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Based on medical records review and staff interviews, the facility failed to develop a Master Treatment Plan for 1 of 10 active sample patients (Patient A2) that included focused interventions that correlated with identified patient problems. This failure hampers the treatment team's ability to provide and evaluate treatment based on the patient's presenting needs and behaviors.

Findings include:

A. Record Review:

Patient A2 is a 77 year old admitted on 6/20/11 to the forensic ward; current diagnosis in master treatment plans dated 6/28/11 and 7/12/11, both included Axis I Diagnoses: "Schizoaffective Disorder, Alcohol Dependence, and Dementia due to alcohol abuse Chronic Schizophrenia and Hypertension." These master treatment plans did not include any interventions related to the Dementia diagnosis.

B. Observation:

During an observation of a Treatment Team meeting on 7/12/11 at 9:00AM, the treatment team discussed Patient A2 with the patient present; the findings from the neuropsychological evaluation related to patient's memory impairment and Dementia were discussed. The treatment team also discussed the need for supervised living arrangements after discharge to enhance and assist with the patient's treatment compliance. The treatment team failed to incorporate the information from this meeting into the patient's master treatment plan dated 7/12/11.

C. Staff Interviews:

1. In an interview on 7/12/11 at 10:00AM, Physician #1 acknowledged and agreed that the treatment team should have included the interventions that address the signs and symptoms of dementia in the master treatment plan.

2. In an interview on 7/13/11 at 8:30AM, the Medical Director agreed that the master treatment plan should reflect interventions related to the Dementia diagnosis for Patient A2.

I. Based on record review and staff interviews, the Medical Director failed to ensure that the treatment team include interventions on the master treatment plan for 1 of 10 active sample patients that are individualized and comprehensive (Patient A2). This failure may negatively affect treatment goals and activities for patients. (Refer to B122).

II. Based on staff interviews and record review, the Medical Director failed to ensure the quality and appropriateness of the services provided by medical staff for 1 of 10 active sample patients (Patient A1). This failure may negatively impact patient care and outcome.

Findings include:

A. Record Review:

1. Patient A1 was prescribed and offered Metformin for treatment of diabetes diagnosed upon admission on 12/2/10. Throughout hospitalization the patient was consistently refusing to take the same medication. The patient's blood glucose finger stick and lab data (Glucose on 3/15/11=98, 6/7/11=85, HbA1C on 3/15/11=5.6 (range 0-5.6%) indicated normal glucose levels.

2. Patient A1's Master Treatment Plan dated 6/29/11, listed Patient A1's Axis III Diagnoses as Hypothyroidism, Hypercholesterolemia, NIDDM [Non Insulin Dependent Diabetes] and Obstructive Sleep Apnea. Problem 3 noted: "Health and Wellness"; Interventions included: "[Physician#2] will coordinate care with the primary care providers to treat hypothyroidism with levothyroxine, Hypertension with furosemide, DM (Diabetes)with Metformin, and will counsel to stop smoking and start regular exercising." Noted in the Treatment Plan Review dated 6/29/11; "Progress since last review"; Problem 3 stated "[Patient A1]has no understanding of [his/her] NIDDM. Has been refusing Metformin, ASA (Aspirin), Calcium, Furosemide and Simvastatin. Resistive to most education efforts. Does comply with levothyroxine." The Treatment Plan Review did not contain any new interventions to deal with the patient's resistance to medications.

B. Staff Interviews:

1. In an interview on 7/11/11 at 12:45PM with RN6, Patient A1's medication refusal was discussed. RN6 stated "This patient always refuses medical medications."

2. In an interview on 7/12/11 at 11:30AM, Physician#2 (attending physician for Patient A1) was aware that Patient A1 was prescribed and offered Metformin for treatment of diabetes diagnosed upon admission on 12/2/10 and that Patient A1 had been consistently refusing to take Metformin. Upon reviewing the patient's refusal of medications and lab values the physician acknowledged "I agree with you [Patient A1] does not need Metformin, I will discontinue today."

3. In an interview on 7/13/11 at 8:30AM, the Medical Director agreed with the findings and stated "then I wonder if the patient should be on Metformin."