HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to include patients in the development and implementation of her or her plan of care for 9 of 10 patients (Patients #1-4 and #6-10). Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10).

Findings were:

Facility policy entitled "Patient Rights," effective date 2/1/2017, included the following:
" ... PURPOSE:
To assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights.
PROCEDURE:
1. Patient Rights according to federal guidelines include the following at a minimum:
a. The right to participate in the development and implementation of his or her plan of care ...
c. The right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment ...
l. The right to participate actively in the development and review of an individualized treatment plan ..."

Facility policy entitled "Interdisciplinary Treatment Planning," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the Wellbridge Hospital of Plano that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress.
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
II. The comprehensive interdisciplinary treatment plan (ITP)
2. Signatures also include the patient, and guardian when applicable, by means of the team reviewing and discussing the plan with the patient ..."

A review of patient medical records revealed only one patient (Patient #5) had signed his initial treatment plan. Thus the facility had no documented evidence that Patients #1-4 and #6-10 were allowed to participate in developing their own plans of care. In addition, Patient #5 had not signed subsequent updates to his treatment plan, nor had the other patients in the records reviewed. There was no reason documented for the patients not having signed the treatment plans despite an area provided on the plan form for doing this.

The above findings were confirmed with the facility chief executive officer and other administrative staff on the afternoon of 3/18/19 in the hospital conference room.

Based on a review of facility documentation and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 2 of 10 patients (Patients #2 and #9) as medical monitoring and treatment was not carried out in accordance with physician orders. In addition, for 10 of 10 patients, there was little or no documented evidence of hygiene care, especially patient baths, provided to the patients.

Findings were:

Facility policy entitled "Vital Signs," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the facility to obtain vital signs at regular intervals and to report vital signs that are out of normal range to the appropriate clinician ...
Procedure: ...
3. Vital signs will be measured at the interval ordered by the physician and more frequently, if required to prior to a particular medication or intervention, or if the RN is concerned that the patient's medical condition has changed ...
5. The following are normal vital ranges and vital sign measurements that require additional interventions: ...
Pulse - 60-100 beats per minutes (BPM) ...Alert, tell RN within thirty minutes [if] <60 BPM or >100 BPM ...
Blood Pressure - 90/60 mm/Hg to 120/80mm/Hg ...Alert, tell RN within thirty minutes [if] <90/60 mm/Hg or >140/90 mm/Hg ...
If B/P (blood pressure) reaches Hypertensive Crisis, which the AHA (American Heart Association) indicates as Systolic mm/Hg 180 or higher of [sic] Diastolic mm/Hg of 110 or higher, an immediate recheck in both arms and notify the Doctor." ... [facility policy bold]

Facility policy entitled "The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), guidelines for performing," included the following:
" ...Policy: It is the policy of the facility to define appropriate processes for recognition and early treatment of Alcohol Withdrawal Syndrome ...
Purpose:
There are significant clinical advantages to quantifying the alcohol withdrawal syndrome. Quantification is key to preventing excess morbidity and mortality in a group of patients who are at risk for alcohol withdrawal. Such instruments help clinical personnel recognize the process of withdrawal before it progresses to more advanced stages, such as delirium tremens. By intervening with appropriate pharmacotherapy in those patients who require it, while sparing the majority of patients whose syndromes do not progress to that point, the clinician can prevent over and under treatment of the alcohol withdrawal syndrome.

The best known and most extensively studied scale is the Clinical Institute Withdrawal Assessment - Alcohol (CIWA-A) and a shortened version, the CIWA-A revised (CIWA-Ar) ...
Guidelines: ...
3. CIWA to be completed on admission; alert physician immediately if score is greater than or equal to 35. Transportation to an ED should be considered ...
6. Notify Attending Physician if BP > 160/100 mmHg or Heart Rate 110 bpm or above ..."


A review of the medical record of Patient #2 revealed he was admitted to the facility on 2/27/19. Medical issues identified in the psychiatric evaluation and history and physical examination included insomnia, chronic pain, alcohol abuse and hypertension. These issues were not included on the patient's master treatment plan, nor on subsequent updates.

Physician orders for the patient included the following:
2/27/19 at 1:59 p.m. -- "V/S (vital signs) Q 6 hours... CIWA (Clinical Institute Withdrawal Assessment for Alcohol) rating Q 4 hrs ..."

Vital signs were recorded from this patient as follows:
2/27/19 at 7:00 p.m.
2/28/19 at 7:00 a.m. -- Pulse 110
2/28/19 at 7:00 p.m. -- BP 142/101
3/1/19 at 7:00 p.m. -- BP 143/109
3/2/19 7p - 7a shift, no time -- "refused"
3/2/19 7p - 7a shift, no time -- BP 140/102
3/3/19 7a-7p shift, no time

No other documented vital signs could be located in the patient record despite the physician order on 2/17/19 that they be conducted every 6 hours. In addition, the pulse and blood pressure readings included above required notification of either the registered nurse or physician. The record of Patient #2 included no documented evidence that these notifications occurred.

Assessments of Patient #2 with the CIWA rating were recorded as follows:
2/28/19 at 9:00 p.m.
3/1/19 at 10:00 p.m.

No other documented CIWA assessments could be located in the patient record, despite the physician order of 2/27/19 that they be conducted every 4 hours.

A discharge summary for Patient #2 dictated on 3/4/19 at 12:56 p.m. included the following psychiatric diagnoses:
"... d. Alcohol use disorder, severe, with withdrawal.
e. Sedative use disorder, severe, with withdrawal..."

A review of the medical record of Patient #9 revealed multiple medical issues. A history and physical assessment on 3/4/19 at 8:11 a.m. included the following diagnoses: hypertension, COPD (chronic obstructive pulmonary disease), hepatitis C, bilateral otitis media, and chronic joint pain. These issues were not included on the patient's master treatment plan, nor on subsequent updates. Her pulse on 3/10/19 at 7:00 p.m. was noted as 108. The patient record included no documented evidence that a registered nurse of physician had been notified of the reading.

Review of Daily Care Monitoring Flow Sheets for Patients #1-10 revealed either no or infrequent documentation of patient hygiene care. According to the flow sheet, the grooming section was to include the time provided and the initials of staff involved in the bathing care of each patient. None of the sheets included a time or staff initials of when the patient bathed. The section included only an occasional "X" marked by the word "independent" for each of these patients, whether the patient was independent or needed assistance with bathing.

In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings. The findings were again reviewed with the hospital chief executive officer and other administrative staff later on the afternoon of 3/18/19 in the facility conference room. No additional evidence of compliance was brought forth by the hospital.

Based on a review of facility documentation and staff interviews, the facility failed to meet the condition for Special Medical Records Provisions for Psychiatric Hospitals as evidenced by:

1) Failing to provide a psychosocial assessment for 1 of 10 patients (Patient #2). In addition, psychosocial assessments for 2 of the remaining 9 patients (Patients #3 and #5) were not performed in a timely manner as defined by facility policy and regulatory requirements. Thus, critical information regarding the patient's social history, support and psychosocial attitudes was not available to develop an individualized treatment plan for these patients. (refer to B0108)

2) Failing to provide an individualized comprehensive treatment plan for each patient as 2 patients of 10 reviewed did not have a true treatment plan in his/her medical record (Patients #2-3). (refer to B0118)

3) Failing to address medical problems identified in the history and physical examinations of 5 of 10 patients in the treatment plan (Patients #2-4 and #9-10), thus resulting in patients possibly having medical issues while at the facility which were left unaddressed. (refer to B0118)

4) Failing to identify problems and goals related to patient medical issues included on the master treatment plans for 2 of 5 patients with medical problems on his/her treatment plan (Patients #6-7). Thus, no therapeutic interventions were developed for the goals/problems. (refer to B0118)

5) Failing to ensure each patient had the opportunity to participate in the development of his or her own plan of care, and if unwilling or unable to do so, documenting the reason, for 9 of 10 patients (Patients #1-4 and #6-10). Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10). (refer to B0125)

These failed practices resulted in patients potentially having unidentified stressors, psychosocial history and familial/social strengths or disabilities which could have had significant impact on the treatment provided by the facility. In addition, due to the inadequacy of the treatment planning, there was no real direction for development of treatment goals and problems, and interventions/therapeutic efforts to guide patient care were non-existent. Also, patient medical issues identified upon admission had the potential to be left unaddressed. Finally, without treatment planning, a facility has no real means to assess the efficacy of interventions provided or whether patient treatment goals were met.

Based on a review of facility documentation and staff interviews, the facility failed to provide a psychosocial assessment for 1 of 10 patients [Patient #2], which included assessment of home plans and family attitudes, as well as community resources which had assisted the patient in the past, among other critical psychosocial information. In addition, psychosocial assessments for 2 of the remaining 9 patients [Patients #3 and #5] were not performed in a timely manner.

Findings were:

Facility policy entitled "Assessment Guidelines," effective date 2/1/2017, included the following:
" ...POLICY:
It is the policy of the facility provide a comprehensive assessment and reassessment of the patient's bio-psycho-social needs such that clinically appropriate interventions can be designed and carried out in a manner that supports recovery ...
PROCEDURE:
1. The following timeframes are required for completion of assessments: ...
Assessment ...Integrated Assessment Part III - Inpatient Psychosocial Assessment ...Completed by ...Patient's assigned inpatient social worker ...Time frame for Completion ...24 hours after admission ...

Assessment ...Psychosocial Assessment Update - Inpatient ...Completed by ...Patient's assigned inpatient social worker ...Time frame for Completion ...24 hours after admission AND only with original psychosocial assessment reviewed and attached ...
2. The formation of the Interdisciplinary Treatment Plan is dependent upon the comprehensive assessment of all members of the treatment team. Therefore, the treatment plan cannot be fully devised until all initial assessments have been completed ..."

Facility policy entitled "Integrated Assessment," effective date 2/1/2017, included the following:
" ...Policy:
It is the policy of the facility to conduct a comprehensive assessment of all relevant factors contributing to the patient's current condition and goals of recovery.
Procedure:
1. All patients will receive three levels of initial assessment by nursing and social work staff: ...
c. Integrated Assessment Part III - Inpatient Psychosocial Assessment. Conducted by the patient's inpatient social worker within 24 hours of admission to the inpatient unit ...
2. Collectively, these three assessments form the Integrative Assessment in its entirety. The integrative assessment addresses the ...elements of the patient's psycho social status ...
3. It is expected that nursing and social work staff complete their respective assessments of each patient within the time frames established in the Assessment Guidelines Policy; that these assessments are conducted in their entirety ..."

A review of the medical record of Patient #2 revealed no psychosocial assessment. The patient was admitted to the facility on 2/27/19 and discharged on 3/3/19.

A review of the medical record of Patients #3 revealed the patient was admitted to the hospital on 2/24/19 and discharged on 3/1/19. A psychosocial assessment was performed Patient #3 on 2/28/19 and co-signed by an LMSW on 3/1/19.

A review of the medical record of Patient #5 revealed he was admitted to the facility on 2/22/19 and discharged on 3/2/19. An inpatient psychosocial assessment was not conducted until 2/26/19 on this patient. An interdisciplinary treatment plan had been completed on 2/25/19.


In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings.

Based on a review of facility documentation and staff interview, the facility failed to provide an individualized comprehensive treatment plan for each patient as:
1) 2 patients of 10 reviewed did not have a true treatment plan in his/her medical record (Patients #2-3)
2) Medical problems identified in the history and physical examinations of 5 of 10 patients were not included in the treatment plan (Patients #2-4 and #9-10)
3) Though medical issues were included on the master treatment plans of 2 of 5 patients with medical problems(Patients #6-7), the issues were not identified as problems and included no care interventions

Findings were:

Facility policy entitled "Interdisciplinary Treatment Planning," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the Wellbridge Hospital of Plano that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress.
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
II. The comprehensive interdisciplinary treatment plan (ITP)
a. The ITP is initiated, developed, and documented in the daily treatment team meetings and is based upon the patient's identified needs and goals for treatment. The initial treatment team meeting should occur within twenty-four (24) hours of admission but no later than seventy-two (72) hours after admission ...
b. The ITP serves to guide the entire team to support the patient in his or her recovery ...
iv ...2. The problem list is derived from the results of the psychiatric evaluation, integrated assessment, history and physical, and any other assessment conducted on the patient ...
III. Problem sheets ...
b. Due to the importance of individualizing care, Wellbridge Hospital of Plano will not use pre-printed problem sheets ..."

1) 2 patients of 10 reviewed did not have a true treatment plan in his/her medical record (Patients #2-3).

A review of the treatment plans of Patients #2-3 revealed no real Interdisciplinary Master Treatment Plan. The treatment planning form on these patients was completely blank. For example, Patient #2 was admitted to the hospital on 2/27/19. Psychiatric problems identified on the Psychiatric Evaluation dictated on 2/28/19 included major depressive disorder, generalized anxiety disorder, insomnia, alcohol use disorder, personality disorder, sedative hypnotic withdrawal, severe, and suicidal ideation. Medical problems included insomnia, chronic pain and hypertension. Psychosocial stressors identified during the Psychiatric Evaluation included lack of insight and lack of coping skills. The Interdisciplinary Master Treatment Plan for Patient #2 included a section entitled "Psychiatric Diagnosis." Under this section was written the following: "Alcohol Use Disorder." Otherwise, the form was completely blank. There were no other psychiatric diagnoses included on the plan. There was no listing of additional psychiatric problems. There was no listing of medical problems the facility planned to address. There were no psychosocial problems identified on the plan, and the patient record included no documented evidence that a psychosocial evaluation was ever performed at the facility. The only person to sign the treatment plan was a psychiatrist on 2/29/19 at 9:30 a.m. No other treatment team members appeared to have been involved in the plan of care. In addition, the patient had not signed the plan and there was no reason identified as to why he was unable or unwilling to sign it.

Similarly, Patient #3 was admitted to the hospital on 2/24/19. Physician's Preadmission Examination Orders identified a psychiatric diagnosis of major depressive disorder, recurrent episode with psychotic features. A history and physical examination performed on 2/25/19 identified hypothyroidism, GERD (gastroesophageal reflux disease) and chronic back pain as medical problems of the patient. The only item written on the Interdisciplinary Master Treatment Plan was the one psychiatric diagnosis: "MDD with Psych" (major depressive disorder with psychotic features). Otherwise the form was completely blank. The plan included no problems of other disciplines - no nursing or psychosocial problems. And, in fact, the psychosocial assessment of this patient was conducted on 2/28/19 - one day prior to patient discharge. Thus, there were no patient care issues identified and no interventions planned regarding the care of this patient - including psychiatric problems/interventions. The only person to sign the treatment plan was a psychiatrist on 2/25/19 at 9:00 a.m. No other treatment team members appeared to have been involved in the plan of care. In addition, the patient had not signed the plan and there was no reason identified as to why she was unable or unwilling to sign it.

2) Medical problems identified in the history and physical examinations of 5 of 10 patients were not included in the treatment plan (Patients #2-4 and #9-10).

A review of the medical records of Patients #2-4 and #9-10 revealed medical diagnoses/problems identified on the Psychiatric Evaluation and on the history and physical examination for each of these patients. For example, on a Psychiatric Evaluation on 3/4/19, Patient #9 was documented to have had multiple medical issues, including arthritis, COPD (chronic obstructive pulmonary disease), diabetes mellitus, hypertension, gout, hepatitis C, and hypercholesterolemia. A history and physical examination performed on 3/4/19 also included bilateral otitis media and chronic joint pain. Her Multidisciplinary Master Treatment Plan had no medical problems or interventions identified to be addressed while she was an inpatient at the hospital.

As an additional example, Patient #4 was admitted to the facility on 2/27/19. A history and physical examination on 2/28/19 included medical diagnoses/problems of hypertension, dry eyes, insomnia and vitamin D deficiency. There were no medical problems listed on the Multidisciplinary Master Treatment Plan for this patient, despite specific physician orders for treatment which addressed these issues.

3) Though medical issues were included on the master treatment plans of 2 of 5 patients with medical problems (Patients #6-7), the issues were not identified as problems and included no care interventions.

Patients #6 and 7 did have medical diagnoses identified on each of his Multidisciplinary Master Treatment Plans. However, no medical problems resulting from the diagnoses, and thus no interventions, were documented on the patients' treatment plans. For example, Patient #6 had the following medical diagnoses listed on his Multidisciplinary Master Treatment Plan on 3/6/19: diabetes mellitus 2, hypertension and hyperlipidemia. However, there were no medical problems listed on the plan, and hence, no medical interventions identified. This patient had even been ordered administration of insulin per a sliding scale by the physician, yet there was no inclusion in multidisciplinary treatment planning.

In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings. The findings were again reviewed with the hospital chief executive officer and other administrative staff later on the afternoon of 3/18/19 in the facility conference room. No additional evidence of compliance was brought forth by the hospital.

Based on a review of facility documentation and staff interview, the facility failed to develop and implement patient care plans based on a inventory of the patient's strengths and disabilities for 8 of 10 patients (Patients #2-7 and #9-10), as the care plans of these patients did not include documentation of patient strengths and disabilities.

Findings were:

Facility policy entitled "Interdisciplinary Treatment Planning," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the Wellbridge Hospital of Plano that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress.
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
II. The comprehensive interdisciplinary treatment plan (ITP)
a. The ITP is initiated, developed, and documented in the daily treatment team meetings and is based upon the patient's identified needs and goals for treatment. The initial treatment team meeting should occur within twenty-four (24) hours of admission but no later than seventy-two (72) hours after admission ...
b. The ITP serves to guide the entire team to support the patient in his or her recovery ...
iv ...2. The problem list is derived from the results of the psychiatric evaluation, integrated assessment, history and physical, and any other assessment conducted on the patient ..."

Facility policy entitled "Assessment Guidelines," effective date 2/1/2017, included the following:
" ...POLICY:
It is the policy of the facility provide a comprehensive assessment and reassessment of the patient's bio-psycho-social needs such that clinically appropriate interventions can be designed and carried out in a manner that supports recovery ...
PROCEDURE:
1. The following timeframes are required for completion of assessments: ...

Assessment ...Integrated Assessment Part III - Inpatient Psychosocial Assessment ...Completed by ...Patient's assigned inpatient social worker ...Time frame for Completion ...24 hours after admission ...

Assessment ...Psychosocial Assessment Update - Inpatient ...Completed by ...Patient's assigned inpatient social worker ...Time frame for Completion ...24 hours after admission AND only with original psychosocial assessment reviewed and attached ...

2. The formation of the Interdisciplinary Treatment Plan is dependent upon the comprehensive assessment of all members of the treatment team. Therefore, the treatment plan cannot be fully devised until all initial assessments have been completed ..."

A review of the medical records for Patients #2-7 and #9-10 revealed no documented listing of each patient's strengths and disabilities. In fact, a review of the medical record of Patients #2-3 and #5 revealed either no inpatient psychosocial assessment (Patient #2) or a significantly late psychosocial assessment (Patients #3 and #5). A psychosocial assessment contains important information regarding each patient's strengths and disabilities and is a critical tool in the formation of a patient's care plan.

In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings.

Based on a review of facility documentation and staff interview, the facility failed to provide an individualized comprehensive treatment plan for each patient as:
1) 2 patients of 10 reviewed did not have a true treatment plan in his/her medical record (Patients #2-3)
2) Medical problems identified in the history and physical examinations of 5 of 10 patients were not included in the treatment plan (Patients #2-4 and #9-10)
3) Though medical issues were included on the master treatment plans of 2 of 5 patients with medical problems on his/her treatment plan (Patients #6-7), the issues were not identified as problems and included no care interventions
4) There was no documented evidence that each patient was involved in the development and implementation of her/her plan of care for 9 of 10 patients (Patients #1-4 and #6-10). Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10).

Findings were:

Facility policy entitled "Patient Rights," effective date 2/1/2017, included the following:
" ... PURPOSE:
To assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights.
PROCEDURE:
1. Patient Rights according to federal guidelines include the following at a minimum:
a. The right to participate in the development and implementation of his or her plan of care ...
c. The right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment ...
l. The right to participate actively in the development and review of an individualized treatment plan ..."

Facility policy entitled "Interdisciplinary Treatment Planning," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the Wellbridge Hospital of Plano that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress.
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
II. The comprehensive interdisciplinary treatment plan (ITP)
a. The ITP is initiated, developed, and documented in the daily treatment team meetings and is based upon the patient's identified needs and goals for treatment. The initial treatment team meeting should occur within twenty-four (24) hours of admission but no later than seventy-two (72) hours after admission ...
b. The ITP serves to guide the entire team to support the patient in his or her recovery ...
iv ...2. The problem list is derived from the results of the psychiatric evaluation, integrated assessment, history and physical, and any other assessment conducted on the patient ...
III. Problem sheets ...
b. Due to the importance of individualizing care, Wellbridge Hospital of Plano will not use pre-printed problem sheets ...
2. Signatures also include the patient, and guardian when applicable, by means of the team reviewing and discussing the plan with the patient ..."

1) 2 patients of 10 reviewed did not have a true treatment plan in his/her medical record (Patients #2-3).

A review of the treatment plans of Patients #2-3 revealed no real Interdisciplinary Master Treatment Plan. The treatment planning form on these patients was completely blank. For example, Patient #2 was admitted to the hospital on 2/27/19. Psychiatric problems identified on the Psychiatric Evaluation dictated on 2/28/19 included major depressive disorder, generalized anxiety disorder, insomnia, alcohol use disorder, personality disorder, sedative hypnotic withdrawal, severe, and suicidal ideation. Medical problems included insomnia, chronic pain and hypertension. Psychosocial stressors identified during the Psychiatric Evaluation included lack of insight and lack of coping skills. The Interdisciplinary Master Treatment Plan for Patient #2 included a section entitled "Psychiatric Diagnosis." Under this section was written the following: "Alcohol Use Disorder." Otherwise, the form was completely blank. There were no other psychiatric diagnoses included on the plan. There was no listing of additional psychiatric problems. There was no listing of medical problems the facility planned to address. There were no psychosocial problems identified on the plan, and the patient record included no documented evidence that a psychosocial evaluation was ever performed at the facility. The only person to sign the treatment plan was a psychiatrist on 2/29/19 at 9:30 a.m. No other treatment team members appeared to have been involved in the plan of care. In addition, the patient had not signed the plan and there was no reason identified as to why he was unable or unwilling to sign it.

Similarly, Patient #3 was admitted to the hospital on 2/24/19. Physician's Preadmission Examination Orders identified a psychiatric diagnosis of major depressive disorder, recurrent episode with psychotic features. A history and physical examination performed on 2/25/19 identified hypothyroidism, GERD (gastroesophageal reflux disease) and chronic back pain as medical problems of the patient. The only item written on the Interdisciplinary Master Treatment Plan was the one psychiatric diagnosis: "MDD with Psych" (major depressive disorder with psychotic features). Otherwise the form was completely blank. The plan included no problems of other disciplines - no nursing or psychosocial problems. And, in fact, the psychosocial assessment of this patient was conducted on 2/28/19 - one day prior to patient discharge. Thus, there were no patient care issues identified and no interventions planned regarding the care of this patient - including psychiatric problems/interventions. The only person to sign the treatment plan was a psychiatrist on 2/25/19 at 9:00 a.m. No other treatment team members appeared to have been involved in the plan of care. In addition, the patient had not signed the plan and there was no reason identified as to why she was unable or unwilling to sign it.

2) Medical problems identified in the history and physical examinations of 5 of 10 patients were not included in the treatment plan (Patients #2-4 and #9-10).

A review of the medical records of Patients #2-4 and #9-10 revealed medical diagnoses/problems identified on the Psychiatric Evaluation and on the history and physical examination for each of these patients. For example, on a Psychiatric Evaluation on 3/4/19, Patient #9 was documented to have had multiple medical issues, including arthritis, COPD (chronic obstructive pulmonary disease), diabetes mellitus, hypertension, gout, hepatitis C, and hypercholesterolemia. A history and physical examination performed on 3/4/19 also included bilateral otitis media and chronic joint pain. Her Multidisciplinary Master Treatment Plan had no medical problems or interventions identified to be addressed while she was an inpatient at the hospital.

As an additional example, Patient #4 was admitted to the facility on 2/27/19. A history and physical examination on 2/28/19 included medical diagnoses/problems of hypertension, dry eyes, insomnia and vitamin D deficiency. There were no medical problems listed on the Multidisciplinary Master Treatment Plan for this patient, despite specific physician orders for treatment which addressed these issues.

3) Though medical issues were included on the master treatment plans of 2 of 5 patients with medical problems on his/her treatment plan (Patients #6-7), the issues were not identified as problems and included no care interventions.

Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10). Patients #6 and 7 did have medical diagnoses identified on each of his Multidisciplinary Master Treatment Plans. However, no medical problems resulting from the diagnoses, and thus no interventions were documented on the patients' treatment plans. For example, Patient #6 had the following medical diagnoses listed on his Multidisciplinary Master Treatment Plan on 3/6/19: diabetes mellitus 2, hypertension and hyperlipidemia. However, there were no medical problems listed on the plan, and hence, no medical interventions identified. This patient had even been ordered administration of insulin per a sliding scale by the physician, yet there was no inclusion in multidisciplinary treatment planning.

4) There was no documented evidence that each patient was involved in the development and implementation of her/her plan of care for 9 of 10 patients (Patients #1-4 and #6-10).

Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10). A review of patient medical records revealed only one patient (Patient #5) had signed his initial treatment plan. However, he had not signed subsequent updates to the plan, nor had the other patients in the records reviewed. There was no reason documented for the patients not having signed the treatment plans despite an area provided on the plan form for doing this.

In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings. The findings were again reviewed with the hospital chief executive officer and other administrative staff later on the afternoon of 3/18/19 in the facility conference room. No additional evidence of compliance was brought forth by the hospital.

Based on a review of facility documentation and staff interview, the facility failed to ensure an initial nursing assessment was provided for each patient as 2 of 10 patients [Patients #4 and #10] did not have one in his/her medical record. In addition, the facility failed to ensure an initial nursing treatment plan was initiated for each patient as 3 of 10 patients [Patients #2-3 and #6] did not have such a plan.

Findings were:

Facility policy entitled "Integrated Assessment," effective date 2/1/2017, included the following:
" ...Policy:
It is the policy of the facility to conduct a comprehensive assessment of all relevant factors contributing to the patient's current condition and goals of recovery.
Procedure:
1. All patients will receive three levels of initial assessment by nursing and social work staff: ...
b. Integrated Assessment Part II - Inpatient Nursing Assessment. Conducted by the RN at the time of transition to the inpatient unit, but no later than 8 hours after transition to the inpatient unit ...
2. Collectively, these three assessments form the Integrative Assessment in its entirety ...
3. It is expected that nursing and social work staff complete their respective assessments of each patient within the time frames established in the Assessment Guidelines Policy; that these assessments are conducted in their entirety ..."

Facility policy entitled "Assessment Guidelines," effective date 2/1/2017, included the following:
" ...POLICY:
It is the policy of the facility provide a comprehensive assessment and reassessment of the patient's bio-psycho-social needs such that clinically appropriate interventions can be designed and carried out in a manner that supports recovery ...
PROCEDURE:
1. The following timeframes are required for completion of assessments:

Assessment...Integrated Assessment Part II - Inpatient Nursing Assessment - includes initial fall assessment, nutrition screening, and functional assessment ...Completed by ... Inpatient (unit) RN ...Time frame for Completion ...Initiated within 1 hours of patient's arrival to the inpatient unit; fully completed within 8 hours of admission ...

2. The formation of the Interdisciplinary Treatment Plan is dependent upon the comprehensive assessment of all members of the treatment team. Therefore, the treatment plan cannot be fully devised until all initial assessments have been completed ..."

A review of the medical record of Patient #4 revealed no initial nursing assessment. The patient was at the facility for 11 days in February and March 2019. A review of the medical record of Patient #10 revealed an initial nursing assessment which was only partially completed.

A review of the medical records of Patients #2-3 and #6 revealed either no or an incomplete initial nursing treatment plan. The records of Patient #2 and #3 included a form for the initial nursing treatment plan, however the form was left completely blank. The record of Patient #6 included an initial nursing treatment plan which included no medical issues, despite the patient's physical examination results having included edema and a urinary tract infection. Neither the patient nor the registered nurse completing the treatment plan had signed it.

The above findings were confirmed in an interview with the chief executive officer and other administrative staff on the afternoon of 3/18/19 in the hospital conference room.