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Based on record review and interview, the facility failed to develop comprehensive treatment plans that clearly identified long term goals for 1 of 8 active sample patients (A21). This failure hinders the treatment team's ability to provide direction to staff for the focus of treatment, and it compromises the team's ability to ensure consistency of approach.

Findings include:

A. Record Review

Patient A21. The treatment plan, dated 5/19/11. Listed a long term goal as "Pt will express desire to live for 3 consecutive days." The intent of this goal was unclear; it sounds like the patient only wants to live for only 3 days.

B. Staff Interview

During a joint interview on 5/25/11 at 11:15a.m., the Director of Nursing (DON) and the Director of Risk Management acknowledged that the long term goal on Patient A21's treatment plan was ambiguous.

Based on record review and staff interviews, it was determined that the hospital failed develop Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A21, B11, C9, C13, D7, E15 and F10) that included treatment interventions (modalities) that specifically addressed the patients' identified problems. The interventions were generic discipline functions and/or failed to address specific patient goals or identify the modalities (and their frequencies) to be used. Failure to document specific treatment approaches on patients' treatment plans can result in lack of consistency of treatment approaches for each patient's problem(s).

Findings include:

A. Record Review

1. Patient A1: The MTP dated 5/19/11 listed the problem as "Depressed/potential for self harm." The listed interventions were "Nursing staff will administer medications as ordered and monitor for SI (suicidal ideation)." This was a generic function of nursing, not a patient specific intervention. "Activities therapist will provide gps 3 x a week for 45-50 minutes to increase coping skills, stress management, and social skills." This intervention was not patient specific; it also failed to designate which groups were to increase what coping skills, and what patient stressors and social skills were to be addressed. "Patient education related to medication regimen/therapeutic goals." This was not a patient specific intervention. It also failed to designate the mode and frequency of the 'education' and which therapeutic goals were to be addressed by which education mode. None of the listed interventions clearly addressed the patient's specific problems.

2. Patient A21: The MTP dated 5/19/11 listed problems as "History of not sleeping at night"; "eats once a day"; "Self medicating" and "Smoking..." The listed interventions were: "Physician will do daily Inpt (inpatient) Rnds (rounds)." This was a generic physician function, not a patient specific intervention. "Nursing staff will monitor, teach, and medicate patient as ordered." This was a generic function for nursing. "Activities therapist will provide gps 3 x a week for 45-50 minutes to increase coping skills, stress management, and social skills." This was not a patient specific intervention. It also failed to designate which groups were to be used to increase the patient's coping skills, and what patient stressors and social skills were to be addressed. None of the above interventions clearly addressed specific patient problems.

3. Patient B11: The MTP dated 5/18/11 listed the problem as "Suicidal ideation: to OD (overdose)." Interventions listed were: LCSW: "Psychotherapeutic groups to process treatment issues and goals 50 min. daily." The specific problems or goals to be addressed were not designated." Activities therapist will provide activities and education 3/wk for 45-50 min. to help orient patient to cope with depression." This intervention did not designate the specific activities and educational modalities to be used to address the patient's problem.

4. Patient C9: The MTP dated 5/18/11 listed the problems as "hallucinations"; "confusion" and "threats to kill self and family." Interventions were listed as: "Physician will meet with Pt.15 minutes daily to prescribe and monitor meds and discuss stress mgmt (management)." This was a generic physician function, not a specific intervention for the patient's identified problems. The stress management approaches to be used also were not specified. LCSW: "Psychotherapeutic groups to process treatment issues and goals 50 min. daily." The specific groups applicable to the patient's identified problems were not identified." Activities therapist will provide activities and education 3/wk for 45-50 min. to help orient patient to reality." This intervention did not designate the specific activities and educational modes that would be applicable to the patient's problems. None of the above interventions clearly addressed the identified patient problems.

5. Patient C13: The MTP dated 5/16/11 listed problems as "Hallucinations: auditory"; "Confusion: found wandering on the road naked" and "Other: Decreased sleep." The listed interventions were: "Physician will meet with patient 15 min. daily to prescribe and monitor meds, and discuss stress mgmt." This was a generic physician function, not a specific intervention for any of the designated problems. LCSW: "Psychotherapeutic groups to process treatment issues and goals 50 min. daily." The specific groups applicable to the patient's designated problems were not identified. "Activities therapist will provide activities and education 3/wk for 45-50 min. to help orient patient to reality." This intervention did not identify the specific activities and educational modalities that would be applicable to the patient's problems. None of the above interventions clearly addressed specific patient problems.

6. Patient D7: The MTP dated 5/18/11 listed problems as "out of touch with reality"; "depression" and "polysubstance abuse." The listed interventions were: "Nursing staff will monitor meds and effects, and encourage pt to verbalize any feelings of self harm." This was a generic function of nursing. The frequency and modality to be used to encourage expression of feelings was not specified, nor was patient goal to be addressed identified. LCSW: "Psychotherapeutic groups to process treatment goals and issues 50 min. daily." This intervention failed to specify what groups would be used to address which patient problems and/or goals. "Activities therapist will provide activities and education 3x/wk for 45-50 min. (minutes) to present positive ways to cope with depression." This intervention failed to designate which specific activities and education modalities would be used to help the patient achieve a specific goal. None of the above interventions clearly addressed specific patient problems.

7. Patient E 15: The MTP dated 5/20/11 listed problems as "Tried to poison M[sic]"; "appetite decreased"; "Sleep disturbance 4 h per night" and "stealing." The listed interventions were: 'Nursing staff will monitor meds and effects and encourage pt to verbalize any feelings of aggression." This was a generic nursing function. The frequency and modality of the intervention for encouraging expression of feelings were not specified, nor was the patient goal identified. LCSW: Psychotherapeutic groups to process treatment goals and issues 50 min. daily." This intervention failed to specify what groups would be used to address which patient problems. "Activities therapist will provide activities and education4/wk for 30-50 min. to increase social skills and decrease aggression." This intervention failed to designate what activities and/or educational modalities would be used to increase the patient ' s social skills and decrease the aggression. None of the above interventions clearly addressed specific patient problems.

8. Patient F10: The MTP dated 5/16/11 listed problems as "alcohol and opiates"; suicidal ideation in the past" and "Hx (history) of Bipolar." The listed interventions were: LCSW: "Psychotherapeutic groups to process treatment issues and goals 50 min. daily." The specific groups applicable to the patient's problems were not identified. "Activities therapist will provide activities and education 3/wk for 45-50 min. to present positive ways to cope with depression." This intervention did not designate what specific activities and educational modalities would be applicable to the patient's problems. None of the above interventions clearly addressed specific patient problems.

B. Staff Interviews

During an interview on 5/25/11 at 11:15AM, the Director of Nursing (DON) and the Director of Risk Management acknowledged the above findings.

Based on record review and interview, the facility failed to develop comprehensive treatment plans for 2 of 2 active adolescent patients (A1 and A21) that identified staff responsible for the listed interventions by name and discipline. This failure hinders the treatment team's ability to determine who is responsible for specific treatment modalities.

Findings include:

A. Record Review

1. Patient A1: The master treatment plan dated 5/19/11 listed 2 nursing interventions as "staff will use behavioral techniques such as personal time out..." and "staff will use behavioral level system to reduce risk of self harm." The specific names and disciplines of the staff responsible for the listed interventions were not identified; the responsible staff was only listed as "all staff."

2. Patient A21: On the treatment plan dated 5/19/11, the physician intervention was listed as "physician will make inpatient rounds." There was no identified physician for the intervention.

B. Staff Interview

During an interview on 5/25/11 at 11:15a.m., the DON and the Director of Risk Management acknowledged that the MTPs of patients A1 and A21 did not identify the name and discipline of staff responsible for the listed interventions.

Based on record review and interview, it was determined that for 1 of 5 closed records, the discharge summary was not recorded in a timely manner. Failure to complete timely discharge summaries compromises the ability of outpatient providers to provide appropriate treatment approaches after the patient's discharge.

A. Record Review

A review of the discharge record of Patient G4, discharged on 4/15/11, revealed no discharge summary in the closed record.

B. Staff Interview

During an interview on 5/24/11 at 10:30a.m., the DON confirmed the absence of a discharge summary in Patient G4's medical record.

Based on record review and interview, it was determined that the Medical Director failed to:

I. Ensure that the Master Treatment Plans (MTPs) provided a clear statement of long term patient goals for 1 of 8 active sample patients (Refer to B121), identified treatment interventions (modalities) related to specific problems and goals for 8 of 8 active sample patients (Refer to B122), and identified the name and discipline of staff responsible for interventions for 2 of 2 active adolescent patients (Refer to B123). These failures hamper staff's ability to provide consistent and individualized treatment.

II. Ensure that timely discharge summaries were recorded in the medical records of 1 of 5 discharged patients. Failure to complete timely discharge summaries compromises the ability of outpatient providers to provide appropriate treatment approaches after the patient's discharge. (Refer to B133)

Based on record review and interview, the Director of Nursing failed to monitor nursing staff activities to assure all required documentation was present. Specifically, the DON failed to:

I. Assure that nursing interventions on the Master Treatment Plans of 4 of 8 active sample patients (A1, A21, D7 and E15) addressed the patients' specific problems and goals, and specified the modalities (and their frequencies) to be used for the interventions. The listed nursing interventions for these patients were generic nursing functions. Failure to clearly identify nursing interventions to address specific patient problems can result in lack of consistency of treatment approaches for each patient's problem(s).

Findings include:

A. Record Review

1. Patient A1: The MTP dated 5/19/11 listed the problem as "Depressed/potential for self harm." The listed nursing interventions were: "Nursing staff will administer medications as ordered and monitor for SI (suicidal ideation)." This was a generic function of nursing, not a patient specific intervention. "Patient education related to medication regimen/therapeutic goals." This was not a patient specific intervention. It also failed to designate the modality and frequency of the 'education' approaches, and which therapeutic goals were to be addressed by which education activities.

2. Patient A21: The MTP dated 5/19/11 listed the problems as "History of not sleeping at night"; "eats once a day"; "Self medicating" and "Smoking..." The listed nursing intervention was "Nursing staff will monitor, teach, and medicate patient as ordered." This was a generic function for nursing, not a patient specific intervention. Neither the modality nor the frequency of the teaching was specified.

3. Patient D7: The MTP dated 5/18/11 listed problems as "out of touch with reality"; "depression" and "polysubstance abuse." The listed nursing intervention was: "Nursing staff will monitor meds and effects, and encourage pt to verbalize any feelings of self harm." This was a generic function of nursing. The frequency and modality to be used to encourage the patient's expression of feelings was not specified, and the patient goal to be addressed was not identified.

4. Patient E15: The MTP dated 5/20/11 listed problems as "Tried to poison M[sic]"; "appetite decreased"; "Sleep disturbance 4 h per night" and "stealing." The listed nursing intervention was: "Nursing staff will monitor meds and effects and encourage pt to verbalize any feelings of aggression." This was a generic nursing function. The frequency and modality of the intervention for encouraging the patient's expression of feelings were not specified, nor was the patient goal identified.

B. Staff Interviews

During an interview on 5/25/11 at 11:15a.m., the Director of Nursing (DON) and the Director of Risk Management acknowledged the above findings.

II. Ensure that the Master Treatment Plans of 1 of 8 active sample patients (A1) identified the name of nursing staff responsible for the listed nursing intervention. This failure hinders the ability of the treatment team to determine who is responsible for specific treatment modalities.

Findings include:

A. Record Review

The master treatment plan for patient A1 dated 5/19/11 listed 2 nursing interventions as "staff will use behavioral techniques such as personal time out..." and "staff will use behavioral level system to reduce risk of self harm." The specific names and disciplines of the staff responsible for the listed interventions were not identified.

B. Staff Interview

During an interview on 5/25/11 at 11:15a.m., the DON acknowledged that the MTP for patient A1 did not name the nursing staff responsible for the listed nursing interventions.