HospitalInspections.org

Based on medical record review and staff interview it was determined that for 10 of 12 patients (Patients A1, A2, A3, A4, B1, B4, C1, C2, C3 and C4), the Master Treatment Plan lacked a description of patient disabilities/problems in a behaviorally descriptive manner. This failure results in no description of what exactly the treatment team considered as the focus of treatment in the determination of goals and the selection of treatment modalities.

The findings include:

I. Record Review:

1. Patient A1: The Master Treatment Plan dated 8/28/2018 contained a description of the Problem "Thought D/O (Disorder) ", defined as "delusional, paranoid and becomes aggressive." There was no further description of how these symptoms manifested themselves behaviorally.

2. Patient A2 The Master Treatment Plan dated 3/12/2018 contained a description of the Problem "Thought D/O and Mood D/O," defined as "delusional ideas and hallucinations." There was no further description of how these problems manifested themselves behaviorally.

3. Patient A3: The Master Treatment Plan dated 10/03/2018 contained a description of the Problem "Thought Disorder," as defined as "Polydipsia". For the Problem "Thought D/O," "delusions" was the sole behavioral description of the patient's symptoms.

4. Patient A4: The Master Treatment Plan dated 4/19/2018 contained a description of the Problem "Aggressive," defined as "Stalking, aggressive, assaultive."

5. Patient B1: The Master Treatment Plan dated 10/17/2018 lacked any Problem identification and had no description of how this patient's Problem, which would be the focus of goal setting and the selection of treatment interventions, manifested itself behaviorally.

6. Patient B4: The Master Treatment Plan dated 7/2/2018 cont

Based on record review and interview, the Master Treatment Plans (MTPs) called "Individualized Treatment Plan" for 12 of 12 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3 and C4)) failed to specify short-term goals (STG) and long-term goals (LTG) stated in observable, measurable patient behaviors to be achieved. Some of the listed goals called "objectives" were stated as staff expectations for the patient's participation in treatment rather than behavioral outcomes for the patient to achieve. There were no incremental outcome statements between the short-term and the long-term goals. The goal statement on the MTP lacked individualized symptoms, specific descriptors, and observable behaviors. It was impossible to judge the effectiveness of treatment and to implement possible changes in the case of lack of progress. These failures can hamper how clinical staff evaluate each patient's changes or improvement based on information provided on the Master Treatment Plans.

Findings include:

A. Record Review

1. Patient A1: MTP dated 9/25/18 listed "Problem" as "Thought D/O (Disorder), Mood D/O." "As Manifested by: Delusional, paranoid, becoming aggressive."

a.) Goal (Not identified as STG or LTG): "Refrain from aggressive/assaultive behaviors and accept reality feedback." This goal was a staff expectation statement. It was not stated in behavioral terms reflecting what non-harmful alternative method(s) the patient would be utilizing to refrain from becoming "aggressive/assaultive."

b.) Goal (Not identified as STG or LTG): "Pt (patient) will comply with meds (medication)....w/o (without) resistance or combativeness." This goal was a staff expectation/compliance-in- treatment statement.

2. Patient A2: MTP dated 9/25/18 listed "Problem" as "Though

Based on record review, staff interviews and policy review, the facility failed to provide MTP (Master Treatment Plan) interventions for 12 of 12 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3 and C4) that identified clearly delineated interventions to address specific patient problems. Many interventions were generic monitoring and discipline functions. In addition, some of the plans failed to identify how theses generic interventions would be delivered (group or individual) or how often the interventions would occur. These deficiencies resulted in Treatment Plans that were not individualized and did not reflect a comprehensive, individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed. This failure potentially results in inconsistent and/or ineffective treatment. The findings include:

I. Medical Record Review:

1.Patient A1: The MTP dated 8/28/18 listed the problem as "Thought D/O, Mood D/O as Manifested By: delusional, tends to be depressive and to isolate, can be resistive to treatment."

Psychiatry: "Reinforce need to comply w/meds, medical appts, labs, and any medication recommendations for [her/his] own health and welfare."

Nursing: "Will encourage and counsel consumer of importance of taking Meds and going on Medical Appts."

2. Patient A2: The MTP dated 3/12/18 listed the problem as "Thought D/O, Mood D/O as Manifested By: holds delusional ideas, hears "voices", does not want meds."

Psychiatry: "Educate regarding needs for meds, med appts, TX's, Lab, P.T., and encourage [her/him]to cooperate."

Nursing: There were no interventions for this problem.

There were no changes in the goal or the interventions by the disciplines on the MTP

Based on record review and staff interview it was determined that for 12 of 12 patients (Patients A1,A2, A3, A4, B1, B2, B3, B4, C1, C2, C3 and C4) in the establishment of Master Treatment Plans the clinical director-----

1. Failed to describe the behavioral manifestations of the identified Problems. This failure resulted in a lack of measurable and observable changes during the patient's treatment. For details, see B119.

2.Failed to ensure that Master Treatment Plans set short and long term goals that could be a basis for assessing the achievement or lack thereof, during the patient's hospital stay. For details, see B121.

3. Ensure that Master Treatment Plans contained interventions that were patient-focused and not simply a description of routine discipline functions and/or staff expectations. This failure resulted in a lack of individualized Treatment Plans. For details, see B 122.

Based on record review and staff interview the Director of Nursing failed to monitor psychiatric nursing care, provide adequate oversight, and take corrective actions to ensure quality nursing services. Specifically, the DON failed to:

1. Develop short-term goals that were individualized for each patient based on their specific problems in 12 out of 12 active sample patients. (A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3 and C4). (Refer to B121)

2. Identify interventions that were specific to the goals and were not routine nursing functions and duties in 12 out of 12 active sample patients. (A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3 and C4). (Refer to B122)