HospitalInspections.org

Based upon record review and staff interview, in 3 of 9 psychiatric evaluations of active sample patients the hospital failed to document tests performed to document memory and intellectual functioning in measurable, behavioral terms which clearly reflected the patients' ability to function in those areas (Patients A5, A7, A14). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Record Review:

1. Patient A5

In the Psychiatric Evaluation dated 1/23/10 the "Recent Memory, Remote Memory and Abstract Reasoning" sections were left blank without explanation. Intelligence was checked as "Average" but the section marked "how tested/assessed" was left blank without explanation.

2. Patient A7

In the Psychiatric Evaluation dated 1/23/10 the "Recent Memory, Remote Memory and Abstract Reasoning" sections were left blank without explanation. Intelligence was checked as "Above Average" but the section marked "how tested/assessed" was left blank without explanation.

3. Patient A14

In the Psychiatric Evaluation dated 1/23/10 the "Concentration/Attention Span, Recent Memory, Remote Memory and Abstract Reasoning" sections were left blank without explanation. Intelligence was checked as "Average" but the section marked "how tested/assessed" was left blank without explanation.

B. Interview

In an interview with the Medical Director on 1/26/10 at 9:30 AM in the administrative conference room, he acknowledged that the blank sections as noted were not acceptable and that this would be addressed in a corrective action plan. B144

Based on record review and interview the Medical Director failed to monitor the adequacy of the assessment of intellectual functioning and memory in the psychiatric evaluations of 3 of 9 active patients. Refer to B116 for the findings.