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Based on record review and interview, it was determined that for two (2) of eight (8) sample patients (A1 and A2), the facility failed to perform and document a physical examination that included a descriptive neurological examination that specified what tests were performed to assess neurological functioning. Absence of this patient information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline functioning, thereby potentially adversely affecting patient care.

Findings include:

A. Record Review

1. Patient A1: In a medical evaluation dated 1/8/11, under the section titled "Neurologic," the medical evaluation stated "Cranial Nerves I-XII intact." There was no evidence as to what tests were performed to assess the functioning of each cranial nerve.

2. Patient A2: In a medical evaluation dated 1/7/11under the section titled "Neurologic," there was no evidence that all cranial nerves (I -XII) were tested individually. Instead, there was an assessment stating "cranial nerves I-XII intact."

B. Interview

In an interview on 01/11/11 with the Medical Director, the above deficiency was discussed. He agreed with the findings noted above.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient's strengths/assets in descriptive fashion for two (2) of eight (8) sample patients (A2 and A3). Failure to identify patients' assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's positive attributes in the therapy.

Findings include:

A. Record Review

1. Patient A2: In a Comprehensive Psychiatric Evaluation dated on 1/7/11 an inventory of the patient's assets was not included in the report.

2. Patient A3: In a Comprehensive Psychiatric Evaluation dated on 1/8/11, an inventory of the patient's assets was not included in the report.

B. Interview

In an interview on 01/11/11, the Medical Director agreed with the above findings.

Based on record review, policy review and staff interview, the facility failed to ensure that patient discharge summaries were completed in a timely manner according to hospital policy requirements for 2 of 5 discharged patients (D1 and D5). This failed practice compromises the effective transfer of the patient's care to the next care provider.

Findings include:

A. Record Review

1 .Patient D1 was discharged on 12/08/10; the discharge summary was not completed and signed until 01/10/11.

2. Patient D5 was discharged on 11/28/19; the discharge summary was still absent as of the date of the survey (01/11/11).

B. Policy Review

The facility policy titled "Discharge Summaries," effective 8/9/10 states that "Charts must be completed within thirty (30) days of discharge. Summaries are to be signed within thirty (30) days of discharge date."

C. Interview:

In an interview on January 11, 2011 at 11:00AM, the Director of Quality Improvement stated "Discharge summaries should be signed by the physician within 30 days."

Based on record review and interview the Medical Director failed to:

I. Ensure that neurological exams were completed and documented on 2 of 8 sample patients (A1 and A2). Absence of this patient information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline functioning, thereby potentially adversely affecting patient care. (Refer to B109)

II. Ensure that psychiatric evaluations included an assessment of patient's strengths/assets in descriptive fashion for two (2) of eight (8) sample patients (A2 and A3). Failure to identify patients' assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's positive attributes in the therapy. (Refer to B117)

III. Ensure that patient discharge summaries were completed in a timely manner according to hospital policy requirements for 2 of 5 discharged patients (D1 and D5). This failed practice compromises the effective transfer of the patient's care to the next care provider. (Refer to B133)