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Based on record review and staff interview, the facility failed to document neurological examinations in such a way as to verify that all areas of a screening neurological were performed for 8 of 8 active sample patients (A5, A8, A11, A14, A17, A20, A23, and A26). In all of the records, the section related to cranial nerve function was checked or had a line through it indicating a normal examination, without providing details on how this determination was made. This failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient A5 - In a medical evaluation dated 11/18/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

2. Patient A8 - In a medical evaluation dated 11/12/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

3. Patient A11 - In a medical evaluation dated 11/23/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

4. Patient A14 - In a medical evaluation dated 8/18/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

5. Patient A17 - In a medical evaluation dated 11/21/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

6. Patient A20 - In a medical evaluation dated 11/10/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

7. Patient A23 - In a medical evaluation dated 10/1/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

8. Patient A26 - In a medical evaluation dated 11/26/10, the neurological exam contained a checklist marked normal, but did not provide a determination of how the examination was performed.

B. Staff Interview

In an interview on 12/7/10 at 1:00p.m., the Medical Director confirmed the findings.

Based on record review and staff interview, the facility failed to provide psychiatric evaluations that included an assessment of memory functioning for 4 of 8 active sample patients (A5, A8, A17, and A20) and an estimate of intellectual function for 4 of 8 active sample patients (A8, A11, A14 and A26). These areas of the examination were either not present, or failed to give the supportive information that formed the basis for the conclusions noted. This deficient practice could lead to failure to identify conditions that impact treatment as well as result in inappropriate treatment goals.

Findings include:

A. Record Review

1. Patient A5 - In a Psychiatric Assessment dated 11/17/10, the mental status examination listed memory as "fair" but did not indicate how this determination was made.

2. Patient A8 - In a Psychiatric Assessment dated 11/12/10, the mental status examination did not give an estimate of intellectual or memory functioning.

3. Patient A11 - In a Psychiatric Assessment dated 11/22/10, the mental status examination did not provide an estimation of intellectual functioning.

4. Patient A14 - In a Psychiatric Assessment dated 8/19/10, the mental status examination did not address intellectual functioning.

5. Patient A17 - In a Psychiatric Assessment dated 11/20/10, the mental status examination stated "memory intact" with no indication of tests conducted to reach that conclusion.

6. Patient A20 - In a Psychiatric Assessment dated 11/9/10, the mental status examination did not provide an estimation of memory functioning.

7. Patient A26 - In a Psychiatric Assessment dated 11/26/10, the mental status examination did not address intellectual functioning.

B. Staff Interview

In an interview on 12/7/10 at 1:00p.m., the medical director confirmed the findings.

Based on medical record reviews, policy review, and staff interviews, the facility failed to document specific psychiatric treatment interventions provided by the treating psychiatrist for 8 of 8 active sample patients (A5, A8, A11, A14, A17, A20, A23, and A26). This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A5 - In a Comprehensive Treatment Plan initiated 11/23/10, and reviewed on 11/30/10 and 12/06/10, no treatment interventions for the psychiatrist were identified.

2. Patient A8 - In a Comprehensive Treatment Plan initiated 11/16/10, and reviewed on 11/22/10, 11/30/10 and 12/06/10, no treatment interventions for the psychiatrist were identified.

3. Patient A11 - In a Comprehensive Treatment Plan initiated 11/24/10 and reviewed on 12/01/10, no treatment interventions for the psychiatrist were identified.

4. Patient A14 - In a Comprehensive Treatment Plan initiated 8/23/10, and reviewed on 9/1/10, 9/8/10, 9/15/10, 9/21/10, 9/29/10, 10/6/10, 10/13/10, 10/20/10 and 11/24/10, no psychiatric treatment interventions were identified.

5. Patient A17 - In a Comprehensive Treatment Plan initiated 11/23/10, and reviewed on 11/30/10 and 12/06/10, no psychiatric treatment interventions were identified .

6. Patient A20 - In a Comprehensive Treatment Plan initiated 11/16/10, and reviewed on 11/22/10, 11/30/10, and 12/06/10, no psychiatric treatment interventions were identified.

7. Patient A23 - In a Comprehensive Treatment Plan initiated 10/6/10, and reviewed weekly through 12/01/10, no psychiatric treatment interventions were identified.

8. Patient A26 - In a Comprehensive Treatment Plan initiated 12/2/10 no psychiatric treatment interventions were identified.

B. Policy Review

1. In a Facility Policy titled, "Comprehensive Treatment Plan (CTP) Development Process," revised 2/1/10, page 3 of 3, item #14 states "Members of each discipline assume responsibility for: writing treatment interventions on each patient's CTP as clinically indicated."

2. In a Facility Policy titled, "Comprehensive Treatment Plan (CTP) Interventions and Documentation," revised 9/30/09, page 1 of 3 #A states "each intervention must: clearly indicate the focus of treatment including the setting, therapeutic strategy, and course of action to be taken by staff; specify the frequency and when applicable, the duration of the identified intervention; be documented on the CTP within 48 hours of development."

C. Staff Interviews

1. In an interview on 12/6/10 at 4:30p.m., the Program Director confirmed the findings and stated "the physician has other places to write interventions such as his progress notes and physician orders."
2. In an interview on 12/7/10 at 1:00p.m., the Medical Director confirmed the findings.

Based on record review and interview, it was determined that the Medical Director failed to monitor and ensure that records included a complete neurological examination; that psychiatric assessments were comprehensive; and that treatment plans contained physician interventions..

Specifically the Medical Director failed to:

I. Ensure medical staff completed comprehensive neurological examinations for 8 of 8 active sample patients (A5, A8, A11, A14, A17, A20, A23, and A26). This deficient practice can compromise the identification of pathology and compromise future comparative re-examination to assess patient's response to treatment interventions. (Refer to B109)

II. Ensure medical staff completed comprehensive psychiatric evaluations which included an estimation of memory, intellectual functioning and orientation, with documentation of the methods used to come to the conclusions noted for 7 of 8 active sample patients (A5, A8, A11, A14, A17, A20, and A26).. This deficient practice could lead to failure to identify conditions that impact treatment, as well as result in inappropriate treatment goals. (Refer to B116)

III. Ensure that treatment plans included specific physician interventions for eight of eight active sample patients (A5, A8, A11, A14, A17, A20, A23, and A26). This deficient practice could result in ineffective treatment and prolonged hospitalization. (Refer to B122)