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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

INDIVIDUAL COMPREHENSIVE TREATMENT PLAN

Tag No.: B0118

Based on record review and interview, the hospital failed to update an individual comprehensive Master treatment Plan for Patient #1 (P1) P1 did not have her individual Master Treatment Plan updated during their hospitalization.


Findings Included:


Record review on 6/14/17 of P1's medical record revealed she was admitted on 5/20/17, at that time an Initial Master Treatment Plan (MTP) was initiated. Further review revealed the MTP was updated every 7 days, per their policy. The last MTP was updated on 6/2/17.


Record review of the policy, titled Master Treatment Plan, effective 7/15/14, states in part: Goal and objectives will be reevaluated and revised on a weekly basis and more often as necessary.


Interview on 6/14/17 with Staff #1 confirmed the above findings.