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Based on review of 8 active sample records, hospital policy and interview, the hospital failed to ensure that social service records were completed in a timely basis for one out of 8 sample patients (P1). As a result, the treatment team did not have current baseline social functioning on this patient for establishing treatment goals and interventions.

Findings include:

A. Record Review

Patient P1: Review of the record found that Patient P1 was admitted on January 16, 2011. As of the date of the survey, January 24, 2011, the record did not contain a copy of a psychosocial assessment.

B. Policy

Hospital Policy (Policy and Procedures Manual, Procedure 615.II.A.4) specifies that a psychosocial assessment must be performed within 72 hours of admission: "Social needs assessment is completed within 72 hours by a social worker."

C. Interview

In an interview on 1-25-11 from 1400 to 1415 with the Director of Social Services, Patient P1's record was discussed. The Director explained "I'm sure somebody just forgot to repeat it," adding that patient P1 had previously been in the hospital only a few weeks earlier.

Based on record review and interview, the facility failed to ensure that physician adequately assess the intellectual and memory functioning of 6 of 8 active sample patients (P2, P4, P5, P6, P7, and P8), and to describe the testing methods used for the assessments. This deficiency compromises the database from which changes in patients' functioning could be measured throughout the course of treatment, and impedes the clinical team's ability to develop treatment goals and interventions that were appropriate for the patients' estimated cognitive functioning.

Findings include:

A. Record Review

1. Patient P2: In a psychiatric evaluation conducted on 12/29/10, no estimate of memory functioning, nor an assessment of intellectual functioning, was included.

2. Patient P4: In a psychiatric evaluation conducted on 1/14/11, no estimate of memory functioning, or an assessment of intellectual functioning was included.

3. Patient P5: In a psychiatric evaluation conducted on 1/20/11, cognitive findings were noted as "recent memory abnormal." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included beyond a statement that general fund of knowledge was "below average." These findings alone could substantiate an Axis I diagnosis of Cognitive Disorder NOS.

4. Patient P6: In a psychiatric evaluation conducted on 11/28/10, summarized the cognitive findings as short-term memory "intact." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included.

5. Patient P7: In a psychiatric evaluation dated 1/10/11, the cognitive findings were noted as "recent memory intact." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included besides stating that general fund of knowledge was "average."

6. Patient P8: In a psychiatric evaluation conducted on 1/23/11, no estimate of memory functioning or assessment of intellectual functioning was included.


B. Staff Interview

In an interview on 1-25-11 from 9:00am to 9:30am, the Medical Director acknowledged that cognitive assessments did not include methods of assessment of memory function or an outline of intellectual function.

Based on the review of the records of patients and on an interview with the Medical Director, the director failed to monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff. This failure is evidenced by charts showing a failure to adequately assess the intellectual and memory functioning of 6 of 8 active sample patients (P2, P4, P5, P6, P7, P8), and to describe the testing methods used for the assessments.

Findings include:

A. Record Review

1. Patient P2. A psychiatric evaluation, conducted on 12/29/10, included no estimate of memory functioning, nor an assessment of intellectual functioning.

2. Patient P4. A psychiatric evaluation, conducted on 1/14/11, included no estimate of memory functioning, nor an assessment of intellectual functioning.

3. Patient P5. A psychiatric evaluation, conducted on 1/20/11, summarized the cognitive findings as "recent memory abnormal." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included beyond a statement that general fund of knowledge was "below average." In a progress note, written on 1/21/11, short-term memory, as well as other cognitive functions, were all listed as "normal" without explanation of how this finding was arrived at, but an Axis 1 diagnosis of "Cognitive Disorder NOS" was recorded.

4. Patient P6. A psychiatric evaluation, conducted on 11/28/10, summarized the cognitive findings as short-term memory "intact." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included.

5. Patient P7. A psychiatric evaluation, dated 1/10/11, summarized the cognitive findings as "recent memory intact." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning was not included besides stating that general fund of knowledge was "average."

6. Patient P8. A psychiatric evaluation, conducted on 1/23/11, included no estimate of memory functioning nor an assessment of intellectual functioning.

B. Staff Interview

In an interview on 1-25-11 from 9:00am to 9:30am, the Medical Director acknowledged that cognitive assessments did not include methods of assessment of memory function or an outline of intellectual function.

Based on record review, policy review and interview the Director of Nursing failed to ensure that registered nurses complete the Adult Inpatient Program Nursing Assessment, upon admission of the patient, in 1 of 8 active sample patients (P2). Failure to do this hampers the nurse's ability to contribute to the development of a complete Master Treatment Plan and provide thorough and effective nursing interventions, and may prolong the patient's hospitalization.

Findings include:

A. Record Review

The Adult Inpatient Program Nursing Assessment for active sample patient (P2), dated 12/29/10, was only partially completed. The sections of the Assessment: Plan, Nutrition Screen, Self Care Problems, Nursing Admission Note, Initial D/C Needs and Patient Goals for Hospitalization were all left blank at the time of the survey 01/24/11. In addition, no dated and timed signature was present in these sections of the form.

B. Policy Review

Facility Assessment of Patients Policy #615 dated 08/10, states under "Procedure:2. Within 24 hours of admission, the admitting RN will perform a nursing admission assessment. This includes screening assessments for further assessment of nutritional needs, discharge planning needs, and the presence of pain. The patient will also be assessed for measures that can be taken to minimize the use of seclusion and restraint."

C. Interview

In an interview on 1/25/11 at 11:05AM the Director of Nursing confirmed that the Adult Inpatient Program Nursing Assessment for active sample patient (P2) was incomplete, unsigned and undated. She acknowledged that failure to have a completed nursing assessment hinders the development of a comprehensive, individualized Master Treatment Plan.

Based on the review of the records and on an interview with the Director of Social Services, and policy review, the director failed to monitor the timely performance and documentation of the Social Work Assessment for one patient (P1) out of the sample of eight.

Findings include:

A. Record Review

Record P1

The patient had been admitted on January 16, 2011. As of January 24, 2011, the record did not contain a copy of a psychosocial assessment.

B. Policy

Hospital Policy (Policy and Procedures Manual, Procedure 615.II.A.4) specifies that a psychosocial assessment must be performed within 72 hours of admission: "Social needs assessment is completed within 72 hours by a social worker."

C. Interview

An interview with the Director of Social Services was conducted on 1-25-11 from 2:00 to 2:15p.m. She explained that in her monthly chart audits she occasionally notices a missing psychosocial assessment. In the current case, "I'm sure somebody just forgot to repeat it," she said, adding that patient P1 had previously been in the hospital only a few weeks earlier.