HospitalInspections.org

Based on record reviews and staff interviews , it was determined that for eight(8) of eight(8) active patients (Patients A1,A2,A3,A4,A5,A6,A7 and A8), the facility failed to ensure that the Psychosocial Assessments met professional social work standards. These assessments did not contain a psychosocial formulation of the data gathered and lacked a description of the social work staff efforts in treatment and discharge planning. This failure results in a lack of information about what the data collected means to a social worker (i.e. an analysis of the data) and what social work interventions will be attempted during hospitalization. The findings include:

I. Medical Record Reviews:

None of the following eight(8) of eight(8) active sample patients (date of Psychosocial Assessment in parenthesis) had a conclusion or psychosocial formulation for the data gathered and all failed to describe the role of the social work staff in treatment and discharge planning (A1(4/10/2015), A2(4/09/2015), A3(4/08/2015), A4(4/08/2015), A5(4/08/2015), A6(4/09/2015), A7(4/08/2015) and A8(4/08/2015)).

II. Staff Interview:

On 4/13/2015 at 1:50PM the Director of Social Work Services (a Master Level Psychologist), the Social Work Co-ordinator (a Master Level Social Worker), the Director of Utilization Review and the survey team met to discuss the findings stated in Section I. above.
The facility's Plan of Correction for this follow-up survey stated the date for inclusion of an analysis and description of social work staff within the Psychosocial Assessments was to have occurred by 3/2015. This was not the case and was explained by the Director of Social Work "We are not using the new form. I sent it (i.e. the revised format for documentation) to the printer." The facility staff enumerated above all agreed that presently Psychosocial Assessments lack these important components.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) of six (6) of eight (8) active sample patients (A3, A4, A5, A6, A7 and A8) identified individualized physician treatment interventions. The MTPs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to have individualized nursing interventions. The MTPs contained generic and routine functions for both psychiatrist and nursing staff. The frequency of staff contact with patients and the specific focus of the modalities listed were not always included. These failures resulted in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record Review

1. Facility policy, titled "Treatment Plans", last revised 2015, stated "Intervention or modality describe the type of intervention (individual or group), frequency of intervention and purpose." The physician and nursing interventions listed below were generic, routine functions, frequently without focus or frequency.

2. Active Sample Patient A1
MTP, dated 4/9/15, had as a problem "Masculine patient arrived for a consultation expressing suicidal thoughts and hanging himself. Patient says 'I was going to grab a cable and hang myself.' Patient verbalized he listens to voices that talk to him."

Nursing interventions: "Observe conduct of patient, educate patient, administer medications, offer relaxation methods."

3. Active Sample Patient A2
MTP, dated 4/9/15, had as a problem "Patient arrives in an involuntary state because of physical and verbal aggressiveness as referred by his/her sister. [S/he] threatens to kill [him/herself] with a knife. The sister also says that the patient talks to self consistently."

Nursing intervention: "Administration of medications per physician's order, vital signs."

4. Active Sample Patient A3
MTP, dated 4/7/15, had as a problem "Visual and verbal hallucination, physical and verbal aggressiveness. Patient has suicidal thoughts of drowning self in sea. Structural homicidal thoughts against [his/her] neighbor and chronic insomnia."

Physician Intervention: "Psychopharmacology."

Nursing Interventions: "Administer medications, individual interventions, observe effectiveness of medications, and educate patient."

5. Active Sample Patient A4
MTP, dated 4/7/15, had as a problem "Manage depression, recurrent with R/O [rule out] bipolar disorder."

Physician Intervention: The space was blank.

Nursing Interventions: "Administer medications, educate patient."

6. Active Sample Patient A5
MTP, dated 4/7/15, had as a problem "[Illegible word] with depressive symptoms with hallucinations."

Physician Intervention: "Psychopharmacology."

Nursing Interventions: "Orient patient about medication administration, observe patient for change in behavior, make preventive rounds during the shift."

7. Active Sample Patient A6
MTP, dated 4/9/15, had as a problem "51 year old female with involuntary 408 order for verbal and physical aggressiveness per the father towards the family, destroying property, breaking car window, screaming at the neighbor, inappropriate walking about early in the morning, disorganized, illogical, incoherent and does not follow directions."

Physician Interventions: "Psychopharmacology, [illegible words], group therapy, individual therapy, recreational therapy, family therapy."

Nursing Interventions: "Medications will be administered according to medical orders, patient will be oriented to medications per physician ' s orders, patient will identify stressors."

8. Active Sample Patient A7
MTP, dated 4/7/15, had as a problem "[Word illegible] with severe depressive symptoms and suicidal ideations."

Physician Intervention: "Psychopharmacology."

Nursing Interventions: "Medication administration per medical order and provide activities for relaxation."

9. Active Sample Patient A8
MTP, dated 4/7/15, had as a problem "This patient presents with profound anhedonia [inability to experience pleasure], lack of energy, visual hallucinations and suicidal thoughts along with feelings of hopelessness, also intense insomnia."

Physician Interventions: "Individual psychotherapy, pharmacology targeting symptoms of depressive/suicide and insomnia."

Nursing Interventions: "Individual interventions, administer medications per medical order and provide safe environment."


B. Interviews

1. In an interview on 4/14/15 at 10:30 a.m., the generic nursing interventions were discussed with the Director of Nursing (DON). She agreed with the findings.

2. In an interview on 4/15/15 at 8:15a.m., the generic psychiatrist interventions were discussed with the Medical Director. He did not dispute the findings.