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Research ArticleRegular Article

United States Department of Justice Findings Letters in Psychiatric Hospital CRIPA Cases: An Aid or a Distraction?

Jeffrey Geller and Leilani Lee
Journal of the American Academy of Psychiatry and the Law Online June 2013, 41 (2) 174-190;
Jeffrey Geller
Dr. Geller is Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School, and Facility Medical Director, Worcester Recovery Center and Hospital, Worcester, MA. Dr. Lee is a forensic psychiatrist, Law and Psychiatry Institute, North Shore-Long Island Jewish Health System, Lake Success, NY.
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Leilani Lee
Dr. Geller is Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School, and Facility Medical Director, Worcester Recovery Center and Hospital, Worcester, MA. Dr. Lee is a forensic psychiatrist, Law and Psychiatry Institute, North Shore-Long Island Jewish Health System, Lake Success, NY.
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    Figure 1.

    Method of analysis of DOJ Findings Letters sent to state hospitals from 2003 through 2009.

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    Table 1

    Groups Analyzed

    DateFindings Letter Source
    Group I
        12/8/2009Georgia state psychiatric hospitals
        8/24/2009Ancora Psychiatric Hospital, Hammonton, NJ
        1/30/2009Kings County Hospital Center, Brooklyn, NY*
        1/15/2009Northwest Georgia Regional Hospital, Rome, GA*
        5/30/2008Georgia Regional Hospital, Atlanta, GA*
        1/9/2008Oregon State Hospital, Portland, OR*
        8/6/2007Connecticut Valley Hospital, Middletown, CT*
    Group II
        5/30/2006St. Elizabeth's Hospital, Washington, DC
        5/2/2006Patton State Hospital, San Bernardino, CA
        5/2/2006Atascadero State Hospital, Atascadero, CA
        7/5/2005Vermont State Hospital, Waterbury, VT
        6/27/2005Napa State Hospital, Napa, CA
        3/17/2004North Carolina mental health facilities
        2/19/2004Metropolitan State Hospital, Norwalk, CA
        5/13/2003Metropolitan State Hospital, Norwalk, CA
    Group III
    All Findings Letters
    • ↵* Findings letters used to create the core set of TOIs.

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    Table 2

    TOI Identified in 10 or More of 15 Findings Letters from 2003 to 2009

    Identified Leading Text of Interest (TOI)As ShownEssentially the SameDuplicates Within Essentially the Same GroupSimilar LanguageSimilar Concept
    _____ shall ensure that their patients receive accurate, complete, and timely assessments and diagnoses, consistent with generally accepted professional standards, and that these assessments and diagnoses drive treatment interventions. More particularly, the _____ shall:491 set of 3
    1 set of 2
    Review and revise, as appropriate, psychiatric assessments of all patients, providing clinically justified current diagnoses for each patient, and removing all diagnoses that cannot be clinically justified. Modify treatment and medication regimens, as appropriate, considering factors such as the patient's response to treatment, significant developments in the patient's condition, and changing patient needs.461 set of 31
    The _____ shall develop and implement an integrated treatment planning process consistent with generally accepted professional standards. More particularly, the _____ shall:481 set of 4
    1 set of 2
    1
    Develop and implement policies and procedures regarding the development of individualized treatment plans consistent with generally accepted professional standards of care.471 set of 3
    1 set of 2
    Provide adequate and appropriate psychiatric and other mental health services, including adequate psychological services and behavioral management, in accordance with generally accepted professional standards.331 set of 34
    2 duplicates
    3
    2 duplicates
    Ensure that all psychotropic medications are:
    1. prescribed in therapeutic amounts;

    2. tailored to each patient's individual symptoms;

    3. monitored for efficacy against clearly-identified target variables and time frames;

    4. modified based on clinical rationales; and

    5. properly documented.

    541 set of 311
    Within the limitations of the court-imposed confinement and public safety, the State should pursue actively the appropriate discharge of patients and ensure that they are provided services in the most integrated, appropriate setting that is consistent with patients' needs. More particularly, _____ should:481 set of 3
    1 set of 2
    2
    Provide its patients with a safe and humane environment and protect them from harm. At a minimum,752 sets of 2
    _____ should ensure that seclusion and restraints are used in accordance with generally accepted professional standards. Absent exigent circumstances—i.e., when a patient poses an imminent risk of injury to himself or a third-party—any device or procedure that restricts, limits or directs a person's freedom of movement (including, but not limited to, chemical restraints, mechanical restraints, physical/manual restraints, or timeout procedures) should be used only after other less restrictive alternatives have been assessed and exhausted. More particularly, _____ should:433 (2 were duplicates)
    Ensure that restraints:
    1. are used only when persons pose an immediate threat to themselves or others and after a hierarchy of less restrictive measures has been exhausted;

    2. are not used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;

    3. are not used as part of a behavioral intervention;

    4. are terminated as soon as the person is no longer an imminent danger to himself or others; and

    5. are used in a reliably documented manner.

    362 sets of 213 (2 were duplicates)
    _____ shall provide medical and nursing services to its patients consistent with generally accepted professional standards. Such services should result in patients of the _____ receiving the individualized services, supports, and therapeutic interventions, consistent with their treatment plans. More particularly, the _____shall:351 set of 22 (2 were duplicates)
    Establish an effective infection control program to prevent the spread of infections or communicable diseases. More specifically, the _____ shall:
    1. actively collect data with regard to infections and communicable diseases

    2. analyze these data for trends;

    3. initiate inquiries regarding problematic trends;

    4. initiate necessary corrective action;

    5. monitor to ensure that appropriate remedies are achieved;

    6. integrate this information into the quality assurance review of the _____; and

    7. ensure that nursing staff implement the infection control program.

    342 sets of 212
    • TOI, text of interest; the number indicates the number of findings letters in which the TOI was identified; as shown, the text was written exactly the same as the identified TOI; essentially the same, ≥50% overlap; similar language, <50% overlap; similar concept, paraphrased TOI; the duplicates are TOIs that were written exactly the same within a specific category (e.g., one set of two: within the specified category, two TOIs were written exactly the same in two separate findings letters; one set of three: within the specified category, three TOIs were written exactly the same in three separate findings letters.

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    Table 3

    Mental Health Assessment, Diagnoses, and Treatment Planning

    Identified Text of InterestState Psychiatric Hospitals, Georgia (12/08/09)Ancora Psychiatric Hospital, Winslow, NJ (8/24/09)Kings County Hospital, NY (1/30/09)NW Georgia Regional Hospital-Rome (1/5/09)George Regional Hospital-Atlanta (5/30/08)
    _____ shall ensure that their patients receive accurate, complete, and timely assessments and diagnoses, consistent with generally accepted professional standards, and that these assessments and diagnoses drive treatment interventions. More particularly, _____ shall:As shown, page 40, C.1.n/aAs shown, page 43, B.1.As shown, page 55, B.1.As shown, page 51, B.1.
    Review and revise, as appropriate, psychiatric assessments of all patients, providing clinically justified current diagnoses for each patient, and removing all diagnoses that cannot be clinically justified. Modify treatment and medication regimens, as appropriate, considering factors such as the patient's response to treatment, significant developments in the patient's condition, and changing patient needs.As shown, page 41, C.1.g.n/aAs shown, page 44, B.1.g.As shown, page 56, B.1.g.As shown, page 52, B.1.g.
    The _____ shall develop and implement an integrated treatment planning process consistent with generally accepted professional standards. More particularly, the _____ shall:As shown, page 41, C.2.Similar Language, page 37, E.3.As shown, page 45, B.2.As shown, page 56, B.2.As shown, pages 52 & 53, B.2.
    Develop and implement policies and procedures regarding the development of individualized treatment plans consistent with generally accepted professional standards of care.Essentially the same I, page 41, C.2.a.n/aAs shown, page 45, B.2.a.As shown, page 56, B.2.a.As shown, page 53, B.2.a.
    _____ shall ensure that their patients receive accurate, complete, and timely assessments and diagnoses, consistent with generally accepted professional standards, and that these assessments and diagnoses drive treatment interventions. More particularly, _____ shall:Essentially the same I, page 36, B.1.Essentially the same I, page 48, B.2.a.Essentially the same I, page 51, C.2.a.Essentially the same II, page 12, IX.B.Essentially the same II, page 9, VIII.B.
    Review and revise, as appropriate, psychiatric assessments of all patients, providing clinically justified current diagnoses for each patient, and removing all diagnoses that cannot be clinically justified. Modify treatment and medication regimens, as appropriate, considering factors such as the patient's response to treatment, significant developments in the patient's condition, and changing patient needs.Essentially the same I, page 37, B.1.g.Essentially the same I, page 49, B.2.a.vi.Essentially the same II, page 52, C.2.a.vi.n/an/a
    The _____ shall develop and implement an integrated treatment planning process consistent with generally accepted professional standards. More particularly, the _____ shall:Essentially the same I, page 38, B.2.Essentially the same I, page 47, B.1.Essentially the same I, page 49, C.1.Essentially the same II, page 12, IX.A.Essentially the same II, page 9, VIII.A.
    Develop and implement policies and procedures regarding the development of individualized treatment plans consistent with generally accepted professional standards of care.As shown, page 38, B.2.a.Essentially the same III, page 47, B.1.a.
    _____ shall ensure that their patients receive accurate, complete, and timely assessments and diagnoses, consistent with generally accepted professional standards, and that these assessments and diagnoses drive treatment interventions. More particularly, _____ shall:Essentially the same III, page 27, B.2.a.Essentially the same IV, page 20, A.1.b.n/an/aEssentially the same V, page 45, B.
    Review and revise, as appropriate, psychiatric assessments of all patients, providing clinically justified current diagnoses for each patient, and removing all diagnoses that cannot be clinically justified. Modify treatment and medication regimens, as appropriate, considering factors such as the patient's response to treatment, significant developments in the patient's condition, and changing patient needs.Essentially the same I, page 28, B.2.a.6.Essentially the same III, page 22, B.3.b.n/aSimilar Language I, page 41, A.4.Essentially the same IV, page 45, B.1.b.
    The _____ shall develop and implement an integrated treatment planning process consistent with generally accepted professional standards. More particularly, the _____ shall:Essentially the same I, page 26, B.1.Essentially the same III, page 19, A.1.a.n/an/aEssentially the same IV, page 44, A.
    Develop and implement policies and procedures regarding the development of individualized treatment plans consistent with generally accepted professional standards of care.Essentially the same II, page 26, B.1.A.Essentially the same II, page 20, A.1.a.1.n/aEssentially the same II, page 41, A.5.Essentially the same I, page 44, A.1.
    • View popup
    Table 4

    Mental Health Care Services

    Identified Text of InterestState Psychiatric Hospitals, Georgia (12/08/09)Ancora Psychiatric Hospital, Winslow, NJ (8/24/09)Kings County Hospital, NY (1/30/09)NW Georgia Regional Hospital-Rome (1/5/09)George Regional Hospital-Atlanta (5/30/08)
    Provide adequate and appropriate psychiatric and other mental health services, including adequate psychological services and behavioral management, in accordance with generally accepted professional standards.As shown, page 42, C.2.f.Similar Concept I, page 36, E.1.Essentially the same I, page 46, B.2.f.As shown, page 57, B.2.f.As shown, page 54, B.2.f.
    Ensure that all psychotropic medications are:
    1. prescribed in therapeutic amounts;

    2. tailored to each patient's individual symptoms;

    3. monitored for efficacy against clearly-identified target variables and time frames;

    4. modified based on clinical rationales; and

    5. properly documented.

    Essentially the same I, page 44, C.2.o.n/aAs shown, page 48, B.3.c.Essentially the same I, page 59, B.2.o.Essentially the same I, page 55, B.2.o.
    Within the limitations of the court-imposed confinement and public safety, the State should pursue actively the appropriate discharge of patients and ensure that they are provided services in the most integrated, appropriate setting that is consistent with patients' needs. More particularly, _____ should:n/aSimilar Concept I, page 32, A.1.Essentially the same, page 55, F.Essentially the same II, page 65, F.Essentially the same II, page 61, F.
    Provide adequate and appropriate psychiatric and other mental health services, including adequate psychological services and behavioral management, in accordance with generally accepted professional standards.Essentially the same I, page 38, B.2.g.n/aSimilar Concept II, page 59, C.2.d.Similar Language I, page 12, IX. C. & D.Similar Language I, page 10, VII. C. & D.
    Ensure that all psychotropic medications are:
    1. prescribed in therapeutic amounts;

    2. tailored to each patient's individual symptoms;

    3. monitored for efficacy against clearly-identified target variables and time frames;

    4. modified based on clinical rationales; and

    5. properly documented.

    As shown, page 40, B.3.d.As shown, page 51, B.2.c.iv.As shown, page 56, C.2.c.iv.n/an/a
    Within the limitations of the court-imposed confinement and public safety, the State should pursue actively the appropriate discharge of patients and ensure that they are provided services in the most integrated, appropriate setting that is consistent with patients' needs. More particularly, _____ should:Essentially the same III, page 45, E.As shown, page 55, C.As shown, page 63, G.Essentially the same IV, page 13, IX.J.Essentially the same IV, page 11, VIII.J.
    Provide adequate and appropriate psychiatric and other mental health services, including adequate psychological services and behavioral management, in accordance with generally accepted professional standards.Similar Concept II, page 33, B.2.d.Similar Language II, page 21, B.3.Essentially the same I, page 26, A.1.a.n/aSimilar Language III, page 49, D.1, & page 51, D.2.
    Ensure that all psychotropic medications are:
    1. prescribed in therapeutic amounts;

    2. tailored to each patient's individual symptoms;

    3. monitored for efficacy against clearly-identified target variables and time frames;

    4. modified based on clinical rationales; and

    5. properly documented.

    As shown, page 30, B.2.c.4.n/aSimilar Concept I, page 28, A.3.a.Similar Language I, page 42, A. 11.Essentially the same II, page 49, D.1.c.
    Within the limitations of the court-imposed confinement and public safety, the State should pursue actively the appropriate discharge of patients and ensure that they are provided services in the most integrated, appropriate setting that is consistent with patients' needs.As shown, page 34, C.Essentially the same IV, page 22, D.1.Similar Concept II, page 31, F.1.Essentially the same V, page 49, I.As shown, page 48, C.
    • View popup
    Table 5

    Protection from Harm

    Identified Text of InterestState Psychiatric Hospitals, Georgia (12/08/09)Ancora Psychiatric Hospital, Winslow, NJ (8/24/09)Kings County Hospital, NY (1/30/09)NW Georgia Regional Hospital-Rome (1/5/09)George Regional Hospital-Atlanta (5/30/08)
    _____ should provide its patients with a safe and humane environment and protect them from harm. At a minimum, _____ should:Essentially the same I, page 37, B.n/aAs shown, page 41, A.Essentially the same II, page 53, A.Essentially the same II, page 49, A.
    Ensure that seclusion and restraints are used in accordance with generally accepted professional standards. Absent exigent circumstances —i.e., when a patient poses an imminent risk of injury to himself or a third-party—any device or procedure that restricts, limits or directs a person's freedom of movement (including, but not limited to, chemical restraints, mechanical restraints, physical/manual restraints, or timeout procedures) should be used only after other less restrictive alternatives have been assessed and exhausted. More particularly, _____ should:n/an/aEssentially the same I, page 50, C.2.Essentially the same II, page 60, C.n/a
    Ensure that restraints:
    1. are used only when persons pose an immediate threat to themselves or others and after a hierarchy of less restrictive measures has been exhausted;

    2. are not used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;

    3. are not used as part of a behavioral intervention;

    4. are terminated as soon as the person is no longer an imminent danger to himself or others; and

    5. are used in a reliably documented manner.

    Essentially the same I, page 45, D.4.Similar Concept, page 36, D.1.As shown, page 50, C.3.As shown, page 60, C.2.As shown, pages 56 & 57, C.2.
    _____ should provide its patients with a safe and humane environment and protect them from harm. At a minimum, _____ should:As shown, page 34, A.As shown, page 45, A.3.As shown, page 44, A.1.Essentially the same III, page 13, IX.K.Essentially the same III, page 11, VIII.K.
    Ensure that seclusion and restraints are used in accordance with generally accepted professional standards. Absent exigent circumstances—i.e., when a patient poses an imminent risk of injury to himself or a third-party—any device or procedure that restricts, limits or directs a person's freedom of movement (including, but not limited to, chemical restraints, mechanical restraints, physical/manual restraints, or timeout procedures) should be used only after other less restrictive alternatives have been assessed and exhausted. More particularly, _____ should:As shown, page 42, C.As shown, page 43, A.2.As shown, page 47, B.Similar Concept I, page 12, IX.E.Similar Concept I, page 10, VIII.E.
    Ensure that restraints:
    1. are used only when persons pose an immediate threat to themselves or others and after a hierarchy of less restrictive measures has been exhausted;

    2. are not used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;

    3. are not used as part of a behavioral intervention;

    4. are terminated as soon as the person is no longer an imminent danger to himself or others; and

    5. are used in a reliably documented manner.

    Essentially the same I, page 42, C.4.Essentially the same II, page 44, A.2.a.Essentially the same III, page 47, B.1.n/an/a
    _____ should provide its patients with a safe and humane environment and protect them from harm. At a minimum, _____ should:As shown, page 23, A.1.n/an/aAs shown, page 51, K.As shown, page 61, G.
    _____ should ensure that seclusion and restraints are used in accordance with generally accepted professional standards. Absent exigent circumstances— i.e., when a patient poses an imminent risk of injury to himself or a third-party—any device or procedure that restricts, limits or directs a person's freedom of movement (including, but not limited to, chemical restraints, mechanical restraints, physical/manual restraints, or timeout procedures) should be used only after other less restrictive alternatives have been assessed and exhausted. More particularly, _____ should:As shown, page 24, A.2.Similar Concept II, page 20, A.2.a.Essentially the same III, page 29, B.n/an/a
    Ensure that restraints:
    1. are used only when persons pose an immediate threat to themselves or others and after a hierarchy of less restrictive measures has been exhausted;

    2. are not used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;

    3. are not used as part of a behavioral intervention;

    4. are terminated as soon as the person is no longer an imminent danger to himself or others; and

    5. are used in a reliably documented manner.

    Essentially the same II, page 24, A.2.a.Similar Language I, page 20, A.2.b.Similar Concept I, page 30, B.2.Similar Concept II, page 46, C.18.Essentially the same IV, page 59, F.1.
    • View popup
    Table 6

    Medical and Nursing Care

    Identified Text of InterestState Psychiatric Hospitals, Georgia (12/08/09)Ancora Psychiatric Hospital, Winslow, NJ (8/24/09)Kings County Hospital, NY (1/30/09)NW Georgia Regional Hospital-Rome (1/5/09)George Regional Hospital-Atlanta (5/30/08)
    _____ shall provide medical and nursing services to its patients consistent with generally accepted professional standards. Such services should result in patients of the _____ receiving individualized services, supports, and therapeutic interventions, consistent with their treatment plans. More particularly, the _____ shall:As shown, page 46, E.n/aEssentially the same I, page 52, D.As shown, page 62, D.As shown, page 58, D.
    Establish an effective infection control program to prevent the spread of infections or communicable diseases. More specifically, the _____ shall:
    1. actively collect data with regard to infections and communicable diseases;

    2. analyzed these data for trends;

    3. initiate inquiries regarding problematic trends;

    4. initiate necessary corrective action;

    5. monitor to ensure that appropriate remedies are achieved;

    6. integrate this information into the quality assurance review of the _____; and

    7. ensure that nursing staff implement the infection control program.

    As shown, page 48, E.11.n/aSimilar Concept I, page 53, D.8.As shown, page 63, D.11.As shown, page 60, D.11.
    _____ shall provide medical and nursing services to its patients consistent with generally accepted professional standards. Such services should result in patients of the _____ receiving individualized services, supports, and therapeutic interventions, consistent with their treatment plans. More particularly, the _____ shall:Essentially the same II, page 44, D.n/aEssentially the same III, page 60, D.Similar Concept I, page 13, IX.H.Similar Concept I, page 10, VIII.H.
    Establish an effective infection control program to prevent the spread of infections or communicable diseases. More specifically, the _____ shall:
    1. actively collect data with regard to infections and communicable diseases;

    2. analyzed these data for trends;

    3. initiate inquiries regarding problematic trends;

    4. initiate necessary corrective action;

    5. monitor to ensure that appropriate remedies are achieved;

    6. integrate this information into the quality assurance review of the _____; and

    7. ensure that nursing staff implement the infection control program.

    Essentially the same I, page 45, D.9.n/aEssentially the same I, page 62, D.9.n/an/a
    _____ shall provide medical and nursing services to its patients consistent with generally accepted professional standards. Such services should result in patients of the _____ receiving individualized services, supports, and therapeutic interventions, consistent with their treatment plans. More particularly, the _____ shall:n/aEssentially the same IV, page 21, B.2.n/an/aEssentially the same IV, page 52, D.3.
    Establish an effective infection control program to prevent the spread of infections or communicable diseases. More specifically, the _____ shall:
    1. actively collect data with regard to infections and communicable diseases;

    2. analyzed these data for trends;

    3. initiate inquiries regarding problematic trends;

    4. initiate necessary corrective action;

    5. monitor to ensure that appropriate remedies are achieved;

    6. integrate this information into the quality assurance review of the _____; and

    7. ensure that nursing staff implement the infection control program.

    n/aSimilar concept II, page 22, B.5.Similar language I, page 31, D.1.Essentially the same II, page 48, F.2.Essentially the same II, page 55, D.6.b.
    • View popup
    Table 7

    Nursing*

    Identified Text of InterestState Psychiatric Hospitals, Georgia (12/08/09)Ancora Psychiatric Hospital, Winslow, NJ (8/24/09)Kings County Hospital, NY (1/30/09)NW Georgia Regional Hospital-Rome (1/5/09)George Regional Hospital-Atlanta (5/30/08)Oregon State Hospital (1/9/08)
    Ensure that, before nursing staff work directly with patients, they have completed successfully competency-based training regarding mental health diagnoses, related symptoms, psychotropic medications, identification of side effects of psychotropic medications, monitoring of symptoms and target variables, and documenting and reporting of the patient's status.As shown, page 47, E.4.n/aEssentially the same I, page 53, D.4.As shown, page 62, D.4.As shown, page 59, D.4.Essentially the same I, page 44, D.2.
    Ensure that nursing staff accurately and routinely monitor, document, and report patients' symptoms and target variables in a manner that enables treatment teams to assess the patient's status and to modify, as appropriate, the treatment plan.As shown, page 47, E.5.Similar Concept, page 35, C.7.Essentially the same I, page 53, D.5.As shown, pages 62 & 63, D.5.As shown, page 59, D.5.Essentially the same I, page 44, D.3.
    Ensure that nursing staff actively participate in the treatment team process and provide feedback on patients' responses, or lack thereof, to medication and behavioral interventions.As shown, page 47, E.6.n/aAs shown, page 53, D.6.As shown, page 63, D.6.As shown, page 59, D.6.As shown, page 44, D.4.
    Ensure that each patient's treatment plan identifies:
    1. the diagnoses, treatments, and interventions that nursing and other staff are to implement;

    2. the related symptoms and target variables to be monitored by nursing and other unit staff; and

    3. the frequency by which staff need to monitor such symptoms

    As shown, page 48, E.10.n/aAs shown, page 53, D.7.As shown, page 63, D.10.As shown, page 59, D.10.As shown, page 45, D.8.
    Ensure sufficient nursing staff to provide nursing care and services in accordance with generally accepted professional standards.As shown, page 47, E.3.n/an/aAs shown, page 62, D.3.As shown, page 58, D.3.As shown, page 44, D.1.
    Ensure that nursing staff are appropriately supervised to ensure that they administer, monitor, and record the administration of medications and any errors according to generally accepted professional standards.As shown, page 47, E.7.Similar Concept, page 35, C.3.n/aAs shown, page 63, D.7.As shown, page 59, D.7.Similar Concept, page 44, D.5.
    Ensure that, prior to assuming their duties and on a regular basis thereafter, all staff responsible for the administration of medication have completed successfully competency-based training on the completion of the Medication Administration Record.As shown, page 47, E.8.n/an/aAs shown, page 63, D.8.As shown, page 59, D.8.As shown, page 44, D.6.
    Ensure that all failures to properly sign the Medication Administration Record and/or the Narcotics Log are treated as medication errors, and that appropriate follow-up occurs to prevent reoccurrence of such errors.As shown, page 47, E.9.n/an/aAs shown, page 63, D.9.As shown, page 59, D.9.Essentially the same, page 44, D.7.
    • ↵* Text of interest in the Nursing Section was observed in only 6 of the 15 Findings Letters.

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Journal of the American Academy of Psychiatry and the Law Online: 41 (2)
Journal of the American Academy of Psychiatry and the Law Online
Vol. 41, Issue 2
1 Jun 2013
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United States Department of Justice Findings Letters in Psychiatric Hospital CRIPA Cases: An Aid or a Distraction?
Jeffrey Geller, Leilani Lee
Journal of the American Academy of Psychiatry and the Law Online Jun 2013, 41 (2) 174-190;

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United States Department of Justice Findings Letters in Psychiatric Hospital CRIPA Cases: An Aid or a Distraction?
Jeffrey Geller, Leilani Lee
Journal of the American Academy of Psychiatry and the Law Online Jun 2013, 41 (2) 174-190;
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