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Based on observation, interview, and record review, the facility failed to ensure activity spaces open to the corridor were protected by a smoke detection system, to ensure each door protecting corridor openings had a working, suitable means for staying closed, to ensure window opening to the corridor had a window, to ensure smoke barriers were free of penetrations, to ensure a door opening in the smoke barrier had a door, to ensure self-closing doors to a hazardous area could self-close,to have installed a supervisory attachment installed to each of the control valves per NFPA 101, 9.7.2, to ensure they had spare sprinkler heads of the type in use, to ensure each damper was tested, to ensure each smoke compartment with sleeping patients were free of space heaters, to ensure each means of egress was continuously maintained free of all obstructions for instant use, and to ensure its generator complied with NFPA 99 and 110. (A709) This has the potential to affect all patients in the facility.

Based on observation, staff interview and review of facility policy, the facility failed to ensure the temperature of one medication refrigerator was checked on a daily basis and to take corrective action when the temperature was out of range. This affected one of three medication refrigerators inspected. The census at the time of the survey was 63.

Findings include:

Facility policy Routine Patient and Unit Assessment (NUR 2.42) was reviewed. Per policy, "the 11-7 shift checks the refrigerator and freezer thermometers at 0200 HRS and records on the Refrigerator Temperature Record."

1. The medication refrigerator on Oldham unit was observed on 07/18/16 at 1:35 PM. The temperature reading was not recorded for the day yet. The refrigerator contained insulin and vials of ativan.

Review of the posted Refrigerator/Freezer Temperature Record for the same unit revealed on 10 of 17 days in July when the temperature was checked, it was out of the acceptable range of 36 to 46 degrees Fahrenheit.

Further review of the Refrigerator/Temperature Record revealed a "Note" to "notify the pharmacy if Medication Refrigerator temperatures are not within the appropriate ranges." The Record also contained a section entitled Corrective Action. Step one (1) instructed staff to "first adjust the thermostat. Wait an hour and recheck the temperature."

Per Step two (2), "if the reading is still outside the acceptable range, check the thermometer to make sure it is working properly."

Step three (3) instructed staff to notify the Nursing Supervisor and "complete a work order for maintenance." There was no evidence any of these steps were followed when reading was out of acceptable range.

Staff D was present and confirmed this finding at the time of observation.

Based on medical record review, staff interview and policy review, the facility failed to ensure a history and physical examination was completed within 24 hours of admission for every patient. This affected seven of 20 current patients whose medical records were reviewed, Patients' #6, #7, #8, #10, #16, #28 and #29. The census at the time of the survey was 63.

Findings include:

Facility policy Physical Examination (NUR 2.5) was reviewed. Per policy, "it is the policy of CBH to ensure that physical examinations will be completed by a provider within 24 hours of admission for the purpose of identifying any medical problems or conditions."

1. Patient #6 was admitted to the facility on 07/06/16 at 10:05 AM per documented Nursing Assessment. A history and physical examination was not completed until 07/07/16 at 5:35 PM, approximately 31 hours after admission. There was no documentation as to why it was not completed within 24 hours.

Staff A was made aware of and confirmed this finding on 07/19/16 at 9:45 AM.

2. Patient #7 was admitted to the facility on 07/05/16 at 4:55 PM per documented Nursing Assessment. A history and physical examination was not completed until 07/06/16 at 8:00 PM, approximately 26 hours after admission. There was no documentation as to why it was not completed within 24 hours.

Staff A was made aware and confirmed this finding on 07/19/16 2:25 PM.

3. Patient #8 was admitted to the facility on 07/10/16 at 2:39 AM per documented Nursing Assessment. A history and physical examination was not completed until 07/11/16 at 7:35 PM, approximately 44 hours after admission. There was no documentation as to why it was not completed within 24 hours.

Staff A was made aware and confirmed this finding on 07/20/16 at 8:30 AM.

4. Patient #10 was admitted to the facility on 07/14/16 at 6:31 PM per documented Nursing Assessment. As of 07/20/16 a history and physical examination had not been completed. On 07/15/16 the RN documented the patient was "unwilling to get up". On 07/16/16 the RN documented the reason for Patient #10's refusal as "no medical." And on 07/17/16 the RN again documented Patient #10 was "unwilling to get up."

There was no documentation regarding Patient #10's refusal of the history and physical on 07/18/16 or 07/19/16.

Staff A was made aware of and confirmed this finding on 07/20/16 at 9:23 AM.

5. Patient #28 was admitted to the facility on 06/29/16 per documented Nursing Assessment. A history and physical examination was not completed until 07/07/16, eight (8) days after the patient was admitted. There was no documentation as to why it was not completed within 24 hours.

Staff A was made aware of and confirmed this findings on 07/20/16 at 2:58 PM.

6. Patient #29 was admitted to the facility on 07/17/16 at 7:00 PM per documented Nursing Assessment. A history and physical examination was not completed until 07/19/16, at unknown time. There was no documentation as to why it was not completed within 24 hours.

Staff A was made aware of and confirmed this findings on 07/21/16 at 8:30 AM.


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7. Review of the medical record for Patient #16 on 07/19/16 revealed an admission date of 06/24/16 with the History and Physical dated as completed on 06/26/16. There was no documentation of the patient refusing to have the History and Physical completed or the reason it was not completed within 24 hours.

Staff B was unable to locate why it was not completed within 24 hours in the medical record on request.

Based on observation, policy review and staff interview, the facility failed to ensure no expired medications were available for patient use. This affected one of three nursing unit medication refrigerators observed. The census at the time of the survey was 63.

Findings include:

Facility policy Medication Storage Area Inspections (PHR-30) was reviewed. Per policy, pharmacy will inspect each location where medications are stored on a regular basis. We will remove any medications that are expired or will expire in the next three months."

1) The medication refrigerator on Fletcher unit was observed on 07/18/16 at 1:41 PM. Twelve pre-filled influenza vaccines (0.5 ml dose) were stored inside. The vaccines expired on 06/30/16.

Staff D was present and confirmed this finding at the time of observation.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients at the facility.

Findings include:

K17 Failed to ensure activity spaces open to the corridor were protected by a smoke detection system
K18 Failed to ensure each door protecting corridor openings had a working, suitable means for staying closed.
K19 Failed to ensure window opening to the corridor had a window
K25 Failed to ensure smoke barriers were free of penetrations
K27 Failed to ensure a door opening in the smoke barrier had a door
K29 Failed to ensure self-closing doors to a hazardous area could self-close
K61 Failed to have installed a supervisory attachment installed to each of the control valves per NFPA 101, 9.7.2
K62 Failed to ensure they had spare sprinkler heads of the type in use
K67 Failed to ensure each damper was tested
K70 Failed to ensure each smoke compartment with sleeping patients were free of space heaters
K72 Failed to ensure each means of egress was continuously maintained free of all obstructions for instant use
K144 Failed to ensure its generator complied with NFPA 99 and 110

Based on observation, interview and policy review, the facility failed to ensure staff performed hand hygiene after performing a blood glucose check for one (Patient #6) of two blood glucose checks observed and failed to ensure staff performed hand hygiene after cleansing a patient's wound for one (Patient #20) of one dressing changes observed. The facility failed to screen one patient (Patient #7) out of 23 medical record reviews for Tuberculosis in accordance with the facility's policy. The census at the time of the survey was 63.

Findings include:


The facility's Precision Xtra Glucose Monitoring policy was reviewed. The policy stated staff are to remove gloves and wash hands after performing patient glucometer testing.


1. On 07/19/16 at 11:30 AM, an observation was conducted of Staff E performing a blood glucose check and Insulin administration to Patient #6. The glucometer had three pieces of tape affixed to the glucometer. Staff E was observed performing the blood glucose check, removing gloves and donning a clean pair of gloves for the Insulin administration. Staff E did not perform hand hygiene after removing the gloves following the blood glucose check and before administering Insulin to Patient #6.

The findings were shared with Staff A immediately following the observations and confirmed.


2. Facility TB (tuberculosis) Prevention Program was reviewed. Per the program, "every patient upon admission to CBH shall receive 2 step tuberculosis testing within 5 days of admission..."

Patient #7 was to have a "2 Step Mantoux 0.1 ml intradermally per admission- repeat in 10 days" per admission orders dated 07/05/16. As of 07/19/16 Patient #7 had not received the test.

On 07/11/16 the physician wrote an order to "send pt for chest X-ray", noting Patient #7 had a history of TB.

Patient #7 was then sent for a chest X-ray on 07/18/16, seven (7) days after physician order.

Staff A was made aware of and confirmed these findings on 07/19/16 at 3:15 PM.




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3. Observation of the dressing change for Patient #20 was completed on 07/21/16 and revealed a skin lesion located on the upper back. Staff C was observed washing hands appropriately before starting the procedure. Staff C donned gloves, cleaned the affected area with normal saline, used a paper towel to wipe down and dry the area. Staff C then proceeded to open the triple antibiotic ointment tube (without removing soiled gloves, cleansing hands, and then donning new clean gloves) and place ointment on a q-tip, Staff C then opened the Band-Aid to cover the lesion.

A request was made to Staff B for procedure on dressing changes, Staff B stated that none was available.

Interview with Staff C completed on 07/21/16 at 9:20 AM revealed paper towels out of the dispenser have been used in the past but individually packaged gauze is available for use.





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Based on record reviews and staff interviews, the facility failed to develop Master Treatment Plans (MTPs) that identified patient specific and individualized treatment interventions by the physician and the nursing staff for eight (8) of eight (8) sample patients (F1, F2, F3, K1, K2, M1, M2 and M3). The Master Treatment Plans included generic functions of the staff disciplines in psychiatry and nursing instead of patient specific and individualized interventions based on patients' needs. Such failure resulted in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed, resulting in prolonged stay.

Findings Include:

A. Record Review:

Review of all the eight (8) sample patients' (F1, F2, F3, K1, K2, M1, M2 and M3) Master Treatment Plans revealed that the plans included lists of generic physician and nursing interventions for the listed problems of "Suicidal impulses", "Psychotic symptoms", "Substance abuse", "Anxiety", "Depressed mode and Danger to self". The interventions were the same or similar for each patient having one or more of these identified problems.

1. Patient F1: For the problem "Anxiety" MTP dated 6/21/16 listed the following interventions.

Physician: "Prescriber to prescribe medications, monitor side effects, and adjust dosage to stabilize mood and minimize side effects. This will occur once per day and will last ten minutes".

Nursing: "Nurse will dispense medications and monitor and record compliance, mood and side effects. This will occur 100¿ (percent) of the time per day and will last length of stay".

For the problem "Psychotic Symptoms" MTP dated 6/21/16 listed the following interventions.

Physician: "Prescriber will educate patient (patient's family) as to the risk and benefits of treatment and obtained informed consent, if appropriate". "This will occur once per day and will last ten minutes".

Nursing: There was no nursing intervention listed for this problem.

2. Patient F2: For the problem "Substance Abuse" MTP dated 6/23/16 listed the following interventions.

Physician: "Prescriber examine patient, assess condition and determine if MEDICATION[sic] is appropriate in the treatment of this patient's substance abuse". This will occur one per day and will last ten minutes".

Nursing: "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes". (b) Nurse will FOCUS AND REDIRECT[sic] patient when behavior becomes disorganized". "This will occur as needed per shift and will last ten minutes". (c) "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes".

For the problem: "Anxiety" MTP dated 6/21/16 listed the following interventions.

Physician: "Prescriber will prescribe medications, monitor side effect, and adjust dosage to prevent anxiety symptoms and stabilize the patient". "This will occur once per day and will last ten minutes".

Nursing: There was no nursing intervention listed for this problem.


3. Patient F3: For the problem "Substance abuse" MTP dated 6/22/16 listed the following interventions.

Physician: "Prescriber examine patient, assess condition and determine if MEDICATION[sic] is appropriate in the treatment of this patient's substance abuse". This will occur one per day and will last ten minutes".

Nursing: "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES[sic]". "This will occur 1-4 times per day and will last for ten minutes". (b) Nurse will FOCUS AND REDIRECT[sic] patient when behavior becomes disorganized". "This will occur as needed per shift and will last ten minutes".

For the problem "Danger to self" MTP dated 6/22/16 listed the following interventions.

Physician: "Prescriber will prescribe medications, monitor side effect, and adjust dosage to extinguish suicidal impulses". "This will occur once per day and will last ten minutes".

Nursing: Nurse will help FOCUS AND DIRECT[sic] patient when anger or self-injurious behavior begins". "This will occur immediately per day and will last as occur". "Nursing staff will engage in conversation and encourage appropriate VERBALIZATION OF FEELINGS instead of dangerous behavior". "This will occur 1-3 times per day and will last ten minutes".


4. Patient K1: For the problem "Anxiety" MTP dated 6/20/16 listed the following interventions.

Physician: "Prescriber will prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD[sic] and minimize side effects". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS[sic]". "This will occur daily per shift and will last to tolerance".

For the problem "Subst. (substance) abuse" MTP dated 6/20/16 listed following interventions.

Physician: Physician: "Prescriber examine patient, assess condition and determine if MEDICATION[sic] is appropriate in the treatment of this patient's substance abuse". This will occur one per day and will last ten minutes".

Nursing: "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES[sic]". "This will occur daily per shift and will last to tolerance".

For the problem "Impulse Control" MTP dated 6/20 /16 listed following interventions.

Physician: "Prescriber to prescribe medications, monitor side effects, and ADJUST DOSAGE TO STABILIZE[sic] impulse control problems". "This will occur once per day and will last ten minutes".

Nursing: "Nurse will actively engage patient and encourage participation I ACTIVITIES". "This will occur daily per shift and will last to tolerance".

5. Patient K2: For the problem "Substance abuse" MTP dated 6/16/16 listed following interventions.

Physician: "Prescriber will EDUCATE[sic] patient (patient's family) as to the risks and benefits of treatment and obtain informed consent if appropriate". "This will occur one per day and will last ten minutes".

Nursing: "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur daily per shift and will last as indicated".

For the problem "Anxiety" MTP dated 6/16/16 listed the following interventions.

Physician: "Prescriber will prescribe medications, monitor side effect, and adjust dosage to prevent anxiety symptoms and stabilize the patient". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS[sic] ". "This will occur daily per shift and will last to tolerance".

For the problem "Depressed Mood" MTP dated 6/16/16 listed the following interventions.

Physician: "Prescriber will prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD[sic] and minimize side effects". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance".

6. Patient M1: For the problem "Anxiety" MTP dated 6/22/16 listed the following interventions.

Physician: Prescriber to prescribe medications, monitor side effect, and adjust dosage to prevent anxiety symptoms and stabilize the patient. This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance".

For the problem of "Depressed Mood" MTP dated 6/22/16 listed the following interventions.

Physician: Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD [sic] and minimize side effects". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance".

For the problem of "Subst. (substance) Abuse" MTP dated 6/22/16 listed the following interventions.

Physician: Physician: "Prescriber examine patient, assess condition and determine if MEDICATION[sic] is appropriate in the treatment of this patient's substance abuse". This will occur one per day and will last ten minutes".

Nursing: Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes". "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES [sic]". "This will occur daily per shift and will last to tolerance".

7. Patient M2: For the problem "Anxiety" MTP dated 6/16/16 listed the following interventions.

Physician: Prescriber to prescribe medications, monitor side effect, and adjust dosage to prevent anxiety symptoms and stabilize the patient. This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance".

For the problem of "Depressed Mood" MTP dated 6/16/16 listed following interventions.
Physician: Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD[sis] and minimize side effects". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance".
For the problem of "Subst. (substance) Abuse" MTP dated 6/16/16 listed following interventions.

Physician: "Prescriber examine patient, and order consultations and lab as needed to arrive at the appropriate DIAGNOSES[sic] and order MEDICATION[sic], as appropriate". This will occur one per day and will last ten minutes".

Nursing: "Nurse to dispense medication, monitor and record compliance, side effects, and response to treatment". "This will occur once per shift and will last ten minutes".

8. Patient M3: For the problem of "Anxiety" MTP dated 6/16/16 listed the following interventions.

Physician: Prescriber to prescribe medications, monitor side effect, and adjust dosage to prevent anxiety symptoms and stabilize the patient. This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance".

For the problem of "Depressed Mood" MTP dated 6/16/16 listed the following interventions.

Physician: "Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD[sis] and minimize side effects". "This will occur once per day and will last ten minutes".

Nursing: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". "Nurse will actively engage patient and encourage participation in ACTIVITIES [sic]". "This will occur daily per shift and will last to tolerance".

For the problem of "Subst. (substance) Abuse" MTP dated 6/16/16 listed the following interventions.

Physician: "Prescriber examine patient, and order consultations and lab as needed to arrive at the appropriate DIAGNOSES[sic] and order MEDICATION[sic], as appropriate". This will occur one per day and will last ten minutes".

Nursing: "Nurse will ADMINISTER MEDICATION [sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes".

B. Interviews

1. In the interview on 6/29/16 at approximately 2:05 p.m. with the Medical Director physician's interventions in the sample patients MTP s was discussed. The Medical Director agreed that the interventions were not individualized and stated "they are general".

2. In the interview on 6/29/16 At approximately 10:00 a.m. with the Nurse Consultant and the Acting Director of Nursing, the nursing interventions on the sample patients MTP's was discussed. Both the consultant and Acting DON agreed that the interventions were not individualized to meet the patient's specific treatment needs. The Nurse consultant stated they are aware of the problems with the treatment plans and had planned to start training the staff that Tuesday, but have postponed the training as a result of the survey. Training is rescheduled for the up-coming week.

Based on record review and staff interview, the Medical Director failed to ensure that the Master Treatment Plan of eight (8) of eight (8) sample active patients (F1, F2, F3, K1, K2, M1, M2 and M3) included specific and individualized psychiatric interventions for the problems listed. Such failure resulted in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed, resulting in prolonged stay. (Refer to B122)

Based on interview and document review, the Nursing Director failed to ensure nursing interventions were included in the Master Treatment Plans (MTPs) based on the individual needs of eight (8) of eight (8) active sample patients (F1, F2, F3, K1, K2, M1 M2, and M3). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery. (Refer to B122)

1. For problem: "Suicidal impulses" Patient F1 MTP dated 6/21/16 interventions stated, "Nurse will dispense medications and monitor and record compliance, mood and side effects. This will occur 100¿ (percent) of the time. per day and will last length of stay".

For problem: "Psychotic symptoms" there was no nursing intervention listed for this problem.

2. For problem: "Substance abuse" Patient F2 MTP dated 6/23/16 interventions stated, "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes". (b) Nurse will FOCUS AND REDIRECT[sic] patient when behavior becomes disorganized". "This will occur as needed per shift and will last ten minutes". (c) "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes". For problem "Anxiety" There was no nursing intervention listed for this problem.

3.. For problem: "Substance abuse" Patient F3 MTP dated 6/22/16 interventions stated, "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES[sic]". "This will occur 1-4 times per day and will last for ten minutes". (b) Nurse will FOCUS AND REDIRECT[sic] patient when behavior becomes disorganized". "This will occur as needed per shift and will last ten minutes".

For problem: "Danger to self " interventions stated, "Nurse will help FOCUS AND DIRECT patient when anger or self-injurious behavior begins". "This will occur immediately per day and will last as occur". "Nursing staff will engage in conversation and encourage appropriate VERBALIZATION OF FEELINGS instead of dangerous behavior". "This will occur 1-3 times per day and will last ten minutes".

4. For problem: "Anxiety" Patient K1 MTP dated 6/20/16 interventions stated, "Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS[sic]". "This will occur daily per shift and will last to tolerance". For problem "Subst. (substance) abuse" interventions stated, "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES[sic]". "This will occur daily per shift and will last to tolerance".
For problem: "Impulse Control" interventions stated, "Nurse will actively engage patient and encourage participation I ACTIVITIES[sic]". "This will occur daily per shift and will last to tolerance".

5. For problem: "Substance abuse" Patient K2 MTP dated 6/16/16 interventions stated, "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur daily per shift and will last as indicated". For problem: "Anxiety" intervention stated, "Nursing staff will engage in conversation and encourage VERBALIZATION OF FEELINGS[sic]". "This will occur daily per shift and will last to tolerance". For problem: "Depressed Mood" interventions stated: "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance".

6.For the problem: "Anxiety" Sample patient M1 MTP dated 6/22/16 interventions stated, "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance". For the problem of "Depressed Mood", interventions stated, "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". "Nursing staff will engage in friendly conversation and ENCOURAGE SOCIALIZATION[sic] with other patients and in activities". "This will occur daily per shift and will last to tolerance". For the problem of "Subst. (substance) Abuse" interventions stated, "Nurse will ADMINISTER MEDICATION[sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes". "Nurse will actively engage patient and encourage participation in therapeutic ACTIVITIES [sic]". "This will occur daily per shift and will last to tolerance".

7. For the problem "Anxiety" Sample patient M2 MTP dated 6/16/16 interventions stated: "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". For the problem of "Depressed Mood", interventions stated, "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". For the problem of "Subst. (substance) Abuse" interventions stated as: "Nurse to dispense medication, monitor and record compliance, side effects, and response to treatment". "This will occur once per shift and will last ten minutes".

8. For the problem "Anxiety" Sample patient M3 MTP dated 6/16/16 interventions stated, "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". For the problem of "Depressed Mood", interventions stated, "Nursing staff will engage in conversation and encourage VERBILIZATION OF FEELINGS [sic]". "This will occur daily per shift and will last to tolerance". "Nurse will actively engage patient and encourage participation in ACTIVITIES [sic]". "This will occur daily per shift and will last to tolerance". For the problem of "Subst. (substance) Abuse" interventions stated, "Nurse will ADMINISTER MEDICATION [sic] for substance abuse and or withdrawal symptoms and monitor and record compliance, symptoms and side effects". "This will occur once per shift and will last ten minutes".

B. Interviews

1. In the interview on 6/29/16 At approximately 10:00 a.m. with the Nurse Consultant and the Acting Director of Nursing, the nursing interventions on the sample patients MTP's was discussed. Both the consultant and Acting DON agreed that the interventions were not individualized to meet the patient's specific treatment needs. The Nurse consultant stated they are aware of the problems with the treatment plans and had planned to start training the staff that Tuesday, but have postponed the training as a result of the survey. Training is rescheduled for the up-coming week.