HospitalInspections.org

Based on record review and interview, the facility failed to identify the names of the registered nurse and/or physician responsible for various interventions on the Master Treatment plan for 3 of 8 active sample patients (E1, F1, and G2). This practice results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out.

Findings include:

A. Record Review

1. Facility Policy, titled "Interdisciplinary Treatment Plan, last revised 1/12, section 600.17" stated, that the intervention includes the following components: - "Responsible staff: The name(s) and credentials/discipline of the specific staff members responsible for the provision of the intervention."

(The underline words and/or spaces below indicate spaces for staff to add information)

2. Active sample patient E1, MTP dated 10/12/13. For the problem "psychosis/hallucinations", the interventions were: (1) "nursing to administer medication for dosage and schedule prescribed to decrease symptoms of [blank space] and document response to medications." The space to list the name of "Discipline Responsible Staff" was left blank. (2) "Dr. (Doctor) will discuss symptoms of psychosis and adjust medications as indicated; provide education on diagnosis of [blank space] related to psychosis and medication compliance and the importance of relapse prevention." The Discipline Responsible Staff" space was left blank.

3. Active sample patient F1, MTP dated 10/12/13. For the problem of "alteration in mood depressive symptoms", the interventions were: (1) "RN to meet 1:1 with patient for 15 minutes to determine change in mood, affect behavior and document outcome and level of depression, any suicidality, changes in mood, mental status and pt's perception of effectiveness of medication." The "discipline responsible staff" space was left blank. (2) "Dr. will discuss symptoms, adjust medications as indicated, and provide education on medication to stabilize mood affect." The "discipline responsible staff " space was left blank.

4. Active sample patient G2, MTP dated 10/11/13. For the problem "delusional thinking", the interventions were: (1) "RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of schizophrenia ongoing suicidality, mood, mental status ant pt perception of effectiveness of medications." (2) "Nursing staff to administer and provide education regarding medication, route, time, dosage, expected use and expected outcome of schizophrenia symptoms." The "discipline responsible staff" space was left blank.

B. Staff Interview

In an interview on 10/16/13 at 10:00 a.m., the absence of names of responsible nursing staff on MTP was discussed with the Nursing Director. She did not dispute the findings. She promised to address the issue.