HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that the comprehensive treatment plans of 8 of 9 active sample patients (A2, A3, A6, A8, A10, A12, B7) either: (1) included physician treatment interventions that addressed medical problems identified in the treatment plan; or (2) included physician interventions that were individualized and based on patients needs. Instead, physician interventions for medical problems were omitted or physician interventions were listed as generic monitoring, assessing and documenting functions. These failures result in a treatment plan that does not reflect an individualized, comprehensive, and integrated approach to multidisciplinary treatment.

Findings include:

A. Record Review:

1. Patient A2 was admitted with a diagnosis of schizophrenia, paranoid. The Master Treatment Plan dated 8/25/11 identified the patient problems as hypertension (HTN), chronic pain, gastro-esophageal reflux disorder (GERD), psychosis, potential to harm others, and edema. No MD intervention was identified for the medical problems (HTN, chronic pain, GERD and edema).

2. Patient A3 was admitted with a diagnosis of schizophrenia. The Master Treatment Plan dated 8/27/11 identified the patient's active psychiatric problems as psychosis and disorganized thoughts, medication compliance, and aggression. The medical problem, lymphedema, was deferred and not addressed in the treatment plan even though Lasix was ordered (8/26/11) as a diuretic and an order was written for a consult for edema (9/12/11).

3. Patient A6 was admitted with a diagnosis of bipolar mood disorder. The Master Treatment Plan dated 9/4/11 identified the patient's problems as aggression, paranoia, delusions, manic/bizarre behaviors. The only listed MD interventions were "MD will assess for signs of aggression and will make medication adjustments as necessary" and "MD will assess for signs of psychosis and will make medication adjustments as necessary." These interventions are generic role functions and not individualized for the specific patient's needs.

4. Patient A8 was admitted with a diagnosis of major depressive disorder. The Master Treatment Plan dated 9/4/11 identified the patient's problems as chronic lower back pain with muscle spasms and depression with suicidal ideation. No MD intervention was identified for the medical problem (chronic lower back pain with muscle spasms).

5. Patient A10 was admitted with a diagnosis of schizophrenia, paranoid type. The Master Treatment Plan dated 9/7/11 identified the patient's problems as auditory and visual hallucinations and paranoia. The only listed MD intervention was "MD will assess for signs of psychosis and will make medication adjustments as necessary." This intervention is a generic role function and were not individualized for the specific patient's needs.

6. Patient A12 was admitted with a diagnosis of major depressive disorder, recurrent with suicidal ideation. The Master Treatment Plan dated 9/8/11 identified the patient's problems as potential for self-harm, potential for aggression, auditory hallucinations, medication non-compliance, and substance abuse. The only listed MD intervention for aggression was "MD will assess for signs of aggression and will make medication adjustments as necessary." The only listed MD intervention for auditory hallucinations was "MD will assess for signs of psychosis and will make medication adjustments as necessary." The only listed MD intervention for depression with suicidal ideation was "MD will order antidepressant medications and titrate dosage to stabilize mood. MD will assess suicidality daily." (identical as MD interventions for Patient A13). These interventions are generic role functions and were not individualized for the specific patient's needs.

7. Patient A13 was admitted with a diagnosis of major depressive disorder and post traumatic stress disorder. The Master Treatment Plan dated 9/13/11 identified the patient problems as depression with suicidal ideation, post-traumatic stress, and substance abuse. The only listed MD intervention for depression with suicidal ideation was "MD will order antidepressant medications and titrate dosage to stabilize mood. MD will assess suicidality daily." (identical as MD interventions for Patient A12). These interventions are generic role functions and were not individualized for the specific patient's needs.

8. Patient B7 was admitted with a diagnosis of alcohol dependence. The Master Treatment Plan dated 9/1/11 identified the patient's problems as substance dependence, back pain, and defiant behavior/agitation. No MD intervention was identified for the medical problem, back pain.


B. Interviews:

1. In an interview on 9/13/11 at 2:00p.m. the attending for Patient B7 stated, "There should be something in the treatment plan regarding my invention with the patient's back pain because I intervene with his pain every day."

2. In an interview on 9/13/11 at 3:00p.m. RN3 stated that the nursing staff starts the treatment plan regarding medical problems and that "physicians generally do not add anything to the treatment plan for the medical problems."

3. In an interview on 9/14/11 at 9:00a.m., the CEO stated, "The specific medication as an intervention is missing from the treatment plan and the physicians were taught in the re-education to do that." During the same interview and meeting, the medical director stated, "We did not audit individual doctor's compliance with individualizing physician interventions and it seems that would be helpful rather than only auditing the overall compliance."

4. In an interview on 9/14/11 at 9:00a.m., the medical director stated that treatment of patient A3's edema should have been addressed in the treatment plan. Furthermore, he stated, that with all medical problems addressed in the treatment plans, "I would want to see in the treatment plan what the physician-consult demonstrated and how the recommendations are carried out through a medical order."