8 of 8 active sample patients (A2, A5, A14, A23, B6, B10, B11 and B12) from 8a.m. until 1:15p.m. daily. Patients were observed sitting idly on the unit or sleeping in their rooms. (Refer to B125-I). In addition, the facility failed to develop active treatment interventions that addressed the self injurious behavior and episodes of restraint for 1 of 8 active sample patients (B11). (Refer to B125-II) These deficient practices potentially delay patient's improvement and their subsequent discharge.

Based on record review and interview, the Acting Director of Nursing (DON) failed to ensure that the Master Treatment Plans of 7 of 9 active sample patients (A2, A14, A23, B6, B10, B11 and B12) identified individualized nursing interventions to address patients' presenting problems and treatment goals. The Master Treatment Plans (MTPs) for these patients contained generic and routine nursing functions, incorrectly listed as individualized interventions. The frequency of staff contact with patients and the modality for interventions (individual or group sessions) also were not specified for registered nurses on the MTPs of 5 of 8 active sample patients (A3, A23, B6, B11, and B12). These failures result in lack of guidance to nursing staff in providing individualized and coordinated treatment, potentially compromising and delaying patients' improvement during their hospital stay.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following sample patients were reviewed (dates of plans in parentheses): A2 (3/11/11), A14 (6/3/11), A23 (6/24/11), B6 (12/8/10 - initial; 6/2/11- revised), B10 (6/22/11), B11( 6/3/11- last revised), and B12 (5/24/11). The review revealed the following findings:

1. Seven patients had the following generic and routine nursing functions listed:

Patient A2, A23: RN interventions: "Staff will intervene immediately and appropriately should the patient endorse violence or attempt to harm others"... "review and adjust medications as needed"... "meet daily with patient to assess medications, note any side effects and make any necessary changes."

Patient A14: RN interventions: "Staff will observe patient for evidence of psychosis and intervene with appropriate medical interventions." "Staff will observe patient for evidence of audio or visual hallucination and intervene with appropriate medical interventions." "Staff will observe patient for evidence of improved self-care."

Patient A23: RN intervention: "Staff will interact and observed patient for clarity of thought, speech and evidence of responding to internal stimuli and note patients progress in the chart on a daily basis.

Patient B6: RN interventions "Staff will monitor and assess client for psychotic symptoms and document observations daily" and "meet daily with pt [patient] to assess psychotic thinking and to help with problem solving to help reduce her level of stress."

Patient B10: Nursing Intervention - "...Staff will prompt pt [patient] with needed ADL's, Bathing, feeding, grooming, incontinent care, medication supervision and any needed personal care."

Patient B11: Nursing Interventions: "Staff will intervene immediately and appropriate should the pt. [patient] endorse or show any self-harming behaviors." "Staff will appropriately intervene to protect the patients [sic] well-being..."

Patient B12: Nursing Intervention: "Staff will engage pt. [patient] in conversation to encourage pt [patient] to respond and allow staff to assess pt.'s [patient's] current level of reality and comprehension."

2. Five patients had the following nursing intervention with no frequency of contact and/or no specified modality (individual or group).

Patient A2: RN intervention: "Staff will educate patient on skills and tools to utilize to deal with feelings of anger on a daily basis."

Patient A23: RN intervention: "Staff will educate patient on alternative to aggression and allow discussion and encouragement as needed."

Patient B11: Nursing Intervention: "Staff will...offer the patient information and direction on coping skills to circumvent self-harm."

Patient B12: Nursing Intervention: "...Nursing will educate the pt. [patient] on her medication and mental illness."

B. Staff Interview

In an interview on 6/28/11 at 2:55p.m. with the Acting Director of Nursing (DON), the Master Treatment Plans of Patients A23, B6 and B12 were reviewed. The DON acknowledged that the treatment plans contained generic nursing functions rather than individualized interventions for the patients. The DON also acknowledged that the some of the plans did not specify whether the interventions would be delivered in individual or group sessions.