HospitalInspections.org

Based on review of documentation and interviews, the Hospital failed to ensure that psychosocial assessments were completed and/or completed in a timely manner for 6 of 8 patients (Patients #1, #3, #4, #5, #7 and #8).

Findings included:

The Hospital's Policy/Procedure titled Discharge Planning, effective June, 2009, indicated discharge planning for patients admitted to the psychiatric inpatient unit was initiated at the time of admission. Initial plans or potential obstacles related to discharge were documented in the initial treatment plan, psychosocial assessment and in the progress notes.

The Case Manager was interviewed several times on 9/15/11. The Case Manager said the Psychosocial Assessment was an electronic document completed at the time of admission and included a section addressing discharge planning.

A) Review of medical record documentation indicated Patient #1 was admitted to the Inpatient Psychiatric Unit (IPU) on 3/3/11.

Review of Patient #1's discharge record indicated the Psychosocial Assessment was not completed until 5/12/11.

B) Review of medical records for Patients #2, #3, #4, #5, #6, #7 and #8 indicated Psychosocial Assessments were not completed for Patients #3, #4, #5, #7 and #8.