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Based on medical record review, and interviews, the facility failed to ensure that the treatment received by one patient who was the focus of the complaint and who had been discharged before the survey (Patient L3) was documented in such a way that all active treatment efforts were included.

The findings include:

Medical Record Review:

Patient L3 was a 32 year-old admitted 3/11/2014 on an involuntary basis with the diagnosis "Schizophrenia, undifferentiated." However, Patient L3 made the decision to sign himself/herself into the facility on 3/17/2014 therefore; Patient L3 was discharged on 4/08/2014 on a voluntary basis having signed himself/herself into the facility on 3/17/2014 as a voluntary patient. The first documented note by the attending psychiatrist (MD#1) was 3/18/2014. By this time Patient L3 had been receiving Seroquel XR 150 mg by mouth at bedtime, then this was changed to late afternoon and Seroquel 200 mg tablet at bedtime had been added. Patient L3 had received Zyprexa 10 mg IM (intramuscular) on 3/13/2014 and Zyprexa zydis 15 mg tablet by mouth. Patient L3 had, also, received Zyprexa zydis 10 mg tablet on 3/15/2014. There was no explanation by MD#1 why a different antipsychotic than the one Patient L3 was receiving daily was chosen.

In the Progress note by MD#1 dated 3/18/2014 he stated "Continue current medication." (See comments in "Section: Interviews" below when this lack of rationale was discussed).

In the Progress note dated 3/21/2014, MD#1 stated "Change Seroquel to Seroquel XR at 7 PM." No rationale was given for this adjustmenton the Doctor's order orin the Progress note dated 3/25/2014.

On 3/27/2014, Patient L3 was started on Depakote ER 500 mg tablet daily. On 3/28/2014 Patient L3 was started on Trazadone 100 mg by mouth at bedtime. The daily Seroquel XR had been increased to 400 mg by mouth in AM. On 4/01/2014 Patient L3 was started on Haldoperidol 5 mg twice daily by mouth and given Haloperidol decanoate 50 mg intramuscularly. On 4/04/2014 the oral Haloperidol was increased to 20 mg in AM and on 4/04/2014 Patient L3 was started on Fluoxitine 20 mg by mouth every AM.

There was no documentation by either MD#1 or MD#2, who was the covering psychiatrist at the time of discharge, why any of the 4 different antipsychotic medications had been chosen, had been used concurrently,or had been adjusted. No comment was present why antidepressant/antianxiety medications and anticonvulsant/mood stabilizer medication had been initiated.

Staff Interviews:

On 5/13/2014 at 11:20 AM attending psychiatrist (MD#1) and the covering psychiatrist (MD#2) at the time of discharge were interviewed. Also, present was the facility's clinical director and the facility's clinical director for forensic services.

MD#1 stated that while there was no evidence within Patient L3's medical record, he had a rationale within his personal notes. Both facility administrative psychiatrists concurred that rationale for medication usage described above was lacking in charted material.

MD#2 agreed that the charted material did not disclose the rationale for the selection of Trazadone, or why on the day of discharge a new antipsychotic had been chosen to be added to the antpsychotics Patient L3 was receiving. MD#2, also, concurred that there was no charted rationale why an anticonvulsant/mood stabilizer had been added to Patient L3's regimen. Again both facility administrative psychiatrists concurred that the chart lacked any information by prescribing physicians for these choices.

Patient L3's mother was interviewed by telephone on 3/12/2014 at 4:00 PM. In this interview with the survey team she repeated her concern about the treatment Patient L3 received while hospitalized and stated upon discharge she took Patient L3 to another treatment facility where Patient L3 was rehospitalized.