HospitalInspections.org

Based on record review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans based on the individual needs of patients. Specifically the facility failed to individualize the treatment needs of one (1) of eight (8) sample patients (A5). Failure to individualize the treatment needs of patients can prevent staff from knowing how to address each patients' specific needs which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

A. Record Review

1. Patient A5 was admitted on 3/5/17. The psychiatric evaluation, dated 3/5/17, listed the primary diagnosis as "Schizophrenia". Patient was aggressive and threatened to harm his/her family prior to admission. Since admission, he/she has refused medication, eaten very little and refused showers and oral hygiene.

2. The MTP, dated 3/7/17, documented that Patient A5 was assigned to ten groups a week: Cognitive Behavior Therapy [3 times a week], Understanding Your Meds [medications], Anger Management [2 times a week], Relaxation Training [2 times a week], Leisure Education and Symptom Management.

3. Review of the patient's record revealed no evidence that Patient A5 had attended any of the assigned groups, nor had he/she attended any of the Engagement groups. As of 4/5/17, there was no mention on the MTP of the patient's refusal to attend groups. There was also no modification of the treatment plan to address the lack of active treatment.

4. Review of the patient's record revealed that he/she had refused medications since admission. There was no modification of the treatment plan to address the medication refusal.

5. Review of the patient's Patient Food Intake sheet revealed that the patient ate only one (1) cookie and one (1) juice from dinner on 3/9/17 to lunch on 3/13/17. The remainder of the Intake Sheet documented that from 3/13/17 to 3/31/17, Patient A5 ate primarily crackers, cookies, potato chips, candy and juice. The MTP did not mention the patient's problem with eating and did not present interventions to address the problem.

6. Review of the patient's Daily Patient Care Assessment Flow Sheet from 3/13/17-4/2/17 revealed that Patient A5 had not showered since admission. The Flow Sheet also revealed that during this same time period, Patient A5 had brushed his/her teeth only twice (3/20/17 and 3/27/17). The MTP did not mention Patient A5's hygiene and did not present interventions to address the problem.

7. Review of Patient A5's Progress Notes revealed the following:

a.Psychiatry Progress Note, dated 3/11/17, documented, "Pt. refusing to eat-has eaten nothing at all for two days and minimal amounts the two days prior to that."

b.Psychiatry Progress Note, dated 3/14/17, documented, "Ate 1 juice [sic], plus 1 cookie last night but refused dinner."

c.Social Work Note, dated 3/29/17, documented, "Pt. is refusing meds. Has not showered since admission. Urine odor coming from room."

B. Interviews

1. During interview on 4/3/17 at 3:45 p.m., RN3 stated that Patient A5 had not showered since admission and had washed his/her clothes only once.

2.During interview on 4/4/17 at 2:00 p.m., the Acting Medical Director acknowledged that the problems of hygiene and eating should have been evident on the MTP.