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Based on observation, record review and interview the facility failed to ensure controlled-egress lock doors released during a fire alarm test in accordance with NFPA 101 - 2012 Edition, failed to ensure exit walkways were provided with a walk surface to the public way, failed to ensure hazardous area separations were maintained, failed to maintain fire alarm smoke detectors, failed to ensure the sprinkler system, spare sprinkler head storage and combustible storage were maintained, to ensure smoke and fire barriers could resist the passage of smoke, failed to ensure rated fire door assemblies latched and failed to ensure flexible cord power strips and extension cords were maintained. (A 710) The cumulative effect of these systemic practices resulted in the facility's inability to ensure a safe environment for all 17 patients.

Based on interview and documentation review, the facility failed to have a water management program to prevent the transmission of the legionella pathogen into the environment and failed to ensure staff followed infection control practices in dietary services. (A 749) The cumulative effect of these systemic practices resulted in the facility's inability to ensure infection control for all 17 patients.

Based on interview and document review, the facility failed to ensure the governing body approved the appointments of the medical staff. This has the potential to affect all patients. This facility census was 17.

Findings include:

On 05/09/19 a review of the credentialing files for all current medical staff was completed. The review revealed the medical executive committee approved Physician X's privileges and credentials on 03/21/18 and granted on 04/14/18.

On 05/09/19 a review of the governing body meeting minutes was completed. The review revealed the governing body met on 06/28/18 and 08/13/18 without discussion of re-approving Physician X to the medical staff.

The review of Physician Y's credentialing file revealed the medical executive committee approved his privileges and credentials on 03/21/18 and granted on 5/22/18.

On 05/09/19 a review of the governing body meeting minutes was completed. The review revealed the governing body met on 06/28/18 and 08/13/18 without discussion of re-approving Physician Y to the medical the staff.

A review of Physician Z's credentialing filed revealed the medical executive committee approved his privileges and credentials on 06/06/18 and granted on 07/09/18.

On 05/09/19 a review of the governing body meeting minutes was completed. The review revealed the governing body met on 08/13/19 and again on 12/10/18 without discussion of re-approving Physician Z to the medical staff.

On 05/07/19 at 11:30 AM in an interview, Staff C confirmed the minutes did not reflect whether the governing body re-approved Physician X, Y, and Z to the medical staff.

Based on document review and interview, the facility failed to ensure its governing body held the medical staff to account for the quality of care to its patients. This has the potential to affect all patients. This facility census was 17.

Findings include:

On 05/07/19 a review of the facility's medical staff bylaws was completed on 05/09/19. The review of the bylaws revealed a basic obligation of medical staff membership is to, among other things, participate in quality assessment and performance improvement activities and that the medical director is responsible to the board of directors for "the quality and efficiency of clinical services and professional performance of the medical staff in the provision of patient care services.

A review of the facility's continuous quality improvement committee meeting minutes since 01/01/18 revealed they met monthly. The review revealed in that time, the medical director attended twice: on 01/17/18 and on 06/20/18 but none since.

On 05/07/19 at 12:03 AM in an interview, Staff C stated she believed the medical director came to the quality meetings, but couldn't remember which ones.

Based on interview and document review, the facility's governing body failed to demonstrate oversight of the facility's contracted services. This has the potential to affect all patients. This facility census was 17.

Findings include:

On 05/06/19 at 11:00 AM in an interview, Staff A stated laboratory, radiology, and pharmacy services are provided under contract.

On 05/07/19 a review of the governing body meeting minutes since 01/01/18 to 05/09/19 was completed. The review did not reveal any discussion of the services provided under contract or the approval of the contractors therein.

On 05/07/19 at 12:10 PM in an interview, Staff C confirmed the minutes did not contain any discussion of the approval of the contracts or an evaluation of the services provided therein.

Based on observation and interview, the facility failed to ensure its medical staff enforced its own bylaws and carried out all of its responsibilities. This has the potential to affect all patients. The facility census was 17.

Findings include:

On 05/07/19 a review of the facility's medical staff bylaws was completed on 05/09/19. The review revealed the creation of a professional activities committee whose function is, among other things, to assure "that all medical records meet the highest standards of patient care usefulness and of historical validity" and "medical staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events." The review revealed the committee shall ensure the medical records properly describe the condition and progress of the patient and the therapy provided.

The bylaws state the professional activities committee must have at least one representative from the medical staff.

On 05/07/19 at 12:03 AM in an interview, Staff A confirmed there is a medical record review committee that reviews records, but a member of the medical staff did not sit on it.

Based on medical staff bylaws review, record review and staff interview it was determined the facility failed to ensure all medical records were completed following a patient discharge. This has the potential to affect all patients patients discharged from the facility. The active census was 17.

Findings include:

Review of the Medical Staff By Laws signed and dated 10/27/16 states a medical record is considered to be delinquent when it has not been completed for any reason within (30) calendar days following a patient's discharge. When a Medical staff member or individual with clinical privileges has failed to complete a medical record and the record becomes delinquent, following notification, his/her clinical privileges shall be automatically suspended. The suspension shall continue until all of the individuals delinquent records are completed.

Review of the medical records revealed there were fifty-eight delinquent medical records at the time of the survey. Further, it was determined the facility lacked policy and procedure for notifying the physician for failure to complete a medical records within (30) days of a patient discharge. This finding was confirmed with Staff A on 05/08/19 at 9:32 AM.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically Chapter 19 of the applicable provisions of the 2012 existing editions of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients. This facility census was 17.

Findings include:

Please see life safety code report for more details.

1. Refer to K222 egress doors.

2. Refer to K271 discharge of exits

3. Refer to K321 hazardous areas.

4. Refer to K347 smoke detection maintenance.

5. Refer to K761 for fire door maintenance.

6. Refer to K353 maintenance of sprinkler systems.

7. Refer to K372 subdivision of smoke compartments.

8. Refer to K920 electrical equipment.

Based on observation, staff interview, and policy review the facility failed to have a water management program to prevent the transmission of the legionella pathogen into the environment and failed to follow infection control practices in dietary services. This had the potential to affect all patients receiving services at the facility. The facility census was 17.

Findings include:

1. On 05/07/19 a review of the facility's infection control documentation did not reveal a water management program.

On 05/09/19 at 2:36 PM in an interview, Staff Z said he was unfamiliar with the term "water management program" and that the facility did not have one. He explained he did sit on the environment of care committee while they do assess waste, they have not discussed the introduction of pathogens into the water system.

Review of policy and procedure for dietary services safety (revised 02/01/19) revealed refrigerator temperatures will be maintained at a range between 38 and 41 degrees Fahrenheit. Dietary staff are required to report temperature readings outside those ranges to Lead Dietary Aid (LDA) for investigation and further action. The LDA will follow proper procedure with receiving, securing, and storage of all food products from authorized vendors. This includes dry goods, non-food support supplies and accessories, and refrigerated and frozen foods. The LDA and dietary staff are responsible for the proper labeling and storage of all open food products.

2. On 05/06/19 from 2:00 PM to 2:45 PM a tour of the kitchen area revealed the following:
A. Two sleeves of large paper bags setting on the floor of the supply room.
B. Three large plastic bowls setting on a metal shelf, stacked on top of each other, were noted to have water on them.
C. A metal bowl setting on the metal shelf under the large plastic bowls were noted to have drops of water in it.
D. A large container of orange liquid was setting on the countertop with no label with content and date made.
E. A container of mayonnaise, salsa, and stir fry sauce were noted to be opened but undated in the walk-in cooler.
F. Six bottles of salad dressing, one bottle of hot sauce, and a bottle of ketchup was noted to be opened but undated in the refrigerator.

Interview with Staff B on 05/06/19 during the tour confirmed the above findings.

3. Review of the Refrigerator/Freezer Temperature Check Sheet (dated May 2019) revealed on 05/01/19 the refrigerator temperature was 45 degrees Fahrenheit (F) in the PM, on 05/02/19 the temperature was 42 degrees F in the AM and 47 degrees F in the PM, on 05/03/19 the temperature was 42 degrees F in the AM, on 05/05/19 42 degrees F in the PM, on 05/07019 the temperature was 45 degrees F in the PM, and on 05/08/19 the temperature was 44 degrees F in the PM. Documentation on the refrigerator temperature log revealed the refrigerator temperature must be between 28 and 41 degrees F. If out of range, recheck in one hour. If temperature remains out of range, re-locate the perishable products to ensure integrity, document action taken, and notify the facility director. The facility staff failed to recheck the refrigerator temperature in one hour and follow the facility process.

Interview with Staff B on 05/06/19 at 2:30 PM confirmed the above findings.

Interview with Staff G on 05/09/19 at 11:30 AM confirmed the dietary staff continued to fail to recheck the temperature of the refrigerator after 05/06/09.

Based on record review and staff interview, the facility failed to develop a written policy and procedure for organ procurement. This has the potential to affect all patients. This facility census was 17.

Findings include:

Review of the organ procurement documentation revealed no documented evidence the facility had a written policy and procedure for organ procurement responsibilities.

Interview with Staff A on 05/06/19 at 11:10 AM confirmed the facility had not developed a policy and procedure for organ procurement.

Based on medical record review and interviews, the facility failed to provide Social Work Assessments that met professional social work standards. These assessments failed to include individualized treatment recommendations that described anticipated social work roles during inpatient treatment for three (3) of eight (8) randomly sampled patients (A1, A5, and A8). In addition, three (3) of the eight (8) sampled patients' social work assessments (A2, A4, and A7) listed patient treatment goals instead of treatment recommendations. This failure has the potential to result in a lack of professional social work treatment services and/or a lack of input to the treatment team to assist in the care of the patient during hospitalizations.

Findings include:

A. Medical Records

1. Patient A1's Psychosocial Assessment (facility entitled "Child/Adolescent Assessment") dated 5/3/19, Patient A5's Psychosocial Assessment dated 3/7/19, and Patient A8's Psychosocial Assessment dated 5/3/19, in the Section, "Treatment Recommendations/Assessment Needs", all three had listed only the check box labeled "To Begin in This" with no interventions/recommendations for treatment listed.

2. Patient A2's Psychosocial Assessment dated 5/3/19, listed for treatment recommendations the following Treatment Goals rather than Treatment Recommendations:

"[Patient] will comply with the rules of PHS (Pomegranate Health System) and learn to control his/her depression and anxiety."

"[Patient] will participate in treatment planning and collaborative meetings."

"[Patient] will understand the symptoms of his/her disorder and develop appropriate coping strategies for each."

3. Patient A4's Psychosocial Assessment dated 5/2/19, listed for treatment recommendations the following Treatment Goals, rather than Treatment Recommendations:

"[Patient] will comply with the rules of PHS" and learn to work through and understand his/her depression and trauma."

"[Patient]will participate in all treatment planning and collaborative meetings."

"[Patient] will understand the symptoms of his/her disorder and develop appropriate coping strategies for each."

4. Patient A7's Psychosocial Assessment dated 4/30/19, listed for treatment interventions the following routine hospital function:

" [Patient] needs to begin therapeutic and medical services."

B. Interviews

1. In an interview on 5/7/19 at 11:15 a.m., the Clinical Director concurred with the findings regarding the lack of social work recommendations and the listing of treatment goals rather than treatment recommendations in the Psychosocial Assessments.

2. In an interview on 5/7/19 at 3:30 p.m. the Director of Quality Improvement concurred with the findings regarding deficient treatment recommendations in the Psychosocial Assessments.

Based on medical record review, policy review, and interview, the facility failed to provide a psychiatric evaluation that was completed within 60 hours of admission for one of eight hospital records (Patient A3). This practice has the potential to delay the initiation of diagnosis and treatment and deprives the treatment team of clinical data necessary to begin an initial plan of

Patient A3 was admitted on 5/3/19 at 3:27 a.m. The psychiatric evaluation was performed on 5/3/19 at 2:15 p.m. This evaluation however was not transcribed and available to the treatment team until 5/6/19 at 4:23 p.m.

B. Hospital Policy

Hospital policy, entitled "PSYCHIATRIC EVALUATION REFERENCE" PC-005A, revised 6/13/19, stated, "Upon admission to the acute unit a patient shall have a psychiatric evaluation completed within 24 hours of admission. Must be in the chart within 60 hours signed."

C. Interviews

1. In an interview on 5/6/19 at 3:00 p.m., the Chief Executive Officer (CEO) concurred with the findings regarding the lateness of the psychiatric evaluation.

2. In an interview on 5/7/19 at 1:25 p.m., the Director of Quality Improvement concurred with the findings regarding the lateness of the psychiatric evaluation.

Based on medical record review, policy review and interview, the facility failed to provide treatment plans that identified patient-related, short-term goals (STGs) in observable and behavioral terms for eight of eight sample patients (Patients A1, A2, A3, A4, A5, A6, A7, and A8) and had identical STGs for three (3) of eight (8) sample patients. (Patients A1, A5, and A8) Specifically, the treatment plans contained one (1) or two (2) STGs for the only listed problem (the patient's diagnosis) for all eight patients. All eight (8) patients had one STG that focused on the use of the Beck Youth Inventories (second edition), which measures severity of Depression and several other categories including Anxiety and Disruptive Behavior. This inventory was completed by the patient on admission and again at discharge, and even though the admission results were known during the patient assessment phase, the results were not used to set goals or design individual treatment interventions. In addition, it was impossible to determine the patients' progress toward the short-term goal since the inventory was not measured again until discharge. This failure to address individual needs in the treatment plan has the potential to hinder the ability of the treatment team to measure change in the patient as a result of treatment intervention this and may contribute to failure of the team to modify plans in response to patient needs, as well as to patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 5/3/19. The Psychiatric Evaluation dated 5/3/19, revealed that the patient was admitted for suicidal ideation with an unsuccessful attempt. The treatment plan, called the Individualized Service Plan (ISP), dated 5/3/19, listed for the problems, "Oppositional defiant disorder" and "Bipolar ll disorder." The short-term goal (STG) was "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDI-Y [Beck Depression Inventory-Youth] score upon admission 49 (moderate depression) to a score of 39 or less (low depression)." A second short-term goal for the same problem stated, "Patient will reduce symptoms of depression and mania so youth can be safe at the home, community, and school. Measurement of progress will be evidenced by identifying at least 5 positive coping skills to help successfully manage depression, suicidal ideations/attempts and self-injurious behaviors." This STG was identical to the STG goal for two other patients (A5 and A8).

2. Patient A2 was admitted on 5/2/19. The Psychiatric Evaluation, dated 5/3/19, revealed that the patient was admitted due to depression and suicidal ideation. The ISP, dated 5/3/19, did not list any problems in the problem section, but did document one short-term goal which stated, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDI ll [Beck Depression Inventory second edition] score upon admission 70 (severe depression) to a score of 60 or less."

3. Patient A3 was admitted on 5/3/19. The Psychiatric Evaluation dated 5/6/19, revealed that the patient was admitted due to experiencing suicidal ideation with multiple plans. The ISP, dated 5/3/19, listed for the problem, "Major depressive disorder, recurrent episode, severe, with psychosis," and the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDBI-Y [Beck Disruptive Behavior Inventory Category-Youth] score upon admission 91 (moderate depression) to a score of lower depression."

4. Patient A4 was admitted on 5/1/19. The Psychiatric Evaluation dated 5/4/19, revealed that the patient was admitted due to suicidal ideation with a plan to kill him/herself with a knife. The ISP dated 5/2/19, listed for the problem, "Major depressive disorder, recurrent severe without psychotic features," the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDI ll score upon admission 69 (severe depression) to a score of 50 or less."

5. Patient A5 was admitted on 5/1/19. The Psychiatric Evaluation, dated 5/4/19, revealed that the patient was admitted for suicidal ideation, cutting his/her arms, and running away from the group home. The ISP, dated 5/2/19, listed for the problem, "Major depressive disorder, recurrent severe without psychotic features," and the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDI-Y score upon admission 75 (severe depression) to a score of 65 or less (moderate depression)." A second short-term goal for the same problem stated, "Patient will reduce symptoms of depression and mania so youth can be safe at the home, community, and school. Measurement of progress will be evidenced by identifying at least 5 positive coping skills to help successfully manage depression, suicidal ideations/attempts and self-injurious behaviors." This STG was identical to the STG goal for two other patients (A1 and A8).

6. Patient A6 was admitted on 4/30/19. The Psychiatric Evaluation, dated 5/3/19, revealed that the patient was admitted for self-harm and suicidal ideation. The ISP, dated 5/1/19, listed for the problem, "Major depressive disorder, recurrent episode, severe," and the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDBI-Y score upon admission 86 (moderate depression) to a score of lower depression."

7. Patient A7 was admitted on 4/30/19. The Psychiatric Evaluation, dated 5/1/19, revealed that the patient was admitted for suicidal threats. The ISP, dated 5/1/19, listed for the problem, "Major depressive disorder, recurrent severe without psychotic features," and the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BDI ll score upon admission 66 (severe depression) to a score of 55 or less."

8. Patient A8 was admitted on 5/3/19. The Psychiatric Evaluation, dated 5/4/19, revealed that the patient was admitted for threatening to kill him/herself by sticking a fork in an electrical outlet. The ISP, dated 5/3/19, listed for the problem, "Major depressive disorder, recurrent severe without psychotic features," and the short-term goal, "Patient will reduce symptoms of depression and self-harming behaviors so youth can be safe at home, community, and school. Measurement of progress will be evidenced by BAI-Y [Beck Anxiety Inventory Category-Youth] score upon admission 77 (severe depression) to a score of 66 or less."(moderate depression)." A second short-term goal for the same problem stated, "Patient will reduce symptoms of depression and mania so youth can be safe at the home, community, and school. Measurement of progress will be evidenced by identifying at least 5 positive coping skills to help successfully manage depression, suicidal ideations/attempts and self-injurious behaviors." This STG was identical to the STG goal for two other patients (A1 and A5).

B. Policy Review

Facility policy entitled, "Planning Care, Treatment and Services," revised 6/18/15, stated that the "Individualized Service Plan (ISP)," should include goals, " ...based on behaviors that a patient must improve upon in order to facilitate movement to a less restrictive environment," and " ...will be determined on an individual specific basis."

C. Interviews

1. In an interview on 5/7/19 at 10:00 a.m., the Clinical Director acknowledged that the Beck Inventory provided little in designing individual treatment interventions and progress towards a decrease in score was impossible to measure until the time of discharge.

2. In an interview on 5/7/19 at 3:30 p.m., the Director of Quality Improvement agreed that some patients had identical short-term goals and that they could not measure progress toward the STG related to scores on the Beck Inventory until the patient was ready for discharge.

Based on medical record review, policy review, and interview the hospital failed to develop individualized treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients in the sample (Patients A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in staff being unable to provide individualized direction, consistent approaches, and focused treatment for patients.

Findings Include:

A. Medical Records

Patient A1's Master Treatment Plan (MTP) (facility term is ISP-Individual Service Plan) dated 5/3/19; Patient A2's MTP dated 5/3/19; Patient A3's MTP dated 5/ 3/19; Patient A4's MTP dated 5/2/19; Patient A5's MTP dated 5/2/19; Patient A6's dated 5/1/19; Patient A7's MTP dated 5/1/19; and Patient A8's MTP dated 5/3/19, all had the following non-individualized, identical treatment interventions for each of the eight (8) patients:
MD: "Patient will participate daily to individually assess mental status and effectiveness of medications."
RN: "Patient teaching with teaching on s/sx [signs/symptoms] of depression effective coping skills and distractions," and "Suicide precautions to prevent dangerous behaviors with 15 minutes checks."

SW: "Patient will receive individual counseling utilizing Brief solution focused therapy (BSFT) to explore understanding of how to process depression without having to resorting [sic] to maladaptive, self-harming behaviors or aggressive behaviors."

B. Policy Review

Hospital Policy entitled, "PLANNING CARE, TREATMENT AND SERVICES, CHAPTER PROVISION OF CARE", REVISED 6/18/15, stated that treatment interventions " ...shall be written to specify what specific interventions will be used by the client and/or staff to improve skills to accomplish objectives," and, "The specific services provided, and the frequency of service delivery shall be determined by the Treatment Team based on the results of the assessment of needs ..."

C. Interviews

1. In an interview on 5/6/19 at 3:00 p.m., the Chief Executive Officer (CEO) concurred with the findings regarding the lack of individualized treatment interventions.

2. In an interview on 5/7/19 at 11:15 a.m., the Clinical Director concurred with the findings regarding the lack of individualized treatment interventions.

3. In an interview on 5/7/19 at 3:30 p.m., the Director of Nursing and the Director of Quality Improvement concurred with the findings regarding the lack of individualized treatment interventions.

Based on medical record review, policy review, and interview the Medical Director failed to ensure:
I. The provision of a psychiatric evaluation that was completed within 60 hours admission for one of eight hospital records (Patient A3). This practice has the potential to delay the initiation of diagnosis and treatment and deprives the treatment team of clinical date necessary to begin an initial plan of care. (Refer to B111)

II. The provision of treatment plans that identified patient-related, short-term goals (STGs) in observable and behavioral terms for eight of eight sample patients (Patients A1, A2, A3, A4, A5, A6, A7, and A8). In addition there were identical STGs for three of eight sample patients. (Patients A1, A5, and A8) Specifically, the treatment plans contained one or two STGs for the only listed problem (the patient's diagnosis) for all eight patients. All eight patients had one STG that focused on the use of the Beck Youth Inventories (second edition) which measures severity of depression and several other categories including Anxiety and Disruptive Behavior. This inventory was completed by the patient at admission and again at discharge and even though the admission results were known during the patient assessment phase, the results were not used to set goals or design individual treatment interventions. In addition, it was impossible to determine the patients' progress toward the short-term goal since the inventory was not measured again until discharge. This failure to address individual needs in the treatment plan has the potential to hinder 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, as well as to patient stays beyond the resolution of the behaviors requiring admission. (Refer to B121)

III. The development of individualized treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients in the sample (Patients A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in staff being unable to provide individualized direction, consistent approaches, and focused treatment for patients. (Refer to B122)

Interview

In an interview on 5/8/19 at 10:00 a.m., the Medical Director concurred with the findings regarding timeliness of psychiatric evaluations, lack of observable behavioral short-term goals, and individualized treatment recommendations.

Based on medical record review and interview, the Director of Nursing failed to ensure the development of individualized treatment interventions based on the individual nursing needs for eight (8) of eight (8) patients in the sample (Patients A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in nursing staff being unable to provide individualized direction, consistent approaches, and focused treatment for patients.

Findings Include:

A. Medical Records

Patient A1's Master Treatment Plan (MTP) (facility term is ISP-Individual Service Plan) dated 5/3/19; Patient A2's MTP dated 5/3/19; Patient A3's MTP dated 5/ 3/19; Patient A4's MTP dated 5/2/19; Patient A5's MTP dated 5/2/19; Patient A6's dated 5/1/19; Patient A7's MTP dated 5/1/19; and Patient A8's MTP dated 5/3/19, all had nursing interventions which stated, "Patient teaching with teaching on s/sx [signs/symptoms] of depression effective coping skills and distractions," and "Suicide precautions to prevent dangerous behaviors with 15 minute checks."

B. Interview

In an interview on 5/7/19 at 3:30 p.m., the Director of Nursing concurred that all patients had the same nursing interventions which were not individualized to the patients' needs.