HospitalInspections.org

Based on record review, staff interview, and observation, the facility failed to:

I. Develop and document individualized "Multidisciplinary Treatment Plans" (Master Treatment Plans) for 8 of 8 sample patients (A8, B7, B14, C9, D4, E11, F2 and G4) that included problem statements, treatment goals, and treatment modalities/interventions based on the patients' assessed needs. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized, and interdisciplinary approach to providing active treatment for patients. (Refer to B118)

II. Ensure the proper use and documentation of Emergency Medications for 1 of 8 active sample patients (B7) and 1 of 4 non-sample patients (I3) who was reviewed for episodes of seclusion/restraint and PRN antipsychotic medications. These patients did not have a face-to-face evaluation within 1 hour of verbal physician orders for involuntary medications. This failure results in a restriction of patient rights without documenting adequate justification. (Refer to B125, Part I)

III. Follow proper procedure to deny a voluntary patient's request for release for 1 of 8 active sample patients (B7). This failure results in a restriction of the patient's rights without documenting adequate justification. (Refer to B125, Part II)