HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure that the psychiatric evaluations of 7 of 8 active sample patients (A1, A2, A3, A5, A6, A7 and A8) included a description of the patients' memory functioning in terms which clearly reflected the patients' abilities to function in those areas. For 3 of the sample patients (A1, A2, A7), the assessments were too general to be useful. The tests used for the assessments also were not identified. For the other 4 sample patients (A3, A4, A6, A8), no memory testing was documented. This failed practice compromises the database from which diagnoses are determined. It also results in lack of objective baseline data on the patients' memory functioning for future comparison.

Findings include:

A. Record Review

1. Patient A1: In a psychiatric evaluation dated 11/05/10, memory function was described as "Memory for remote, recent past, and recent events appeared to be grossly intact." There was no information related to the forms of testing that were used to make these determinations.

2. Patient A2: In a psychiatric evaluation dated 7/30/10, the patient's memory was described as: "Memory appeared to be grossly intact." There was no information related to the forms of testing that were used to make these determinations.

3. Patient A3: In a psychiatric evaluation dated 09/23/10, there was no information related to memory testing.

4. Patient A5: In a psychiatric evaluation dated 11/18/10, there was no information related to memory testing.

5. Patient A6: In a psychiatric evaluation dated 11/12/10, there was no information related to memory testing.

6. Patient A7: In a psychiatric evaluation dated 12/02/10, the patient's memory function was described as "Memory for remote, recent past, and recent events appeared to be grossly intact." There was no information related to the forms of testing that were used to make these determinations.

7. Patient A8: In a psychiatric evaluation dated 11/12/10, there was no information related to memory testing.

B. Staff Interview

In an interview on 1/26/11 at 9:00AM, which included a discussion of the lack of memory testing documentation in the psychiatric evaluations for patients, the Medical Director said "Sometimes it is forgotten."

Based on record review and interview, the facility failed to ensure that the Comprehensive Treatment Plans (Master Treatment Plans):

I. Defined short-term and/or long-term goals as specific measurable patient behaviors to be achieved for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A7 and A8). This deficiency compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans.

II. Included goals related to substance abuse for 4 of 4 active sample patients (A1, A4, A7 and A8) who had documented substance abuse problems on their Master Treatment Plans. This failure hinders the treatment team's ability to measure and document change in patients with co-occurring illnesses.

III. Specified new treatment goals for 1 of 8 active sample patients (A2) after an incident of self-injurious behavior. This patient required extensive treatment for medical problems identified after an incident of "self-injurious" behavior which resulted in blindness. The MTP was revised to include the problem of "self-injurious behavior," but there were no goals added for the medical problems. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment provided.

Findings include:

I. Failure to define measurable goals on treatment plans

A. Record Review

1. Patient A1 was admitted 11/3/10 with Axis I diagnoses of Bipolar Disorder, Opioid Dependence, and Alcohol Dependence. The Comprehensive Treatment Plan developed 11/16/10 identified a problem of "audio hallucination, substance abuse, paranoia" with a long-term goal of "Get this thinking thing fixed and think more clearly" and a short-term goal of "Work with staff to find medication combination that helps to stabilize her and to formulate an appropriate class schedule." These goals were not written in measurable terms.

2. Patient A2 was admitted to the hospital on 7/28/10 with a diagnosis of Schizophrenia, Paranoid Type. The Comprehensive Treatment Plan, developed on 8/10/10 identified a problem of "Schizophrenia, paranoid type, negative symptoms" with short-term goals of "comply with psychotropic meds to reduce negative symptoms" and "Communicate physical and emotional needs to staff to the best of my ability." These goals were not written in measurable terms.

3. Patient A3 was admitted on 9/22/10 with an Axis I diagnosis of Schizoaffective Disorder, Bipolar Type. The Comprehensive Treatment Plan developed on 10/5/10 identified a problem of "Bipolar D/D (manic)/pressured speech/flight of ideas/mood lability" with a long-term goal of "To get calmed down and help other patients" and a short term goal of "I will comply with medications to reduce mood disturbance and mania." These goals were not written in measurable terms.

4. Patient A4 was admitted on 10/6/10 with Axis I diagnoses of Schizoaffective Disorder, Bipolar Type, and Polysubstance Dependence. The Comprehensive Treatment Plan developed on 10/19/10 identified a problem of "paranoid, poor hygiene, substance abuse, delusions" with a short-term goal of "manage paranoia, delusions, and other symptoms by compliance with medication and attending classes/groups." This goal was not written in specific measurable terms. 5. Patient A5 was admitted on 11/17/10 with Axis I diagnoses of Bipolar Disorder, PTSD, and Dissociative Identity Disorder. The Comprehensive Treatment Plan developed on 12/1/10 identified a problem of "self-harming behaviors, mood instability, anger issues" with a short-term goal of "I want to work on anger." This goal was not written in measurable terms.

5. Patient A5 was admitted on 11/17/10 with Axis I diagnoses of Bipolar Disorder, PTSD, and Dissociative Identity Disorder. The Comprehensive Treatment Plan developed on 12/1/10 identified a problem of "self-harming behaviors, mood instability, anger issues" with a short-term goal of "I want to work on anger." This goal was not written in measurable terms.

6. Patient A7 was admitted on 12/1/10 with Axis I diagnoses of Schizophreniform Disorder and Cannabis Abuse. The Comprehensive Treatment Plan developed on 12/15/10 identified a problem of "psychosis, substance abuse" with a short-term goal of "To get stabilized on medications to reduce psychosis and anxiety." This goal was not written in measurable terms.

7. Patient A8 was admitted on 11/18/09 with Axis I diagnoses of Bipolar Disorder, Cocaine Abuse, and Alcohol Abuse. The Comprehensive Treatment Plan updated on 11/23/10 identified a problem of "mood instability-current depression-substance abuse" with a long term goal of "I want to have a stable life" and a short term goal of "I would like to work with staff to gain a more stable mood." These goals were not written in measurable terms.

B. Staff Interview

In an interview on 1/25/11 at 1:30PM, the Nurse Executive stated that she was aware that the treatment plans were "a problem."

II. Failure to include MTP goals for documented substance abuse problems

A. Record Review

There were no short-term or long-term goals listed on the treatment plans related to substance abuse for active sample patients A1, A4, A7 and A8, even though substance abuse was identified as a problem on the treatment plans.

1. Patient A1 was admitted 11/3/10 with Axis I diagnoses of "Bipolar Disorder, Opioid Dependence, and Alcohol Dependence." The Comprehensive Treatment Plan developed 11/16/10 identified a problem of "audio hallucination, substance abuse, paranoia" with a long-term goal of "Get this thinking thing fixed and think more clearly" and a short-term goal of "Work with staff to find medication combination that helps to stabilize her and to formulate an appropriate class schedule." The MTP did not include any specific goals for substance abuse.


2. Patient A4 was admitted on 10/6/10 with Axis I diagnoses of "Schizoaffective Disorder, Bipolar Type" and "Polysubstance Dependence." The Comprehensive Treatment Plan developed on 10/19/10 identified a problem of "paranoid, poor hygiene, substance abuse, delusions" with a short-term goal of "manage paranoia, delusions, and other symptoms by compliance with medication and attending classes/groups." There were no specific goals for substance abuse.

3. Patient A7 was admitted on 12/1/10 with Axis I diagnoses of "Schizophreniform Disorder" and "Cannabis Abuse." The Comprehensive Treatment Plan developed on 12/15/10 identified a problem of "psychosis, substance abuse." The short-term goal was "To get stabilized on medications to reduce psychosis and anxiety." There were no specific goals for substance abuse.

4. Patient A8 was admitted on 11/18/09 with Axis I diagnoses of "Bipolar Disorder, Cocaine Abuse, and Alcohol Abuse." The Comprehensive Treatment Plan updated on 11/23/10 identified a problem of "mood instability-current depression-substance abuse." The long term goal was "I want to have a stable life" the short term goal was "I would like to work with staff to gain a more stable mood." There were no specific goals to address the substance abuse.

B. Staff Interview

In an interview on 1/25/11 at 1:30PM, the Nurse Executive, she stated that she was aware that treatment plans were "a problem."

III. Failure to specify new MTP goals for patient A2's medical problems

A. Record Review

Patient A2 was admitted 7/28/10 with an Axis I diagnosis of Schizophrenia, Paranoid Type. According to the medical record progress notes dated 11/27/10, the patient inflicted a self-injury on 11/27/10 at approximately 6:35AM. The patient was hospitalized at a local community hospital immediately following the incident and treated surgically for vision problems. As a result of the self-injury, the patient was blind in both eyes. While at the community hospital, a benign throat tumor also was identified; this required a tracheostomy (trach) and a feeding tube. The patient was returned to the facility on 12/21/10 at 4:35PM with a feeding tube (PEG), a capped trach, and a VRE [sic] infection which subsequently cleared up. The patient required medical intervention and skilled nursing care and was placed on 1:1 with an RN or LPN 24/7. The problem of "self-injurious behavior" was added to the Comprehensive Treatment Plan on 11/27/10. However, there were no new treatment goals documented on the plan to address the patient's medical problems after his return to the facility on 12/21/10.

B. Staff Interview

In an interview on 1/25/11 at 1:30PM, the Nurse Executive confirmed that the treatment plan for patient A2 failed to include any goals related to medical problems.

Based on record review and staff interviews, it was determined that the facility failed to develop Comprehensive Treatment Plans (MTPs) that:

I. Clearly delineated individualized interventions to address the specific problems of 7 of 8 active sample patients (A1, A2, A3, A4, A5, A7 and A8). Most of the interventions listed on the treatment plans were generic and non-specific discipline tasks, regardless of the identified problems. This deficient practice compromises staff's ability to provide appropriate and coordinated care to patients.

II. Specified new interventions for 1 of 8 active sample patients (A2) after an incident of self-injurious behavior. This patient required extensive treatment for medical problems identified after an incident of "self-injurious" behavior which resulted in blindness. The MTP was revised to include the problem of "self-injurious behavior," but there were no interventions added for the medical problems. This failed practice hinders the ability of the treatment team to provide needed treatment for patients, potentially resulting in prolonged hospitalizations.

Findings include:

I. Failure to include individualized interventions on MTPs

A. Record Review

1. Patient A1 was admitted 11/3/10 with Axis I diagnoses of Bipolar Disorder, Opioid Dependence, and Alcohol Dependence. The Comprehensive Treatment Plan developed 11/16/10 identified a problem of "audio hallucination, substance abuse, and paranoia," and included the following modalities: "Psychiatrist will meet with patient weekly, then biweekly, then monthly to monitor symptoms and side effects and make medication changes as needed." "RN will meet with patient weekly for eight weeks then monthly. Will educate and review medications with pt, encourage compliance and assess for side effects." "PsychoSocRehab to provide 7-day schedule of classes and activities to educate and support pt in issues related to substance abuse, coping, socialization, and sympt.(symptom) .management." "Clinical counselor will meet with pt. biweekly and then monthly to monitor progress and offer counseling."

2. Patient A2 was admitted to the hospital on 7/28/10 with a diagnosis of Schizophrenia, Paranoid Type. The Comprehensive Treatment Plan developed 8/10/10 identified a problem of Schizophrenia, paranoid type, negative symptoms and included the following modalities: "The psychiatrist will meet with patient every other week and then monthly to assess medication needs and make changes as necessary." "RN will encourage med compliance and classes to gain insight and coping skills." "PsychoSocial Rehab PEI to enroll pt in grps, classes and activities to educate and support pt in med compliance, coping skills, life skills." "Clinical counselor will meet with patient biweekly to monitor needs and." "Tech will meet weekly to discuss progress and monitor for any changes in psychotic symptoms."

3. Patient A3 was admitted on 9/22/10 with an Axis I diagnosis of Schizoaffective Disorder, Bipolar Type. The Comprehensive Treatment Plan developed on 10/5/10 identified a problem of "Bipolar D/D (manic)/pressured speech/flight of ideas/mood lability" and included the following interventions: "Psychiatrist will meet with patient biweekly and then monthly to monitor medication side effects and make adjustments as needed." "RN will encourage med compliance and classes to gain insight and coping skills." "PsychoSocRehab to provide 7-day sched. of grps and classes to educate pt re: sx mgt., med compliance, coping skills and mood D/O." "Clinical counselor will meet with patient biweekly and then monthly to monitor mood behaviors and provide treatment interventions as necessary."

4. Patient A4 was admitted on 10/6/10 with Axis I diagnoses of Schizoaffective Disorder, Bipolar Type, and Polysubstance Dependence. The Comprehensive Treatment Plan developed on 10/19/10 identified a problem of "paranoid, poor hygiene, substance abuse, delusions" and included the following interventions: "Psychiatrist will meet with patient biweekly then monthly to monitor symptoms, medication compliance and progress and make adjustments as needed." "RN will encourage med compliance and monitor for both positive and negative effects." "Tech will meet with pt. to discuss progress and prompt pt every medication time." "PsychoSocRehab to provide 7-day schedule of groups and classes to educate and support pt in sx mgt, ADDP, coping skills, life management skills." "Clinical counselor will meet with patient biweekly then monthly to monitor symptoms and progress and to offer counseling as needed."

5. Patient A5 was admitted on 11/17/10 with Axis I diagnoses of Bipolar Disorder, PTSD, and Dissociative Identity Disorder. The Comprehensive Treatment Plan developed on 12/1/10 identified a problem of "self-harming behaviors, mood instability, and anger issues" and included the following interventions: "Psychiatrist will meet with patient weekly then monthly to monitor her symptoms, medications, and side-effects and make adjustments as needed to reduce mood instability, self-harming behaviors, and anger." "Nursing will meet with pt. 1:1x8 weeks weekly then monthly to provide medication education, monitor for med side effects, encourage medication compliance, and monitor effectiveness of treatment." "Clinical counselor will meet with patient at least once biweekly to build rapport and develop goals for treatment." "Psychosocial Rehab will provide pt with a 7-day schedule of groups and classes to educate pt on skills to communicate and cope in order to maintain stability in the community."

6. Patient A7 was admitted on 12/1/10 with Axis I diagnoses of Schizophreniform Disorder and Cannabis Abuse. The Comprehensive Treatment Plan developed on 12/15/10 identified a problem of "psychosis, substance abuse" and included the following interventions: "Psychiatrist will meet with patient weekly then monthly to monitor medications, symptoms, and side effects and make adjustments as needed to decrease psychosis and anxiety." "Nursing will meet with pt 1:1 x 8 weeks weekly then monthly to provide medication education, monitor for med side effects, and encourage medication compliance and monitor effectiveness of treatment." No other interventions were listed on the treatment plan.

7. Patient A8 was admitted on 11/18/09 with Axis I diagnoses of Bipolar Disorder, Cocaine Abuse, and Alcohol Abuse. The Comprehensive Treatment Plan updated on 11/23/10 identified a problem of "mood instability-current depression-substance abuse" and included the following interventions: "Psychiatrist will meet with patient weekly then monthly to monitor side effects and make changes as needed to promote stability of mood." "Nursing will meet with pt 1:1 x8 weeks weekly then monthly to provide medication education, monitor for med side effects, encourage medication compliance, and monitor effectiveness of treatment." "Clinical counselor will meet with patient at least once monthly to monitor symptoms and provide coping skills to better manage mood." "Clinical counselor will provide coping skills, interventions and discussion related to substance abuse through BDDP [sic] groups and individual sessions."

B. Staff Interview:

In an interview on 1/25/11 at 1:30PM, the Nurse Executive stated that she was aware that treatment plans were "a problem."

II. Failure to specify interventions for Patient A2's medical problems

A. Record Review

Patient A2 was admitted 7/28/10 with an Axis I diagnosis of Schizophrenia, Paranoid Type. According to the medical record progress notes dated 11/27/10, the patient inflicted a self-injury on 11/27/10 at approximately 6:35AM. The patient was hospitalized at a local community hospital immediately following the incident and was treated surgically for vision problems related to the injury. As a result of the self-injury, the patient was blind in both eyes. While at the community hospital, a benign throat tumor also was identified; this required a tracheostomy (trach) and a feeding tube. The patient was returned from to the facility on 12/21/10 at 4:35PM with a feeding tube (PEG), a capped trach, and a VRE infection which subsequently cleared up. The patient required medical intervention and skilled nursing care and was placed on 1:1 with an RN or LPN 24/7. The Comprehensive Treatment Plan was revised on 11/27/11 to include a problem of self-injurious behavior. However, there were no new interventions documented on the plan to address the patient's medical problems after his return to the facility on 12/21/10.

B. Staff Interview

In an interview on 1/25/11 at 1:30PM, the Nurse Executive confirmed that the treatment plan for patient A2 failed to include interventions related to medical problems.

Based on document review and interview, the facility failed to ensure that there is a Clinical Director who meets the training and experience requirements for board examination in psychiatry. This failure compromises the quality and appropriateness of the supervision available to staff in their assessment and treatment of patients.

Findings include:

A. Document Review

In a review of the Curriculum Vitae of the Medical Director provided by the facility, the document showed that the Medical Director is Board Eligible in OB-GYN and was not trained in Psychiatry.

B. Staff Interview

In an interview on 1/25/11 at 8:50AM, the Medical Director, said that she is head of the medical staff but has not had training in Psychiatry. She said that previously, a Clinical Director who was a psychiatrist was employed, but that currently, there is no Clinical Director.

Based on record review and staff interview, the Medical Director failed to ensure quality control of the psychiatric evaluations conducted and the treatment plans developed to guide the patients' treatment. Specifically the Medical Director failed to:

I. Ensure that the psychiatric evaluations of 7 of 8 active sample patients (A1, A2, A3, A5, A6, A7 and A8) included a description of the patients' memory functioning in terms which clearly reflected the patients' abilities to function in those areas. For 3 of the sample patients (A1, A2, A7), the assessments were too general to be useful. The tests used for the assessments also were not identified. For the other 4 sample patients (A3, A4, A6, A8), no memory testing was documented. This failed practice compromises the database from which diagnoses are determined. It also results in lack of objective baseline data on the patients' memory functioning for future comparison. (Refer to B116)

II. Ensure that the facility's Comprehensive Treatment Plans (Master Treatment Plans): a) defined measurable short-term and/or long-term goals for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A7 and A8). b) included goals related to substance abuse for 4 of 4 active sample patients (A1, A4, A7 and A8), and c) specified new treatment goals for 1 of 8 active sample patients (A2) to address medical problems incurred after an incident of self-injurious behavior. (Refer to B121). These failures hinder the ability of the treatment team to measure change in the patient as a result of treatment provided. (Refer to B121)

III. Ensure that the facility's Comprehensive Treatment Plans: a) included individualized interventions for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A7 and A8), and b) specified interventions to address sample patient A2 medical problems incurred after a self inflicted injury. These deficiencies compromise staff's ability to provide appropriate and coordinated care to patients. (Refer to B122)

Based on record review and staff interview, the Nurse Executive (Director of Nursing) failed to ensure that the Comprehensive Treatment Plans of 7 of 8 active sample patients (A1, A2, A3, A4, A5, A7 and A8) included nursing interventions/modalities to address the individual patients' needs. The listed nursing modalities/interventions on the treatment plans were generic nursing tasks that were basically the same on all treatment plans reviewed. This deficiency hampers staff's ability to assist patients in making progress towards attaining their goals.

Findings include:

A. Record Review (treatment plan dates in parentheses)

1. Patient A1 was admitted 11/3/10 with Axis I diagnoses of Bipolar Disorder, Opioid Dependence, and Alcohol Dependence. The Comprehensive Treatment Plan (11/16/10) identified a problem of "audio hallucination, substance abuse, and paranoia," and included the following generic nursing interventions: "RN will meet with patient weekly for eight weeks then monthly. Will educate and review medications with pt, encourage compliance and assess for side effects."

2. Patient A2 was admitted to the hospital on 7/28/10 with a diagnosis of Schizophrenia, Paranoid Type. The Comprehensive Treatment Plan (8/10/10) identified a problem of Schizophrenia, paranoid type, negative symptoms and included the following generic nursing interventions: "RN will encourage med compliance and classes to gain insight and coping skills." "Tech will meet weekly to discuss progress and monitor for any changes in psychotic symptoms."

3. Patient A3 was admitted on 9/22/10 with an Axis I diagnosis of Schizoaffective Disorder, Bipolar Type. The Comprehensive Treatment Plan (10/5/10) identified a problem of "Bipolar D/D (manic)/pressured speech/flight of ideas/mood lability" and included the following generic nursing interventions: "RN will encourage med compliance and classes to gain insight and coping skills."

4. Patient A4 was admitted on 10/6/10 with Axis I diagnoses of Schizoaffective Disorder, Bipolar Type, and Polysubstance Dependence. The Comprehensive Treatment Plan (10/19/10) identified a problem of "paranoid, poor hygiene, substance abuse, delusions" and included the following generic nursing interventions: "RN will encourage med compliance and monitor for both positive and negative effects." "Tech will meet with pt. to discuss progress and prompt pt every medication time."

5. Patient A5 was admitted on 11/17/10 with Axis I diagnoses of Bipolar Disorder, PTSD, and Dissociative Identity Disorder. The Comprehensive Treatment Plan (12/1/10) identified a problem of "self-harming behaviors, mood instability, and anger issues" and included the following generic nursing interventions: "Nursing will meet with pt. 1:1x8 weeks weekly then monthly to provide medication education, monitor for med side effects, encourage medication compliance, and monitor effectiveness of treatment."

6. Patient A7 was admitted on 12/1/10 with Axis I diagnoses of Schizophreniform Disorder and Cannabis Abuse. The Comprehensive Treatment Plan (12/15/10) identified a problem of "psychosis, substance abuse" and included the following generic nursing interventions: "Nursing will meet with pt 1:1 x 8 weeks weekly then monthly to provide medication education, monitor for med side effects, and encourage medication compliance and monitor effectiveness of treatment."

7. Patient A8 was admitted on 11/18/09 with Axis I diagnoses of Bipolar Disorder, Cocaine Abuse, and Alcohol Abuse. The Comprehensive Treatment Plan update (11/23/10) identified a problem of "mood instability-current depression-substance abuse" and included the following generic nursing interventions: "Nursing will meet with pt 1:1 x8 weeks weekly then monthly to provide medication education, monitor for med side effects, encourage medication compliance, and monitor effectiveness of treatment."

B. Staff Interview:

In an interview on 1/25/11 at 1:30PM, the Nurse Executive, stated that she was aware that treatment plans were "a problem."