HospitalInspections.org

Based on record review and staff interview, the facility failed to consistently develop long term and short term goals stated as behavioral outcomes and written as observable measurable patient behaviors to be achieved for 6 of 8 active sample patients (A1, A2, A3, A4, A5 and A6). This failure results in staff being unable to clearly measure patient goal achievement.

Findings include:

A. Record Review

1. Patient A1: In a treatment plan dated 12/10/10, goals included:
LTG (long term goal):
"[Pt A1] will demonstrate a reduction in his preoccupied behavior and disorganized thought process and be able to formulate a reasonable plan for self care by discharge."
STG (short term goals):
"[Pt A1] will demonstrate improvement in insight and judgment by 12/24/10"
"[Pt A1] will verbalize a progressive decrease in the frequency and/or intensity of grandiosity within 5-7 days"
"[Pt A1] will learn medication compliance"
These goals failed to be written as measurable behavioral outcomes.

2. Patient A2: In a treatment plan dated 12/13/10, goals included:
LTG:
"[Pt A2] will...demonstrate a reduction in her disorganized thought process and unstable mood by discharge"
STGs:
"[Pt A2] will verbalize and demonstrate a sense of personal control by 12/27/10"
"[Pt A2] will verbalize and demonstrate increasing mood stability by 12/27/10"
"[Pt A2] will demonstrate decreased delusional thought by making reality based statements by 12/27/10"
These goals failed to be written as measurable behavioral outcomes.

3. Patient A3: In a treatment plan dated 12/06/10, goals included:
LTG:
"[Pt A3] will demonstrate a reduction in her irritable mood and difficulty processing information by discharge"
STGs:
"[Pt A3] will verbalize and demonstrate a sense of personal control by 12/20/10"
"[Pt A3] will demonstrate improvement in insight and judgment by 12/20/10"
"Pt will learn to gain insight into the dangers of drug abuse"
These goals failed to be written as measurable behavioral outcomes.

4. Patient A4: In a treatment plan dated 12/03/10, goals included:
LTG:
"[Pt A4} will...demonstrate a reduction in his disorganized thought process and paranoid behavior by discharge."
STGs:
"[Pt A4] will verbalize a progressive decrease in the frequency and/or intensity of paranoid delusion within 5-7 consecutive days by 12/17/10"
"[Pt A4] will recognize signs of increasing restlessness and approach staff for assistance by 12/17/10"
These goals failed to be written as measurable behavioral outcomes.

5. Patient A5: In a treatment plan dated 12/08/10, goals included:
LTG:
"[Pt A5] will demonstrate a reduction in his withdrawn, isolative, and sad mood; and be able to formulate a reasonable plan for self care by discharge."
STGs:
"[Pt A5] will recognize signs of increasing sad mood and approach staff for assistance by 01/05/10 [sic]"
"[Pt A5] will increase social interaction with peers"
These goals failed to be written as measurable behavioral outcomes.

6. Patient A6: In a treatment plan dated 12/06/10, goals included:
LTG:
"[Pt A] will demonstrate a reduction in his paranoid delusions and visual hallucinations by discharge."
STGs:
"[Pt A6] will verbalize a progressive decrease in the frequency and/or intensity of paranoid delusions and visual hallucinations within 5-7 days by 01/03/11"
"[Pt A6] will demonstrate improvement in insight and judgment by 01/03/11"
"[Pt A6] will increase efforts to maintain grooming and hygiene efforts from 4x-7x per [sic]"
"[Pt A6] wants to go to his Aunt's upon discharge to clean up his moments"
These goals failed to be written as measurable behavioral outcomes.

B. Interview

In an interview conducted on 12/21/10 at 3:00PM, after reviewing the treatment plans with the surveyor, the Director of Nursing reported that she could see the need for the goals to be stated in measurable behavioral terms, and that many of the goals for patients on the adult unit were not currently stated in that manner.

Based on record review and staff interviews, the treatment teams failed to consistently identify treatment modalities, specifying the frequency and focus of each modality for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, B2 and B7) when writing treatment plan interventions. The written interventions on the MTPs were routine discipline functions and practices instead of individualized interventions for patients. This failure impairs the staff's ability to provide consistent approaches and focused treatment for the problems that require the patient to be in the acute care hospital.

Findings include:

A. Record Review

1. Patient A1: In a treatment plan dated 12/10/10, the following interventions were included:
"Monitor and document the presence, absence and content of grandiosity as evidenced by verbalizations and/or gestures"
"Provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"[Pt A1] will attend 1-2 level "A/B", 30-45 minutes each, 5-6 days per week.
Level "A" O.T. groups (exercise, sea, ADL, Life skills, soc (social) game, soc skills)
Level "B" O.T. Groups (exercise...Life skills, str mngmt [stress management], soc [social] games, soc skills, values, leisure ed [education])"
These interventions failed to name specific modalities with the specific purpose for the patient.

2. Patient A2: In a treatment plan dated 12/13/10, the following interventions were included:
"Provide the patient with opportunities to demonstrate self-control"
"Discuss the impact the patient's behaviors and verbal messages have on others, and encourage the use of more appropriate interacting styles"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"[Pt A2] will attend 2-3 groups per day, 5x-6x per week for at least 30 minutes"
These interventions failed to name specific modalities with the specific purpose for the patient.

3. Patient A3: In a treatment plan dated 12/06/10, the following interventions were included:
"Provide patient with opportunities to demonstrate self-control"
"Provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"Social worker will be encouraged to attend AA/NA program in AIP (adult inpatient program) 1x a eeek [sic]"
"Social worker will search for county funded treatment program for women"
"Patient will attend 1-2 rehab treatment groups per day for 30 minutes, 5-6 days a week"
These interventions failed to name specific modalities with the specific purpose for the patient.

4. Patient A4: In a treatment plan dated 12/03/10, the following interventions were included:
"Monitor and document the presence, absence and content of grandiosity as evidenced by verbalizations and/or gestures"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"Social worker will assist patient in restructuring his irrational beliefs by reviewing reality based evidence and patient's misinterpretations."
"Social worker will reinforce the patient's socially and emotionally appropriate responses to others"
"Patient will attend 1-2 groups, for 15 minutes or longer, 5-6 times per week"
These interventions fail to name specific modalities with the specific purpose for the patient.

5. Patient A5: In a treatment plan dated 12/08/10, the following interventions were included:
"Continue to encourage patient to remain out of his room and participate in milieu activities"
"Encourage patient to approach staff when feeling sad"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"[Pt A5] will increase peer interaction from 2x-4x per day by actively participating in groups"
"[Pt A5] will attend 2-3 groups, for the full duration, 5-6 times a week"
"[Pt A5] will attend AA meetings once a week"
These interventions failed to name specific modalities with the specific purpose for the patient.

6. Patient A6: In a treatment plan dated 12/06/10, the following interventions were included:
"Monitor and document the presence, absence and content of paranoid delusions and visual hallucinations as evidenced by verbalizations and/or gestures"
"Continue to encourage patient to remain out of his room and participate in milieu activities"
"Continue to provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
"Physician will: Explain the risks and benefits of medication or alternative treatments,
Initiate psychotropic intervention and titrate as needed"
"Social worker will provide supportive therapy, encouraging patient to bathe and dress appropriately. Social worker will provide positive and/or constructive feedback"
"Patient will attend 1-2 level "A" group sessions per day for a duration of 15 minutes or longer. Level "A" OT groups (Exercise, sea, ADL, Life skills, str mngmt, soc games, soc skills"

These interventions failed to name specific modalities with the specific purpose for the patient.

7. Patient B2: In a treatment plan dated 12/06/10, the following interventions were included:
"Psychiatrist will: Explain the risks and benefits of medications or alternative treatments to patient and parent"
"Nursing will: Ensure safe environment every shift; closely monitor/document frequency & precursors of self harm thoughts or symptoms to establish baseline and maintain safety; Administer medications per MD's orders, monitor & document response & side effects and notify MD; give positive reinforcements for goals met through points, verbal praise and tangible reward"
"OT (Occupational therapy) and DT (drama therapy) groups for ages 5-9, 1-2 hours per day, 5x-6x per week"
These interventions failed to name specific modalities with the specific purpose for the patient.

8. Patient B7: In a treatment plan dated 12/06/10, the following interventions were included:
"Psychiatrist will: Explain the risks and benefits of medications or alternative treatments to patient and parent"
"Nursing will: Ensure safe environment every shift/SPII; closely monitor/document frequency & precursors of self harm thoughts or symptoms to establish baseline and maintain safety; Administer medications per MD's orders, monitor & document response & side effects and notify MD; give positive reinforcements for goals met through points, verbal praise and tangible reward"
"OT (Occupational therapy) and DT (drama therapy) groups for ages 10-12, 1-2 hours per day, 5x-6x per week"
These interventions failed to name specific modalities with the specific purpose for the patient.

B. Interview

In an interview conducted 12/21/10 at 3:00PM, after reviewing the treatment plans of the sample patients, the Director of Nursing reported that she could see many of the interventions needed to be more specific in identifying the modalities and purpose as related to each individual patient's problems. She also acknowledged that, at times, the staff was identifying the basic function of the discipline as opposed to stating a specific treatment modality the discipline will offer or provide.

Based on, record review and interview, the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the medical staff. Specifically, the Medical Director failed to:

I. Ensure that long and short term goals were stated as behavioral outcomes and were written as observable measurable patient behaviors to be achieved for 6 of 8 active sample patients (A1, A2, A3, A4, A5 and A6). This deficient practice hampers the ability of the treatment team to provide goal directed treatment, to measure patient goal achievement and to determine the effectiveness of interventions, based on changes in patient behaviors. (Refer to B121)

II. Ensure that the treatment teams consistently identified treatment modalities, specifying the frequency and specific focus of the modality for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, B2 and B7) when writing the treatment plans. The written interventions on the MTPs identified routine discipline functions and practices instead of individualized interventions for patients. This failure impairs staff's ability to provide consistent approaches and focused treatment for the problems that require the patient to be in the acute care hospital. (Refer to B122)

Based on record reviews and interviews, the Director of Nursing failed to ensure that nursing staff consistently identified specific nursing interventions on the Master Treatment Plans of 8 of 8 sampled patients (A1, A2, A3, A4, A5, A6, B2 and B7), specifying the frequency and specific focus of the modality for each patient. Failure to specify nursing interventions on treatment plans results in lack of direction for nurses in providing care for patients.

Findings include:

1. Patient (Pt) A1 treatment plan dated 12/10/10 included the following nursing interventions:
"Monitor and document the presence, absence and content of grandiosity as evidenced by verbalizations and/or gestures"
"Provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
These interventions failed to name specific modalities with frequency and specific purpose for the patient.

2. Patient A2's treatment plan dated 12/13/10 included the following interventions:
"Provide the patient with opportunities to demonstrate self-control"
"Discuss the impact the patient's behaviors and verbal messages have on others, and encourage the use of more appropriate interacting styles"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
These interventions failed to name specific modalities with frequency and specific purpose for the patient.

3. Patient A3's treatment plan dated 12/06/10 included the following interventions:
"Provide patient with opportunities to demonstrate self-control"
"Provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
These interventions failed to name specific modalities with frequency and specific purpose for the patient.

4. Patient (Pt) A4's treatment plan dated 12/03/10 included the following interventions:
"Monitor and document the presence, absence and content of grandiosity as evidenced by verbalizations and/or gestures"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"

These interventions failed to name specific modalities with frequency and specific purpose for the patient.

5. Patient A5's treatment plan dated 12/08/10 includes the following interventions:
"Continue to encourage patient to remain out of his room and participate in milieu activities"
"Encourage patient to approach staff when feeling sad"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
"Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
These interventions failed to name specific modalities with frequency and specific purpose for the patient.

6. Patient A6's treatment plan dated 12/06/10 includes the following interventions:
"Monitor and document the presence, absence and content of paranoid delusions and visual hallucinations as evidenced by verbalizations and/or gestures"
"Continue to encourage patient to remain out of his room and participate in milieu activities"
"Continue to provide the patient with realistic feedback regarding symptoms"
"Nursing will encourage patient to participate in all appropriate scheduled groups"
Nursing will administer all prescribed medications"
"Teach/review/document patient medication symptoms, name, dosage, frequency, adverse reaction, medication compliance"
These interventions failed to name specific modalities with frequency and specific purpose for the patient.

7. Patient B2's treatment plan dated 12/06/10 includes the following interventions:
"Nursing will:
Ensure safe environment every shift; closely monitor/document frequency & precursors of self harm thoughts or symptoms to establish baseline and maintain safety; Administer medications per MD's orders, monitor & document response & side e3ffects and notify MD; give positive reinforcements for goals met through points, verbal praise and tangible reward"
These interventions failed to name specific modalities with the frequency and specific purpose for the patient.

8. Patient B7's treatment plan dated 12/06/10 includes the following interventions:
"Nursing will: Ensure safe environment every shift/SPII; closely monitor/document frequency & precursors of self harm thoughts or symptoms to establish baseline and maintain safety; Administer medications per MD's orders, monitor & document response & side effects and notify MD; give positive reinforcements for goals met through points, verbal praise and tangible reward"
These interventions failed to name specific modalities with the frequency and specific purpose for the patient.

B. Interview

In interview conducted 12/21/10 at 3:00PM, after reviewing the treatment plans with the surveyor, the Director of Nursing reported that she could see that many of the interventions needed to be more specific in identifying the modalities and purpose of the modalities as related to each individual patient's problem or problems. The DON also acknowledged that at times, nursing was identifying the basic function as opposed to stating a specific treatment modality with frequency and purpose that nursing will offer or provide.