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Based on observation, staff interview, medical record review, policy review, and review of incident reports, it was determined the facility failed to take appropriate and immediate action to protect all patients from abuse (A145). The facility also failed to fully implement their plan of correction developed after the substantial allegation survey completed 09/03/14, which determined an immediate jeopardy existed under the Condition of Patient Rights. The systemic effect of these practices resulted in the facility's inability to ensure the safety of all 21 patients.

Based on interview and review of the quality assessment and performance improvement program (QAPI) the facility failed to ensure the (QAPI) program measured, tracked, and analyzed quality indicators to improve the health and safety of the patients (A273) and failed to ensure the (QAPI) program was implemented and monitored by the governing body (A309). This deficient practice has the potential to affect all 21 patients.

Based on interview and review of proposed medical staff bylaws, the facility failed to ensure the medical staff bylaws examine credentials for medical staff membership (A341); failed to ensure the medical staff was well organized and accountable to the governing body (A347) failed to ensure medical staff followed procedures to adopt bylaws (A353); failed to ensure the bylaws were approved by the governing body (A354); failed to ensure the bylaws included a requirement that a history and physical be completed and documented for each patient (A358); and failed to ensure the bylaws included a requirement that an updated examination of the patients change in condition be completed and documented within twenty four hours of admission, before anesthesia services or when history and physical is completed thirty days prior to admission (A359). This has the potential to affect all patients in the facility. The facility's census was 21 patients.

See A341, A347, A353, A354, A358, and A359.

Based on interview, medical record review, and policy and procedure review it was determined that the facility failed to ensure nursing staff developed and implemented goals and interventions for fall risk care plans based on patient assessments and needs (A396); failed to ensure nursing staff prepared, administered, and documented sliding scale insulin per physician order and failed to provide monitoring of the administered insulin to determine therapeutic effect to meet the patient's need while promoting patient safety (A405) and failed to ensure nursing staff documented medications on a medication consent form prior to getting a telephone verbal consent from a guardian or power of attorney and that a second nurse witnessed and signed the consent form when no medications were listed (A405). The cumulative effects of these systemic practices resulted in the facility's inability to ensure effective nursing practice to meet patient needs and promote patient safety for all 21 patients.

Based on observation, interview, and record review, the facility failed to ensure the environment was maintained in a manner safe from fire in regard to failure to ensure each door closed properly, failure to maintain the stated rating for construction enclosing exit components such as stairways, failure to maintain the rating assigned to each of its rated walls that formed a smoke compartment, failure to maintain the stated fire resistive ratings to the walls, failure to ensure each hazardous area was protected, failure to ensure fire drills were conducted, failure to maintain its sprinkler system as required, failure to implement the smoking policy, failure to maintain each means of egress was continuously maintained free of all obstructions and failed to ensure safety features obvious to the public were labeled properly. (A709). This deficient practice has the potential to affect all 21 patients, staff, and visitors to the facility.

Based on facility policy review and staff interview, the facility failed to ensure a hospital-wide infection prevention and control program was in place ( A749) and failed to ensure there was a qualified infection control officer with education, training, or experience in infection control (A748). This deficient practice has the potential to affect all 21 patients in the facility.

Based on observation, interview, and document review, the facility failed to maintain medical records that contained accurate and complete information regarding the development of Master Treatment Plans, active psychiatric treatment, assessment and treatment of medical issues, active psychiatric treatment for evenings and weekends, and discharge summaries.

Findings include:

I. Consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment. (Refer to B122)

II. Ensure that active treatment measures, such as group treatment and therapeutic activities, were available for two (2) of eight (8) active sample patients (3 and 18) who were unwilling or unable to attend groups or was sufficiently cognitively impaired so that s/he could not benefit from the active psychiatric treatment offered. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 Part I)

III. Assess and treat the medical problems of two (2) discharged patients (E1 and E2) reviewed medical care in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health. (Refer to B125 Part II)

IV. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients on the geriatric unit with a census of 21 patients. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125-III)

V. Provide a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for three (3) out of five (5) discharged patients (D2, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments, treatments, and discharge plan with providers providing follow-up care. (Refer to B133)

Based on observation, interview and document review, the failed to ensure that the Medical Director monitored and took the needed corrective actions to ensure that clinical staff members were deployed to provide assessments, treatment plans, treatment, and/or document structured active treatment measures including therapeutic activities that staff provided.

Findings include:

The Medical Director failed to monitor and take needed corrective actions to:

I. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

II. Ensure that staff developed Master Treatment Plans that included an inventory of patients strengths for two (2) of eight (8) active sample patients (13, and 19). This failure diminishes the effectiveness of the treatment interventions by not engaging the patients through use of their strengths to overcome their disabilities. (Refer to B119)

III. Ensure that staff developed Master Treatment Plans that included a substantiated psychiatric diagnosis for four (4) of eight (8) active sample patients (3, 13, 17, and 19). In addition physical diagnosis was not identified for eight (8) of eight (8) active sample patients (dates of plans in parentheses): 3 (9/17/14), 9 (9/14/14), 13 (8/27/14), 14 (9/20/14), 17 (9/4/14), 18 (8/10/14), 19(9/10/14), and 20 (9/5/14). The facility's own treatment plan form does not contain an area for the staff to include physical diagnosis. The absence of substantiated diagnosis on the treatment plan compromises the treatment team ' s ability to deliver focused treatment. (Refer to 120)

IV. Ensure that staff developed Master Treatment Plans that include short term and long term goals stated in observable, measurable, behavioral terms for 8 out of 8 sample patients (3, 9, 13, 14, 17, 18, 19, and 20). The facility uses pre-printed templates for various symptoms, with pre-printed goals that were not categorized to indicate whether they were long or short term goals. These pre-printed goals were not individualized, observable, or measurable. This resulted in a document that failed to identify individualized expected treatment outcomes in a manner that staff could observe or measure. (Refer to B121)

V. Ensure that the Master Treatment Plans of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20) included physician treatment interventions. This results in the facility not delineating the role of the physician in the treatment of patients.

Findings include:

A. Record Review

The Master Treatment Plans (dates in parentheses) for the following patients did not contain treatment interventions to be performed by the psychiatrist or the medical providers: Patient 3 (9/17/14), Patient 9 (9/14/14), Patient 13 (8/27/14), Patient 14 (9/20/14), Patient 17 (9/4/14), Patient 18 (8/10/14), Patient 19 (9/10/14), and Patient 20 (9/5/14).

B. Staff Interview

During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the treatment plans did not contain psychiatric interventions or interventions for medical problems for Patients 3, 9, 13, 14, 17, 18, 19, and 20.

VI. Ensure that staff developed Master Treatment Plans that identify the specific team member by name as the primary responsible staff for treatment interventions listed on the MTPs for eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). Instead, each intervention is listed under the clinical department title such as nursing, occupational therapy, social service and psychiatrist. This practice results in a lack of staff accountability for the interventions and failure to deliver treatment to meet the patient ' s identified need. (Refer to B123)

VII. Ensure that staff provided active treatment measures, such as group treatment and therapeutic activities, were available for two (2) of eight (8) active sample patients (3 and 18) who were unwilling or unable to attend groups or were sufficiently cognitively impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 Part I)

VIII. Ensure that medical staff assessed and treated the medical problems of 2 discharged patients (E1 and E2) reviewed for medical care, in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients lives/health. (Refer to B125 Part II)

IX. Ensure that staff provided sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients on the geriatric unit with a census of 21 patients. There were only 3 hours of activities were scheduled each day. These activities were leisure-focused. The only treatment-focused group, "Life Skills" conducted by social work staff on weekdays, was not being provided. No treatment activities were scheduled in the evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125-III)

X. Ensure that medical staff provided a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for three (3) out of five (5) discharged patients (D2, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan with providers providing follow-up care. (Refer to B133)

Based on interview and review of proposed medical staff bylaws, the governing body failed to ensure the medical staff followed bylaw procedures to adopt bylaws. This has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the proposed medical staff bylaws revealed one version was signed as adopted by Staff A on 09/01/14 (one day after the governing body had met) and another was signed as adopted by Staff E on 08/29/14. Both staff signed as president of medical staff.

2. Review of the proposed medical staff bylaws revealed at 11.1-2 that "officers must be a physician. " On 09/25/14 at 12:00 P.M. in an interview, Staff A stated he/she is not a physician and signed the bylaws because the last person to sign was the chief operation officer, who was not a physician. Staff A and Staff F confirmed Staff E is a physician and the president of the medical staff.

3. Review of the proposed bylaws at 11.1-4 state, "Officers shall be elected at the Annual meeting of the Staff in each year. " By 09/25/14 at 5:30 P.M. at exit Staff A and F could not provide evidence an election for president of the medical staff was completed.

Based on interview and review of governing body meeting minutes, the facility failed to approve medical staff bylaws and regulations. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the governing body's meeting minutes dated 08/29/14, did not document the medical staff bylaws were approved by the governing body.
On 09/25/14 at 11:30 A.M. in an interview, Staff A and F stated they thought the bylaws were discussed on 08/29/14, but weren't sure.
Review of the governing body's meeting minutes dated 09/18/14 documented the minutes from the last board meeting (08/29/14) were reviewed and approved by the board.

REMAINS CITED
Based on observation, and review of medical records, and the facility's admission packet the facility failed to ensure patients were provided the toll free state hotline number to file a complaint with the State Agency. This affected ten (Patients #3, #4, #6, #7, #8, #9, #12, # 17, #19, and #20) of twenty one medical records reviewed. This deficient practice has the potential to affect all patients admitted to the facility. The facility census was 21.

Findings include:

Review of the medical records for Patients #3, #4, #6, #7, #8, #9, #12, # 17, #19, and #20 revealed a long distance state hotline number was provided to the patient upon admission to the facility. No toll free number was provided to the patients to file a complaint/grievance to the state agency.

Staff A stated in an interview on 09/25/14 at 10:20 AM that social workers were using a different form to have the patients sign upon admission. Staff A stated it is unclear why this form is being utilized and does not provide the toll free state hotline number. The number provided was a long distance state hotline number that may not be feasible to the patient population.

Interview with Staff D on 09/25/14 at 10:30 AM confirmed the form was an outdated form that included a long distance number provided to patients upon admission. Staff D also stated in an interview on 09/25/14 at 10:20 AM that he/she was unaware of a toll free state hotline number and does not provide this information to admitted patients.

Based on observation of the psychiatric inpatient unit and staff interview it was determined the facility failed to provide a safe environment of care for Patient #17 who was admitted for suicidal ideation with a plan. The following safety risks were observed in all twelve psychiatric patient rooms and had the potential to affect all 21 patients in the facility. No environmental safety measures were in place to prevent suicide in patient rooms. A total sample of twenty one patient medical records were reviewed. The facility census was 21 patients.

Findings include:

1. Review of the medical record for Patient #17 revealed the seventy-four year old male was admitted to the facility on 09/16/14 after being placed on a seventy two hour hold at local hospital. The application for emergency admission to the facility was due to suicidal ideation. Further reivew of the medical record reveald Patient #17 represented a substantial risk of physical harm to self as manifested by threats, or attempts at, suicide or serious self-inflicted bodily harm. The admission summary indicated the patient reported being hopeless and wanted to kill self and had a plan of using oxygen tubing to choke self. Patient #17 was admitted to a room on the inpatient mental health unit that failed to ensure safety measures were in place for suicidal patients as observed in findings 2-5.

2. Observation of the call light system cords being utilized presented as a potential ligature suicide point in all twelve patient rooms.

3. Observation of the ceiling Heating, Venting, and Air Conditioning (HVAC) vents had wide grids that could be used as a potential ligature suicide point in all twelve rooms.

4. Observation of the shower curtain rods in patient rooms were moveable metal rods that could potentially be used as a weapon.

5. Observation of the electrical wires on the patient beds presented a potential ligature suicide point in all twelve patient rooms.

Staff L stated in an interview on 09/25/14 at 9:00 AM that the facility is working to correct some of these findings.

Based on medical record review, staff interview, review of incident reports and investigation notes and policy review the facility failed to ensure all patients were free from actual or potential abuse and/or injury while in the facility. The facility also failed to fully implement their plan of correction developed after the substantial allegation survey completed 09/03/14, which determined an immediate jeopardy existed under Patient Rights and failed to follow the facility's policy regarding reporting, investigating and follow up. This deficient practice affected three patients of 21 medical records reviewed with the potential to affect all 21 patients in this facility. (Patients #1, #17, #21)

Findings include:

Review of the facility's plan of correction submitted to ensure compliance with the Condition of Patient Rights effective 09/12/14 revealed each unit charge nurse would be responsible for completing unannounced monitoring of patient care assistants (PCA) to ensure appropriateness of interactions/interventions with patients. This monitoring tool would be documented on a daily basis on the 7:00 AM to 7:30 PM shift and the 7:00 PM to 7:30 AM shift. Staff B was responsible for reviewing all monitoring tools submitted for ongoing compliance.
Review of the Registered Nurse shift report log lacked evidence the monitoring tools were completed per the facility's plan of correction. This finding was confirmed with Staff B on 09/22/14 at 4:30 PM.

As per the facility's plan of correction facilty staff were also trained from 09/04/14 through 09/12/14 on the Administrative Policy; Allegations of Patient Mistreatment, Abuse, and Neglect, no effective date. The facility's policy includes "All Hospital employees have an obligtion to protect patients, prevent abuse or neglect from occurring."

The purpose of this training was to provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, when other information is received indicating that patient abuse or neglect may have occurrred and to provide procedures for notifying external agencies of allegations and investigation findings as required. All staff had completed the training with the exception of two employees who remained on approved leave from the facilty.

Following the mandatory staff trainings the facility staff failed to follow the facility's policy for reporting, investigating, and following up, even though Patient #1 displayed agressive behaviors towards other patients at the facility.


1. Review of the medical record for Patient #1 revealed the fifty-five year old female patient was admitted to the facility on 08/26/14 with a diagnosis of schizoaffective disorder. The symptoms documented throughout the medical record included delusions, auditory hallucinations, and religiosity type behaviors. The patient was monitored every thirty minutes on the locked inpatient psychiatric unit.

The following behaviors were documented by nursing in the medical record for Patient #1:

a) On 09/11/14 at 4:24 PM Patient #1 was agitated and reported wanting to leave the mental health facility. After ineffective education and redirection by facility staff, the patient walked down the hall and verbalized "I will just go home with a male resident."

b) On 09/12/14 at 1:51 PM indicated the patient continues to be sexually inappropriate with another male patient and to increase supervision on the unit.

c) On 09/12/14 at 2:01 PM Patient #1 was observed wandering the unit with a male patient. Nursing documentation indicated the patient had been exhibiting intrusive behaviors with a male patient. Patient #1 verbalized she had to help this patient and was going to assist him with a divorce from his wife. Furthermore, documentation stated the patient had exhibited inappropriate behaviors towards this patient in the past and staff is aware and to monitor closely.

d) On 09/13/14 at 5:28 AM Patient #1 was resting in bed with another male and has been very sexually inappropriate this shift, inviting another male to come to her room and have sex.

e) On 09/13/14 at 4:10 PM Patient #1 has been sexually inappropriate with one male patient and to increase supervision on the unit.

f) On 09/14/14 at 5:28 AM Patient #1 verbalized she is pregnant and having two babies belonging to a male patient on the unit. The documentation also indicated she pulled a male patient into her room and verbalized that she has to have sex with him.

g) On 09/15/14 at 5:48 AM the patient continues to invite a male patient to her room. Patient #1 verbalized the two patients had only touched each other but had not had sex yet.

h) On 09/16/14 at 5:24 PM Patient #1 was verbally aggressive towards staff and other patients and began screaming out give me sex and I will shut up. Patient #1 reported both patients were able to get naked and attempt to have sexual intercourse. Nursing staff advised Patient #1 not take any male patients to the room with intentions of having a sexual relationship.

i) On 09/18/14 at 11:10 PM the patient care assistant (PCA) reported to nursing staff that Patient #17, a 74 year old male reported Patient #1 entered the room and raped him. Patient #17 was crying and upset over the incident. The facility investigation included video footage confirming Patient #1 entered the room of Patient #17 on 09/18/14 at 11:05 PM and was in the room for approximately 3-4 minutes.
Both patients were placed on fifteen minute observation following the incident.

A physician's order dated 09/18/14 at 11:42 PM insructed staff to send Patient #17 to the hospital for further evaluation. Emergency room documentation revealed the patient arrived by ambulance on 09/19/14 at 1:48 AM with chief complaints of a sexual assault and shoulder pain. According to emergency medical services (EMS) the patient was crying uncontrollably stating a female patient came into his room and tried to rape him. Patient #17 states that he pushed her with his right arm. He also reported having a small amount of pain on the right side of his abdomen where she scratched him while trying to kiss him.

No evidence of sexual assault was found on physical examination by the emergency department. The patient was discharged and returned to the facility on 09/19/14 at 5:45 AM. Patient #17 continued to report to the mental health facility staff that he was sexually assaulted.

j) Review of an incident report dated 09/19/14 at 6:40 AM revealed Patient #1 and Patient # 21 (male) were sitting next to each other in the common area of the facility. Several minutes later Patient #21 hit Patient #1 in the face three times. Patient #1 was transported to the local emergency department for further evaluation. The discharge diagnosis was a facial contusion. It was not clearly documented why the altercation had occurred between the two patients.

k) A Social Worker conducted a face to face interview with Patient #1 on 09/19/14 at 2:30 PM to discuss the alleged sexual assault incident. Patient #1 verbalized entering the room with no intentions of harming the patient sexually or physically. The patient had concerns of being in trouble for the incident. Patient #1 also stated she is hypersexual and has to masturbate constantly to feel better. Patient #1 additionally reported there was another male patient that she wants to have sex with however he is married.

l) On 09/19/14 at 5:21 PM Patient #1 continues to be sexually inappropriate with a male patient on the unit.

m) On 09/20/14 at 7:09 AM and 12:25 PM Patient #1 continues to make sexually inappropriate remarks.

n) On 09/21/14 at 12:35 PM revealed Patient #1 aggressive and sexually inappropriate.

2. Review of Patient #1's care plan did not have interventions to prevent or address the patient's sexually inappropriate behaviors after multiple reports of this behavior and the need for increased supervision was documented until the physician ordered one on one observation with twenty four hour supervision on 09/19/14 at 1:15 PM after the incident occurred. No other interventions were implemented to address Patient #1's behaviors.

3. Review of Policy Title: Guidelines for Performing Observations/Precautions; Revised date 04/02/14. Policy to ensure for the safety and well being of all geriatric behavioral health patients guidelines are established when observation or precautions are ordered by the psychiatrist. Special observations can be used to assess the patient and gain insight into helpful interventions. Special observations include those patients who may sexually act out; observe for preoccupation with sexual thoughts, seductive remarks or gestures, insufficient physical boundaries with others, attempts to touch others inappropriately. Be observant of the patient's location and with whom they are socializing and any loitering near certain rooms.

The administrative staff was notified on 09/23/14 at 5:25 PM of the above findings. The facility provided a physican's order dated 09/23/14 at 5:40 PM for Patient #1 to remain under supervision until discharge. No other information was provided prior to exit.

Based on interview and review of the quality assessment and performance improvement program (QAPI) the facility failed to ensure the program measured, tracked, and analyzed quality indicators to improve the health and safety of all 21 patients.

Findings include:

1. Interview with Staff A, Staff C, and Staff F on 09/24/14 at 4:35 PM confirmed the facility is not measuring, analyzing, and/or tracking any quality assessment performance program indicators. Medication errors were just starting to be tracked. The facility contracts an outside risk management company to evaluate the facility annually. Staff F stated in the same interview the risk management company recommended the facility to complete root cause analysis following incidents to help reduce incidence.

Review of the Sentinel Events Policy/ Procedure (no effective date) defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury. Appropriate response includes a thorough and credible root cause analysis, implementation of improvements to reduce risk, and monitoring of the effectiveness of those improvements.

If an event is designated as a severe or lethal event, a root cause analysis will be initiated by the unit director within seventy two hours in coordination with the attending physician, quality improvement coordinator, chief executive officer, and direct staff within two weeks. Staff F stated in an interview on 09/24/14 at 4:30 PM the facility was not aware of the Sentinel Events Policy/procedure policy and based on the incident will initiate a root cause analysis within two weeks if applicable.

Based on interviews and review of the quality assessment and improvement program (QAPI) the facility failed to ensure the program was implemented and monitored by the governing body. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the facility's policy on the QAPI process revealed the governing body, medical staff, and hospital administration determines priorities regarding which process to monitor with data collection and the subsequent development of improvement efforts. Priorities for performance improvement include a focus on high risk, problem-prone areas, consider the incidence, prevalence, and severity in those problem areas, the affected health outcomes, patient safety, and quality of care. Monthly meeting minutes were being documented; however, based on interview with newly appointed staff the facility failed to ensure everyone participated in the quality assessment improvement program.
Staff E stated in an interview on 09/25/14 at 9:00 AM, " I believe I'm on that committee."

2. Interview with Staff C on 09/25/14 at 1:38 PM stated, "there have been changes to the facility's administrative staff on many levels. Fundamental problems were identified and we could not move forward. I've only been in this position for three weeks."

3. Staff K stated in an interview on 09/23/14 at 9:32 AM the facility did not staff the (QAPI) manager position. Staff K took the position on 08/13/14.

Based on review of the facility's proposed staff bylaws and staff interviews, the facility failed to follow said bylaws and examine credentials for medical staff membership. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

Review of the facility's medical staff by laws was completed on 09/25/14. The review revealed at 12.1 that members of the credentials committee shall consist of the President of Staff, Chief Executive Officer, Medical Director, and one other active member of the medical staff.

On 09/25/14 at 12:00 P.M. in an interview, Staff A and F stated the credentials committee consisted of the medical director, chief operating officer, chief nursing officer, human resources director, and quality assurance manager. They stated it did not include another active member of the medical staff.

Review of the governing body meeting minutes for 08/29/14 revealed they were trying to hire a credentialing consultant to train human resources on credentialing process, and "need to approve the doctors we have. "

Review of the governing body meeting minutes for 09/18/14 revealed, "We have a name of the credentialing consultant ...and we have left message to try to have her help .... "

Based on interview and review of the facility's proposed staff bylaws, the facility failed to ensure it was well organized and accountable to the governing body. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the medical staff bylaws was completed on 09/25/14. The review revealed at 11.1-1 that the officers of the staff shall be president of medical staff, vice president of medical staff, and immediate past president of staff. On 09/25/14 at 12:00 P.M. in an interview, Staff A and F stated there wasn't a vice president or immediate past president of staff.

2. Review of the bylaws revealed a medical staff executive committee shall consist of the president of staff, vice president of staff, facility medical director, and Chief Executive Officer. On 09/25/14 at 12:00 P.M. in an interview, Staff A and F stated there wasn't a medical staff executive committee.

3. Further review revealed the proposed medical staff bylaws revealed one version signed as adopted by Staff A on 09/01/14, and another signed as adopted by Staff E on 08/29/14. Both signed as president of staff. Review of the proposed medical staff bylaws revealed at 11.1-2 that "officers must be a physician. " On 09/25/14 at 12:00 P.M. in an interview with Staff A and F, Staff A stated he/she is not a physician, but signed because the last person to sign was the chief operation officer, who was also not a physician. Staff A and F stated that Staff E is a physician and the president of the medical staff.

4. Review of the proposed bylaws at 11.1-4 state, "Officers shall be elected at the Annual meeting of the Staff in each year. On 09/25/14 at 5:30 P.M. at exit Staff A and F could not show evidence an election for the president of the staff was done. Review of the governing body meeting minutes dated 08/29/14 did not have documentation the medical staff bylaws were approved by the governing body. On 09/25/14 at 11:30 A.M. in an interview, Staff A and F stated they thought the bylaws were discussed on 08/29/14, but weren't sure.

Based on interview and review of proposed medical staff bylaws, the medical staff failed to follow procedures to adopt bylaws. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the proposed medical staff bylaws revealed at 11.1-2 that officers must be a physician. Review of the proposed medical staff bylaws revealed one version was signed as adopted by Staff A on 09/01/14 (one day after the governing body had met), and another was signed as adopted by Staff E on 08/29/14. Both staff signed as president of staff. On 09/25/14 at 12:00 P.M. in an interview with Staff A and F, Staff A stated he/she is not a physician, but signed because the last person to sign was the chief operation officer, who was also not a physician. Both Staff A and F stated that Staff E is a physician and the president of the medical staff.

2. Review of the proposed bylaws at 11.1-4 state, "Officers shall be elected at the Annual meeting of the Staff in each year. " By exit on 09/25/14 at 5:30 P.M. Staff A and F was unable to provide evidence an election for president of the staff had been completed.

Based on interview and review of meeting minutes, the facility failed to ensure its medical staff bylaws were approved by the governing body. This deficient practice has the potential to affect all 21 patients in the facility.

Findings include:

1. Review of the governing body meeting minutes dated 08/29/14 did not have documentation the medical staff bylaws were approved by the governing body meeting. On 09/25/14 at 11:30 A.M. in an interview, Staff A and F stated they thought the bylaws were discussed on 08/29/14, but weren't sure.

Based on interview and review of proposed medical staff bylaws, the facility failed to ensure said bylaws included a requirement that a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This deficient practice has the potential to affect all future patients to the facility. The facility has a capacity of 24 beds.

Findings include:

1. On 09/25/14 a review of proposed medical staff bylaws was completed. Review of the proposed medical staff bylaws failed to reveal a requirement that a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

On 09/25/14 at 11:30 A.M. in an interview, Staff A and F confirmed the bylaws did not contain this requirement.

Based on interview and review of proposed medical staff bylaws, the facility failed to ensure said bylaws included a requirement that an updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. This deficient practice has the potential to affect all future patients to the facility. The facility has a capacity of 24 beds.

Findings include:

1. On 09/25/14 a review of proposed medical staff bylaws was completed. The review did not reveal any requirement that an updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration.

On 09/25/14 at 11:30 A.M. in an interview, Staff A and F confirmed the bylaws did not contain this requirement.

Based on observations, medical record review, staff interview, and policy review the facility failed to ensure patient care plans included fall risk, intake and output, and 15 minute checks were implemented with appropriate goals, interventions, and responsible disciplines based on patient needs and assessments. This deficient practice affected 11 (Patients #2, #3, #7, #8, #9, #12, #14, #16, #18, #19, and #20) of 21 patients whose medical records were reviewed with the potential to affect all patients receiving care in this facility.


Findings include:


1. The medical record review for Patient #14 revealed the patient was admitted to the facility on 08/21/14 for a chief complaint of restlessness and combativeness. Review of the admission summary dated 08/21/14 revealed Patient #14 was in a long term care facility and had been more combative with care and urinating in public areas "inappropriately". The summary also stated the staff there was no longer able to manage the patient safely and was requesting an in-patient assessment and evaluation. The summary further stated the patient was diagnosed with orthostatic hypotension and was taking medication.

A review of a nursing admission assessment dated 08/21/14 at 4:05 P.M. revealed Patient #14 was a fall risk. Review of a care plan dated 08/21/14 for impaired mobility and fall risk revealed staff was directed to utilize fall precautions. Review of a nurses note dated 08/28/14 at 7:30 A.M. stated Patient #14 needed limited assistance with locomotion. Although the patient had a history of urinating in public areas, and the care plan template had a line to offer toileting minimally every two hours, the box was not checked. The care plan also failed to address the orthostatic hypotension. The care plan did not have any nursing long term goals selected.

A social worker note dated 08/28/14 at 2:46 P.M. revealed Patient #14 was wandering the unit with no mention assistance was provided. Review of nurse's note in regard to fall and acute plan of care dated 08/28/14 at 11:20 P.M. stated, "Patient had been walking the floor since the beginning of the shift, this writer was (illegible writing) patient to go sit down. While going to bring the wheelchair, staff called that patient was on the floor. The note further stated the patient was not a fall risk, even though the care plan called for fall precautions, and the admitting nursing assessment stated Patient #14 was a fall risk. The note went on to state the patient complained of pain to his/her left leg and neck and was unable to move his/her left leg. The physician was notified and Patient#14 was sent to the emergency department for evaluation.

Review of a nursing note dated 08/29/14 at 5:41 A.M. revealed Patient #14 had been pacing up and down the unit nonstop since the beginning of the shift and did not respond to request, to sit down and rest or lay in bed. The patient was given Haldol for constant pacing and refusing to follow directions. The note further stated the patient was observed to have a shuffling gait, but the patient refused to sit down.

Review of a discharge summary dated 08/29/14 stated, "Prior to the fall it appeared that Patient #14 was walking with a shuffling gait and staff was going to get a wheelchair for the patient to sit down in. Patient #14 apparently then fell to the floor." Review revealed a social worker note dated 08/29/14 at 1:59 P.M. that stated the patient had been admitted to the hospital for concerns related to his/her head and hip.

Review revealed a release form for the county corner that stated Patient #14 had died on 09/02/14 with a request for the patient's history and physical, medications, and 08/29/14 fall incident report.

On 09/25/14 at 10:30 A.M. in an interview, Staff G stated the nurse was supposed to have written what type of assistance was given to help the patient walk, and didn't know what that was, if any at all was provided.

2. The medical record review for Patient #2 revealed an admission summary dated 09/20/14 that stated the patient was admitted involuntarily to the facility on 09/19/14 for recent suicidal plan with partial attempt. The summary Patient #2 was diagnosed with major depression. The summary further stated Patient #2 had lost as much as thirty pounds and had stopped taking medications because the patient could no longer afford them.

Further review of the medical record revealed on 09/22/14 Patient #2 weighed 79 pounds. Review of Patient #2's care plan dated 09/19/14 revealed no patient strengths were identified and lacked evidence any long term nursing goals were established. The medical record review did contain a nutritional care plan (undated) that stated to honor the patient's food preference, however, it did not state what these preferences were.

The nursing care plan did not document food preferences for Patient #2. On 09/25/14 at 2:00 P.M. in an interview, Staff G confirmed the absence of identified strengths and long term nursing goals, as well as nothing in the record to indicate what the Patient #2's food preferences were.





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3. Per review of the admission assessment, Patient #16 was transferred to the facility from a nursing home on 01/21/14 at 1:30 PM after becoming increasingly agitated and aggressive. Patient #16 had rapidly declined in his overall functioning while inpatient in the nursing home. Patient #16 was admitted with a diagnosis of organic mood disorder and noted to have renal insufficiency with a BUN of 85 (normal range 7-25).


The Psychiatric Physician ordered Patient #16's Intake and Output to be monitored daily and noted the patient should be monitored every 15 minutes because of noted aggressive behavior.


Review of an Intake and Output Form dated 01/21/14 revealed Patient #16 had an oral intake of 120 mL and urine output at 9:00 AM, however, review of the record revealed Patient #16 was admitted at 1:30PM.

There were no Intake and Output Forms noted for the days of 01/22/14, 01/23/14, and 01/24/14. The Psychiatric Physician ordered an infusion of Normal Saline intravenously for 24 hours on 01/23/14 at 11:45 AM. The medical record lacked documentation the Normal Saline, ordered to infuse at 75 mL/hr, was ever recorded on the Intake and Output Form. The completion of the Intake and Output Forms resumed on 01/25/14. Patient #16 was noted to have an oral intake of 240 mL at 8:00 PM and a urine output at 12:00 AM (01/26/14). No oral intake was noted again until 01/27/14 at 12:00 AM. Urine output on 01/26/14 was noted at 8:00 PM, 1:00 AM (01/27/14), and 6:00 AM (01/27/14). Patient #16 was discharged from the facility at 12:30 PM on 01/27/14.


The facility policy titled Nursing Responsibility and Documentation (no effective date)/s was reviewed. According to the policy staff are instructed to maintain intake and output records 24 hours daily when the physician writes an order for Intake and Output. It was further noted that all fluids should be measured. Staff G was interviewed on 09/24/14 at 10:30 AM and confirmed that Intake and Output Forms for three days were missing and confirmed the intake and output documented on 01/21/14 was prior to Patient #16's admission to the facility.


The Flowsheet for 15 Minute Monitoring for Patient #16 revealed documentation of 15 minute monitoring on 01/21/14 from 2:00 PM to 11:45 PM, 01/22/14 from 12:00 AM to 12:00 PM. The medical record lacked documentation of 15 minute monitoring from 12:15 PM on 01/22/14 until 10:15 PM on 01/23/14, more than 24 hours later. Staff G confirmed the medical record lacked 15 minute monitoring as ordered by the Psychiatric Physician on 09/24/14 at 10:45 AM.



















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4. Review of the medical record for Patient #3 revealed on 09/24/14 at 11:00 AM the patient was observed using a walker for mobility. The Admission Nursing Assessment completed fall assessment section indicated the patient as a high risk for falls.

The Interdisciplinary Plan of Care for Patient #3 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


5. On 09/24/14 at 11:00 AM Patient #7 was observed using a walker for mobility. The Admission Nursing Assessment evaluated the patient as a moderate fall risk. The Interdisciplinary Plan of Care for Patient #7 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


6. On 09/24/14 at 11:00 AM Patient #8 was observed using a wheelchair for mobility. The Admission Nursing Assessment evaluated the patient as a fall risk with generalized weakness. The Interdisciplinary Plan of Care for Patient #8 included a generic impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


7. On 09/24/14 at 11:00 AM Patient #9 was observed using a wheelchair for mobility. The nurse who conducted the Admission Nursing Assessment failed to complete the fall assessment section. The Interdisciplinary Plan of Care for Patient #9 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


8. On 09/25/14 at 11:00 AM Patient #12 was observed with a shuffling gait. The Admission Nursing Assessment failed to complete the fall assessment section. The Interdisciplinary Plan of Care for Patient #12 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


9. On 09/25/14 at 11:00 AM Patient #18 was observed with a shuffling gait. The Admission Nursing Assessment evaluated the patient as a low risk for falls. The Interdisciplinary Plan of Care for Patient #18 included a generic impaired mobility/fall risk care plan with a list of established goals and interventions but lacked any selected goals or interventions for nursing services.


10. On 09/25/14 at 11:00 AM Patient #19 was observed using a walker for mobility. The nurse who conducted the Admission Nursing Assessment failed to complete all of the fall assessment section. The Interdisciplinary Plan of Care for Patient #19 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


11. On 09/25/14 at 11:00 AM Patient #20 was observed using a wheelchair for mobility. The Admission Nursing Assessment failed to complete any of the fall assessment section. The Interdisciplinary Plan of Care for Patient #20 included an impaired mobility/fall risk care plan with a list of established goals and interventions but did not document any selected goals or interventions for nursing services.


On 09/25/14 at 11:00 AM Staff B stated the Admission Nursing Assessment should have a completed fall assessment and the Interdisciplinary Plan of Care for fall risks needed to have goals and interventions provided by nursing services. Staff B confirmed the nursing assessments and the care plans did not have the expected documentation.


The facility revised policy for Treatment Plans effective 04/02/14 documented individualized treatment plans would be developed and implemented within 24 hours of the admission and updated at least weekly. The facility policy for Fall Risk Prevention documented interventions would be initiated on all patients upon admission and then reevaluated if change was needed. The Fall Risk Prevention policy revised 05/20/14 also documented specific interventions would be implemented as identified by the patient assessment and those interventions would be included in the patients treatment plan.

Based on medical record review, staff interview, and policy review the facility failed to ensure administered doses of sliding scale insulin were recorded in a patient's medication administration record and the doses were monitored for safe therapeutic effect and also failed to ensure an Informed Consent for Medication form listed medications prior to obtaining a verbal telephone consent. The insulin medication affected Patient #15 and the informed consent for medication affected Patient #18. This deficient practice had the potential to affect all 21 patients. There were 21 medical records reviewed.


Findings include:


1. On 09/24/14 the medical record for Patient #15 was reviewed including physician orders, the medication administration record, blood sugar monitor logs, and nursing notes.


The physician order sheet dated 03/18/14 documented a house sliding scale using Novolog insulin before meals and at bedtime. The sliding scale included 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units, 300-349 = 8 units, 350-399 = 10 units, 400 and above = 12 units and notify the physician.


The medication administration record dated 03/19/14 through 04/09/14 lacked documentation of the amount of insulin given on 03/20/14 at 8:00 PM, 03/28/14 at 5:00 PM, 03/28/14 at 6:00 AM, 03/31/14 at 6:00 AM, 04/02/14 at 5:00 PM, 04/04/14 at 12:00 PM, and 04/09/14 at 6:00 AM.


The blood sugar monitoring logs dated 03/25/14 through 04/09/14 lacked documentation of the blood sugar levels and the amounts of insulin given before meals and at bedtime throughout the logs except for one day on 04/05/14. The other days lacked complete documentation.


A nursing note dated 04/09/14 at 11:11 AM documented Patient #15 was lethargic and unable to eat breakfast. A nursing note dated 04/09/14 at 2:12 PM documented Patient
#15's blood sugar was 29 before lunch. Two injections of glucogel were given per hospital protocol. Patient #15's blood sugar rose to 64, was unresponsive to painful stimuli and eyes were unresponsive to light. Vital signs were within normal limits. The physician ordered a transfer to the emergency department at a nearby hospital for further evaluation. The patient was transferred at 1:30 PM.


A review of the earlier blood sugar monitoring on 04/09/14 revealed Patient #15's blood sugar was 383 at 6:00 AM but lacked documentation of how much insulin was given. On 09/24/14 Staff G stated the facility did not know how much insulin was given since there was no documentation. Staff G stated the facility did no investigation to find out the root cause of Patient #15's low blood sugar at noon when the blood sugar was 383 at 6:00 AM. Staff G indicated insulin was obviously given to lower the blood sugar level but did not know how much was provided to cause the low blood sugar level of 29 at noon.


The facility policy Blood Glucose Monitoring and Insulin Administration (no effective date) lacked documentation of recording the amount of insulin given in the medication administration record. The facility policy Nursing Responsibility and Documentation documented the registered nurse was responsible for ensuring the accuracy, completeness and timeliness of all nursing documentation.


2. On 09/25/14 the medical record for Patient #18 was reviewed including an Informed Consent for Medication form dated 09/24/14. The medical record documented the patient's admission date on 09/24/14 with a voluntary admission by the patient's guardian. The Informed Consent for Medication had no medications listed on the form and was documented on the guardian's signature line as "verbal consent" dated 09/24/14". The witness signature was signed by a registered nurse and a second witness signature, (when a telephone consent was obtained), was signed by another registered nurse.


On 09/25/14 at 3:00 PM Staff G confirmed there were no medications listed on the Informed Consent for Medication form and the two nurse signatures were the nurses identified above. Staff G reviewed the medical record and was unable to identify any other medication consent form. On 09/25/14 at 3:15 PM Staff B also confirmed there were no medications listed on the signed Informed Consent for Medication form and stated the patient's medications should be listed on the form prior to obtaining the consent.


The facility policy Informed Consent for Medication (no effective date) documented informed consent would be secured prior to the initial dose of medication and the informed consent form would include the name of the medication with the anticipated dosage and route, the reason the medication was being recommended, the benefits of the medication, the side effects or risk of side effects, alternatives to the medications, consequence of not receiving the medications, and the right to withdraw consent.

Based on observation, interview, and record review, the facility failed to maintain the environment in a manner safe from fire. This has the potential to affect all 21 patients, staff, and visitors to the facility.

Findings include:

Each door in a corridor failed to stay closed. Please refer to findings under K18.

The facility failed to maintain the stated rating for construction enclosing exit components such as stairways. Please refer to findings under K33.

The facility failed to maintain the rating assigned to each of its rated walls that formed a smoke compartment. Please refer to findings under K25.

The facility failed to ensure each hazardous area were protected. Please refer to findings under K29.

The facility failed to have fire drills under varying conditions. Please refer to findings under K50.

The facility failed to maintain its sprinkler system. Please refer to findings under K62.

The facility failed to implement its smoking policy. Please refer to findings under K66.

The facility failed to maintain each means of egress was continuously maintained free of all obstructions. Please refer to findings under K72.

The facility failed ensure safety features obvious to the public were properly labeled to comply with 4.6.12.2 of the L.S.C. 101, 2000 edition. Please refer to findings under K130.

Based on staff interview and policy review, the facility failed to have a qualified infection control officer with education, training, or experience in infection control. This deficient practice had the potential to affect all 21 patients, staff, and visitors.


Findings include:


The Infection Control Officer/Chief Nursing Officer (Staff B) was interviewed on 09/23/14 at 9:35 AM. Staff B was asked to describe his/her training or qualifications as the facility's infection control officer. Staff B stated: "I have no qualifications. I have registered for two classes." Registration material for two online APIC courses were noted. Staff B indicated that these online courses have not yet been completed.


The facility policy entitled Infection Control revised 07/21/14 was reviewed on 09/23/14 at 11:00 AM. According to the policy the Infection Control Practitioner has the overall responsibility for coordinating data collection, evaluation of data for the department, and various other tasks. Staff B confirmed on 09/23/14 at 9:45 AM that he/she has no education, experience, or training to qualify him/her to be the facility's Infection Control Officer.

Based on facility policy review and staff interview, the facility failed to ensure an active infection control plan developed to govern the identification and prevention of infections and communicable diseases within the hospital was present. This deficient practice has the potential to affect all 21 patients, visitors, and staff in the facility.

Findings include:


Staff B (Infection Control Officer) was interviewed on 09/23/14 at 9:30 AM. Staff B was asked to provide an infection control plan for the hospital, an infection control log with all incidents related to infections, and committee meeting minutes for the past year. Although an agenda for a meeting that took place on 07/23/14 was provided, no meeting minutes for this meeting were provided. Staff B stated: "I just started the infection control program. There were no meetings prior to our first meeting in July." Staff B was again asked to provide an infection control log. Staff B stated: "I can't. I don't have access to that information because it doesn't exist."


Staff B provided a binder on 09/24/14 at 10:00 AM reporting the binder contained the infection control program and registration information for two online classes he/she would be taking. A five page policy titled Infection Control revised 07/21/14 was noted inside the binder. The policy outlined the responsibilities of the Infection Control Practitioner and listed a generic, bullet point description of services provided by the infection control program. Staff B confirmed on 09/25/14 at 4:00 PM the information provided did not outline the successful development of a hospital-wide infection prevention and control program.

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (3, 9, 13, 14, 17, 18, 19, and 20). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include an evaluation of psychosocial issues, conclusions and recommendations, or a description of the social worker's role in treatment and discharge planning: Patient 3 (9/10/14), 9 (9/14/14), 13 (8/27/14), 14 (9/20/14), Patient 17 (9/5/14), 18 (8/11/14), 19 (9/10/14), and 20 (9/8/14).

B. Staff Interview

6. During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she/he acknowledged that the Psychosocial Assessments lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment or discharge planning.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient.

Findings include:

A. Record Review

The following Psychiatric Evaluations (dates in parentheses) failed to include specific patient assets that could be used in treatment planning: Patient 3 (9/10/14), Patient 9 (9/14/14), Patient 13 (8/27/14), Patient 14 (9/20/14), Patient 17 (9/5/14), Patient 18 (8/10/14), Patient 19 (9/10/14), and Patient 20 (9/6/14).

B. Staff Interview

During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the psychiatric evaluations for Patients 3, 9, 13, 14, 17, 18, 19, and 20 did not include specific patient assets to be used in treatment planning.

Based on record review and interview, the facility failed to ensure that treatment plan were based on an inventory of patients strengths for two (2) of eight (8) active sample patients (13, and 19). This failure diminishes the effectiveness of the treatment interventions by not engaging the patients through use of their strengths to overcome their disabilities.

Findings include:

A. Record Review


1. The Master Treatment Plan (MTP) called Interdisciplinary Plan of Care by this facility completed 8/27/14 for sample patient 13 had no inventory of assets/strengths identified within the section titled "identification of patient strengths and problem areas" on the facility form. Additionally, strength/assets identified in the social work assessment completed 8/27/14 were not incorporated into the treatment plan.

2. The Master Treatment Plans (MTP) completed 9/10/14 for sample patient 19 had no inventory of assets/strengths identified within the section titled "identification of patient strengths and problem areas" on the facility form. Additionally, strength/assets identified in the social work assessment completed 9/10/14 were not incorporated into the treatment plan.

B. Interview

1. In an interview on 9/23/14 at 10:00 a.m. the treatment plans for sample patient 13 and 19 were discussed with the RN Manager. She agreed the section on the treatment plans titled "identification of patient strengths and problem areas" was not completed.

2. In an interview on 9/23/14 at 12:15 p.m., patient's strengths were discussed with the Director of Nursing. She stated she is aware there are problems with the plans and that she is working on the total revamping of the treatment plans. She acknowledges that the plans of sample patients 13 and 19 did not have documented strength/asset listed for the identified patients.

Based on record review and interview, the facility failed to develop MTPs that included a substantiated psychiatric diagnosis for four (4) of eight (8) active sample patients (3, 13, 17, and 19). In addition physical diagnosis was not identified for 8 of 8 active sample patients ((dates of plans in parentheses): 3 (9/17/14), 9 (9/14/14), 13 (8/27/14), 14 (9/20/14), 17 (9/4/14), 18 (8/10/14), 19(9/10/14), and 20 (9/5/14). The facility's own treatment plan form does not contain an area for the staff to include physical diagnosis. The absence of substantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment.

A. Record Review

1. Patient 3 treatment plan dated 9/17/14 area labeled "Pt. Psychiatric diagnosis" was left blank.

2. Patient 13 treatment plan dated 8/27/14 area labeled "Pt. Psychiatric Diagnosis" was left blank.

3. Patient 17 treatment plan dated 9/4/14 area labeled "Pt. Psychiatric Diagnosis" was left blank.

4. Patient 19 treatment plan dated 9/10/14 area labeled "Pt. Psychiatric Diagnosis" was left blank.

B. Interview

1. In an interview on 9/23/14 at 10:00 a.m. the treatment plans for sample patients 3, 13, 17, and 19 were review with the RN (Registered Nurse) Manager. She agreed the section on the treatment plans titled "Pt. Psychiatric Diagnosis" was left blank.

2. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that substantiated psychiatric and medical diagnoses were not included on the MTP's for the sample patients.

Based on record review and interview, the facility failed to develop Master Treatment Plans (called Interdisciplinary Plan of Care in this facility) that include short term and long term goals stated in observable, measurable, behavioral terms for eight (8) out of eight (8) sample patients (3, 9, 13, 14, 17, 18, 19, and 20). The facility uses pre-printed templates for various symptoms, with pre-printed goals that were not categorized to indicate whether they were long or short term goals. These pre-printed goals were not individualized, observable, or measurable. This resulted in a document that failed to identify individualized expected treatment outcomes in a manner that staff could observe or measure.

Findings include:

A. Policy review

Facility policy titled "Treatment Plans" effective 4/21/11 and updated 4/2/2014, stated: "Each patient must have a written, individualized, comprehensive treatment plan that is based on an inventory of the patient's strengths, restorative needs, and potential." "The nursing admitting treatment must include short- term and long term goals with the expected outcome for each problem addressed." "Outcomes must be measurable, functional, timed framed, and directly related the cause of the patient's admission." "The treatment plan is the tool used by the physician and interdisciplinary treatment team to move the patient toward the expected outcomes and goals." This policy is lacking information to guide clinical staff when writing treatment goals.

The medical records provided pre-written goals and interventions based on specific identified problems. The staff selected a problem and then selected goals and interventions from a list of generic options provided by the templates/program. Many of these pre-written goals were not measurable, not written in descriptive behavioral terms and/or was staff oriented rather than patient focused.

B. Record review

1. Active sample patient 3, Master Treatment Plan (MTP), dated 9/17/14 has the problem of "agitation/disruptive behavior/impulse control as AEB (as evidenced by) (sic); hitting staff, combative with personal care & hits other pt (patient)." The goal is identified by check marks on the per-printed form for each discipline is as follows; Nursing: "Pt. will remain safe from harm to self or others X 3 days in a row." "Pt. will report and/or exhibit decreased agitation on unit X 2 days in a row." "Pt. will display socially acceptable behavior on the unit X 2 days in a row." "Pt. will demonstrate decreased restlessness/wandering (sic) behaviors for 3 hours out of the day X 3days." Occupational Therapy; "Pt. symptoms will not interfere with ability to participate in OT treatment groups 1:1 X 3days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3 days AEB:." "Patient will participate without agitation." "Pt. will tolerate group treatment process verses 1:1 treatment for one day." Social Services: "Follow up care will be discussed with Pt./family prior to discharge." For the problem "Potential for harm to self and/or harm to others, hits others, staff & pt. Nursing: Pt. will report improved thought processes daily, X, 2 days." "Pt. will tolerate progressive environmental stimulation X 2 days." Occupational Therapy: "Pt. will demonstrate appropriate social interactions during OT treatment group." Social Services: "Follow up care will be discussed with Pt. /family prior to discharge." Psychiatrist has no goal identified on the treatment plan for this patient.

2. Active sample patient 9, MTP, dated 9/14/14 has the problem of "agitation/disruptive behavior/impulse control AEB (sic) per report from NH - pt. was exhibiting aggressive/combative behaviors." The goal(s) identified by each discipline on the pre-printed form is as follows; Nursing has no goal identified for this problem. Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups 1:1 X 3 days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3 days AEB: active participation with no noted agitation." "Pt. will tolerate group treatment process verses 1:1 treatment for one day." Social Services: "Follow up care will be discussed with Pt. /family prior to discharge."
For the problem "Cognitive impairment AEB: Pt was observe (sic) walking around her apt naked." Nursing goals: "Pt. will appropriately respond to redirection/reorientation X 2 days." "Pt. will follow 1 step direction with good consistency and cues PRN X 2 days." "Pt. will demonstrate improved ability to participate in ADL tasks." "Pt. will demonstrate acceptable social behaviors while on unit within milieu X 3 days AEB." Occupational Therapy: "Pt. will tolerate group treatment process verses 1:1 treatment." Social Services: "Follow up care will be discussed with PT./family prior to discharge." Psychiatrist has no goal identified on the treatment plan for this patient.

3. Active sample patient 13, MTP, dated 8/27/14 has the problem of "Impaired mobility and/or fall risk AEB: h/o (history of) falls." The goal(s) identified by each discipline on the pre-printed form is as follows; Nursing has no goal identified for this problem. Occupational Therapy: "Pt. will comply with established safety plan to prevent falls, during OT treatment group sessions daily, X 3 days AEB: no falls during OT tx (treatment) sessions." Social Services: "Follow up care will be discussed with Pt. /family prior to discharge."

For the problem "Altered perceptions of reality/delusional thoughts AEB:" Nursing has no goal identified for this problem. Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups AEB: pt will not discuss hallucinations delusions during OT sessions." Social Services: "Follow up care will be discussed with pt. /family prior to discharge." Psychiatrist has no goal identified on the treatment plan for this patient.

4. Active sample patient 14, MTP, dated 9/20/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: stating that someone came and raped her." The goals that each discipline identified is as follows; Nursing: "Pt. will communicate improved reality orientation X 2 days." "Pt. will sleep at least (blank) hours nightly X 2 days." "Pt. will accept foods, fluids and medications X2 days." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups, AEB: no evidence of hallucinations or delusions during OT tx sessions." For the problem of "Agitation/disruptive behavior/impulse control AEB: Report from nursing home pacing, talking non-stop." Nursing: "Pt. will remain safe from harm to self or others X 3days in a row." "Pt. will report and /or exhibit decreased agitation on the unit X 2days in a row." "Pt. will display socially acceptable behavior on the unit X2 days in a row." "Pt. will demonstrate decreased restlessness/wandering (sic) behaviors for 3 hours out of the day X 3 days." "Pt. will demonstrate decreased sexually inappropriate behaviors X 3days in a row AEB." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups/1:1 X 3 days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3days AEB: calm, appropriate behavior during OT groups." For the problem "Impaired mobility and or fall risk" Nursing had no identified goal for this problem. Occupational Therapy: "Pt. will comply with established safety plan to prevent falls, during OT treatment group sessions daily, X 3 days AEB: No falls during OT tx sessions."
Social Services and Psychiatrist has no goal identified on the treatment plan for this patient.

5. Active sample patient 17, MTP, dated 9/4/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: various delusions." The goals that each discipline identified on the plan are as follows; Nursing, Occupational Therapy and Social services has no identified goals for this problem. Psychiatrist: "Pt. will demonstrate/express a decrease in altered perceptions X 2 days." "Pt. will demonstrate positive response(s) to current medications prescribed X 2 days." For the problem of "Anxiety AEB." Nursing: "Pt. will communicate a decrease in noted anxiety X 2 days." "Pt. will routinely accept medications X 2 days in a row." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will effectively demonstrate stress reduction skills with 1(one) assistance." "Pt. will ID (identify) 1 (one) positive leisure options which decrease stress and improve quality of life." Social Services: "Pt. /family will have no further questions regarding diagnosis prior to discharge." "Follow up care will be discussed with Pt. /family prior to discharge."
For the identified problem of "Cognitive impairment AEB." Nursing: "Pt. will appropriately respond to redirection/reorientation X 2 Days." "Pt. will follow 1 step directions with good consistency and cues PRN X 2 days." "Pt. will demonstrate improved ability to participate in ADL tasks." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will tolerate group treatment process verses 1:1 treatment." Social Services: "Pt. /family will have no further questions regarding diagnosis prior to discharge." "Follow up care will be discussed with Pt. /family prior to discharge." Psychiatrist has no treatment goal identified for this problem.

6. Active sample patient 18, MTP dated 8/10/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: Pt. states that FBI caused the rash on her legs and that we should asked (sic) FBI for any information regarding her." The goals identified by each discipline are as follows; Nursing: "Pt. will accept foods, fluids and medications X2 days." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups AEB: without evidence of hallucinations/delusions." Social Services: "Follow up care will be discussed with pt./family prior to discharge." For the problem "Agitation/disruptive behavior/impulse control AEB:" Nursing has not identified goal(s) for this problem. Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3 days AEB: calm behavior during tx (sic) sessions." Social Services: "Follow up care will be discussed with Pt. /family prior to discharge." MTP up-dated 8/11/14 to include the problem of "Cognitive Impairment AEB: Nursing has no goal identified for this problem. Occupational Therapy: Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will tolerate group treatment process verses 1:1 treatment." Psychiatrist has no treatment goal identified on the treatment plan for this patient.

7. Active patient 19, MTP dated 9/10/14 has the problem of "Agitation/disruptive behavior/impulse control AEB:." The goals identified by each discipline is as follows; Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3 days AEB: pt. remains calm & participate in group." For the problem "Cognitive impairment AEB:." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment group/1:1 X 3 days." "Pt. will follow 1(one) step directions/1-2 words commands, during OT treatment with good consistency." Nursing, Social Services and Psychiatrist has no treatment goals identified on the treatment plan for this patient.

8. Active sample patient 20, MTP dated 9/5/14 has the problems "Agitation/disruptive behavior/impulse control AEB: Patient is agitated and threatening other patients." The goals identified by each discipline are as follows. Nursing: "Pt. will remain safe from harm to self or others X 3days in a row." "Pt. will report and /or exhibit decreased agitation on the unit X 2days in a row." "Pt. will display socially acceptable behavior on the unit X2 days in a row." "Pt. will demonstrate decreased restlessness/wandering (sic) behaviors for 3 hours out of the day X 3 days." "Pt. will demonstrate decreased sexually inappropriate behaviors X 3days in a row AEB:." Occupational Therapy: "Pt. symptoms will not interfere with ability to participate in OT treatment groups/1:1 X 3 days." "Pt. will demonstrate no agitated behavior during OT treatment sessions X 3days AEB: calm, appropriate behavior during OT groups." Social Services: "Pt. /family will have no further questions regarding diagnosis prior to discharge." "Follow up care will be discussed with Pt. /family prior to discharge." Psychiatrist: "Pt. will demonstrate/express a decrease in altered perceptions X 2 days." "Pt. will demonstrate positive response(s) to current medications prescribed X 2 days."

C. Interviews

1. In an interview on 9/23/14 at 10:00 a.m. the treatment plans goals were discussed with the RN Manager. She stated "this is why I got my job to make the plans better." She agreed the goals are not individualized.

2. In an interview on 9/23/14 at 12:15 p.m., the non-measurable goals were discussed with the Director of Nursing. She stated she is aware there are problems with the plans and that she is working on the total revamping of the treatment plans. She agreed that goals are not described as short or long term goals and identified goals are neither individualized nor measurable.

Based on record review and interview, the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to consistently state the frequency of contact, specific focus for interventions, and whether interventions would be delivered in groups or individual sessions. In addition, all patients were expected to attend all the groups listed on the unit's schedule regardless of their presenting problem and need. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

1. Failure to include individualized treatment interventions on MTPs.

A. Policy Review

Facility policy titled "Treatment Plans" effective 4/21/11 and updated 4/2/2014, stated: "Each patient must have a written, individualized, comprehensive treatment plan that is based on an inventory of the patient's strengths, restorative needs, and potential." The nursing admitting nurse treatment plan must include, "nursing staff identified in relation to implementing and monitoring intervention." The policy does not provide the clinical staff with sufficient information to guide them in writing treatment interventions statements.

B. Record review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): 3 (9/17/14), 9 (9/14/14), 13 (8/27/14), 14 (9/20/14), 17 (9/4/14), 18 (8/10/14), 19(9/10/14), and 20 (9/5/14). This review revealed that the MTPs had routine and generic statements (assist, provide, employ, and encourage) and/or generic discipline functions written as treatment interventions to be delivered by nursing, occupational therapy, social services, and psychiatrist. Additionally, treatment plans did not include how interventions would be delivered, the frequency of contact, responsible person for delivery and monitoring, and/or the focus or purpose of treatment related to the patient presenting and behaviorally descriptive symptoms. Some interventions were identically worded for several of the sample patients. Listed below are the generic lists of intervention for by discipline in regards to the identified problem for eight (8) of eight (8) sample patients.

1. Active sample patient 3 had a problem of "Agitation/disruptive behavior/impulse control AEB (sic); hitting staff, combative with personal care & hits other pt (patient)."

Nursing: "Assist pt. in resolving conflict PRN." "Provide 1:1 to de-escalate PRN." "Employ Crisis Prevention Intervention (CPI) techniques PRN." "Provide PRN medication as indicated." "Assist in providing a safe and structures environment." "Utilize quiet room/sensory room PRN." "Provide external controls to maintain safety as indicated." These statements were not individualized and were routine nursing functions that would be provided for any patient regardless of presenting symptoms.

Occupational Therapy: "Assist pt. in resolving conflict PRN." "Assist in providing a safe and structured environment." "Facilitate group participation to promote appropriate socialization skills." "Establish clear, simple and reasonable limits PRN." "Encouraged establishment of daily short term goal (STG)." These interventions were not individualized and are OT staff routine functions for all patients.

Social Services: "Arrange follow up care as appropriate for discharge." "Provide 1:1 to de-escalate PRN." These interventions were not individualized and are social work task rather than specific interventions related to this patient.

Psychiatrist: The treatment plan did not include interventions from psychiatrist.


2. Active sample patient 9, MTP, dated 9/14/14 has the problem of "agitation/disruptive behavior/impulse control AEB (sic) per report from NH - pt. was exhibiting aggressive/combative behaviors."

Nursing: The treatment plan did not include nursing intervention for this problem.

Occupational Therapy: "Assist pt. in resolving conflict PRN." "Assist in providing a safe and structured environment." "Facilitate group participation to promote appropriate socialization skills." "Establish clear, simple and reasonable limits PRN." "Encouraged establishment of daily STG." These interventions were not individualized and are the routine functions of the discipline which are required for all patients.

Social Services: "Educated pt. and family regarding diagnosis." "Arrange follow up care as appropriate for discharge." "Provide 1:1 to de-escalate PRN." These interventions were not individualized and are social work routine tasks rather than specific intervention which could be used for all patients regardless of presenting problems and needs.

Psychiatrist: The treatment plan did not include interventions from psychiatrist for identified problem.

3. Active sample patient 13, MTP, dated 8/27/14 has the problem of "Impaired mobility and/or fall risk AEB: h/o (history of) falls."

Nursing: The treatment plan did not include interventions from nursing for identified problem.

Occupational Therapy: "Promote emotional and physical health and wellness." "Encourage establishment of a daily STG." "ID (identify) obstacles in hospital to help prevent fall." "Utilized fall precautions as indicated." These interventions were not individualized and are the routine functions of the discipline.

Social Services: "Arrange follow up as appropriate for discharge." This intervention is not individualized and is social work routine function which applies to all patients regardless of reason for admission.

Psychiatrist: The treatment plan did not include interventions from psychiatrist for identified problem.

4. Active sample patient 14, MTP, dated 9/20/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: stating that someone came and raped her."

Nursing: "Document hours of sleep." "Establish therapeutic relationship." "1:1 interactions PRN." "Administer PRN medications as indicated." "Encourage appropriate interaction during meals/general milieu activities." "Encourage treatment group participation." These statements were not individualized and are routine nursing functions that would be provided for any patient regardless of presenting symptoms.

Occupational Therapy: "Assist in providing a safe and structural environment." "Establish therapeutic relationship." "Encourage appropriated interactions during OT treatment sessions." "Encourage establishment of a daily STG." "Promote emotional health through treatment group treatment (1:1 PRN)." "Monitor for hallucinations and delusional thinking." "Facilitate improvement of coping skills." These interventions were not individualized and are the routine functions of the discipline.

Social Services and Psychiatrist: The treatment plan did not include interventions for these two disciplines for the identified problem.

5. Active sample patient 17, MTP, dated 9/4/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: various delusions."

Nursing, Occupational therapy and social services did not include interventions in the treatment plan for the above identified problem.

Psychiatrist: Interventions include "meet 1:1 with patient/review chart." "address patient family concerns PRN." "adjust medications PRN." These are all routine required task for all patients regardless of presenting symptoms.

For the problem identified as "Anxiety AEB."

Nursing: " Approach in a calm and direct manner." "Administer medication as indicated." "Encourage appropriate interaction during meals/general milieu activities." "Encourage treatment group participation." These interventions were not individualized and are the routine functions of the discipline.


Occupational Therapy: "Provide structured activity to facilitate appropriate social skills/promote socialization." "Assist in ID of positive coping alternative and or leisure pursuits." "Provide sensor/cognitive stimulation." "Promote emotional health through group treatment (1:1 PRN)." These interventions were not individualized and are the routine functions of the discipline.


Social Services: "Educated pt. and family regarding diagnosis." "Arrange follow up care as appropriate for discharge." "Provide 1:1 to de-escalate PRN." These interventions were not individualized and are the routine functions of the discipline.


Psychiatrist: The treatment plan did not include interventions from psychiatrist for identified problem.

For the problem identified as "Cognitive impairment AEB."

Nursing: "Provide external control when impaired judgment contributes to self or harm of others on the unit." "Assist with ADL's PRN." "Provide redirection and reorientation PRN." "Use clear 1 step direction/ 1-2 words commands PRN." "Encourage treatment group participation." "Facilitate socialization with peers." These interventions were not individualized and are the routine functions of the discipline.


Occupational Therapy: "Facilitate group participation to promote appropriate socialization skills." "Assist with providing a safe and structured environment." "Provide redirection and reorientation PRN." "Provide sensory/cognitive stimulation to increase awareness/decrease impulsivity." "Assist in ID of purposeful activity to decrease restlessness/wondering." "Promote emotional health through group treatment (1:1 PRN)." These interventions were not individualized and are the routine functions of the discipline.


Social Services: "Educated pt. and family regarding diagnosis." "Arrange follow up care as appropriate for discharge." "Provide 1:1 to de-escalate PRN." These interventions were not individualized and are the routine functions of the discipline.


Psychiatrist: The treatment plan did not include interventions from psychiatrist for identified problem.

6. Active sample patient 18, MTP dated 8/10/14 has the problem of "Altered perceptions of reality/delusional thoughts AEB: Pt. states that FBI caused the rash on her legs and that we should asked (sic) FBI for any information regarding her."

Nursing: "Reorient to reality PRN." "Document hours of sleep." "Establish therapeutic relationship." "1:1 interactions PRN." "Administer PRN medications as indicated." "Encourage appropriate interaction during meals/general milieu activities." "Encourage treatment group participation." "Monitor for hallucinations and delusional thinking." These statements were not individualized and are routine nursing functions that would be provided for any patient regardless of presenting symptoms.

Occupational Therapy: "Assist in providing a safe and structural environment." "Establish therapeutic relationship." "Encourage appropriated interactions during OT treatment sessions." "Encourage establishment of a daily STG." "Promote emotional health through treatment group treatment (1:1 PRN)." "Monitor for hallucinations and delusional thinking." "Facilitate improvement of coping skills." These interventions were not individualized and are the routine functions of the discipline.

Social Services: "Educated pt. and family regarding diagnosis." "Arrange follow up care as appropriate for discharge." "Assess for hallucinations and delusional thinking." These interventions were not individualized and are the routine functions of the discipline.
Psychiatrist: The treatment plan did not include interventions from psychiatrist for identified problem.


7. Active patient 19, MTP dated 9/10/14 has the problem of "Agitation/disruptive behavior/impulse control AEB: "

Occupational Therapy: "Assist pt. in resolving conflict PRN." "Assist in providing a safe and structured environment." "Facilitate group participation to promote appropriate socialization skills." "Establish clear, simple and reasonable limits PRN." "Encourage establishment of daily STG." "Facilitate improvement of coping skills." These interventions were not individualized and are the routine functions of the discipline which are required for all patients.

Nursing, psychiatrist and social services did not include interventions in the treatment plan for the above identified problem.

8. Active sample patient 20, MTP dated 9/5/14 has the problems "Agitation/disruptive behavior/impulse control AEB: Patient is agitated and threatening other patients."

Occupational Therapy: "Assist in providing a safe and structural environment." "Establish therapeutic relationship." "Encourage appropriated interactions during OT treatment sessions." "Encourage establishment of a daily STG." "Promote emotional health through treatment group treatment (1:1 PRN)." "Monitor for hallucinations and delusional thinking." "Facilitate improvement of coping skills." These interventions were not individualized and are the routine functions of the discipline.

Nursing, psychiatrist and social services did not include interventions in the treatment plan for the above identified problem.

For the problem identified as Agitation/disruptive behavior/impulse control AEB:

Nursing: "Assist pt. in resolving conflict PRN." "Provide 1:1 to de-escalate PRN." "Employ Crisis Prevention Intervention (CPI) techniques PRN." "Provide PRN medication as indicated." "Assist in providing a safe and structures environment." "Provide external controls to maintain safety as indicated." These statements were not individualized and were routine nursing functions that would be provided for any patient regardless of presenting symptoms

Occupational Therapy: "Assist pt. in resolving conflict PRN." "Assist in providing a safe and structured environment." "Facilitate group participation to promote appropriate socialization skills." "Establish clear, simple and reasonable limits PRN." "Encouraged establishment of daily STG." These interventions were not individualized and are the routine functions of the discipline which are required for all patients.

Social Services: "Educated pt. and family regarding diagnosis." "Arrange follow up care as appropriate for discharge." These interventions were not individualized and are social work routine tasks rather than specific intervention which could be used for all patients regardless of presenting problems and needs.

Psychiatrist: Interventions include "meet 1:1 with patient/review chart." "Address patient family concerns PRN." "Adjust medications PRN." These are all routine required task for all patients regardless of presenting symptoms.

C. Interviews

1. In an interview on 9/23/14 at 10:00 a.m. with the Registered Nurse Manager, the generic interventions on the MTPs were discussed. She acknowledged that the interventions were generic and routine nursing staff functions. She agreed that some of the treatment plans had no listed interventions for the problem identified. She further stated "that is why I got my job, to help work on these problems."

2. In an interview on 9/23/14 at 12:15 p.m. with the Director of Nursing, the generic interventions on the MTPs were discussed. She stated "I know there are problems with the treatment plans and I am working and revamping the whole plan." "Yes, I agree that the interventions are routine tasks for nursing staff."

3. During an interview with the Director of Therapy Services on 9/23/14 at 2:50 p.m., she acknowledged that the interventions on the MTP's for the sample patients were generic and not specific to patient needs.

4. During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she acknowledged that the social work interventions on the MTP's were generic and not specific to patient needs of Patients 3, 9, 13, 14, 17, 18, 19, and 20.

5. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the interventions on the MTP's for the sample patients were generic and not specific to patient needs and that no interventions were included on the MTP's for the psychiatrist or to address medical problems.

Based on record review and interview the facility failed to identify the specific team member by name as the primary responsible staff for treatment interventions listed on the MTPs for eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). Instead, each intervention is listed under the clinical department title such as nursing, occupational therapy, social service and psychiatrist.

This practice resulted in a lack of staff accountability for the interventions and failure to deliver treatment to meet the patient's identified need.

Findings are:

A. Policy Review

1. Facility policy titled "Treatment Plans" effective 4/21/11 and updated 4/2/2014, stated "Nursing staff are identified in relation to implementing and monitoring intervention."
This facility policy does not require the name and discipline of the primary responsible staff person to be listed with intervention in the interdisciplinary treatment plan.

B. Record review

1. Patient treatment plans 3, 9, 13, 14, 17, 18, 19, and 20 had the department discipline title (nursing, occupational therapy, social service and psychiatrist) listed near treatment interventions but no specific responsible person listed with any.

C. Interview

1. In an interview on 9/23/14 at 10:00 a.m. the treatment plans were discussed with the RN Manager. She stated "this is why I got my job to make the plans better". She agreed the primary responsible person was not assigned to nursing interventions on the treatment plans.

2. In an interview on 9/23/14 at 12:15 p.m., the treatment plans were discussed with the
Director of Nursing. She stated she is aware there are problems with the plans and that she is working on the total revamping of the treatment plans. She agreed that primary responsible nursing staff were not assigned to interventions.

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

I. Ensure that active treatment measures, such as group treatment and therapeutic activities, were available for two (2) of eight (8) active sample patients (3 and 18) who were unwilling or unable to attend groups or were sufficiently cognitively impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

II. Assess and treat the medical problems of 2 discharged patients (E1 and E2) reviewed for medical care in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients lives/health.

III. Ensure that patients received sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients on the geriatric unit with a census of 21 patients. There were only 3 hours of activities were scheduled each day. These activities were leisure-focused. The only treatment-focused group, "Life Skills" conducted by social work staff on weekdays, was not being provided. No treatment activities were scheduled in the evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge.

Findings include:

I. Active Treatment

A. Patient 3

1. Patient 3 was admitted 9/9/14 due to combative behaviors, depression, and stating that [s/he] wished [s/he] was dead. The admission psychiatric assessment, dated 9/10/14 at 12:39 p.m., stated that the diagnoses were "Organic mood disorder" and multiple medical diagnoses. The interventions for the Problem of "Agitation/Disruptive Behavior/Impulse Control AEB [as evidenced by]: Hitting staff, combative [with] personal care & hits other pt [patients]" included "Facilitate group participation to promote appropriate socialization skill " and "Promote emotional health through group treatment (1:1 prn [as needed])." The interventions for the Problem of "Potential for Harm to Self " included "Promote socialization during group treatment sessions and milieu."

2. During observations of the scheduled groups, "Leisure/Crafts" conducted by Occupational Therapy on 9/22/14 at 10:30 a.m. and "Coping Skills" conducted by Occupational Therapy on 9/23/14 at 10:45 a.m., Patient 3 was observed sitting alone in the dayroom area.

3. The "Occupational Therapy Re-Assessment" note on 9/17/14 at 1:15 p.m. stated that Patient 3 refused to participate in 25 of 28 groups provided "due to not being appropriate for group and/or refusing." The "O.T. Group/1:1 Progress Notes" from 9/17/14 to 9/21/14 documented that Patient 3 attended only 2 of 18 groups provided. These notes indicated no individual sessions were provided during this time.

4. During an interview with the Director of Therapy Services on 9/23/14 at 2:50 p.m., she acknowledged that that Patient 3 had refused to participate in most group sessions and no alterative treatments were provided for Patient 3.

5. During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she acknowledged that Patient 3 had not participated in group sessions and no alternative treatments were provided for Patient 3 other than brief 1:1 meetings.

6. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that Patients 3 had not participated in group therapy and no other treatments were offered other than medications.

B. Patient 18

1. Patient 18 was admitted 8/10/14 due to psychosis with paranoid and bizarre delusions. The admission psychiatric assessment, dated 8/10/14 at 12:06 p.m., stated that the diagnosis was "Paranoid schizophrenia." The interventions for the Problem of "Altered Perceptions of Reality/Delusional Thoughts AEB: Pt. states that FBI caused the rash on [her/his] legs and that we should ask FBI for any information regarding [him/her]" included "Encourage treatment group participation" and "Promote emotional health through group treatment (1:1 prn)." The interventions for the problem of "Agitation/Disruptive Behavior/Impulse Control AEB [as evidenced by]:" included "Facilitate group participation to promote appropriate socialization skills" and "Promote emotional health through group treatment."

2. During observations of the scheduled groups, " Leisure/Crafts " conducted by Occupational Therapy on 9/22/14 at 10:30 a.m. and " Coping Skills " conducted by Occupational Therapy on 9/23/14 at 10:45 a.m., Patient 18 was found sitting alone in [his/her] room or walking in the hallway.

3. The "O.T. Group/1:1 Progress Notes" from 8/12/14 to 8/30/14 documented that Patient 18 refused to participate in 17 of 18 groups provided. The weekly "Occupational Therapy Re-Assessment" summary notes documented the following: On 9/3/14 at 11:30 a.m., "Patient has not attended any O.T. treatment sessions during the past week...Patient stated "I do not need therapy," On 9/10/14 at 3:30 p.m., "Patient attended 2 groups of 20 sessions and one 1:1 session," and on 9/17/14 (no time), "Patient has not attended any groups... Patient does interact briefly [with] in hallways [sic], but she is often short/brief & then moves on."

4. During an interview with the Director of Therapy Services on 9/23/14 at 2:50 p.m., she stated that Patient 18 had refused to participate in most group sessions. She stated that she "interacted" with Patient 18 in the hallways of the unit for short periods of time and educated [him/her] on the need to attend groups.

5. During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she stated that Patient 18 had not participated in group sessions. The Director of Social Work stated that Patient 18 also refused most individual interactions with the Director of Social Work. She stated "ten minutes is the most [Patient 18] has ever given me."

6. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that Patients 18 had not participated in group therapy and no alternative treatments were offered other than medications.

II. Medical Treatment

A. Patient E1

1. Patient E1 was admitted 8/12/14 due to becoming restless and combative with care at a nursing care facility. The admission psychiatric assessment, dated 8/22/14 at 3:10 p.m. stated [her/his] diagnoses were "Mood disorder secondary to general medical condition" and "Dementia with behavioral disturbance." The "Medical History" stated "The patient has a history of seizures and takes Keppra. Again, details are not available...He has become hypotensive at times. According to the medical notes from the facility, he has orthostatic type hypotension. He was prescribed midodrine."

2. The orders for the admission of Patient E1 dated 8/21/14 (no time) included "vital signs twice daily." A review of the physician orders indicated no orthostatic blood pressure measurements were ordered during this hospitalization.

3. The Master Treatment Plan for Patient E1 dated 8/21/14 did not identify Patient E1's seizure disorder or orthostatic hypotension as a problem or include interventions to address assessment and treatment of these issues.

4. The "Contact Note" by nursing staff on 8/29/14 at 5:41 a.m. stated "This writer turn (sic) round (sic) to get the wheel chair that was standing (sic) down the hall way (sic) to assists (sic) patient on it and that is when staff called that patient was on the floor...Patient was transferred from [local medical hospital] to [local university medical center] where he will be treated for head bleed and fractured hip."

5. The "Initial Medicine Consult" dated 8/22/14 at 2:00 a.m. and "Medicine Progress Notes" dated 8/23/14 at 9:30 a.m., 8/24/14 at 5:20 p.m., 8/25/14 (no time), 8/26/14 at 7:36 a.m., 8/27/14 at 12:30 p.m., 8/28/14 at 7:30 a.m. did not identify or address Patient E1's seizure disorder or history of orthostatic hypotension.

6. A review of the "Graphics" vital sign record from 8/21/14 to 8/28/14 did not indicate that Patient E1 was monitored for orthostatic blood pressure changes during this hospitalization.

7. The "Medical Release" from the county coroner's office dated 9/2/14 indicated that Patient E1 died on 9/2/14.

8. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the clinical monitoring of the medical issues related to Patient E1's risk for falling was not documented. He stated "I would be more involved in that [the monitoring of Patient E1's medical conditions related to the risk of falling]." The Medical Director stated that he would have monitored Patient E1's blood pressure lying and standing every shift for at least three days. He stated that documentation of an assessment of Patient E1's seizure disorder was indicated. The Medical Director stated that Patient E1's medications also needed assessment in relation to an increased risk for falling, especially the prescription of Trazodone for Patient E1. He acknowledged that none of these assessments were documented in the medical record for Patient E1. The Medical Director stated that further assessment of these conditions and interventions may have prevented Patient E1's fall on 4/9/14.

B. Patient E2

1. Patient E2 was admitted 3/17/14 due to "getting combative and agitated" and visual hallucinations. The diagnoses on admission included "Delusion Disorder" and Axis III diagnoses included "Lung CA [cancer] [with] mets [metastases] to Liver and Bone, CAD [coronary artery disease], COPD [chronic obstructive pulmonary disease], Htn [hypertension], DM [diabetes] type 2, [left] BKA [below the knee amputations], Hx CVA [cerebrovascular accident]." The admission orders dated 3/17/14 at 7:00 p.m. stated "Institute House Sliding Scale Protocol (Novolog): [For] Blood sugar < 75 [administer] give 16 oz. [ounces] orange juice and call medical consultant, [For] Blood sugar 150-199 [administer] 2 units [Novolog insulin], [For] Blood sugar 200-249 [administer] 4 units [Novolog insulin], [For] Blood sugar 250-299 [administer] 6 units [Novolog insulin], [For] Blood sugar 300-349 [administer] 8 units [Novolog insulin], , [For] Blood sugar >350 [administer] 10 units [Novolog insulin] and call medical consultant."

2. The Medication Administration Record for April 2 to April 9, 2014 for Patient E2 documented a blood sugar result of "18" on 4/4/14 at 6 a.m. The amount of Novolog insulin administered was illegible but appeared to be "40" or "90." A review of the medical record revealed no documentation of Patient E2's condition at this time, of an intervention for the low blood sugar, or of an assessment by a medical physician.

3. The Medication Administration Record for April 2 to April 9, 2014 for Patient E2 documented a blood sugar result of "383" on 4/9/14 at 6 a.m. The amount of insulin administered at that time was blank on the Medication Administration Record. No documentation in the medical record indicated the amount of Novolog insulin given at that time. The "Contact Note" by the nurse on 4/9/14 at 2:12 p.m. stated "Before lunch assign patients [sic] FSFS [finger stick blood sugar]. Noticed patient presents pallor cool to touch and with decrease LOC [level of consciousness]...FSBS at 29, reassessment and new result of 31. Following 2 IM [intramuscular] hypokit glucogel injections [his/her] FSBS rose to 64...Patient noted with comatose disposition at this time, [his/her] eyes were open and non-responsive to light. Patient non-responsive to painful stimuli...Notified 911 to pick up patient to transport to [medical facility]." Patient E2 did not return to the facility and died on 4/11/14 at the outside medical facility.

4. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that there was no documentation of an assessment or intervention for the low blood sugar for Patient E2 on 4/4/14. He acknowledged that the amount of insulin administered to Patient E2 on 4/9/14 at 6:00 a.m. was not documented prior to the low blood sugar at 12:00 noon and that the amount of insulin administered to Patient E2 prior to becoming comatose was unknown.

III. Failure to ensure sufficient hours of active treatment

A. Observations

1. During an observation on 9/22/14 at 11:15 a.m. at the time of the scheduled group conducted by Occupational Therapy, "Leisure/Crafts (OT)," a total of 5 of 21 patients were in the group. The remaining patients were either in bed, walking the hallway or sitting in other areas of the dayroom. Sample Patient 3 was observed sitting in another area the dayroom where the group was being held. Sample Patient 18 was found to be alone in [his/her] room at that time. During an observation on 9/23/14 at 11:10 a.m. at the time of the scheduled group conducted by Occupational Therapy, "Leisure/Crafts (OT)," a total of 6 patients were involved in the group. The remaining patients were either in bed, walking the hallway or sitting in other areas of the dayroom. Sample Patient 3 was observed sitting in the dayroom where the group was being held. Sample Patient 18 was observed walking in the hallway at that time.

2. During observations on the unit on 9/22/14 at 2:30 p.m. and on 9/23/14 at 2:15 p.m., the scheduled "Life Skills" group was not being conducted. The patients were either in bed, walking the hallway or sitting in the waiting room.

B. Document reviews

A review of the "Active Treatment Schedule" revealed that only 3 hours of activities were scheduled each day. These activities were leisure-focused. The only treatment-focused group, "Life Skills" conducted by social work staff on weekdays, was not being provided. No treatment activities were scheduled in the evenings.

C. Staff Interviews

1. During an interview with the Director of Therapy Services on 9/23/14 at 2:50 p.m., she stated that she assessed all patients at the time of admission for their ability to tolerate group therapy. She stated "if I think they can be in group and not be disruptive, I will give it a try." She estimated that less than half of the patients admitted to the hospital were appropriate to participate in group but acknowledged that only 4 or 5 current patients were currently appropriate for group therapy. She acknowledged that the scheduled group activities were leisure-focused and no activities were provided during evening hours.

2. During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she stated that she was assigned to conduct the scheduled social work group, "Life Skills." However, she stated that she did not usually conduct the group but "designated that hour to 1:1" with patients. She stated that she did not conduct the group because the patients "typically don't want to meet together." She stated that she met with patients individually for "education, discharge planning" and "for [patients with] advanced dementia," "comfort and 1:1 redirection." She acknowledged that the other scheduled group activities were leisure-focused and no activities were provided during evening hours.

3. During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that there was only 3 hours of the scheduled group activities each day and no activities scheduled during evening hours. He acknowledged that these groups were leisure-focused.

Based on interview and record review, the facility failed to provide a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for 3 out of 5 discharged patients (D2, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments, treatments, and discharge plan with providers providing follow-up care.

Findings include:

A. Record review

No Discharge Summary was provided for the following patients (dates of discharge in parentheses): Patient D2 (7/25/14), Patient D3 (7/23/14), Patient D4 (7/22/14).

B. Interview

During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the medical record for Patients D2, D3, and D4 did not contain a discharge summary.

Based on record review, and interview, the Medical Director failed to:

I. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

II. Ensure that staff developed Master Treatment Plans that included an inventory of patients strengths for two (2) of eight (8) active sample patients (13, and 19). This failure diminishes the effectiveness of the treatment interventions by not engaging the patients through use of their strengths to overcome their disabilities. (Refer to B119)

III. Ensure that staff developed Master Treatment Plans that included a substantiated psychiatric diagnosis for four (4) of eight (8) active sample patients (3, 13, 17, and 19). In addition physical diagnosis was not identified for eight (8) of eight (8) active sample patients (dates of plans in parentheses): 3 (9/17/14), 9 (9/14/14), 13 (8/27/14), 14 (9/20/14), 17 (9/4/14), 18 (8/10/14), 19(9/10/14), and 20 (9/5/14). The facility's own treatment plan form does not contain an area for the staff to include physical diagnosis. The absence of substantiated diagnosis on the treatment plan compromises the treatment team's ability to deliver focused treatment. (Refer to 120)

IV. Ensure that staff developed Master Treatment Plans that include short term and long term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) sample patients (3, 9, 13, 14, 17, 18, 19, and 20). The facility uses pre-printed templates for various symptoms, with pre-printed goals that were not categorized to indicate whether they were long or short term goals. These pre-printed goals were not individualized, observable, or measurable. This resulted in a document that failed to identify individualized expected treatment outcomes in a manner that staff could observe or measure. (Refer to B121)

V. Ensure that the Master Treatment Plans of eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20) included physician treatment interventions. This results in the facility not delineating the role of the physician in the treatment of patients.

Findings include:

A. Record Review

The Master Treatment Plans (dates in parentheses) for the following patients did not contain treatment interventions to be performed by the psychiatrist or the medical providers: Patient 3 (9/17/14), Patient 9 (9/14/14), Patient 13 (8/27/14), Patient 14 (9/20/14), Patient 17 (9/4/14), Patient 18 (8/10/14), Patient 19 (9/10/14), and Patient 20 (9/5/14).

B. Staff Interview

During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he acknowledged that the treatment plans did not contain psychiatric interventions or interventions for medical problems for Patients 3, 9, 13, 14, 17, 18, 19, and 20.

VI. Ensure that staff developed Master Treatment Plans that identify the specific team member by name as the primary responsible staff for treatment interventions listed on the MTPs for eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). Instead, each intervention is listed under the clinical department title such as nursing, occupational therapy, social service and psychiatrist. This practice results in a lack of staff accountability for the interventions and failure to deliver treatment to meet the patient's identified need. (Refer to B123)

VII. Ensure that staff provided active treatment measures, such as group treatment and therapeutic activities, were available for two (2) of eight (8) active sample patients (3 and 10) who were unwilling or unable to attend groups or were sufficiently cognitively impaired so that s/he could not benefit from the active psychiatric treatment offered. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 Part I)

VIII. Ensure that medical staff assessed and treated the medical problems of 2 discharged patients (E1 and E2) reviewed for medical care, in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health. (Refer to B125 Part II)

IX. Ensure that staff provided sufficient hours of active treatment, including groups, individual sessions, and therapeutic activities especially on evening hours and weekends for all patients on the geriatric unit with a census of 21 patients. There were only 3 hours of activities were scheduled each day. These activities were leisure-focused. The only treatment-focused group, "Life Skills" conducted by social work staff on weekdays, was not being provided. No treatment activities were scheduled in the evenings. Failure to provide sufficient active treatment potentially results in patients being hospitalized without the level and intensity of treatment needed to achieve their optimum level of functioning prior to discharge. (Refer to B125-III)

X. Ensure that medical staff provided a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, and treatments provided for 3 out of 5 discharged patients (D2, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan with providers providing follow-up care. (Refer to B133)

Interviews

During an interview with the Medical Director on 9/24/14 at 8:20 a.m., he stated that he had been in the role of Medical Director for approximately one month. He stated that no communication had occurred between the previous Medical Director and himself about ongoing monitoring, concerns, quality assurance, or other issues being monitored and addressed by the previous Medical Director. The Medical Director stated that issues involving patient care were only reported to him directly by nursing staff working on the unit. He stated if there was an issue, "nursing staff would have to tell me about it." He stated that he did not review incident reports, medication variances, or other individual or aggregated data to monitor patient care and the performance of staff. He stated the Director of Nursing had the responsibility for reviewing incidents and issues of patient care and outcome and that he had no involvement. He stated that he had not reviewed the medical care provided to Patient 3 and Patient 18 or reviewed the patient care provided by the hospital to Patient 3 and Patient 18 prior to their deaths.

Based on record review and interview, the Director of Nursing failed to ensure:

1. The MTPs for eight (8) of eight (8) active sample patients (3, 9. 13, 14, 17, 18, 19, and 20) identify nursing goals and interventions that were individualized, has specific frequency for care and were assigned a primary responsible person for compliance and accountability. These failures can result in fragmented nursing care, non-compliance with planned treatment interventions, and lack of accountability putting the patient at risk for adverse treatment outcomes. (See B121, B122, and B123)

A. Interview

In an interview on 9/23/14 at 12:15 p.m., the treatment plans were discussed with the
Director of Nursing. She stated she is aware there are problems with the plans and that she is working on the total revamping of the treatment plans. She agreed that nursing goals were not individualized and interventions were generic nursing staff functions and primary responsible nursing staff were not assigned to interventions.

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

I. Ensure that social work staff provided social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (3, 9, 13, 14, 17, 18, 19, and 20). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that social work interventions on treatment plans stated specific treatment modalities with a frequency of contact and a specific focus or purpose of treatment based on the each patient's individual problems and goals for eight (8) of eight (8) active sample patients (3, 9, 13, 14, 17, 18, 19, and 20). Instead, MTPs included identical routine social work discipline functions and/or generic vague and global statements of a treatment focus written as treatment interventions. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review (MTP dates in parenthesis)

1. Patient 3 (9/17/14)

For the problem of "Agitation/disruptive behavior/impulse control AEB; hitting staff, combative with personal care & hits other pt (patient)," the social services interventions stated "Arrange follow up care as appropriate for discharge" and "Provide 1:1 to de-escalate PRN."

2. Patient 9 (9/14/14)

For the problem of "agitation/disruptive behavior/impulse control AEB per report from NH - pt. was exhibiting aggressive/combative behaviors," the social services interventions stated "Educated pt. and family regarding diagnosis," "Arrange follow up care as appropriate for discharge, " and " Provide 1:1 to de-escalate PRN."

3. Patient 13 (8/27/14)

For the problem of "Impaired mobility and/or fall risk AEB: h/o (history of) falls," the social services intervention stated "Arrange follow up as appropriate for discharge."

4. Patient 14 (9/20/14)

For the problem of "Altered perceptions of reality/delusional thoughts AEB: stating that someone came and raped [him/her]," no social work interventions were documented.

5. Patient 17 (9/4/14)

For the problem "Altered perceptions of reality/delusional thoughts AEB: various delusions," the social services interventions stated "Pt./family will have no further questions regarding diagnosis prior to discharge" and "Follow up care will be discussed with Pt./family prior to discharge." For the problem "Anxiety AEB," the social services interventions stated "Educated pt. and family regarding diagnosis," "Arrange follow up care as appropriate for discharge," and "Provide 1:1 to de-escalate PRN."

6. Patient 18 (8/10/14)

For the problem of "Altered perceptions of reality/delusional thoughts AEB: Pt. states that FBI caused the rash on [his/her] legs and that we should asked (sic) FBI for any information regarding [him/her]," the social services interventions stated "Educated pt. and family regarding diagnosis," "Arrange follow up care as appropriate for discharge," and "Assess for hallucinations and delusional thinking."

7. Patient 19 (9/10/14)

For the problem of "Agitation/disruptive behavior/impulse control AEB:," no social work interventions were documented.

8. Patient 20 (9/5/14)

For the problem of "Agitation/disruptive behavior/impulse control AEB: Patient is agitated and threatening other patients," the social services interventions stated "Pt. /family will have no further questions regarding diagnosis prior to discharge" and "Follow up care will be discussed with Pt. /family prior to discharge."

These interventions were not individualized and are social work tasks rather than specific interventions for Patients 3, 9, 13, 14, 17, 18, 19, and 20.

B. Interview

During an interview with the Director of Social Work on 9/23/14 at 3:10 p.m., she acknowledged that the social work interventions on the MTP's were generic and not specific to patient needs of Patients 3, 9, 13, 14, 17, 18, 19, and 20.