HospitalInspections.org

The hospital failed to ensure patients' rights for personal privacy were provided (See A Tag 143).

The registered nurse failed to supervise and evaluate the nursing care of a patient observed in restraint (see Tag A 395); and, the registered nurse failed to assign nursing care of a patient observed in restraints in accordance with the patient's special needs and the specialized qualifications and competence of the nursing staff available (see Tag A 397).

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

I. Provide the identification of patient specific physician roles on the individual written plans for 7 of 10 records reviewed (Patients G2, G4, G5, B1, B3, B4, and B5). This failure results in the necessity for staff to rely on oral communication of treatment focus. (See B118) (See also B121, B122, and B123)

II. Provide for 10 of 10 active sample patients (G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5) an active therapeutic program or purposeful alternative interventions for significant periods of time during their hospital stay (including evening hours and weekends). This lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them in a timely manner, potentially delaying their improvement. (See B125)

III. Ensure the provision of patient discharge summaries were completed in a timely manner as defined by hospital policy requirements for five (5) of 11 discharged patients (Patients D7, D8, D9, D10, and D11). These five (5) discharge records were all from the forensic Unit N1. This deficiency compromises the effective transfer of the patient's care to the next care provider. (See B133)

Based on observation, staff interview and record review it was determined the hospital failed to ensure patients' rights for personal privacy were provided. This deficient practice was observed in two (2) of three (3) units toured (C 1, G 1) and involved a total of nine (9) patients who were observed to be assigned to alternative rooms (patients # 11, 12, 13, 14, 15, 16, 17, 18 and 19). This failure results in a violation of personal privacy rights for all patients assigned to and receiving treatment in rooms designed for use other than a bedroom. It also has the potential to violate personal privacy rights of all patients who are forced to share the bathroom in their assigned bedroom with other patients who have no bathroom or shower facilities. Additionally, all patients have the right to receive examination and treatment in a private setting and the failure to maintain personal privacy for treatments can have a potentially negative impact on the care and condition of all other patients who are exposed.

Findings include:

1. An observation was conducted on the C 1 Unit from approximately 11:20 a.m. through 11:50 a.m. on 1/10/17. A large window enclosed room in the back hallway was observed. The windows were partially covered with window contact paper. From the hallway the surveyors visualized patient #11 in restraints lying on the bed farthest from the door. The surveyors could observe the uncovered patient to be in five (5) point restraints. Her shirt was pulled up with her abdomen exposed. A staff member was observed to be sitting in a chair inside the room behind the door. Patient #12 was observed in a bed directly behind the staff member. The surveyors knocked lightly, opened the door and identified themselves.

The staff member in the room was asked to identify herself. She gave her name and stated she was a Health Service Assistant (HSA). HSA #1 was observed to be holding a clipboard containing restraint flowsheets on patient #11. She was asked why the patient was being restrained, why she was being restrained in a room where she could be visualized from the hallway and why she was being restrained in the presence and close proximity to another patient. She was also asked if the patient had received an IM (intramuscular injection) of medication during the restraint episode. HSA #1 stated she just came back from lunch and didn't get a report of why patient #11 was restrained nor did she know if the patient was medicated. She also stated both patient #11 and 12 were assigned to this room due to over-bedding (more patients than bedrooms available on the unit). She confirmed the glass enclosed room was the room assigned to these two (2) patients.

The surveyors then went to the nurse's station and knocked on the locked door. A staff member opened the door and identified the woman at the desk as the nurse in charge. The surveyors identified themselves to the staff member at the desk and asked her name. She identified herself as the registered nurse. When asked if she was the nurse currently in charge of the floor, she stated, 'yes'. The surveyors' questions and observations related to patient #11 and 12 were shared with the Charge Nurse. She stated she didn't know anything about what was going on with the patient. She was requested to provide the surveyors with a copy of her Patient Unit Group (PUG) Schedule which is the daily nursing worksheet. The PUG was noted to have a few hand written notations on it. She refused to provide a copy of her PUG with the handwritten notes, but did provide a blank copy of the PUG to surveyors. The Charge Nurse stated patients #11, 12, 13, 14 and 15 had been assigned to alternative rooms on the C 1 Unit since admission because the unit had more patients than available bedrooms.

2. Review of the clinical records for above noted patients revealed admission dates as follow:

Patient #11: admit date 12/27/16.
Patient #12: admit date 1/4/17.
Patient #13: admit date 1/8/17.
Patient #14: admit date 1/6/17.
Patient #15: admit date 1/10/17.

3. Patients #13 and #14 were observed in another glass enclosed room in the front hallway of the C 1 Unit which was identical to the room utilized for patients #11 and 12. Patient #15 was observed to be sleeping in the seclusion room. None of the rooms had storage for patient clothing or personal belongings. None of the rooms had attached bathrooms or privacy curtains. The seclusion room had a toilet room next door but no shower facilities. The observations and concerns related to the lack of personal privacy observed with all the patients housed in rooms not designed for patient use were discussed.

4. An interview was conducted with the Lead Nurse when she returned from lunch (at approximately 11:47 a.m.). She confirmed the C 1 Unit was over-bedded and that patients are routinely housed in rooms which are not designed as patient bedrooms and have no bathroom and shower facilities.

The Lead Nurse stated she had not yet entered the notes related to the restraint episode in the clinical record for patient #11 but confirmed she received an IM injection of medication at the initiation of the restraint episode. A later review of the clinical record revealed the injection was administered in the patient's hip.

The Lead Nurse agreed patients #11, 12, 13, 14, and 15 could not be provided personal privacy in the alternative rooms they were assigned to. When asked about bathroom access for these patients, she stated they all used the single toilet in the room beside the seclusion room. When asked about access to showering she stated each hallway had a patient room with a bathroom designated for use by the over-bedded patients. This practice results in four (4) to five (5) patients sharing the use of the shower in the patient room. The patients assigned to rooms not designed as patient bedrooms would be required to travel down the hallway and enter the bedroom of another patient to access the assigned shower.

The Lead Nurse was asked about the housekeeping protocol to ensure cleaning of the bathroom/shower rooms shared by multiple patients. She stated nursing had no such protocol or process for cleaning the shared spaces. She acknowledged patients' personal privacy rights were not being met.

5. Observation was conducted on the G 1 Unit from approximately 1:10 p.m. to 1:30 p.m. on 1/10/17. Patients #16, 17 and 18 were observed to be sleeping in two (2) glass enclosed rooms which were not designed as patient bedrooms. Patient #19 was observed to be sleeping in the seclusion room. The rooms were identical to the rooms observed and utilized in the C 1 Unit and violated the personal privacy rights of patients.

6. On 1/10/17 at 1:21 p.m. the Lead Nurse confirmed the G 1 Unit was also over-bedded. She confirmed the unit was also utilizing rooms which were not designed as patient bedrooms and lacked personal storage space, bathrooms, showers and accommodation for personal privacy. The Nurse Manager stated it was a bad situation and acknowledged the practice interferes with the provision of personal privacy for patients.

Based on observation, staff interview and record review it was determined the registered nurse failed to supervise and evaluate the nursing care for one (1) of one (1) patients observed in restraints (patient #11). This failure increases the risk for an adverse outcome to any and all patients who are placed in restraints.

Findings include:

1. An observation was conducted on the C 1 Unit from approximately 11:20 a.m. through 11:50 a.m. on 1/10/17. A large window enclosed room in the back hallway was observed. The windows were partially covered with window contact paper.

From the hallway the surveyors visualized patient #11 in restraints lying on the bed farthest from the door. The surveyors could observe the uncovered patient to be in five (5) point restraints.

A staff member was observed to be sitting in a chair on the door side of the room. Patient #12 was observed in a bed directly behind the staff member. The surveyors knocked lightly, opened the door and identified themselves.

The staff member in the room identified herself upon request and stated she was a Health Service Assistant (HSA). HSA #1 was observed to be holding a clipboard containing restraint flowsheet documentation on patient #11 and indicated she was responsible for restraint monitoring. The patient was noted to have a few drops of a dark substance on the right front side of her sweatpants, over the thigh area, which had the appearance of blood.

The HSA was asked why the patient was being restrained, why she was being restrained in a room where she could be visualized from the hallway, why the patient was restrained in the presence and close proximity to another patient (patient #12) and if the patient was medicated during the course of the restraint. HSA #1 stated she just came back from lunch and didn't get a report of why the patient was restrained and didn't know if the patient had been medicated. She also stated both patients #11 and 12 were assigned to the room due to over-bedding and confirmed this was where they routinely received care.

2. The surveyors then went to the nurse's station and knocked on the locked door. A staff member opened the door and identified the woman at the desk as the nurse in charge. The surveyors identified themselves to the staff member and she identified herself as a registered nurse. When asked if she was the nurse currently in charge of the floor, she stated, 'yes'.

The surveyors' observations and questions related to patient #11 and 12 were shared with the Charge Nurse. She stated she didn't know anything about what was going on with the patient in restraints. She stated she was not on the floor when the restraint was initiated. The Charge Nurse stated the Lead Nurse, who was now off the floor at lunch, had initiated the restraint and she had not received any report prior to her leaving for lunch.

The Charge Nurse was observed to be holding a Patient Unit Group (PUG) Schedule which is the daily nursing worksheet The PUG was observed to have a few handwritten notations on it. A copy of the PUG was requested from the Charge Nurse. She refused to provide her copy with the notations on it but provided a blank copy of the PUG. She was then asked to provide the surveyors access to the clinical record notes for patient #11 regarding the restraint. She stated no notes had been entered into the record yet and she was unable to answer any questions about the patient's care and condition.

3. The surveyors' observations and concerns with lack of nursing supervision and oversight were discussed with the Lead Nurse when she returned to the unit at approximately 11:47 a.m. She stated she did not know why the Charge Nurse stated she did not know anything about what was going on with the patient being restrained. She confirmed patient #11 received IM (intramuscular) administration of medication just prior to her leaving the unit for lunch. She also confirmed she had not yet completed any documentation related to the restraint episode.

When asked her assessment of the performance of the Charge Nurse, the Lead Nurse acknowledged she had received recent complaints from staff regarding her failure to come out from behind the desk to assist staff with patient care. She acknowledged the nursing staff response to the surveyors' questions about care was inadequate, and stated she could not understand nor explain it.

4. An interview was conducted with the Chief Nursing Officer (CNO) at approximately 3:00 p.m. on 1/11/17. The above noted observations were shared and discussed. The CNO stated the lack of nursing supervision and oversight was not acceptable and indicated it would be addressed and corrected.

Based on observation, staff interview and record review it was determined the registered nurse failed to assign the nursing care of one (1) of one (1) patients observed in restraints in accordance with the patient's needs (patient #11). This failure results in an increased risk for an adverse event for any and all patients who are restrained.

Findings include:

1. An observation was conducted on the C 1 Unit from approximately 11:20 a.m. through 11:50 a.m. on 1/10/17. The windows were partially covered with window contact paper. From the hallway the surveyors visualized patient #11 in restraints lying on the bed farthest from the door. A staff member was observed to be sitting in a chair on the other side of the door. Patient #12 was observed in a bed directly behind the staff member. The surveyors knocked lightly, opened the door and identified themselves.

The staff member in the room was asked to identify herself. She gave her name and stated she was a Health Service Assistant (HSA). HSA #1 was observed to be holding a clipboard containing restraint flowsheets on patient #11. She was asked why the patient was being restrained, why she was being restrained in a room with another patient where she could be visualized from the hallway and whether she had been medicated. HSA #1 stated she just came back from lunch and didn't get a report of why the patient was restrained nor did she know if the patient had been medicated.

2. The job description for Health Service Assistant (HSA) was requested and provided. Job descriptions for both HSA serving as 'Programmer' and HSA serving as 'Charge' were provided and reviewed. Both job descriptions were dated 3/2011 and stated, in part: "The Health Service Assistant...under the direction of the Charge Nurse monitors the patients' physical and emotional well-being and reports unusual behavior or physical ailments to the appropriate staff."

3. The surveyors' observations and questions related to patient #11 and 12 were shared with the Charge Nurse. She stated she didn't know anything about what was going on with the patient in restraints. She stated she was not on the floor when the restraint was initiated and that the Lead Nurse, who was now off the floor at lunch, had initiated the restraint and did not give her a report prior to her leaving for lunch.

The Charge Nurse was observed to be holding a Patient Unit Group (PUG) Schedule which is the daily nursing worksheet The PUG was observed to have a few handwritten notations on it. A copy of the PUG was requested from the Charge Nurse. She refused to provide her copy with the notations on it but provided a blank copy of the PUG. She was then asked to provide the surveyors access to the clinical record notes for patient # 11 regarding the restraint. She stated no notes had been entered into the record yet and she was unable to answer any questions about the patient's care and condition.

Based on medical record review and staff interview, the facility failed to meet professional social work standards that included conclusions and recommendations that described anticipated social work roles in patient treatment and discharge planning. As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions by the social work staff and the treatment team. In all 10 records reviewed (G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5) there were no social work assessments that included conclusions and recommendations for treatment.

FINDINGS INCLUDE:

A. MEDICAL RECORDS

1. Patient G1was admitted on 9/13/16 with a diagnosis of "Major Depressive Disorder, Recurrent, Severe" noted on the psychiatric evaluation dated 9/14/16. The psychosocial history dated 9/15/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

2. Patient G2 was admitted on 12/28/16 with a diagnosis of "Bipolar Disorder, Most Recent Episode Manic" noted on the psychiatric evaluation dated 12/28/16. The psychosocial history dated 1/1/17 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

3. Patient G3 was admitted on 4/30/14 with a diagnosis of "Bipolar Disorder" listed on the initial psychiatric evaluation dated 5/9/14 and updated 11/2/16. The psychosocial history dated 4/29/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

4. Patient G4 was admitted on 12/13/16 with a diagnosis of "Antisocial Personality Disorder with Borderline Personality Traits" listed on the psychiatric evaluation dated 12/14/16. The psychosocial evaluation dated 12/15/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

5. Patient G5 was admitted on 12/19/16 with a diagnosis of "Schizophrenia" listed on the psychiatric evaluation dated 12/21/16. The psychosocial evaluation dated 12/21/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

6. Patient B1 was admitted on 10/31/16 with diagnoses of "Schizoaffective Disorder, Bipolar Type; History of Polysubstance Dependence" listed on the psychiatric evaluation dated 10/31/16. The psychosocial evaluation dated 11/1/16/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

7. Patient B2 was admitted on 3/2/16 with a diagnosis of "Schizophrenia, Paranoid Type /Schizoaffective Disorder with Paranoia" listed on the psychiatric evaluation dated 3/3/16. The psychosocial evaluation dated 3/7/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

8. Patient B3 was admitted on 7/14/16 with a diagnosis of "Bipolar Disorder, Most Recent Episode, Manic" listed on the psychiatric evaluation dated 7/14/16. The psychosocial evaluation dated 7/19/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

9. Patient B4 was admitted on 12/27/16 with diagnoses of "Major Depression; Bipolar Depression; Seasonal Depression Component " listed on the psychiatric evaluation dated 12/27/16. The psychosocial evaluation dated 12/29/16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

10. Patient B5 was admitted on 4/27/14 with diagnoses of "Pervasive Developmental Disorder; Mood disorder, Not Otherwise Specified; Impulse Control Disorder, Not Otherwise Specified" listed on the psychiatric evaluation dated 4/28/16. The psychosocial evaluation dated 4/29/14 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

B. INTERVIEWS

1. In an interview on 1/10/17 at 11:20 AM Social Worker 1 concurred that the psychosocial evaluations do not contain conclusions and recommendation regarding treatment recommendations for the patients.

2. In an interview on 1/10/17 at 11:20 AM Social Worker 4 concurred that the psychosocial evaluations do not contain conclusions and recommendation regarding treatment recommendations for the patients.

3. In an interview on 1/9/17 at 12:00 PM Social Worker 2 and Social Worker 4 concurred that social histories performed by them did not contain conclusions and treatment recommendations.

Based on record review and interview, the facility failed to identify patient specific physician roles on the individual written plans for seven (7) of 10 records reviewed (Patients G2, G4, G5, B1, B3, B4, and B5). This failure results in the necessity for staff to rely on oral communication of treatment focus. See also B122, B123, and B125

FINDINGS INCLUDE:

A. RECORD REVIEW

1. Patients G5's MTP dated 12/28/16; Patient B1's MTP dated 12/21/16; Patient B3's MTP 12/29/16; Patient B4's MTP dated 12/30/16; and Patient B5's MTP dated 12/6/16 list as the physician intervention "Med [medication] rounds."

2. Patient G2's MTP 12/28/16 listed as the physician intervention "meds per orders."

3. Patient G4's MTP dated 12/19/16 listed no physician interventions.

B. INTERVIEW

In an interview on 1/10/16 at 1:50 PM, the Medical Director indicated that treatment plans should be more specific.

Based on record review, policy review, and interview, the facility failed to provide Master Treatment Plans that identified patient related Short Term Goals stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions, and may contribute to failure of the team to modify plans in response to patient needs.

FINDINGS INCLUDE:

A. MEDICAL RECORDS:

1. Patient G1 was admitted on 9/13/16 with a diagnosis of "Major Depressive Disorder, Recurrent, Severe" listed on the Master Treatment Plan (MTP) dated 12/12/16 (Current Treatment Plan). For the Problem "Trauma" the Short-Term Goal (STG) listed was "[Patient] will reduce the negative impact trauma-related symptoms have on daily functioning as evidenced by documented use of coping skills and ability to participate in ADL's, meals, and treatment by time of discharge."

2. Patient G2 was admitted on 12/28/16 with a diagnosis of "Bipolar I Disorder with Psychotic Features" listed on the MTP dated 1/03/17. For the Problem "Aggression as evidenced by paperwork accompanying patient from regional jail stating [s/he] was aggressive with staff and 'volatile' during confinement." The STG listed "[S/he] will report any increase in anxiety to medical staff and request PRN medication if necessary thereby demonstrating insight into the need for the medication and will not have any aggressive behavior for at least 5 days,"

3. Patient G3was admitted on 4/30/14 with diagnoses of "Bipolar Disorder and Cognitive Impairment due to Deafness" listed on the psychiatric evaluation dated 5/14/14. The Patient's MTP dated 12/27/16 listed for the problem "Disturbance in Mood" the following STG: "[Patient] will be compliant with treatment and report to staff when [s/he] feels [s/he] is getting angry for the next 39 days to begin in exercise self-management and to ready [himself/herself] for discharge."

4. Patient G4 was admitted 12/13/16 with a diagnosis of "Bipolar Disorder" listed on the MTP dated 12/19/16. For the Problem "disturbance in Mood" the STG listed was "[Patient] will improve [his/her] coping skills by displaying zero anger outbursts and reporting any bouts of anxiety or depression to the staff as documented in behavior notes."

5. Patient G5 was admitted on 12/1/16 with a diagnosis of "Schizophrenia, Paranoid Type" listed on the MTP dated 12/28/16. For the Problem "Substance Use," the STG listed was "[Patient] will demonstrate willingness to participate in recovery by cooperating with treatment and groups as ordered during the next 30 days to make progress toward recovery and discharge as evidenced by medical/nursing staff progress notes and group attendance."

6. Patient B1 was admitted on 10/31/16 with diagnoses of "Schizoaffective Disorder, Bipolar Type and History of Polysubstance Dependence" listed on the MTP dated12/21/16. For the Problem "Altered Thought" the STG listed was "[Patient] will have clear and organized thoughts that do not interfere with his/her daily life..."

7. Patient B2 was admitted on 3/2/16 with diagnoses of "Schizophrenia, Paranoid Type/Schizoaffective Disorder with Paranoia" listed on the psychiatric evaluation dated 3/3/16. The MTP dated 12/29/16 listed for the problem "Disturbance of Mood" the following STG: "[Patient] will agree to attend at least one group to assist with [his/her] social interaction and decrease his/her paranoia as evidenced by chart documentation and [his/her] self-report."
8. Patient B3 was admitted on 7/14/16 with a diagnosis of "Bipolar Disorder, Most Recent Episode Manic" listed on the MTP dated 12/29/16, For the problem "History of making fictitious statements" the listed STG was "[Patient] will refrain from providing inaccurate information as evident (sic) of internal records to assist in preparation to a less restrictive environment."

9. Patient B4 was admitted on 12/27/16 with a diagnosis of "Major Depression, Bipolar Depression, Seasonal Depression Component" listed on the MTP dated 12/30/16. For the problem "SUICIDAL IDEATION," the listed STG was "[Patient] will not express thoughts to harm self during [his/her] hospitalization as evidenced by chart documentation."

10. Patient B5 was admitted on 4/27/14 with diagnoses of "Pervasive Developmental Disorder, Mood Disorder, Not Otherwise Specified" listed on the MTP dated 12/6/16. For the problem "Altered Mood," the STG listed was "[Patient] will learn to recognize and manage feeling of depression, anger, and agitation in a constructive way so to reduce instances of anger, aggression and self-harm to assist with a successful discharge."

B. POLICY REVIEW

Facility policy 45.007 "Treatment Planning" states the following:
"The treatment plan shall have established long term and short-term goals for each problem. The goal will be concise, behaviorally descriptive, measurable, and specific to the patient ' s problems/needs."

C. INTERVIEWS

1. In an interview on 1/10/17 at 2:00 PM, the Director of Nursing acknowledged that the treatment plan short term goals were not observable, behavioral, and measurable.

2. In an interview on 1/11/17 at 9:30 AM, the CEO confirmed that the patient goals were not observable, measurable, or behavioral.

3. In an interview on 1/10/16 at 1:50 PM, the Medical Director indicated that treatment plans should be more specific.

Based on record review, policy review, and staff interview, it was determined that the facility failed to develop treatment interventions based on the individual needs of 10 of 10 active sample patients (Patients G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5). This failure results in staff being unable to provide direction, consistent approaches and focused treatment for patient's identified problems.

FINDINGS INCLUDE:

A. RECORD REVIEW

1. Patient G1 (master treatment plan dated 12/12/16) had the following interventions for the identified problem, "Trauma":
"Monitor/Document PTSD [post-traumatic stress disorder] stressors, as reported."
"Monitor/Document use of coping skills, when experiencing stressors."
"Medical rounds, to assess patient progress, as ordered."
"1:1 nursing/HSW [health service worker] interaction, to prompt to use self-calming and coping skills, as needed."
These interventions were not individualized and were generic, job description tasks.

2. Patient G2 (master treatment plan dated 1/3/17) had no interventions for the identified problem, "Altered Thoughts."

3. Patient G3 (master treatment plan dated 12/27/16) had the following interventions for the identified problem, "Aggression":
"Medication(s) as ordered."
"Medication education as scheduled."
"Safety checks as ordered."
"Debriefing after physical hold each incident."
"Monitor/document agitation/aggression q [every] shift."
"1:1 nursing interventions as needed."
These interventions were not individualized and were generic, job description tasks.

4. Patient G4 (master treatment plan dated 12/19/16) had the following interventions for the identified problem, "Disturbance in Mood":
"Medications as ordered."
"Monitor/document changes q [every] shift."
"1:1 interactions and encouragement as needed."
"Prompting to physician rounds as needed."
"Medication education as needed."
"Physician rounds as scheduled to educate on mental illness."
These interventions were not individualized and were generic, job description tasks.

5. Patient G5 (master treatment plan dated 12/28/16) had the following interventions for the identified problem, "Substance Abuse":
"Monitor/document cravings, as voiced."
"Monitor/document requests for PRNs, each occurrence."
"Medication, as ordered."
"Medication education, Q [every] 2 weeks."
"Medical rounds, as ordered."
"Groups, when appropriate."
These interventions were not individualized and were generic, job description tasks.

6. Patient B1 (master treatment plan dated 12/21/16) had the following interventions for the identified problem, "Suicidal Ideations":
"Monitor/document suicidal ideation/behavior Q [every] shift."
"Security Status, as ordered."
"1:1 nursing interaction, as needed."
"Provide safe environment, Q [every] shift."

These interventions were not individualized and were generic, job description tasks.

7. Patient B2 (master treatment plan dated 12/29/16) had the following interventions for the identified problem, "Altered Thoughts":
"Monitor/document altered thoughts, Q [every] shift."
"Medication, as ordered."
"Medication Education, twice monthly/as needed."
"Medical rounds, as scheduled and as needed."
"1:1 nursing interaction for support when experiencing delusions/paranoia."
These interventions were not individualized and were generic, job description tasks.

8. Patient B3 (master treatment plan dated 12/29/16) had the following interventions for the identified problem, "Altered Thoughts":
"Monitor/Document behaviors, each shift."
"1:1 nursing interaction, as needed."
"Medical rounds, weekly."
These interventions were not individualized and were generic, job description tasks.

9. Patient B4 (master treatment plan dated 12/30/16) had the following interventions for the identified problem, "Suicidal Ideations":
"Medical rounds, as scheduled."
"Safety checks, as ordered."
"Monitor/Document any threats to harm self q [every] shift."
These interventions were not individualized and were generic, job description tasks.

10. Patient B5 (master treatment plan dated 12/6/16) had the following interventions for the identified problem, "Suicidal Ideation":
"Medication orders."
"Dispense medications as ordered."
"Medication education as needed."
"Monitor/document behavior/mood q [every] shift."
"Redirection/support as needed q [every] shift."
These interventions were not individualized and were generic, job description tasks.

B. POLICY REVIEW

The facility policy No. 45.007 titled "Treatment Planning" (reviewed 12/16) stated, "Each patient admitted to Sharpe Hospital will participate in the development of an individual treatment plan based on interdisciplinary clinical assessments." The policy further stated, "Interventions shall be identified, which clearly state: date started, what is being done, who is responsible for seeing that the intervention is being done (name and credentials), and the frequency of the intervention."

C. STAFFF INTERVIEWS

1. On 1/10/17 at 2:00 PM, the Director of Nursing acknowledged that the treatment plan interventions were not individualized and were tasks that would be done for all patients.

2. On 1/11/17 at 9:30 AM, the CEO confirmed that the interventions were not individualized to address each patient's unique problems.

Based on record review, policy review, and staff interview, the facility failed to ensure that the staff member responsible for each intervention was specifically identified in 10 of 10 master treatment plans (Patients G1, G2, G3, G4, G5, B1, B2, B3, B4 and B5). This failure results in the patient and other staff being unaware of which staff person was responsible for the intervention being implemented and documented.

FINDINGS INCLUDE:

A. RECORD REVIEW

1. Patient G1 (master treatment plan dated 12/12/16) had no staff names identified for nursing interventions.

2. Patient G2 (master treatment plan dated 12/28/16) had no interventions or staff names.

3. Patient G3 (master treatment plan dated 12/27/16) had no staff names identified for nursing interventions.

4. Patient G4 (master treatment plan dated 12/19/16) had no staff names identified for nursing interventions.

5. Patient G5 (master treatment plan dated 12/28/16) had no staff names identified for nursing interventions.

6. Patient B1 (master treatment plan dated 12/21/16) had no staff names identified for nursing and activity therapy interventions.

7. Patient B2 (master treatment plan dated 12/29/16) had no staff names identified for nursing and activity therapy interventions.

8. Patient B3 (master treatment plan dated 12/29/16) had no staff names identified for nursing interventions.

9. Patient B4 (master treatment plan dated 12/30/16) had no staff names identified for nursing interventions.

10. Patient B5 (master treatment plan dated 12/6/16) had no staff names identified for nursing interventions
.
B. POLICY REVIEW

The facility policy No. 45.007 titled "Treatment Planning" (reviewed 12/16) stated, "Interventions shall be identified, which clearly state: who is responsible for seeing that the intervention is being done (name and credentials)."

C. STAFF INTERVIEWS

1. On 1/10/17 at 2:00 PM, the Director of Nursing stated, "We should have the nurses responsible identified in the interventions."

2. On 1/10/17 at 10:00 AM, the Assistant CEO stated, "Of course, the interventions should have staff names."

3. On 1/11/17 at 9:30 AM, the CEO concurred that interventions should have staff names identified.

4. On 1/10/17 at 3:00 PM, the Interim Director of Activity Therapy acknowledged that interventions should have staff names identified.

Based on document review, policy review, observations, patient interviews, and staff interviews, it was determined that 10 out of 10 active sample patients (G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5) lacked an active therapeutic program or purposeful alternative interventions for significant periods of time during their hospital stay (including evening hours and weekends). This lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them in a timely manner, potentially delaying their improvement.

FINDINGS INCLUDE:

A. DOCUMENT REVIEW

1. A review of the "Therapeutic Activity Groups" brochure revealed that there were only two (fifteen minutes each) social work groups on Saturdays and no other on unit therapeutic groups for the 6 inpatient units in the evenings or on weekends/holidays.

2. Patient B1 (admitted 10/31/16 and confined to the unit) did not attend any groups 1/3/17-1/9/17. B1 did not have documented alternative programming.

3. Patient B2 (admitted 3/2/16 and confined to the unit) did not attend any groups 1/3/17-1/10/17. B2 did not have documented alternative programming.

4. Patient B3 (admitted 7/4/16 and confined to the unit) did not attend any groups 1/9/17 or 1/10/17. B3 did not have documented alternative programming.

5. Patient B4 (admitted 12/27/16 and confined to the unit) attended one group "Stress Recognition" since admission. B4 did not have documented alternative programming.

6. Patient B5 (admitted 4/27/14 and confined to the unit) did not attend any groups 1/1/17-1/9/17. B5 did not have documented alternative programming.

7. Patient G1 (admitted 9/13/16 and confined to the unit) did not attend groups on 1/9/17 and 1/10/17. G1 did not have documented alternative programming.

8. On 1/9/17, the "Non-Attendance Monitoring Form" for Unit C1 indicated that nine (9) patients were "in bed" refusing groups and there was no documentation of alternative programming. On 1/10/16, there were eight (8) patients "in bed" on C2 who refused groups and there was no documentation of alternative programming.

9. On 1/9/17, the "Non-Attendance Monitoring Form" for Unit C2 indicated that 3 patients refused groups and there was no documentation of alternative programming. On 1/10/16, there were four (4) patients who refused group on C2 and there was no documentation of alternative programming.

10. On 1/10/17, the "Non-Attendance Monitoring Form" for Unit N1 indicated that five (5) patients refused groups and there was no documentation of alternative programming.

11. On 1/9/17, the "Non-Attendance Monitoring Form" for Unit G1 indicated that seven (7) patients were "in bed" refusing groups. There was no documentation of alternative programming. On 1/10/17, there were four (4) patients "in bed" refusing groups. There was no documentation of alternative programming.

12. On 1/9/17, the "Non-Attendance Monitoring Form" for Unit G2 indicated that 12 patients refused groups. here was no documentation of alternative programming. n 1/10/17, there were nine (9) patients refusing groups. There was no documentation of alternative programming.

B. POLICY REVIEW

The William R. Sharpe Jr. Hospital policy/procedure dated 12/16 and titled "Procedure for Patient Participation in Therapeutic Groups" stated, "The Hospital will provide therapeutic programming to the patients. In the event a patient declines to attend a therapeutic group he/she has a doctor's order to attend, staff will offer an alternative to the group participation."

C. OBSERVATIONS

1. On Unit C1 on 1/10/17 at 11:10 AM, there were four (4) patients off the unit. Three (3) patients playing cards, six (6) patients in their rooms, and 11 patients walking around in the halls. The Assistant Director of Nursing accompanied the surveyor at the time of these observations.

2. On Unit C2 on 1/10/17 at 10:40 AM, there were six (6) patients in group, four (4) patients watching television, one (1) patient walking in the hall, one (1) patient in a geriatric chair, and 10 patients were asleep. The Assistant Director of Nursing accompanied the surveyor at the time of these observations.

3. On Unit G1 on 1/9/17 at 11:15 AM, there were 11 patients in bed, seven (7) walking in the halls, and 6 watching television.

4. On Unit G2 on 1/10/17 at 10:30 AM, there were three (3) patients in group, six (6) patients watching television, six (6) patients walking around, and nine (9) patients in their rooms.

5. On 1/9/17 at 11:00 AM, the nurses and activity staff were unable to locate the schedule for groups for each of the six (6) inpatient units.

D. PATIENT INTERVIEWS

1. On 1/9/17 at 12:45 PM, Patient B4 stated, "There is not enough to do here. It is boring and there is nothing to do on the weekends."

2. On 1/9/17 at 1:00 PM, Patient B5 stated, "There is nothing to do here. I just sleep on the weekends."

3. On 1/9/17 at 1:30 PM, Patient B1 stated, "I am always bored. Hopefully, I will be discharged soon."

4. On 1/10/17 at 10:30 AM, three patients who were in a Social Work group stated, "We don't know what is scheduled. There is no schedule." Throughout the group, they were requesting information about activities/groups.

E. STAFF INTERVIEWS

1. At 12:20 PM on 1/9/17, RN2 stated, "There are no groups/activities on the unit on the weekends."

2. At 2:00 PM on 1/9/17, RN4 confirmed that there are no groups on weekends, evenings or holidays.

3. At 11:15 A.M. on 1/10/17, SW5 stated, "I cannot locate a schedule." Also, SW4 confirmed what the patients stated about not knowing when groups are scheduled.

4. At 11:30 A.M. on 1/10/17, the Director of Social Work stated, "This place is disjointed. We live the chaos day to day."

5. At 1:30 P.M. on 1/10/17, the Director of Psychology stated, "There is no coordination of care here. The nurses will not follow through on groups."

6. At 2:00 P.M. on 1/10/17, the Director of Nursing stated, "We do not do nursing groups. It is a problem that I am trying to correct."

7. At 3:00 P.M. on 1/10/17, the Interim Director of Activity Therapy stated, "No one knows on the unit when groups are being done. Nursing does not get patients to the groups that are held. Patients are not even assigned to enough groups."

Based on record review, document review, and interview, the facility failed to ensure that patient discharge summaries were completed in a timely manner as defined by hospital policy requirements for five (5) of 11 discharged patients (Patients D7, D8, D9, D10 and D11). These five (5) discharge records were all from the forensic Unit N1. This deficiency compromises the effective transfer of the patient's care to the next care provider.

FINDINGS INCLUDE:

A. RECORD REVIEW

1. Patient D7 (discharged 10/27/16) had no discharge summary.

2. Patient D8 (discharged 11/3/16) had no discharge summary.

3. Patient D9 (discharged 11/5/16) had no discharge summary.

4. Patient D10 (discharged 11/17/16) had no discharge summary.

5. Patient D11 (discharged 12/2/16) had no discharge summary.

B. DOCUMENT REVIEW

The "William R. Sharpe, Jr. Hospital Medical staff Rules and Regulations" (Reviewed October 2016) stated on page 8: "A final dictated Discharge Summary will be completed within 14 days after the date of the discharge by the attending physician or his/her designee."

C. INTERVIEW

The Health Information Management Director stated on 1/9/17 at 1:00 PM, "There are no completed discharge summaries from Unit N1 since 9/9/16."

Based on record review, document review, and interview, the medical director failed to ensure:

I. The provision of patient specific physician roles on the individual written plans for seven (7) of 10 records reviewed (Patients G2, G4, G5, B1, B3, B4, and B5). This failure results in the necessity for staff to rely on oral communication of treatment focus. (See B118)

II. The provision for 10 of 10 active sample patients (G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5) an active therapeutic program or purposeful alternative interventions for significant periods of time during their hospital stay (including evening hours and weekends.) This lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them in a timely manner, potentially delaying their improvement. (See B125)

III. The provision of patient discharge summaries completed in a timely manner as defined by hospital policy requirements for five (5) of 11 discharged patients (Patients D7, D8, D9, D10 and D11). These five (5) discharge records were all from the forensic Unit N1. This deficiency compromises the effective transfer of the patient's care to the next care provider. (See B133).

INTERVIEW

In an interview on 1/10/16 at 1:50 PM, the Medical Director indicated that treatment plans should be more specific and there should be provision for more active treatment.

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

1. Monitor nursing interventions outlined on the treatment plans to ensure that they were individualized to address patients identified problems. (Refer to B122)

2. Ensure that nursing interventions included the names and credentials of the staff responsible for implementation. (Refer to B123)

3. Ensure that nursing groups were provided on the nursing units (including evenings, weekends and holidays) to demonstrate active programming. (Refer to B125)

Based on record review and interview, the facility failed to provide professionally designed and directed social work services in the care of 10 of 10 patients in the sample (Patients G1, G2, G3, G4, G5, B1, B2, B3, B4, and B5) and failed to provide a Social Work Director qualified to design and monitor a Social Work program. Without monitoring, there is potential for major gaps in social services provision of services for patient care. (See B108)

FINDINGS INCLUDE:

INTERVIEWS

1. In an interview on 1/10/16, SW 1 and SW4 concurred that at the present time there was not a formal director of Social Services that was responsible for professional designed and directed social work services for all social worker within the facility.

2. In an interview on 1/11/16 at 9:00 AM, the CEO concurred that the former Director of Social Work had resigned and at the time of the survey there was not a duly appointed Social Services Director.

Based on record review, interview and policy review, the Interim Director of Activity Therapy failed to:

I. Monitor therapeutic activity interventions outlined on the treatment plans to ensure that they were individualized to address patient's identified needs. (See B122)

II. Ensure that activity therapy interventions included the names and credentials of the staff responsible for implementation. (See B123)

III. Provide on unit therapeutic activities (including evenings, weekends and holidays). (See B125)