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Based on record review and staff interviews, it was determined that the hospital failed to document neurological examinations in such a way as to verify specific testing performed in 8 of 8 active patient records (A1, A2, A3, A4, B1, B2, B3, and C1). Failure to document current status precludes future comparative re-examinations to assess the patients' ongoing functioning.

Findings include:

A. Record Review: (History and Physical dates in parentheses.)

In 8 of 8 active sample (A1(9/21/10), A2,(8/25/10), A3 (8/25/10), A4 (8/20/10), B1(9/21/10), B2 (9/19/10), B3 (9/21/10) and C1(9/20/10).) neurological examinations, Motor Function, Sensory Function, Speech and Language, and Reflexes were reported as "Normal Exam."

B. Interviews

1. In an interview on 9/22/10 at approximately 1:20p.m., the above findings were acknowledged by the Adult Program Director.

2. In an interview on 9/22/10 at approximately 3:45p.m., the above findings were acknowledged by the Hospital Medical Director.

Based on record review and interviews, it was determined that the psychiatric evaluations for 7 of 8 active sample patients (A1, A2, A3, A4, B2, B3 and C1) did not report memory functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A1 (admitted 9/17/10). The psychiatric evaluation dated 9/18/10 stated that the patient could not be assessed consequent to "lack of cooperation on his part." Subsequent Psychiatrist progress notes did not mention follow up attempts to assess memory function.

2. Patient A2 (admitted 9/13/10). The psychiatric evaluation dated 9/14/10 did not mention assessment of memory function

3. Patient A3 (admitted 8/25/10). The psychiatric evaluation dated 8/25/10 did not mention assessment of memory function.

4. Patient A4 (admitted 8/20/10). The psychiatric evaluation dated 8/21/10 did not mention assessment of memory function.

5. Patient B2 (admitted 9/17/10). The psychiatric evaluation dated 9/18/10 reported "the patient did not cooperate to do anymore cognitive other testing particularly in the interest of his recent complaint of having memory problems." Subsequent Psychiatrist progress notes did not mention follow up attempts to assess memory function.

6. Patient B3 (admitted 9/20/10). The psychiatric evaluation dated 9/22/10 at 8:15a.m.did not mention memory assessment. A mini mental status examination performed prior to admission by a mental health tech not under the supervision of a physician reported a score but did not address memory findings.

7. Patient C1 (admitted 9/19/10 at 1:59p.m.). The admitting psychiatric note dated 9/20/10 at 11:24a.m.did not mention memory function.

B. Interviews

1. In an interview on 9/22/10 at approximately 1:20p.m., the above findings were acknowledged by the Adult Program Director.

2. In an interview on 9/22/10 at approximately 3:45p.m., the above findings were acknowledged by the Hospital Medical Director.

Based on record review and interview, the facility failed to provide Master Treatment Plans for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and C1) that identified patient-related short term and long-term goals in observable, measurable, behavioral terms. The goals were generic, repetitive from patient to patient, and lacking individualization. This deficiency results in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients.

Findings include:

A. Record Review

The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (9/17/10, last updated 9/21/10); A2 (9/13/10, last updated 9/16/10); A3 (8/25/10, last updated 8/27/10); A4 (8/20/10, last updated 8/24/10); B1 (9/20/10); (B2 (9/17/10, last updated 9/18/10); B3 (9/20/10, last updated 9/21/10); and C1 (9/19/10, last updated 9/20/10). For all patients in the sample, the treatment plans contained the following goals that were generic and lacked individualization:

1. Patient A1: For the problem "Altered behavioral patterns as evidence by pt urinated on neighbor's porch," no short term goals were listed. One long term goal was "...will agree to be compliant with prescribed medication and follow up with mental health professionals."

2. Patient A2: For the problem "Psychotic thought processes," the listed goals were "Compliance with prescribed medication daily"; "Actively participate in groups and interact daily"; "Patient will participate in daily sessions with the Psychiatrist to assess response to treatment" and "family will participate in treatment."

3. Patient A3: For the problem "mania," the listed goals were "Compliance with prescribed medication daily"; "Actively participate in groups and interact daily"; "Patient will participate in daily sessions with the Psychiatrist to assess response to treatment" and "Family will participate in treatment."

4. Patient A4: For the problem "psychotic thought processes," a listed long term goal was "patient will agree to be compliant with prescribed medication and follow up with mental health professionals."

5. Patient B1: For the problem "depression," the listed goals were "Patient will actively participate in groups daily"; "Patient will participate in daily sessions with the Psychiatrist to assess response to treatment"; "patient will take medications daily" and "By discharge patient will not be suicidal."

6. Patient B2: For the problem "depression," listed long term goals were "compliant with follow up treatment and prescribed medications" and "Patient will agree to attend all aftercare appointments."

7. Patient B3: For the problem "depression," listed goals were "patient will agree to be compliant with prescribed medication daily"; "Actively participate in groups and interact daily"; "Patient will participate in daily sessions with the Psychiatrist to assess response to treatment" and "Family will participate in treatment."

8. Patient C1: For the problem "depression," listed goals were "patient will agree to be compliant with prescribed medication daily"; "Patient will participate in daily sessions with the Psychiatrist to assess response to treatment" and "Family will participate in treatment."

B. Interviews:

1. In an interview on 9/22/10 at approximately 1:20p.m., the above findings were acknowledged by the Adult Program Director.

2. In an interview on 9/22/10 at approximately3:45p.m., the above findings were acknowledged by the Hospital Medical Director.

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTP) for 8 of 8 sample patients (A1, A2, A3, A4, B1, B2, B3, and C1) which included interventions with specific modalities and focus (purpose), based on the each patient's individual problems and goals. The MTPs included generic and routine discipline functions written as treatment interventions instead of specific modalities to address treatment goals listed. In addition, the intervention statements did not specify the frequency or duration of contact with the patient for one of the intervention statements assigned to Registered Nurses (RN) and all of those assigned to the Social Worker, Art Therapist, and Recreational Therapist. These deficiencies potentially result in lack of guidance to staff in providing consistent and effective treatment related to goals identified on the treatment plans.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (9/17/10, last updated 9/21/10); A2 (9/13/10, last updated 9/16/10); A3 (8/25/10, last updated 8/27/10); A4 (8/20/10, last updated 8/24/10); B1 (9/20/10); (B2 (9/17/10, last updated 9/18/10); B3 (9/20/10, last updated 9/21/10); and C1 (9/19/10, last updated 9/20/10).

1. For all sample patients, the treatment plans contained the following identical routine and generic Registered Nurses and Physicians functions instead of specific and individualized interventions to assist patients to accomplish treatment goals. There were no other interventions listed. One of the intervention statements assigned to the RN did not include the frequency and duration of contact with the patient.

a. Nursing: "Administer medications as ordered daily." "Encourage daily group attendance participation."

b. Physician: "Psychiatrist will assess patient daily for response to therapeutic modalities (see physician progress notes)."

2. The treatment plans contained the following routine and generic interventions assigned to social workers and recreational therapists. The statements also did not include the frequency or duration of contact planned for each intervention.

a. Social Work:

Patient A4 - "To encourage healthy coping skills, reality orientation, and advocate for patient safety."

Patient B2 - "Contact pt's [patient's] family, assess level of functioning, support and assistance with treatment and discharge planning."

Patient B3 - "To Contact pt's [patient's] husband to assess the structure and level of involvement, obtain information to assist with treatment and discharge planning, and provide updates regarding pt's [patient's] progress with treatment and readiness for discharge."

b. Recreational Therapy:

Patient A1- "To provide patient with the opportunity to participate in reality based leisure activities to help orient him to person, place and time."

Patient A2 - "To provide patient with the opportunity to participate in reality based leisure activities to improve positive social interactions."

Patient A4 - "To provide patient with the opportunity to participate in reality based leisure activities."

B. Interviews

1. In an interview on 9/21/10 at 10:50a.m., after reviewing the treatment plan of Patient A2, RN #2 acknowledged that there were no RN interventions except for administering medication.

2. In an interview on 9/21/10 at 11:49a.m., RN #3 stated, "I am not involved in patient education. I give patient information about their medication when we give medications."

3. In an interview on 9/22/10 at 9:20a.m., after reviewing the treatment plan for Patient A1 and A3, Adult Unit Nurse Manager acknowledged that the treatment plans interventions for nurses were generic nursing functions rather than specific interventions to assist the patients with presenting problems. She confirmed that the frequency section for interventions on the treatment plans was not completed. She stated, "The admitting nurse initiates the plan using the electronic medical records. They can easily change interventions to be more specific." The Adult Unit Nurse Manager demonstrated how the electronic medical record could be changed to include the treatment modality, focus of treatment, and frequency and duration of contact.

4. In an interview on 9/22/10 at 2:30p.m., the treatment plans for Patient A1, A2, A3, and A4 were reviewed with the Adult Program Director, Adult Nurse Manager, and Director of Nursing. They acknowledged that intervention statements were routine and generic and RNs and other clinical staff did not document the frequency or duration of contact with the patient.

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

I. Provide sufficient alternative active treatment measures for 1 of 4 patients (A2) on the Intensive Treatment Unit (ITU) who refused or was unwilling to participate in the scheduled active treatment program, and 2 of 3 sample patients (B1 and B3) on the Adult Psychiatric Unit (APSY) who were not permitted, due to their risk status, to participate in their scheduled active treatment programs held off unit. This deficiency results in potential delays of improvement in the patients' level of function and their subsequent discharge.

II. Revise the treatment plan to reflect active treatment measures to address the aggressive and disruptive behaviors of 1 of 4 patients (A2) on the Intensive Treatment Unit who had multiple episodes of seclusion. In addition, the facility failed to complete the required documentation consistently regarding Patient A2's episodes of seclusion. This results in the failure to use consistent alternatives and approaches to prevent and/or reduce the use of seclusion. It also potentially delays patients' movement to least restrictive levels of supervision, thereby delaying discharge.

Findings include:

I. Lack of Alternative Active Treatment measures

A. Patient A2

1. Observations

a. During an observation on the ITU on 9/21/10 at 10:06a.m., Patient A2 was lying in his bed during the time of his scheduled "Community Meeting." No staff efforts to engage the patient in conversation were observed.

b. During an observation on the ITU on 9/21/10 at 11:00a.m., Patient A2 was lying in his bed during the time of his scheduled "Physical Fitness." The patient refused when staff asked him to attend. No alternative activity was offered or provided.

c. During an observation on the ITU on 9/21/10 at 1:10p.m., Patient A2 was lying in his bed during the time of his scheduled "Group Art Therapy". No staff efforts to engage patient in conversation were observed.

d. During an observation on the ITU on 9/21/10 at 2:15p.m., Patient A2 was in his bed during the time his scheduled "Group Therapy." No staff efforts to engage the patient in conversation were observed.

2. Record Review

a. The admission psychiatric evaluation dated 9/14/10 stated that Patient A2 was a 49 -year-old male admitted on 9/13/10.

b. Patient A2's "Treatment Plan," initiated 9/13/10 and last updated on 9/16/10, identified the patient's problem as "Psychotic Thought Process: Hallucinations as evidenced by patient actively responding to internal stimuli and posturing in the hallway..." The listed interventions were: "Group Art Therapy to assist pt [patient] in decreasing hallucinations, improving reality orientation, safely expressing feelings, and developing positive coping skills through therapeutic art tasks"; "Group Therapy to allow pt [patient] to process his thoughts and feelings in a therapeutic environment and assist pt [patient] with reality orientation" and "Physical Fitness to provide patient with the opportunity to participate in reality based leisure activities to improve positive social interactions." Even though the medical record documented that Patient A2 failed to attend the majority of his planned treatment activities, as of 9/22/10 his treatment plan was not revised to address his lack of participation in treatment.

c. Review of the electronic medical record revealed documentations that Patient A2 did not attend Group Art Therapy, Group Therapy, and Physical Fitness on 9/15/10, 9/16/10, 9/17/10, 9/20/10, and 9/21/10, and did not attend Physical Fitness on 9/15/10, 9/18/10, 9/20/10, and 9/21/10. There was no documentation by group leaders and/or other clinical staff noting that Patient A2 was provided alternative active treatment measures such as individual sessions.

3. Interviews

a. In an interview on 9/21/10 at 2:00p.m., Activity Therapist AT #2 stated that Patient A2 had not been attending group. Upon inquiry about individual sessions or other alternative active treatment measures, AT #2 stated, "We are not required to do individual treatment."

b. In an interview on 9/22/10 at 12:45p.m., attending Physician #2 acknowledged that Patient A2 was not provided alternative active treatment measures and the treatment plan was not revised to include planned individual sessions with the patient. Attending Physician #2 noted that the patient has had multiple hospital admissions and had not participated in the Unit's group sessions during these admissions. He stated that the patient's behaviors (isolating, little or no interactions with others, menacing gaze) are considered baseline and that significant changes in the patient's behavior were not expected.


B. Patients B1 and B2

1. Observation

Sample patients B1 and B3 were observed on the Adult Psychiatric Unit on 9/21/10 at approximately 1:30p.m. Patient B3 was sleeping in a chair in the group room, and patient B1 was talking to a staff person at the nursing station. Both patients' treatment plans listed the "Physical Fitness" group (taking place in the gymnasium at that time) as an expected intervention modality.

2. Record Review

The Treatment Plans of B1 (dated 9/20/10) and B-3 (dated 9/20/10) listed "physical fitness" as an intervention.

3. Interviews

a. On 9-21-10 at 1:20p.m., the RT supervisor conducting the physical fitness activity was asked where other patients from adult program were. He responded that they were restricted to the unit, had refused, or were preparing for discharge. All patients were listed as assigned to the physical fitness activity. The RT supervisor also stated that there is no alternative activity scheduled for patients restricted to the unit and unable to attend off unit activities.

b. In an interview on 9/21/10 at 1:30p.m., when asked whether patients unable or unwilling to attend an off unit therapeutic activity were offered an alternative therapeutic activity on the unit, RN #1stated that the patients were free to use the group room for games if they chose. RN #1 added, "The time is free time."

c. In an interview on 9/21/10 at 1:45p.m., the surveyor asked patient B3 whether she had been offered an organized activity since she was restricted to the unit. She stated that she had not.

II. Failure to revise treatment plan to address aggressive behaviors

A. Observation

During an observation on 9/22/10 at 11:00a.m., Patient A3 was observed being monitored while in seclusion. The patient was screaming and banging on the door.

B. Record Review

1. A review of the "Manual Hold/Seclusion/Restraint REVIEW & DEBRIEFING" Form in the medical record revealed that patient A3 had experienced multiple episodes (7) of seclusion. The review revealed the following information regarding the dates of and reason for seclusion:

8/28/10 (8:00 a.m. to 8:45 a.m.) for "Threatening to physically hurt peers and staff. Refused/unable to de-escalate."

9/10/10 (12:00a.m. to 4:00a.m.) for "Patient threatening staff, Agitated."

9/15/19 (1:15p.m. to 3:30p.m.) for "Yelling, screaming, threatening to harm others."

9/16/10 (5:45p.m. to 9:45p.m.) for "Threatening others, swinging at staff and others."

9/20/10 (8:20a.m. to 9:15a.m.) [Section entitled; "Behavior Necessitating Manual Hold, Seclusion or Restraint" was left blank].

9/20/10 (1:15 p.m. to 3:35 p.m.) for "Disruptiveness; Screaming and yelling."

9/22/10 (8:20 a.m. to 5:20 p.m.) [Section entitled; "Behavior Necessitating Manual Hold, Seclusion or Restraint" was left blank].

2. A review of the Master Treatment Plan for patient A3, initiated 8/25/10 and last updated on 8/27/10, revealed that the clinical staff had not revised the plan to address aggressive behavior or outline strategies to reduce the episodes of seclusion.

C. Policy Review

A review of the facility's policy and procedure for seclusion and restrained (Date of origin: 4/1982; last revision date 4/2010) revealed the following requirement: "Use of seclusion and restraint is also discussed in treatment team meetings and attempts to eliminate the need for these interventions are addressed in the patient's/resident's treatment plan."

D. Interviews

1. In an interview on 9/23/10 at 9:05a.m., the "Treatment Team Review/Update" notes were reviewed with the Adult Unit Nurse Manager to determine whether Patient A3's episodes of seclusions had been discussed, documented, and addressed. The Nurse Manager confirmed that there was no evidence that reflected a review by the treatment team for the seclusions that occurred on 9/10/10 at 12:00a.m.; 9/15/19 at 1:15p.m.; 9/16/10 at 5:45p.m.; 9/20/10 at 8:20a.m. and 1:15p.m. She acknowledged that the treatment plan had not been revised to reflect alternatives to seclusion for this patient.

2. In an interview on 9/23/10 at approximately 9:45a.m., the seclusion episodes documented for Patient A3 were discussed with the Director of Nursing, the Program Director for Adults, and the Director of Quality Management. All of these Directors acknowledged that the process for patients experiencing multiple episodes of seclusion needed to be improved. The Program Director for Adults noted that episodes of seclusion are generally discussed during the "Huddle" [A daily morning meeting with Psychiatrists and Charge Nurses (Monday -Friday)] but acknowledged that there was no follow through to revise the treatment plan, document the discussion in the medical record, or share possible alternatives with psychiatric technicians.

Based on record review and interview, it was determined that the Medical Director failed to assure the:
I. Documentation of neurological examinations in such a way as to verify specific testing performed in 8 of 8 active patient records Failure to document current status precludes future comparative re-examinations to assess the patients' ongoing functioning. (Refer to B109)

II. Documentation of mental status examinations includes the specific testing performed in assessing memory function in 7 of 8 active patient records. This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

III. Provision of treatment plans that identified patient-related short term and long-term goals in observable, measurable, behavioral terms in 8 of 8 active records. The goals were generic, repetitive from patient to patient, and lacking individualization. This deficiency results in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

IV. Provision of alternative active treatment measures for 1 of 4 patients (A2) on ITU and 2 of 3 patients (B1 & B3) on APSY. This deficiency results in potential delays of improvement in the patients' level of function and their subsequent discharge. (Refer to B125-I)

V. Revision of the treatment plan to reflect active treatment measures to address the aggressive and disruptive behavior of 1 of 4 patients (A2) in the sample. In addition, the facility failed to complete the required documentation consistently, regarding Patient A2's episodes of seclusion. This results in the failure to use consistent alternatives and approaches to prevent and/or reduce the use of seclusion. It also potentially delays patients' movement to least restrictive levels of supervision, thereby delaying discharge. (Refer to B125-II).

Based on observation, record review, and interview, the Director of Nursing (DON) failed to:

I. Provide sufficient monitoring to ensure that nursing interventions on the treatment plans of 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and C1) addressed patients' individualized presenting problems and treatment goals. The treatment plans only included routine and generic nursing functions that were inappropriately listed as treatment interventions (modalities). In addition, one of these intervention statements did not specify the frequency or duration of contact with patient. These deficiencies potentially result in lack of guidance to staff in providing consistent and effective treatment related to goals identified on the treatment plans.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (9/17/10, last updated 9/21/10); A2 (9/13/10, last updated 9/16/10); A3 (8/25/10, last updated 8/27/10); A4 (8/19/10, last updated 8/24/10); B1 (9/20/10); (B2 (9/17/10, last updated 9/18/10); B3 (9/20/10, last updated 9/21/10); and C1 (9/19/10, last updated 9/20/10).

For all of the above patients, the treatment plans contained the following identical routine, generic nursing functions written as interventions instead of individualized interventions to assist patients accomplish their treatment goals. There were no other interventions listed.

Nursing: "Administer medications as ordered daily." "Encourage daily group attendance participation."

B. Staff Interviews

In an interview on 9/22/10 at 2:30p.m., the treatment plans for Patient A1, A2, A3 and A4 were reviewed with the Adult Program Director and Director of Nursing. Both Directors acknowledged that the intervention statements on the treatment plans were routine and generic nursing functions.

II. Assure that nursing staff revised the treatment plan to reflect active treatment measures to address the aggressive and disruptive behavior of 1 of 4 patients (A2) in the sample who had multiple episodes of seclusion. In addition, the nursing staff failed to consistently complete the required documentation regarding Patient A2's episodes of seclusion. This results in the failure to use consistent alternatives and approaches to prevent and/or reduce the use of seclusion. It also potentially delays patients' movement to least restrictive levels of supervision, thereby delaying discharge. (Refer to B125-II)