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Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 7 of 8 active sample patients (A1, A2, B1, B2, C2, D1 and D2) included an assessment of recent and remote memory function, stated in measurable, behavioral terms that clearly reflected patients' abilities in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions might be measured.

Findings include:

A. Record Review

The psychiatric evaluation is dictated and entered into a computerized medical record with the "Mental Status Exam" (MSE) as a section of the evaluation.

1. Patient A1, admitted 1/27/11, had a psychiatric evaluation done 1/27/11 with an MSE which reported "MEMORY: His remote, intermediate and recent memory functions are intact. He is able to talk about events from a long time ago and current problems." There was no indication of specific memory tests being performed, limiting the opportunity to assess the patient's change over the course of treatment.

2. Patient A2, admitted 1/20/11, had a psychiatric evaluation done 1/21/11 with an MSE which had no mention of memory function.

3. Patient B1, admitted 1/21/11 for paranoid delusions and muteness, had a psychiatric evaluation done 1/21/11 with an MSE which had no mention of memory or any indication of a plan to re-evaluate her when she became more able to cooperate.

4. Patient B2, admitted 1/28/11, had a psychiatric evaluation done 1/28/11 with an MSE which had no report of memory function.

5. Patient C2, admitted 1/25/11, had a psychiatric evaluation done 1/26/11 with an MSE which had no report of memory function.

6. Patient D1, admitted 1/26/11, had a psychiatric evaluation done 1/27/11 with an MSE which reported "His remote, recent and immediate memory appeared to be intact, as he could remember events from the distant past, events leading up to hospitalization, and events just prior to the interview on the unit." There was no indication of specific memory tests being performed, limiting the opportunity to assess the patient ' s change over the course of treatment.

7. Patient D2, admitted 1/27/11, had a psychiatric evaluation done 1/28/11 with an MSE which reported "Her remote, recent and immediate memory appear to be intact as she could remember events from the distant past, events leading up to hospitalization, and events just prior to the interview on the unit." There was no indication of specific memory tests being performed, limiting the opportunity to assess the patient ' s change over the course of treatment.

B. Staff Interview

In an interview on 2/3/11 at 1:00p.m., when asked about the MSE and the lack of documentation of specific memory tests performed, the Medical Director said "I am probably one of the offenders."

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an inventory of patient assets for 5 of 8 active sample patients (A1, A2, B1, B2 and C1). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation.

Findings include:

A. Record Review

The psychiatric evaluation is dictated and entered into a computerized medical record with "STRENGTHS" as a section of the evaluation.

1. Patient A1, admitted 1/27/11, had a psychiatric evaluation done 1/27/11 with "STRENGTHS: He is mostly medication compliant." This is a very limited list that can be used in treatment planning.

2. Patient A2, admitted 1/20/11, had a psychiatric evaluation done 1/21/11 with "STRENGTHS AND ASSETS: 'Name' (sic) has some family and community support as she has contact with her older son and his two daughters. They live in 'State' [sic]." There were no personal strengths listed that could be useful in treatment planning.

3. Patient B1, admitted 1/21/11 for paranoid delusions and muteness, had a psychiatric evaluation done 1/21/11 which had no mention of strengths or any indication of a plan to re-evaluate her when she became more able to cooperate.

4. Patient B2, admitted 1/28/11, had a psychiatric evaluation done 1/28/11 with "STRENGTHS: He reports he enjoys anything and everything." This will have limited use in treatment planning.

5. Patient C1, admitted 1/28/11, had a psychiatric evaluation done 1/29/11 with "ASSETS AND STRENGTHS: Apparently she has a very supportive mom. She identifies her as being very supportive. When asked if she is motivated for treatment she goes 'No. I don't really want help because the last two times I have received help I didn't get any better and I believe I can get well on my own.'" There were no personal strengths listed that could be useful in treatment planning.

B. Staff Interview

In an interview on 2/3/11 at 1:00p.m. with the Medical Director, the issue of identifying assets in the psychiatric evaluation was discussed. He asked for more information and said he would discuss this with the medical staff.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans of 4 of 8 active sample patients (B1, C2, D1 and D2) included the personal strengths of each patient which could be useful in treatment. Three of the patients' treatment plans had no patient strengths listed; the fourth treatment plan had items listed which were not personal strengths of the patient. The lack of identified patient strengths compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Record Review (treatment plan dates in parentheses)

1. For patient B1 (1/21/11), the Master Treatment Plan did not include any strengths or assets on the check list of suggested alternatives entitled "Inventory of Patient Strengths and Assets."

2. For patient C2 (1/27/11), the Master Treatment Plan included check marks for "Community support network" with "Sac Co CTS [Sacramento County community treatment service]" written in; and for "Employed/Enrolled in school" with "Has IEP [individual education plan]" written in.

4. For patient D1 (1/27/11), the Master Treatment Plan did not include any strengths or assets on the check list of "Inventory of Patient Strengths and Assets."

5. For patient D2 (1/31/11), the Master Treatment Plan did not include any strengths or assets on the check list of "Inventory of Patient Strengths and Assets."

B. Interview

In an interview at 3:20p.m. on 2/03/11, the Director of Nursing agreed that patient strengths are not always on the treatment plans.

Based on record review and interview, the facility failed to identify specific group therapies and therapeutic activities on the Master Treatment Plans of 8 of 8 active sample patients (A1, A2, B1, B2, C1, C2, D1 and D2) which addressed each patient's individual treatment needs. No specific group therapies or therapeutic activities were listed on the plans. Instead, patients were expected to attend the "therapeutic milieu program": "all on-unit activities" or "all off-unit activities." This deficiency results in failure to guide staff in providing goal-directed treatment.

Findings include:

A. Record Review (treatment plan dates in parentheses)

1. For patient A1 (1/30/11), interventions included "Encourage patient to explore self worth issues by attending the therapeutic milieu program." There were no specific group therapies or therapeutic activities listed.

2. For patient A2 (2/01/11), interventions included "Encourage participation in therapeutic milieu program." There were no specific group therapies or therapeutic activities listed.

3. For patient B1 (1/21/11), interventions included "Encourage attendance of therapeutic milieu program." There were no specific group therapies or therapeutic activities listed.

4. For patient B2 (1/31/11), interventions included "Encourage patient to participate in therapeutic milieu program: Will attend all on-unit activities (Day 2). Will attend all off-unit activities (Day 3-4)"; "Utilize group therapy to identify behaviors (daily)." There were no specific group therapies or therapeutic activities listed.

5. For patient C1 (1/31/11), interventions included "Encourage patient to explore self worth issues by attending the therapeutic milieu program (Day 2-4)." There were no specific group therapies or therapeutic activities listed.

6. For patient C2 (1/27/11), interventions included "Encourage patient to explore self worth issues by attending the therapeutic milieu program (Day 2-4)." There were no specific group therapies or therapeutic activities listed.

7. For patient D1 (1/27/11), interventions included "Educate patient on [blank not filled in] coping skills for expression of anger/agitation q [every] day." There were no specific group therapies or therapeutic activities listed.

8. For patient D2 (1/31/11), "Encourage patient to explore self worth issues by attending the therapeutic milieu program (Day 2-4)." There were no specific group therapies or therapeutic activities listed.

B. Interview

In an interview at 3:20p.m. on 2/03/11, the Director of Nursing stated that some of the treatment modalities are not specific.

Based on record review and interview, the Medical Director failed to assure quality and appropriateness of care of 8 of 8 active patients (A1, A2, B1, B2, C1, C2, D1 and D2). Specifically, the Medical Director failed to:

I. Ensure that psychiatric evaluations of 7 of 8 active sample patients (patients A1, A2, B1, B2, C2, D1 and D2) included an assessment of recent and remote memory function, stated in measurable, behavioral terms that clearly reflected patients' abilities in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions might be measured. (Refer to B116)

II. Ensure that the psychiatric evaluations of 5 of 8 active sample patients (A1, A2, B1, B2 and C1) included an inventory of patient strengths/assets. This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation. (Refer to B117)

III. Ensure that Master Treatment Plans for 4 of 8 active sample patients (B1, C2, D1 and D2) included the personal strengths of each patient which could be used in treatment. Three of these patients' treatment plans had no patient strengths listed; the fourth treatment plan had items listed which were not personal strengths of the patient. The lack of identified patient strengths compromises the staff's ability to deliver clinically focused treatment.

IV. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (A1, A2, B1, B2, C1, C2, D1 and D2) identified specific group therapies and therapeutic activities that addressed each patient's individual treatment needs. No specific group therapies or therapeutic activities were listed on the plans. Instead, patients were expected to attend the "therapeutic milieu program": "all on-unit activities" or "all off-unit activities." This deficiency results in failure to guide treatment staff in providing goal-directed treatment.