HospitalInspections.org

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

I. Ensure that the Master Treatment Plans for 5 of 8 active sample patients (A32, A36, A39, B13, and B32) were based on the patients' abilities and were revised when the patients failed to participate in the prescribed treatment. These patients demonstrated severe impairment, but the only psychiatric treatments prescribed on the Master Treatment Plans other than medication adjustments were group therapy sessions, from which the patients were incapable of benefiting. Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients. (Refer to B118)

II. Ensure that active individualized psychiatric care was provided for 5 of 8 active sample patients (A32, A36, A39, B13, and B32) based on their presenting needs. The facility failed to ensure structured treatment for their specialized needs. Patients failed to attend most of the structured groups listed on their plans. No alternative treatment modalities were provided during these times. These patients were observed to be sleeping or walking about the wards during the times their group treatments were taking place. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125-I)

III. Utilize and document the use of restraints as external controls of violence toward self and others for 1 of 8 active sample patients (A33) and 3 of 3 discharged patients (C1, C2, and C3) reviewed for the use of seclusion and restraint procedures. These patients were restrained by a physician's order which included criteria to continue the procedures beyond the emergency situations that included violent behaviors towards themselves or others. This failure exposes patients to potential harm from unnecessary restraint and can result in a violation of the patients' right to be free from restraints. (Refer to B125-II)

Based on observation, interview and document review,

A. the Medical Director failed to:

I. Provide necessary leadership to ensure that periodic psychiatric evaluations were completed, resulting in a lack of a current assessment to justify the diagnosis and treatment of patients. (Refer to B144, Section I)

II. Adequately monitor the development of appropriate individualized treatment modalities on the treatment plans, and the implementation of appropriate treatment to meet patient needs. These failures can result in delaying patient improvement and delaying discharge to appropriate levels of care. (Refer to B144, Sections II-III)

III. Assure that staff utilized and documented restraints as external controls of violence toward self and others. This exposes patients to potential harm from unnecessary restraints and is a violation of the patient's right to be free from restraints except for immediate protection of self and others. (Refer to B144, Section IV)

IV. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment. This results in possible physical harm for all patients. (Refer to B144, Section V)

B. the Director of Nursing (DON) failed to:

I. Assure the immediate availability of a Registered Nurse (RN) on the night tour of duty on Unit 1 during the time periods that acutely ill patients were assigned to sleep on the ward. This results in lack of on-going professional assessments of patients and supervision of technical nursing personnel, creating a safety risk for all patients and staff on this ward. (Refer to B149)

II. Assure that staff provided appropriate treatment to meet all patient needs. This can result in delays in patient improvement and discharge to appropriate levels of care. (Refer to B148, Section II)

III. Assure that staff appropriately utilized and documented restraints as external controls of violence toward self and others. This exposes patients to potential harm from unnecessary restraints, and it violates patients' right to be free from restraints except for the immediate protection of self and others. (Refer to B148, Section III)

IV. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment. This results in possible physical harm for all patients. (Refer to B144, Section IV)

Based on observation, interview and record review, the facility failed to ensure that the Master Treatment Plans for 5 of 8 active sample patients (A32, A36, A39, B13, and B32) were based on the patients' abilities and were revised when the patients were unwilling to participate in the prescribed treatment. These patients demonstrated severe impairment, but the only psychiatric treatments prescribed on the treatment plans other than medication adjustments were group therapy sessions, from which the patients were incapable of benefiting. The treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients.

Findings include:

A. Patient A32:

1. As documented in a treatment team psychiatric progress note dated 2/15/11, Patient A32 was admitted to the facility on 8/7/08. Patient A32's diagnosis was "Schizoaffective disorder."

2. A review of the master treatment plan most recently revised 2/10/11, revealed that Patient A32 was scheduled to attend the following daily structured treatment groups: "Basic Relaxation," "Structured Activity Group," and "Social Skills." Review of "Interdisciplinary Progress Notes" from 2/14/11 through 2/25/11 revealed that Patient A32 attended only 3 of 20 group sessions during this time period. These notes stated, "Patient refused to attend."

3. A review of the medical record revealed that as of 3/1/11, there was a failure to address Patient A32's lack of attendance at in the prescribed group therapy or programming activities and no revisions were made in the plan.

B. Patient A36:

1. As documented in the psychiatric evaluation date 1/24/11, Patient A36 was admitted on 1/21/11 with diagnoses of "Depressive disorder" and "Borderline intellectual functioning."

2. A review of the Master Treatment Plan dated 1/24/11 revealed that Patient A36 was scheduled to attend the following daily structured treatment groups: "Basic Relaxation Group," "Structured Activity," "Social Skills," and "Recreation Therapy." Review of "Interdisciplinary Progress Notes" from 1/31/11 through 2/25/11 revealed that Patient A36 attended only 8 of 42 group sessions during this time period. The notes stated, "Patient refused to attend."

3. A review of the medical record revealed that as of 3/1/11, there was a failure to address Patient A36's lack of attendance at group therapy or programming activities and no revisions were made in the plan.

C. Patient A39

1. The Admission Psychiatric Evaluation for Patient A39, dated 2/14/11, stated that Patient A39 was admitted on 2/14/11 for "evaluation and treatment of psychosis." The diagnoses were "Psychosis NOS (probable schizophrenia versus schizoaffective disorder)" and "Polysubstance dependence in remission."

2. A review of the Master Treatment Plan dated 2/14/11 stated that Patient A39 was scheduled for daily structured treatment groups. The "Interdisciplinary Progress Notes" from admission on 2/14/11 through 2/25/11 indicated that Patient A39 attended only 2 group activities, "AM Social Skills Group" on 2/16/11 and on 2/17/11, "with limited participation and with no documented treatment response.

3. A review of the Master Treatment Plan for Patient A39 dated 2/14/11 revealed that, as of 3/1/11, there was a failure to address Patient A39's lack of attendance in group therapy or programming activities, and no revisions were made in the plan.

4. During an interview with MD 1, SW B1, Psychologist B1, RN B6, and TR1 on 3/1/11 at 9:30 a.m., they all acknowledged that the Master Treatment Plan had not been revised despite Patient A39's inability to attend or participate in his/her scheduled therapeutic groups. They also all acknowledged that group therapy and medication management were the only two active psychiatric treatments provided for Patient A39. They all acknowledged that Patient A39 was unable to participate in or benefit from group therapy due to his uncooperative and disruptive behaviors that were based on his religious delusions.

D. Patient B13

1. As documented in a psychiatric evaluation dated 12/21/10, Patient B13 was admitted to the facility on 12/21/10. Patient B13 had "been acting in an increasingly psychotic and delusional manner..." The diagnoses were listed as "Psychosis, NOS, Opiate dependence, Benzodiazepine dependence and Alcohol dependence."

2. A review of the Master Treatment Plan dated 12/21/10, with revision on 1/18/11, revealed that Patient B13 was scheduled to attend the following daily structured treatment groups: "Basic Relaxation," "Rec [Recreation] Therapy," "Structured Activity," and "Social Skills." Review of "Interdisciplinary Progress Notes" from 2/14/11 through 2/25/11 revealed that Patient B13 attended only 2 of 25 group sessions during this time period.

3. A review of the medical record revealed that, as of 3/1/11, there was a failure to address the inability of Patient B13 to participate in or benefit from group therapy or programming activities and no revisions were made in the plan.

4. During an interview on 2/28/11 at 2:40p.m., RN B6 stated that Patient B13 had only improved physically by performing his/her ADL's [activities of daily living], drinking Ensure and eating more of his/her snacks. S/he stated that Patient B13 was "unable to report any other improvement." RN B6 added, "[S/he] comes into the dayroom and watches TV but spends lots of time lying on [his/her] bed." After review of this patient's failure to attend scheduled treatment activities, RN B6 verified that this patient required alternative individualized treatment since s/he had not responded to scheduled treatment programming designed for the patient population.

E. Patient B32

1. The Admission Psychiatric Evaluation for Patient B32, dated 3/23/09, stated that Patient B32 was admitted on 3/23/09 with a history of schizoaffective disorder "after becoming aggressive." The diagnosis was "Schizoaffective Disorder."

2. A review of the Master Treatment Plan dated 1/13/11 stated that Patient B32 was scheduled for daily structured treatment groups. A review of the "Interdisciplinary Progress Notes" from 1/1/11 through 2/25/11 indicated that Patient A39 attended no group activities during this period of time.

3. A review of the Master Treatment Plan for Patient B32 dated 1/13/11 revealed that, as of 3/1/11, there was a failure to address the inability of Patient B32 to participate in or benefit from group therapy or programming activities and no revisions were made in the master treatment plan.

4. During an interview with MD1, SW B1, Psychologist B1, RN B6, and TR1 on 3/1/11 at 9:30a.m., they acknowledged that the Master Treatment Plan had not been revised despite Patient B32's inability to attend or participate in his/her scheduled therapeutic groups. They acknowledged that group therapy and medication management were the only two active psychiatric treatments provided for Patient B32 although s/he could not tolerate or benefit from group therapy at that time.

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

I. Ensure that active individualized psychiatric care was provided for 5 of 8 active sample patients (A32, A36, A39, B13 and B32) based on their presenting needs. The facility failed to ensure structured treatment for these patients' specialized needs. Patients did not attend most of the structured groups listed on their plans. No alternative treatment modalities were provided during these times. These patients were observed to be sleeping or walking about the wards during the times their group treatments were taking place. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement.

II. Properly utilize and document the use of restraints as external controls of violence toward self and others for 1 of 8 active sample patients (A33) and 3 of 3 discharged patients (C1, C2 and C3) whose records were reviewed for the use of seclusion and restraint procedures. These patients were restrained by a physician's order which included criteria to continue the procedures beyond the emergency situations that included violent behaviors towards themselves or others. This failure exposes patients to potential harm from unnecessary restraint and results in a violation of the patient's right to be free from restraint except for immediate protection of self and others.

Findings include:

I. Failure to provide individualized treatment for active sample patients:

Findings Include:

A. Patient A32

1. The patient was admitted to the facility on 8/7/08 (eighth hospitalization). As documented in a treatment team psychiatric progress note (2/15/11), Patient A32's diagnosis was Schizoaffective disorder- "continues to be disorganized and labile...[S/h]e continues to be impulsive which has lead (sic) to multiple injuries." This note stated that during treatment team meeting Patient A32 mumbled and told a joke that the team "could not understand," walked out of the team meeting and refused to return.

2. During Unit 2 rounds on 2/28/11 between 11:20and11:45a.m., Patient A32 was observed alternately sitting and walking around the dayroom. When approached by the surveyor, s/he repeatedly stated, "Get away from me." He cursed and paced the room until the surveyor exited the area. During this time, s/he was scheduled to attend an off-ward program, "Basic Relaxation Group."

3. During an interview on 2/28/11 at 11:20a.m., RN A2 stated that Patient A32 had not attended the treatment groups off the ward today because of "inappropriate behavior."

4. During an interview on 2/28/11 at 11:25a.m., HCT [Health Care Technician] A3 stated that Patient A32 often stays on the ward rather than attending programming off the ward.

5. During an interview on 2/28/11 at 12:15p.m., RN A5 stated that Patient A32 "causes a lot of disruptions in groups." S/he reported that the only activities this patient usually attended were walks in the fresh air and some recreational activities.

6. Patient A32 was observed sitting in the dayroom on 2/28/11 at 3:30p.m. At times s/he walked around the dayroom, approached and mumbled to staff.

7. A review of the patient's Master Treatment Plan dated 2/10/11 revealed that for the problem, "Thought/mood disorder leading to aggression toward others and property...difficulty communicating, intrusive into other patients conversations and treatment...," Patient A32 was scheduled to attend the following groups Monday through Friday: "Basic Relaxation Group 1-B to learn self calming skills so [s/he] can handle situation/s [without] aggression," "Structured Activity Group (pm) to focus on leisure activity in a group setting to promote clear thoughts," and "Social Skills Group to assist the pt. (patient) in improving [his/her] interactions with others."

8. A review of the "Interdisciplinary Progress Notes" from 2/14/11 through 2/25/11 revealed that Patient A32 attended only 3 of 20 group sessions during this time period. The sessions that s/he attended were either a "popcorn party" or a "Valentine's Day party."

9. Even though Patient A32 seldom attended his/her scheduled treatment groups, there was no documented evidence that alternative treatment was provided for this patient.

B. Patient A36

1. The patient was admitted on 1/21/11 following a previous discharge from this facility on 1/7/11. As documented in psychiatric evaluation dated 1/24/11, Patient A36's diagnoses were Depressive disorder and Borderline intellectual functioning. [S/he] also had diagnoses of Diabetes Type II and bilateral amputations, causing him/her to be confined to a wheelchair. The psychiatric evaluation stated, "Patient has been having suicidal ideation. [S/he] is very combative gentleman [sic], and [s/he] is very noncompliant."

2. During Unit 2 rounds on 2/28/11 at 11:30a.m., Patient A36 was observed asleep in his/her assigned bed. At this time s/he was scheduled to attend a social skills group.

3. During an interview on 2/28/11 at 11:40a.m., HCT A4 stated that Patient A36 "usually refuses to attend any groups/activities off of the ward."

4. During an interview on 2/28/11 at 12:15p.m., RN A5 stated that Patient A36 "sits in the dayroom most of the time." S/he reported that Patient A36 usually stays in bed every day until mid-morning.

5. On 2/28/11 at 3:30p.m., Patient B36 was observed lying in his/her assigned bed on Unit 2. When asked if s/he had been to any activities today, s/he stated, "I have not been off the ward in a while." S/he reported that s/he lies in bed or sits on the ward.

6. A review of the Master Treatment Plan dated 1/24/11 revealed that for the problem, "Depression secondary to general medical problems," Patient A36 was scheduled to attend the following groups Monday through Friday: "Basic Relaxation Group 1-C to aid in calming mood, adjusting to new situation," "SAG [Structured Activity Group] to focus on leisure activities to assist in improving mood," "Social Skills Group to improve social interactions," and "Recreation Therapy 1-C to focus on TR [Therapeutic Recreation] groups + [and] activities instead of thoughts of self harm."

7. A review of the "Interdisciplinary Progress Notes" from 1/31/11 through 2/25/11 revealed that Patient A36 attended only 8 of 42 group sessions during this time period. Notes for 4 of these 8 sessions reported that s/he only "actively participated" in a popcorn party and a Valentine's Day party.

8. Even though Patient A36 seldom attended his/her scheduled treatment groups, there was no documented evidence that alternative treatment was provided for this patient.

C. Patient A39:

1. The Admission Psychiatric Evaluation for Patient A39, dated 2/14/11, stated that Patient A39 was admitted on 2/14/11 for "evaluation and treatment of psychosis." The diagnoses were "Psychosis NOS (probable schizophrenia versus schizoaffective disorder)" and "Polysubstance dependence in remission."

2. During the scheduled "Basic Relaxation Group" on 2/28/11 at 11:45a.m., Patient A39 was observed kneeling on the floor with a sheet pulled over his head. When approached, the patient responded that he was praying. During an interview with RN B6 at the time, s/he stated that Patient A39 experienced religious delusions and frequently spent time in his room, on the floor under a sheet, praying. No alternative treatments were observed at this time.

3. During the scheduled "AM Social Skills Group" on 3/1/11 at 10:20a.m., Patient A39 was observed lying in his/her bed with the covers pulled over his/her head. No alternative treatments were observed at this time.

4. A review of the Master Treatment Plan for Patient A39, dated 2/14/11, stated the identified problem as "Thought disorder." The listed interventions for this problem included the following interventions and intended goals: "Structure Activity Group (PM) to focus on leisure activity in a group setting to interact (with) others (without) aggression," "AM Basic Relaxation Group 1-B to learn self calming skills so [s/he] can handle situations (without) aggression," and "Social Skills Group to assist the pt. in improving [his/her] interaction with others." According to medical record documentations, Patient A39 failed to attend the majority of his/her planned treatment activities. However, his/her Master Treatment Plan was not revised as of 3/1/11.

5. A review of the "Interdisciplinary Progress Notes" from admission on 2/14/11 through 2/25/11 indicated that Patient A39 attended only 2 of 24 scheduled group activities: on 2/16/11 at 10:00a.m. "Pt. reportedly attended, but walked out a number of times" and on 2/18/11 at 10:00p.m. "Came late, but did not participate in the group activity."

6. During an interview with MD1, SW B1, Psychologist B1, RN B6, and TR 1 on 3/1/11 at 9:30 a.m., they all acknowledged that no alternative interventions or treatments had been developed to address Patient A39's inability to attend or participate in his/her scheduled therapeutic groups.

D. Patient B13

1. The patient was admitted to the facility on 12/21/10. As documented in a psychiatric evaluation dated 12/21/10, Patient B13 had "been acting in an increasingly psychotic and delusional manner, [s/he] talks in riddles, [s/he] claims things are oozing from [his/her] body, [s/he] thinks [s/he] has a bad odor..." The diagnoses were listed as "Psychosis NOS, Opiate dependence in unknown state of remission, Benzodiazepine dependence in unknown state of remission and Alcohol dependence in presumed remission."

2. During Unit 3 rounds on 2/28/11 at 11:55a.m., Patient B13 was observed sitting in the middle of the dayroom. When approached by the surveyor, s/he reported that s/he had been on the ward this morning. During this time period, Patient B13 failed to attend his/her scheduled off-ward groups: "Social Skills" at 10:00a.m., "Recreation Therapy" at 10:30a.m. and "Basic Relaxation" at 11:30a.m.

3. Patient B13 was observed lying in his/her assigned bed on 2/28/11 at 2:15p.m. and again at 3:20p.m. S/he stated that s/he had not been off the ward this afternoon. During this time period, Patient B13 failed to attend his/her off-ward structured activity group scheduled from 1:30-2:00p.m.

4. During an interview on 2/28/11 at 2:40p.m., RN B6 stated that Patient B13 had only improved physically by performing his/her ADL's [activities of daily living], drinking Ensure and eating more of his/her snacks. RN B6 stated that s/he was "unable to report any other improvement." RN B6 added, "[S/he] comes into the dayroom and watches TV but spends lots of time lying on [his/her] bed." RN B6 reported that Patient B13 stated, "I do not want to come out of my room because I don't want people to smell me." After review of this patient ' s failure to attend scheduled treatment activities, RN B6 verified that Patient B13 required alternative individualized treatment since s/he had not responded to scheduled treatment programming designed for the patient population.

5. An RN progress note dated 2/25/11 stated, "Withdrawn. Pt spends most of [his/her] time lying on [his/her] bed. Pt continues to believe [s/he] has body odor."

6. A review of the master treatment plan dated 12/21/10, with revision on 1/18/11, revealed that for the problem, "Thought disorder," Patient B13 was scheduled to attend the following groups Monday through Friday: "Basic Relaxation Group 1-B to learn self calming skills to assist in improving sleep," "Rec [Recreation] Therapy to improve leisure skills promoting clear thoughts," "Structured Activity Group (pm) to focus on leisure activity in a group setting to promote clear thoughts," and "Social Skills Group to assist the pt. in improving [his/her] interactions with others."

7. A review of the "Interdisciplinary Progress Notes" from 2/14/11 through 2/25/11 revealed that Patient B13 attended only 2 of 25 group sessions during this time period.

8. Even though Patient B13 seldom attended scheduled treatment groups, there was no documented evidence in the medical record that alternative treatment was provided for this patient.

E. Patient B32:

1. The Admission Psychiatric Evaluation for Patient B32, dated 3/23/09, stated that Patient B32 was admitted on 3/23/09 with a history of schizoaffective disorder "after becoming aggressive." The diagnosis was "Schizoaffective Disorder."

2. During the "PM SAG (afternoon structured activity group)" scheduled off the unit on 2/28/11 at 1:45p.m., Patient B32 was observed sitting in the unit dayroom.

3. During the scheduled "AM Social Skills Group" on 3/1/11 at 10:25a.m., Patient B32 was observed sitting in the dayroom. On interview, his/her responses were unintelligible. No alternative treatment was observed during this time.

4. A review of the master treatment plan for Patient B32, dated 1/13/11, stated the identified problem as "Thought disorder." The listed interventions for this problem included the following interventions and goals: "Structure Activity Group (PM) to focus on leisure activity in a group setting to promote clear thoughts" and "AM Basic Relaxation Group 1-B to learn self calming skills in a group setting to improve sleep." Even though the medical record documented that Patient B32 failed to attend the majority of his/her planned treatment activities, his/her master treatment plan was not revised as of 3/1/11.

5. A review of the "Interdisciplinary Progress Notes" from 1/1/11 through 2/25/11 indicated that Patient B32 attended none of the scheduled 133 group activities.

6. During an interview with MD1, SW B1, Psychologist B1, RN B6, and TR1 on 3/1/11 at 9:30a.m., they all acknowledged that no alternative interventions or treatments had been developed to address Patient B32's inability to attend or participate in his/her scheduled therapeutic groups.

F. Additional Interviews

1. During an interview on 3/1/11 at 12:50p.m. with the Director of Social Work, she acknowledged that Patients A32, A36, A39, B13, and B32 did not attend structured groups. She stated that individual, family, or other alternative treatments were not being provided for these patients by social work staff. She stated that she believed that the psychiatric condition of Patient A39 had worsened since the time of admission and the condition of Patient A32 was "no better."

2. During an interview on 3/1/11 at 1:50p.m. with the Director of Therapeutic Recreation, he stated that Patients A32, A36, A39, B13, and B32 attended structured groups "every once in a while." He acknowledged that the treatment plans for these patients had not been revised to address not attending groups or for patients for who group therapy was not appropriate. He stated that no alternative treatments had been offered by therapeutic activities staff for these patients. He stated that he believed that current modes of treatment are "not working."

3. During an interview on 3/1/11 at 2:15p.m. with the Director of Psychology, he stated that no alternative therapies such as individual or behavioral therapies were being provided by psychology staff for Patients A32, A36, A39, B13, or B32. He stated that all of these patients either refused group treatments and/or were too disruptive to the group process to be included. He stated that some of these patients might benefit from "1:1 interactions" but that these were not being provided by facility staff. He stated that patients lying in their beds or remaining on their wards during treatment times was "seen as an issue." He stated that mental health workers did not engage patients in structured therapeutic interactions because they lacked training and the facility did not have a method of documenting these therapeutic interactions.

II. Findings related to the use of seclusion/restraint:

A. Patient C2

The "Restraint/Seclusion Order AND Progress Notes" dated 12/6/10 stated that Patient C2 was restrained on 12/6/10 at 10:10a.m. "to prevent harm to self or others" after s/he began "cursing, slamming doors and banging [his/her] hands on walls." The "criteria for release" included "Pt will agree to follow unit rules." A review of the "Description of Patient's Behavior" section (staff documentation every 15 minutes of patient behaviors while in restraints) revealed the following:

On 12/6/10 at 10:25a.m. - "Pt screaming [s/he] doesn't want to go to jail. I don't want to be in restraints calling for Steven to let [him/her] out [sic]."

On 12/6/10 at 10:40a.m. - "Pt screaming want to see family My family is downstairs, Steven please [sic]."

On 12/6/10 at 10:55a.m. - "Appears angry, wanting released [sic], wanting to see family. Explained criteria for release."

On 12/6/10 at 11:10a.m. - "Pt states [s/he] has an anger problem and I don't understand. Explained to pt. that [s/he] should talk with staff when upset or move to a more quiet area. Pt again states that I don't understand."

On 12/6/10 at 11:25a.m. - "'Let me out of here.' Screaming talking to (illegible) - 'you don't care about me.' Trying to sit up. Explained criteria for release."

On 12/6/10 at 11:40a.m. - "Screaming 'I want to go home' over and over again. Stated you all do not care about me. I need the person who put me in restraints to release me."

On 12/6/10 at 11:55a.m. - "Requesting to be released. Screaming, I want out of restraints. Criteria explained for release."

On 12/6/10 at 12:10p.m. - "(illegible) They are going to keep me here forever.' 'Please don't leave me.' Pt. stating that he is talking to [his/her] family when s/he is yelling. Continues to be agitated. Encourage pt to calm down and follow unit rules in order to meet release criteria."

On 12/6/10 at 12:25p.m. - "Pt is yelling 'please get me out.' [Patient] Will not calmly talk to staff. Pt was told requirements to get out [sic] pt responded 'yall are trying to kill me."

On 12/6/10 at 12:40p.m. - "Pt continues to yell 'get me out of here...you all are mean to me. 'Pt was told requirement for release. Responded 'shut up.'"

On 12/6/10 at 12:55p.m. - "Pt was yelling then layed [sic] down for minute. Told pt requirement for release."

On 12/6/10 at 1:10p.m. - "Pt eating lunch. [S/he] continues to be agitated and yelling between bites. Reminded pt to talk with staff when upset instead of yelling."

On 12/6/10 at 1:25p.m. - "Pt is yelling intermittingly. Seems to be calming down some. Pt was told requirements for release."

On 12/6/10 at 1:40p.m. - "Pt is sleeping. Pt. calm, States [s/he] plans to go to [his/her] room and be quiet [sic]. Pt released at this time."

The inability or unwillingness of Patient C2 to verbalize his/her intent to agree to follow unit rules was not evidence of imminent danger and did not justify the continued use of restraint.

B. Patient C1

The "Restraint/Seclusion Order AND Progress Notes" dated 12/22/10 stated that Patient C1 was restrained on 12/22/10 at 4:05p.m. after s/he became "assaultive and threatening." The "criteria for release" included "agree to follow unit rules." A review of the "Description of Patient's Behavior" section revealed the following:

On 12/22/10 at 6:35p.m. - "Pt. swearing. Still stating 'none of this is [his/her] fault.' and is listing names of individuals that 'are responsible for [his/her] being her [sic].' Shows no understanding of the criteria for [his/her] release and stated that [s/he] didn't care what staff had to say because '[s/he] did nothing wrong.' Circulation check - OK."

On 12/22/10 at 6:50p.m. - "Pt. not as loud. However still doesn't acknowledge the reason for restraint. Still claims [s/he] did not try to hit nurse. Rather than trying to call police. Pt. recieve [sic] prn (as needed) IM (intramuscular) at time of note."

On 12/22/10 at 7:05p.m. - "Pt. repeatedly says that [s/he] has done nothing wrong. [S/he] states that [s/he] doesn't belong here and that [s/he] has to get back to [his/her] job and [his/her] kids. [S/he] says [s/he] only wanted to use the phone to call the police."

On 12/22/10 at 7:20p.m. - "Pt reports [s/he] feels someone teaching [his/her] 'sexually orally.' Pt demands immediate release. Pt is physically calm, but reports [s/he] is 'serially traumatized.' Pt. unable to verbalize release criteria. "

On 12/22/10 at 7:35p.m. - "Release criteria explained. Patient unable to verbalize release criteria. Patient calm at this time."

On 12/22/10 at 7:50p.m. - "Release criteria explained. Patient unable to verbalize release criteria. Patient calm at this time. Patient denied that s/he wanted anything to eat."

On 12/22/10 at 8:05p.m. - "Patient quiet, calm, didn't need to go to the bathroom. Patient physically calm, verbalized release criteria."

On 12/22/10 at 8:15p.m. - "Pt physically calm. Pt verbalizes [s/he] will refrain from aggression, that [s/he] has (no) aggressive ideation and that [s/he] will follow all unit rules. 'I just wanna go to bed.' Pt released."

The inability or unwillingness of Patient C1 to verbalize his/her intent to agree to follow unit rules was not evidence of imminent danger and did not justify the continued use of restraint.

C. Patient C3

The "Restraint/Seclusion Order AND Progress Notes" dated 1/3/11 stated that Patient C3 was restrained on 1/3/11 at 4:15p.m. after s/he began to "swing and kicking at staff." The "criteria for release" included "Pt will verbalize no intent to harm self or anyone else." A review of the "Description of Patient's Behavior" section revealed the following:

On 1/3/11 at 4:30p.m. - "Pt lying in restraints, wanting to be release [sic] explained criteria for release, no distress noted."

On 1/3/11 at 5:00p.m. - "The pt laying [sic] in restraints."

On 1/3/11 at 5:15p.m. - "Pt. lying in restraints wanting to be released asking questions about (illegible). Criteria for release explained. No distress noted."

On 1/3/11 at 5:30p.m. - "Pt offer (sic) water & bathroom break. Pt states that [s/he] is OK. Pt states that [s/he] wants off 1:1. Release criteria explained."

On 1/3/11 at 5:45p.m. - "Pt lying in restraints wanting out. Pt has agreed to stay calm once out of restraints. Release criteria explained."

On 1/3/11 at 6:00p.m. - "Pt is calm & agrees to release criteria. Explained to pt that the net would be removed and if pt cont. (continued) to stay calm [s/he] will be release [sic] shortly. Net was removed."

On 1/3/11 at 6:15p.m. - "Pt agrees to all release criteria. Pt is calm & cooperative. Pt was released from all restraints."

The inability or unwillingness of Patient C3 to verbalize her intent not to harm him/herself or anyone else was not evidence of imminent danger and did not justify the continued use of restraint.

D. Patient A33

The "Restraint/Seclusion Order AND Progress Notes" dated 1/11/11 stated that Patient A33 was restrained on 1/11/11 at 1:20p.m. after s/he began fighting and threatening staff. The "criteria for release" included "expresses a willingness to follow ward rules." A review of the "Description of Patient's Behavior" section stated the following:

On 1/11/11 at 2:20p.m. - "Pt. responding to self, pt also asked if [s/he] can get [his/her] money today. Pt resp (respirations) are calm & steady."

On 1/11/11 at 2:35p.m. - "Pt. responding to self. Pt asking when is [s/he] coming back. Pt resp (respirations) are calm and steady."

On 1/11/11 at 2:50p.m. - "Pt. quiet at this time. No verbalizations to make or report."

On 1/11/11 at 3:05p.m. - "Pt tells me that no one told [him/her] what [s/he] had to do to come out of restraints. Told [him/her] [s/he] had to be non-threatening, not hit anyone and follow hospital rules. Pt asked about [his/her] money, that's all."

On 1/11/11 at 3:20p.m. - "[S/he] in the room quit [sic]."

On 1/11/11 at 3:35p.m. - "[S/he] in the room quit (sic) went to bathroom nurse took [pt.] out."

On 1/11/11 at 3:40p.m. - "Asked pt what [s/he] had to do to come out of restraints. Pt said 'I gotta be good, stay out ta trouble, mind my own business, and ah, follow rules.' Pt released."

The inability or unwillingness of Patient A33 to verbalize his/her intent to agree to follow unit rules was not evidence of imminent dangerousness and did not justify the continued use of restraint.

E. Interview

1. During an interview on 2/28/11 at 11:40a.m. with RN B3, s/he stated that the "release criteria" for the restraint episode for Patient A33 included a requirement that the patient verbalize "a willingness to follow ward rules" before s/he could be released.

2. During an interview on 2/28/11 at 11:30a.m. with RN B4, s/he agreed that documentation for the restraint episode for Patient A33 did not include evidence of immediate dangerousness that would warrant continued restraint.

3. During an interview on 3/1/11 at 1:25p.m. with the Acting Director of Nursing, she acknowledged that documentation for the restraint episodes for Patients A33, C1, C2, and C3 did not include evidence of immediate dangerousness that would warrant continued restraint.

4. During an interview on 3/1/11 at 3:00p.m. with the Clinical Director, he acknowledged that documentation for the restraint episodes for Patients A33, C1, C2, and C3 did not include evidence of immediate dangerousness that would warrant continued restraint.

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

I. Ensure that periodic psychiatric evaluations were completed for 2 of 8 active sample patients (A32 and B32) that included a total assessment of the patient's illness, and necessary information to justify the diagnosis and planned continued treatment. This failed practice results in the lack information to justify the diagnosis, develop a current Master Treatment Plan, and assess the patient's response to treatment. It also may delay a patient's discharge.

Findings include:

1. Record Review

a. Patient A32 was admitted to the facility on 8/7/08. The most recent psychiatric evaluation was dated 8/7/08.

b. Patient B32 was admitted to the facility on 3/23/09. The most recent psychiatric evaluation was dated 3/23/09.

2. Interview

During an interview on 3/1/11 at 3:00p.m. with the Clinical Director, he acknowledged that no complete psychiatric evaluations were performed for Patients A32 and B32 following their admission psychiatric evaluations. He stated that the facility did not require periodic complete psychiatric evaluations.

3. Policy Review

The policy "Functional Assessments/Re-assessments/Schedule of Frequency" "420-40," dated 8/15/10, presented by the facility as the current policy regarding assessments, stated that a psychiatric evaluation was required within 60 hours of admission. However, there was no requirement for a periodic complete psychiatric reassessment.

II. Ensure that the Master Treatment Plans for 5 of 8 active sample patients (A32, A36, A39, B13, and B32) were based on the patients' abilities and were revised when the patients failed to participate in the prescribed treatment. These patients demonstrated severe impairment, but the only psychiatric treatments prescribed on the master treatment plans other than medication adjustments were group therapy sessions, from which the patients were incapable of benefiting. Master Treatment Plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of these patients. (Refer to B118)

III. Ensure that active individualized psychiatric care was provided for 5 of 8 active sample patients (A32, A36, A39, B13, and B32) based on their presenting needs. The facility failed to ensure structured treatment for their specialized needs. Patients did not attend most of the structured groups listed on their plans. No alternative treatment modalities were provided during these times. These patients were observed to be sleeping or walking about the wards during the times their group treatments were taking place. This failure results in patients being hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125-I)

IV. Ensure that staff utilized and documented the use of restraints as external controls of violence toward self and others for 1 of 8 active sample patients (A33) and 3 of 3 discharged patients (C1, C2, and C3) whose records were reviewed for the use of seclusion and restraint procedures. These patients were restrained by a physician's order which included criteria to continue the procedures beyond the emergency situations that included violent behaviors towards themselves or others. This failure exposes patients to potential harm from unnecessary restraints, and it violates patient's right to be free from restraints except for the immediate protection of self and others. (Refer to B125-II)

V. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment. All patient bedrooms were equipped with horizontal metal drapery rods above the windows affixed to the wall with metal strips and screws. This failed practice results in potential physical harm for all patients.

A. Observation

During observations of the ward on 2/28/11 between 11:00a.m. and 12:00p.m., the following potential safety hazards were noted:

In rooms utilized as patient bedrooms (# 134, 136, 138, 141, 144, 202, 205, 207, 210, 220, 223, 225, 228, 231, 232, 233, 320, 323, 325, 326, 328, 331, 332, 333, 334, and 336), horizontal metal drapery rods above the windows were secured away from the walls attached with four perpendicular metal strips. Each strip was constructed of sturdy metal affixed to the rod and the wall with metal screws. A space was created between the drapery rods and walls of approximately three inches.

B. Interviews

1. During an interview on 2/28/11 at 11:00a.m., RN A1 stated that s/he was not aware that the patient bedroom drapery rods were not break-away.

2. During an interview on 3/1/11 at 12:15p.m., the Chief Executive Officer (CEO) reported that he had consulted with facility maintenance and he agreed that portions of the drapery fixtures could potentially support sufficient weight to pose a hanging hazard.

Based on interview, observation and document review, the Director of Nursing failed to establish policies and procedures, and provide leadership to the nursing staff in the provision of nursing care. Specifically, the DON failed to:

I. Ensure immediate availability of a Registered Nurse (RN) on the night tour of duty on 1 of 3 Units/Wards (Unit 1). During times that the facility experienced a high patient census on the two Acute Adult Admissions Units (2 and 3), a number of patients were transferred to Unit 1 (a ward on the 1st floor that was usually not utilized for patient bedroom space). During these times, these acutely ill patients were monitored and supervised by mental health workers without an RN on the Unit/Ward. Failure to ensure adequate staff to provide on-going assessment of patients and supervision of technical nursing personnel results in a safety risk for all patients and staff on this ward.
(Refer to B149)

II. Ensure that active individualized psychiatric care was provided for 5 of 8 active sample patients (A32, A36, A39, B13, and B32), based on their presenting needs. The facility failed to ensure structured treatment for their specialized needs. Patients failed to attend most of the structured groups listed on their plans. No alternative treatment modalities were provided during these times. These patients were observed to be sleeping, walking about the wards or talking on the telephones during the times their group treatments were taking place. This failure results in patients being hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement. (Refer to B125, Section I)

III. Ensure that staff properly utilized and documented the use of restraints as external controls of violence toward self and others for 1 of 8 sample patients (A33) and 3 of 3 discharged patients (C1, C2, and C3) whose records were reviewed for the use of seclusion and restraint procedures. Restraints were continued by nursing staff beyond the emergency situation (violent behaviors towards themselves or others) and without documented justification, based on physician's orders. This failed practice exposes patients to potential harm from unnecessary restraints, and it violates patients' right to be free from restraints except for the immediate protection of self or others. (Refer to B125-II)

IV. Ensure that safeguards were in place to protect patients from potential safety hazards in the environment. All patient bedrooms were equipped with horizontal metal drapery rods above the windows affixed to the wall with metal strips and screws. This failure resulted in a risk for physical harm for all patients. (Refer to B144)

Based on observation, interview and document review, the facility failed to ensure immediate availability of a Registered Nurse (RN) on the night tour of duty on 1 of 3 Units/Wards (Unit 1). During times that the facility experienced a high patient census on the two Acute Adult Admissions Units (2 and 3), a number of patients were transferred to Unit 1 (a ward on the 1st floor that was usually not utilized for patient bedroom space). During those times, these acutely ill patients were monitored and supervised by mental health workers without an RN on the Unit/Ward. Failure to ensure adequate staff to provide on-going assessment of patients and supervision of technical nursing personnel results in a safety risk for all patients and staff.

Findings include:

A. Interviews

1. During an interview on 2/28/11 at 9:30a.m., the CEO stated that the census was frequently over the bed capacity of patient Units (2 and 3). He reported that during these times, some patients were assigned to sleep on a ward that was closed (Unit 1) except when it was used for patient overflow.

2. During an observation of Unit 1 on 2/28/11 at 11:00a.m., RN A1 reported that, when Units 2 and 3 were over census, patients who had adapted to their unit and were able to follow instructions were assigned to sleep on Unit 1. S/he stated that patients assigned to sleep on Unit 1 could be only male, only female or a combination of both. S/he stated that patients assigned to sleep on Unit 1 were transferred from their respective Units (2 and/or 3) at about 8:30 p.m., and were returned to their unit at breakfast time the next morning. RN A1 added that these patients brought their personal belongings, but their medications remained on their respective "home" units. S/he reported that an RN from Unit 2 or Unit 3 made rounds but that Unit 1 was only staffed by 2 technicians during these hours.

3. During an interview on 3/1/11 at 1:25p.m., the Acting Director of Nursing verified the information provided by RN A1 as documented in B. above. She stated that, even though the patients chosen to sleep on Unit 1 were believed to be more stable, they were viewed as acutely ill patients, and that during the day tour of duty they received programming and treatment with the patients on Units 2 and 3. The Acting DON verified that during the time patients are on Unit 1, an RN is not always present on the unit to ensure on-going patient assessments. She agreed that this staffing pattern posed a safety risk for patients.

4. During an interview on 3/1/11 at 3:10p.m., the Clinical Director verified that the patients who were assigned to sleep on Unit 1 were part of the acute patient population. He stated, "I do not understand why an RN is not down there (Unit 1 on first floor)." He agreed that allowing these patients to sleep on a ward without an RN being immediately present was a safety risk.

B. Document Review:

1. Review of patient census and use of Unit 1 revealed that 4-14 patients slept on Unit 1 on the nights of April 27-29, 2010, May 3-20, 2010, June 22-29, 2010 and September 11-16, 2010. Both male and female patients slept on Unit 1 during the May time period. Female patients slept on this Unit during the other time periods.

2. Facility procedure, "Staffing (dated 6/15/10)," stated "Overflow Staffing: In the event of legal commitments of patients beyond a Census of 80 (more than 40 per Unit), the 1st floor overflow area can be utilized...The Shift Supervisors will determine the patients placed in the overflow area and assign appropriate staff. Generally, patients will sleep in the overflow area and program during the day on Units 2 and 3. A minimum of 2 staff must be in the overflow area at all times when any number of patients are present [sic]."

This procedure indicated that facility staffing should include an additional RN when Unit 1 was being utilized. However, the Acting Director of Nursing stated on 3/1/11 at 4:15p.m. that this additional RN was not assigned to Unit 1 because patient records were kept on Units 2 and 3.