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Based on medical record review, interview, and document review, the hospital failed to ensure that the medical records maintained by the hospital permitted determination of the degree and intensity of the treatment provided to individuals who were furnished services in the hospital as evidenced by: failed to ensure that psychiatric admission evaluations established the patient's memory functioning and/or orientation (B-0116), failed to ensure that written treatment plans were based on an inventory of the patient's strengths (B-0119), failed to ensure that written treatment plans included short-term and long range goals (B-0121), failed to ensure that written treatment plans included specific treatment modalities utilized (B-0122), failed to ensure that written treatment plans included the responsibilities of each member of the treatment team (B-0123), and failed to ensure that treatment received by patients were documented in such a way to assure that all active therapeutic effects were included (B-0125).

Based on medical record review, the hospital failed to ensure that a patient's psychiatric admission evaluation included an assessment of the patient's memory functioning in 2 (patient #5, and #24) of 8 active sampled medical records. Findings include:

The 8/17/2010 and 8/18/2010 medical record review revealed that:

(1) The psychiatric admission evaluation of patient #5 completed on 8/16/2010 did not include an assessment of the patient's memory functioning.

(2) The psychiatric admission evaluation of patient #24 completed on 8/16/2010 did not include an assessment of the patient's memory functioning.

Based on medical record review, the hospital failed to ensure that a patient's psychiatric admission evaluation included an inventory of the patient's assets in 3 (patient #5, #21, and #24) of 8 active sampled medical records. Findings include:

The 8/17/2010 and 8/18/2010 medical record review revealed that:

(1) The psychiatric admission evaluation of patient #5 completed on 8/16/2010 did not include an inventory of the patient's assets.

(2) The psychiatric admission evaluation of patient #21 completed on 8/15/2010 did not include an inventory of the patient's assets.

(3) The psychiatric admission evaluation of patient #24 completed on 8/16/2010 did not include an inventory of the patient's assets.

Based on medical record review, the hospital failed to ensure that developed individualized comprehensive treatment plan entitled Individualized Plan of Care (IPOC) included an inventory of the patient's strengths and assets that were identified and incorporate into an Individual Treatment Plan in 5 (patient #9, #17, #18, #19, #20, #22) of 13 sampled cases. Findings include:

The 8/17/2010 and 8/18/2010 medical record review revealed that:

1) Patient #9's IPOC initiated 7/20/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

2) Patient #17's IPOC initiated 8/11/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

3) Patient #18's IPOC initiated 6/5/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

4) Patient #19's IPOC initiated 7/20/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

5) Patient #20's IPOC initiated 5/18/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

6) Patient #22's IPOC initiated 6/13/2010 did not identify any patient strengths. The section of the IPOS entitled "Patient Strengths/Weakness Related To Ability To Achieve Goal/Readiness For Change" was left blank.

Based on medical record review, the hospital failed to ensure that a patient's written individualized comprehensive treatment plan included short term and long term goals in 8 (patient #5, #6, #7, #14, #16, #17, #21, and #24) of 8 sampled active cases. Findings include:

The 8/17/2010 and 8/18/2010 review of patient #5, #6, #7, #14, #16, #17, #21, and #24 Individualized Plan of Care (IPOC) revealed that:

1) Identified long term goals were not measurable nor stated an expected date of achievement.

a) Patient #5's IPOC stated that the patient's problem was "behavior danger to others" The long range goal was to "eliminate behavior".

b) Patient #6 was admitted to the hospital on 8/16/2010. The patient's IPOC did not specify a patient problem or any long range goals even though treatment interventions were activated for the behavioral health clinician, nursing, recreational therapy and the IPOC was signed on 8/17/2010 by the attending psychiatrist, a representative from nursing, a clinical therapist, and a recreation therapist

c) Patient #7's IPOC stated that the patient's problem was "suicidal ideation attempt". The long range goal was to "eliminate suicidal thoughts/actions."

d) Patient #14's IPOC stated that the patient's problem was "depression with inability to care for self". The long range goal was to "elevate mood so patient care for self."

e) Patient #16's IPOC stated that the patient's problem was "psychosis". The long range goal was to "eliminate active psychotic symptoms".

f) Patient #17's IPOC stated that the patient's problem was "suicidal impulse". The long range goal was to "eliminate suicidal impulse."

g) Patient #21 was initially admitted to the hospital on 8/15/2010. On 8/16/2010 the patient was sent to a local medical hospital due to chest pains. The patient was readmitted to the hospital on 8/17/2010. The patient's IPOC stated that the patient's problem was "suicidal ideation" but did not specify any long range goals even though interventions were activated for nursing, and recreational therapy and the IPOC was signed on 8/17/2010 by the attending psychiatrist, a representative from nursing, and an activity therapist.

h) Patient #24's IPOC stated that the patient's problem was "impulsivity". The long range goal was to "alleviate frequency and intensity of impulsivity to continue treatment outpatient".

2) The format of the hospital's IPOC does not formally specify "short term goals" but has a section entitled "objectives" in which discipline related objectives were recorded.

Reviewed objectives were generic, repetitious, not measurable, and not always related to the patient's problem. For example, goal #1 in patient #5, #7, #14, #16, #17, #21, and #24 IPOC stated that "the patient will take medications", irrespective of whether the patient had a history of medication compliance. Goal #4 in patient #5, #6, #7, #14, # 24 IPOC stated that "patient will attend social work group and interact with peers and staff".

Based on medical record review, the hospital failed to ensure that written individualized comprehensive treatment plans included specific treatment modalities in 8 (patient #3, #5, #6, #7, #14, #16, #21, and #24) of 12 sampled cases. Findings include:

(1) The 8/17/2010 and 8/18/2010 review of patient #5, #6, #7, #14, #16, #21, and #24 written individualized comprehensive treatment plans entitled Individualized Plan of Care (IPOC) revealed that the intensity of treatment interventions to be provided were not specified.

a) Patient #14's IPOC stated that psychiatrist to conduct "daily face to face contact to assess progress on goals and objectives, evaluate treatment and modify treatment as appropriate." The IPOC did not specify the expected time duration of the planned daily face to face contact.

b) Patient #7's IPOC stated that behavioral health clinician to "provide group psychotherapy focusing on relationship issues, relapse prevention, aftercare planning, improving treatment compliance, improved coping skills." The IPOC did not specify the expected time duration of the planned group therapy.

c) Patient #21's IPOC stated that nursing to "provide nursing group focusing on medical compliance, physical health issues, health living, improved coping skills, progress on goals and objectives." The IPOC did not specify the expected time duration of the planned nursing groups.

d) Patient #24's IPOC stated that recreational functional activities to increase self esteem, increase frustration tolerance, increase leisure education, increase coping skills." The IPOC did not specify the expected time duration of the planned recreational functional activities. The format did not specify which recreational functional activities would be provided.

(2) Based on medical record review, the hospital failed to ensure that psychiatric interventions were specified in 7 (patient #5, #6, #7, #16, #17, #21, and #24) of 8 active sampled patient Individualized Plan of Care (IPOC).

The 8/17/2010 and 8/18/2010 review of patient medical records revealed that:

a) Patient #5's IPOC was signed by the psychiatrist on 8/16/2010. The signed IPOC did not include any psychiatric interventions.

b) Patient #6's IPOC was signed by the psychiatrist but was undated. The signed IPOC did not include any psychiatric interventions.

c) Patient #7's IPOC was signed by the psychiatrist on 8/17/2010. The signed IPOC did not include any psychiatric interventions

d) Patient #16's IPOC was signed by the psychiatrist on 8/17/2010. The signed IPOC did not include any psychiatric interventions.

e) Patient #17's IPOC was signed by the psychiatrist on 8/17/2010. The signed IPOC did not include any psychiatric interventions.

f) Patient #17's IPOC was signed by the psychiatrist on 8/17/2010. The signed IPOC did not include any psychiatric interventions.

g) Patient #21's IPOC was signed by the psychiatrist but was undated. The signed IPOC did not include any psychiatric interventions.

h) Patient #24's IPOC was signed by the psychiatrist on 8/17/2010. The signed IPOC did not include any psychiatric interventions.




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(3) Based on observation, interview and record review the facility failed to ensure that two (patient #14 and #3) of five patients had individualized comprehensive interventions for physical health problems. Findings include:

On 8/19/2010 at approximately 1000 hours, patient #14's current care plan was reviewed with the Director of Patient Care Services. Patient #14 has a diagnosis of Diabetes Mellitus and a physician's order to check his blood sugar twice daily. Above normal blood sugars were documented by nursing on 8/16/2010 (213 mg/dL) and 8/17/2010 (224 mg/dL). Diabetes and obesity were listed as problems on the admitting care plan problem list, dated 8/15/2010. The Director of Patient Care Services confirmed that there were no interventions in patient #14's care plan specific to diabetes or obesity.

On 8/18/2010 at approximately 1630 hours, patient #3's closed medical record was reviewed with the Director of Patient Care Services. According to an Occurrence Report dated 5/1/2010, patient #3 experienced a swollen right hand following a physical altercation with another patient on the Adolescent Unit. The report notes that patient #3 stated: "it was probably broke before" and that ice was applied. On 5/1/2010 an untimed entry by the physician states: "sup (superficial) lacerations noted right hand...swelling noted...If no improvement in symptoms next 2 days-48 hours will order x-ray pt. (patient's) hand."

Further review of patient #3's chart revealed a Nursing Note dated 5/3/2010, at 0515 hours, stating: "Rx (medication) for his right hand pain." According to the 5/3/2010 Medication Administration Record (MAR), patient #3 received PRN (as needed) doses of Motrin for right hand pain at 0100 hours and 0830 hours. A physician's progress note dated 5/3/2010 at 0945 hours makes no mention of the patient's right hand pain or injury. A Nursing Note states that patient #3 was discharged at 1300 hours on 5/3/2010. There was no documentation of a right hand x-ray prior to discharge or recommendations for treatment of right hand pain. The Director of Patient Care Services confirmed that patient #3's care plan contained no interventions for monitoring or treatment of right hand pain.

Based on medical record review and interview, the hospital failed to ensure that a patient's written comprehensive individualized treatment plan included the responsibilities of each member of the treatment team in 8 of 8 sampled active patients (patient #5, #6, #7, #14, #16, #21, and #24). Findings include:

The 8/17/2010 and 8/18/2010 review of patient patient #5, #6, #7, #14, #16, #21, and #24 written comprehensive individualized treatment plan entitled Individualized Plan of Care (IPOC) lists treatment intervention to be completed by a psychiatrist, behavioral health clinician, nursing, recreational therapist, and discharge planning. The reviewed IPOC's did not identify by name the individual who was responsible to promulgate the treatment interventions specified in the patient's IPOC.

Based on observation, interview, record review, and policy review the facility failed to ensure active treatment for 6 (patient #3, #4, #8, #14, #15, and #23) of 12 sampled patients. Findings include:

(1) Based on medical record review, interview, and policy review, the hospital failed to ensure that an admitted adult patient was asked whether s/he had an advance directive in 3 (patient #8, #15, and #23) of 5 applicable sampled patients.

a) Hospital policy entitled Advance Medical Directives (Policy #2028) received 8/19/2010 at 0910 hours was reviewed. Review revealed that the policy states that an admitted patient is to be provided written information regarding advance directives.

Intake staff person in the admission office was interviewed 8/19/2010 at 0900 hours. The staff person acknowledged that the hospital did not have any written information regarding advance directives to provide to an admitted adult patient.

b) The 8/17/2010 and 8/18/2010 medical record review revealed that:

i) Information regarding whether the patient has an advance directive is documented on the intake assessment sheet.

ii) Documented intake assessment inquiry regarding advance directives does not differentiate between medical advance directives and psychiatric advance directives.

iii) Patient #8's intake assessment completed 4/3/2010 did not include any documentation as to whether the patient had an advance directive.

iv) Patient #15's intake assessment completed 4/6/2010 did not include any documentation as to whether the patient had an advance directive.

v) Patient #23's intake assessment completed 7/27/2010 did not include any documentation as to whether the patient had an advance directive.


(2) Based on policy review and medical record review, the hospital failed to to ensure that the physical restraint of patient was subject to a physician's order and that a physically restrained patient was formally assessed for any signs or symptoms of injury resulting from the physical restraint in 1 of 2 sampled applicable cases.

(a) Harbor Oaks Hospital Policy #1972.00 received 8/17/2010 was reviewed. Review revealed that the policy:

i) Requires that a physician's restraint order needs to be obtained if a patient is to be "forcibly held" in order to administer an intramuscular injection.

ii) Defines "personal restraint" as physical management to a surface that exceeds five minutes in length. The policy states that "once a patient is held to any surface by staff members for longer than 5 minutes, it becomes a personal restraint all restraint documentation must be completed."

iii) Defines "therapeutic holds" as physical management hold as taught by the Crisis Prevention Institute...to be managed by staff in a standing position and do not involve managing the patient to the floor or bed.

iv) As the hospital's restraint/seclusion policy is written, "personal restraint" of less than 5 minutes and "therapeutic holds" do not require that the hospital follow the hospital's restraint requirements.

Physically holding a patient from which the patient cannot easily remove the hold or escape the grasp is considered physical restraint and all restraint requirements should apply. See 42 CFR 482.13(e)(1)(i) and 42 CFR 482.13(e)(1)(i)(C).

(b) The 8/17/2010 review of patient #4 medical record revealed that on 3/22/2010 the patient was physically held on the floor to be given an intramuscular injection. The medical record did not document that a physician's order was requested or secured to physically restraint the patient. The patient's medical record did not include any restraint documentation as required by hospital Policy #1972.00.


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(3) Based on observation, interview and record review the facility failed to ensure that two (patient #14 and #3) of five patients had individualized comprehensive interventions for physical health problems. Findings include:

On 8/19/2010 at approximately 1000 hours, patient #14's current care plan was reviewed with the Director of Patient Care Services. Patient #14 has a diagnosis of Diabetes Mellitus and a physician's order to check his blood sugar twice daily. Above normal blood sugars were documented by nursing on 8/16/2010 (213 mg/dL) and 8/17/2010 (224 mg/dL). Diabetes and obesity were listed as problems on the admitting care plan problem list, dated 8/15/2010. The Director of Patient Care Services confirmed that there were no interventions in patient #14's care plan specific to diabetes or obesity.

On 8/18/2010 at approximately 1630 hours, patient #3's closed medical record was reviewed with the Director of Patient Care Services. According to an Occurrence Report dated 5/1/2010, patient #3 experienced a swollen right hand following a physical altercation with another patient on the Adolescent Unit. The report notes that patient #3 stated: "it was probably broke before" and that ice was applied. On 5/1/2010 an untimed entry by the physician states: "sup (superficial) lacerations noted right hand...swelling noted...If no improvement in symptoms next 2 days-48 hours will order x-ray pt. (patient's) hand."

Further review of patient #3's chart revealed a Nursing Note dated 5/3/2010, at 0515 hours, stating: "Rx (medication) for his right hand pain." According to the 5/3/2010 Medication Administration Record (MAR), patient #3 received PRN (as needed) doses of Motrin for right hand pain at 0100 hours and 0830 hours. A physician's progress note dated 5/3/2010 at 0945 hours makes no mention of the patient's right hand pain or injury. A Nursing Note states that patient #3 was discharged at 1300 hours on 5/3/2010. There was no documentation of a right hand x-ray prior to discharge or recommendations for treatment of right hand pain. The Director of Patient Care Services confirmed that patient #3's care plan contained no interventions for monitoring or treatment of right hand pain.

Based on medical record review and interview, the hospital failed to ensure that the record of each discharged patient had a discharge summary that included an accurate recapitulation of the patient's hospitalization in 6 (patient #2, #3, #4, #9, #12, and #15) of 15 reviewed closed cases. Findings include:

(1) Interviewed on 8/18/10 at approximately 1630 hours, the hospital's Director of Nursing confirmed that a patient's discharge summary must be dictated within 30 days of a patient's discharge from the hospital.

(2) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed:

a) Patient #3 was discharged from the hospital on 5/02/10. The patient's medical record did not include a discharge summary. The Director of Nursing on 8/18/2010 confirmed that a discharge summary had not been dictated or completed.


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b) Patient # 15 was discharged from the hospital on 6/08/2010. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/19/2010 at 0935 hours confirmed that a discharge summary had not been dictated or completed.



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c) Patient #12 was discharged from the hospital on 6/04/2010. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/18/10 confirmed that a discharge summary had not been dictated or completed.

(3) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed within 30 days of the patient's discharge.

a) Patient #2 was discharged from the hospital on 5/08/2010. The medical record discharged summary stated that the summary was dictated on 6/14/2010.

b) Patient #4 was discharged from the hospital on 3/23/2010. The medical record discharged summary stated that the summary was dictated on 4/27/2010.

c) Patient #9 was discharged from the hospital on 3/26/2010. The medical record discharged summary stated that the summary was dictated on 5/7/2010.

Based on medical record review and interview, the hospital failed to ensure that the record of each discharged patient had a discharge summary that included recommendations for follow up and after care in 6 (patient #2, #3, #4, #9, #12, and #15) of 15 reviewed closed cases. Findings include:

(1) Interviewed on 8/18/2010 at approximately 1630 hours, the hospital's Director of Nursing confirmed that a patient's discharge summary must be dictated within 30 days of a patient's discharge from the hospital.

(2) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed:

a) Patient #3 was discharged from the hospital on 5/02/2010. The patient's medical record did not include a discharge summary. The Director of Nursing on 8/18/2010 confirmed that a discharge summary had not been dictated or completed.

b) Patient # 15 was discharged from the hospital on 6/08/2010. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/19/2010 at 0935 hours confirmed that a discharge summary had not been dictated or completed.

c) Patient # 12 was discharged from the hospital on 6/04/10. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/18/10 confirmed that a discharge summary had not been dictated or completed.


(3) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed within 30 days of the patient's discharge.

a) Patient #2 was discharged from the hospital on 5/08/2010. The medical record discharged summary stated that the summary was dictated on 6/14/2010.

b) Patient #4 was discharged from the hospital on 3/23/2010. The medical record discharged summary stated that the summary was dictated on 4/27/2010.

c) Patient #9 was discharged from the hospital on 3/26/2010. The medical record discharged summary stated that the summary was dictated on 5/7/2010.

Based on medical record review and interview, the hospital failed to ensure that the record of each discharged patient had a discharge summary that included a brief summary of the patient's condition on discharge in 6 (patient #2, #3, #4, #9, #12, and #15) of 15 reviewed closed cases. Findings include:

(1) Interviewed on 8/18/2010 at approximately 1630 hours, the hospital's Director of Nursing confirmed that a patient's discharge summary must be dictated within 30 days of a patient's discharge from the hospital.

(2) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed:

a) Patient #3 was discharged from the hospital on 5/02/2010. The patient's medical record did not include a discharge summary. The Director of Nursing on 8/18/2010 confirmed that a discharge summary had not been dictated or completed.

b) Patient #15 was discharged from the hospital on 6/08/2010. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/19/10 at 0935 hours confirmed that a discharge summary had not been dictated or completed.

c) Patient #12 was discharged from the hospital on 6/04/10. The patient's medical record did not include a discharge summary. The hospital's risk manager on 8/18/2010 confirmed that a discharge summary had not been dictated or completed.


(3) The 8/17/2010 and 8/18/2010 medical record review revealed that in the following 3 cases, discharge summaries were not completed within 30 days of the patient's discharge.

a) Patient #2 was discharged from the hospital on 5/08/2010. The medical record discharged summary stated that the summary was dictated on 6/14/2010.

b) Patient #4 was discharged from the hospital on 3/23/2010. The medical record discharged summary stated that the summary was dictated on 4/27/2010.

c) Patient #9 was discharged from the hospital on 3/26/2010. The medical record discharged summary stated that the summary was dictated on 5/7/2010.