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Based on observation and record review, the facility failed to ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) for four (4) of four (4) active sample patients (1, 2, 3 and 4) and four (4) of four (4) discharged patients (5, 6, 7 and 8) reviewed for compliance with the Plan of Correction. This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

A. Record Review (MTP dates in parentheses)

1. Patient 1 (4/10/17)

The MTP included no discipline for the listed interventions.

2. Patient 2 (4/10/17)

The MTP included no discipline for the listed interventions.

3. Patient 3 (4/7/17)

The MTP included no discipline for the listed interventions.

4. Patient 4 (4/7/17)

The MTP included no discipline for the listed interventions.

5. Patient 5 (3/7/17)

The MTP included no discipline for the listed interventions.

6. Patient 6 3/10/17)

The MTP included no discipline for the listed interventions.

7. Patient 7 (3/14/17)

The MTP included no discipline for the listed interventions.

8. Patient 8 (3/15/17)

The MTP included no discipline for the listed interventions.

Based on record review and interview, the facility failed to ensure that medical staff provided a discharge summary that included a recapitulation of the patient's hospitalization including the circumstances of admission, assessments, treatments provided, and condition at the time of discharge for one (1) of four (4) discharged patients (11), reviewed for compliance with the Plan of Correction. This deficiency results in a failure to communicate assessments, treatments, and discharge plan to providers providing follow-up.

Findings include:

A. Record review

No discharge summary was documented in the medical record for Patient 11 (date of discharge, 2/7/17).

B. Staff Interviews

1. During an interview with MD 1 on 4/12/17 at 10:50 a.m., she acknowledged that she had not completed a discharge summary for Patient 11.

2. During an interview with the Medical Director on 4/11/17 at 9:00 a.m., he acknowledged that no discharge summary was documented for Patient 11.