HospitalInspections.org

Based on record review and interview, the facility failed to provide psychosocial assessments, called "Biopsychosocial Assessments" by the facility, that included conclusions and recommendations of the anticipated necessary steps for discharge to occur and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the anticipated social work role in treatment planning was not individualized but was identical or similarly worded despite different presenting symptoms and discharge needs for each patient in the sample. As a result, the social work role, conclusions regarding clinical information collected, and specific recommendations regarding treatment of patients' psychosocial problems are not described for the treatment team.

Findings include:

A. Record Review

The social work assessments for the following patients were reviewed (dates of assessments in parentheses): A1 (4/4/16), A2 (3/23/16), A3 (4/4/16), A4 (3/14/16), A5 (4/1/16), A6 (4/1/16), A7 (4/4/16), and A8 (4/4/16). This review revealed that none of the "Biopsychosocial Assessments" included the anticipatory social work role based on clinical findings collected during the assessment. These assessments had the following identical or similarly worded general statements:

1. The "Conclusion and Recommendations" section for Patients A2, A3, A4, A5, A6, A7 and A8 all contained the following identical or similarly worded statements: "...Psychiatric follow-up referral, Individual psychotherapy follow-up recommended referral. Primary Care Provider follow-up as needed..." This statement did not include a recommendation based on the results of clinical findings from the assessment of each patient. This statement failed to include individualized potential steps needed for discharge, high-risk issues, and/or specified potential community resources that might be useful for each patient based on presenting symptoms and needs.

2. "Social Worker role" - "...Schedule follow-up appointments, educate patients and family on Social Workers role while admitted to the facility..." This statement did not describe or spell out specific recommendations for social work treatment interventions and discharge plans based on each patient's presenting problems, needs, and/or issues.

B. Policy Review

A review of the facility's policy titled, "Biopsychosocial Assessment" stated, "If a Registered Nurse completes the Biopsychosocial Assessment, there must be inclusion from a Master's level Social Worker to oversee the quality and appropriateness of the service provided. Although the Director of Social Worker stated that the RN does not complete the section of the assessment, which included the social worker's role in treatment, this was not stipulated in policy.

C. Interview

In an interview on 4/5/16 at 8:40 a.m. with the Director of Social, the psychosocial assessments were discussed for the active sample patients. She did not dispute the findings. She stated, "We can be more specific in the recommendations for the social worker's role."

Based on record review and interview, the facility failed to consistently develop Master Treatment plans (MTPs) that evidenced sufficient individualized planning of active treatment interventions with specific focus based on individual needs and abilities of seven (7) of eight (8) active sample patients (A1, A2, A4, A5, A6, A7 and A8). Specifically, many interventions were stated as generic monitoring and discipline functions written as active treatment interventions to be performed by clinical staff. Most MTPs also failed to state the frequency of contact, specific focus of treatment, and whether interventions would be delivered in groups or individual session. In addition, for six (6) of sight (8) active sample patients (A1, A2, A4, A5, A6 and A7), the MTPs failed to include the specific groups listed on the unit schedule that they were attending. These deficiencies results in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff in carrying out the specific interventions and purposes for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy, titled "Treatment Plan Documentation," dated reviewed/revised 3/23/16, stated: "Treatment plan - The outline of what the hospital has committed itself to do for the patient, based on an assessment of the patient's needs."---"Written treatment plan must include:"---"Specific treatment interventions utilized, including the focus of the treatment."

2. Active sample patient A1, MTP dated 4/4/16, had for a problem "Danger to self as evidenced by patient's report of being with him/herself and wanting to hurt him/herself." The generic discipline interventions were:

Nursing: "Evaluate suicidal thoughts regularly, Frequent rounding for safety checks and Monitor and record any self-injurious behavior. These were nursing tasks, not active treatment interventions that include a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms.

Psychologist: "Assist in the development of healthy coping skills to better manage [his/her] thoughts of self harm, anxiety, and responses to triggers." This intervention lacked frequency of contact and mode of delivery (1:1 or group).

Psychiatrist: "Evaluate symptoms and determine the need for changes in mood stabilizing medications." These were psychiatrist tasks, not active treatment interventions that included a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms.

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social work tasks, not active treatment interventions that included a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms. This intervention statement was identical for all active sample patients.

3. Active sample patient A2, MTP dated 3/23/16, had for a problem "Danger to self as evidenced by patient's report of having suicidal ideations for the past 2 days with a plan." The generic discipline interventions were:

Nursing: "Frequent rounding for safety checks, Evaluate suicidal thoughts regularly, and Provide information on healthy coping skills to utilize when having the urge to self-harm." The first two intervention statements were nursing tasks not active treatment interventions. The third intervention lacked a specific focus of treatment, frequency of contact, and mode of delivery (1:1 or group).

Psychology: "Working on the development of healthy distress tolerance skills to manage stressful situations and emotions." This intervention is very broad and lacked frequency of contact and mode of delivery (1:1 or group).

Psychiatrist: "Evaluate symptoms and determine the need for the addition of psychotropic medications." These were psychiatrist tasks, not active treatment interventions that included a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms.

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social work tasks, not active treatment interventions based on this patient's symptoms and/or needs.

4. Active sample patient A4, MTP dated 3/14/16, had for a problem "Danger to self as evidenced by patient report of being suicidal 'everyday' with a plan to overdose along with the history of suicide attempts which are increasing in frequency and potential lethality." The generic discipline interventions were:

Nursing: "Provide education on healthy coping skills and techniques." This intervention lacked specific focus of treatment, such as skills to handle anger, suicidal impulses, etc. It also lacked frequency of contact and mode of delivery (1:1 or group).

Psychiatrist: "Evaluate symptoms and determine the need for changes in mood and anxiety medications." These intervention statements were not active treatment interventions based on this patient's symptoms and/or needs.

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social worker tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Rehab [Rehabilitation] services: "Provide 1:1 evaluation of needs. Provide occupational therapy group to help in the development of coping and relaxation strategies." The first intervention was a rehabilitation staff task. The second intervention did not include any specific group(s) to be offered or frequency of contact.

5. Active sample patient A5, MTP dated 4/1/16, had as a problem "Danger to self as evidenced by patients [sic] overdose on his/her brother's Clonidine medications." The generic discipline interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate and record suicidal thoughts of self-injurious behaviors regularly and Provide education on healthy coping strategies." The first two intervention statements were nursing tasks. The third intervention statement lacked a frequency of contact and mode of delivery (1:1 or group).

Psychiatrist: "Evaluate symptoms and determine if medications are needed." These were psychiatrist tasks, not active treatment interventions based on this patient's presenting symptoms and potential medication(s) planned).

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social work tasks, not active treatment interventions based on this patient's symptoms and/or needs.

O.T. [Occupational therapy]: "Provide 1:1 evaluation of needs." This was an OT task, not an active treatment intervention that included a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms.

6. Active sample patient A6, MTP dated 4/1/16, had as a problem "Danger to self as evidenced by reports of patient stating s/he would take the whole bottle of Fluoxetine and a history of attempting to jump out of a moving vehicle." The generic discipline interventions were:

Nursing: "Evaluate suicidal thoughts regularly and Frequent rounding for safety checks." These intervention statements were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Psychiatrist: "Evaluate symptoms and determine the need for psychotropic medications." These were psychiatrist tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social work tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

7. Active sample patient A7, MTP dated 4/4/16, had as a problem "Danger to self as evidenced by patient's suicidal ideations with a plan to cut [sic] or overdose." The generic discipline interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate suicidal thoughts regularly and Monitor and record any self-injurious behaviors." These were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Psychiatrist: "Evaluate symptoms and determine the need for medication." These were psychiatrist tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Social work: "Evaluate discharge need and ensure that all discharge needs are addressed." These were social worker tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

O.T. (Occupational Therapy): "Provide 1:1 evaluation on needs." This was an OT task, not an individualized active treatment intervention based on the patient's presenting symptoms and/or needs.

8. Active sample patient A8, MTP dated 4/4/16, had as a problem "Danger to self as evidenced by patients [sic] report to the Northern Lights (group home) staff of being suicidal." The generic discipline interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate suicidal thoughts regularly and Provide a low stimulation environment in the High Acuity Unit." These were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Psychologist: "Provide supportive listening and establishing support," and "Explore underlying causes to suicidal and homicidal comments." These interventions lacked specific focus of treatment, frequency of contact, and mode of delivery.

Psychiatrist: "Evaluate symptoms and determine the need for changes in antidepressant medications." These were psychiatrist tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

Social work: "Evaluate discharge needs and ensure that all discharge needs are addressed." These were social worker tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

9. The following six (6) of eight (8) active sample patients (dates of MTPs in parenthesis) did not have any groups from the unit schedule (which all patients were expected to attend) listed on their Master Treatment: (A1 (4/4/16), A2 (3/23/16), A4 (3/14/16), A5 (4/1/16), A6 (4/1/16), A7 (4/4/16), and A8 (4/4/16)).

B. Interviews

1. In an interview on 4/5/16 at 8:00 a.m., the generic discipline interventions without a specific focus of treatment, frequency of contact, and/or mode of delivery were discussed with RN #1. She agreed with the findings.

2. In an interview on 4/5/16 at 10:20 a.m., with the Nursing Director, the generic interventions on the Master Treatment Plans was discussed. She did not dispute the findings.

Based on record review and interview, the Nursing Director failed to ensure that Master Treatment plans (MTPs) for seven (7) of eight (8) active sample patients (A1, A3, A4, A5, A6, A7 and A8) included nursing interventions that were individualized with specific focus, frequency and included a mode of delivery (1:1 or group). "Specifically, many nursing interventions were stated as generic monitoring and nursing functions written as treatment interventions to be performed by the nursing staff." These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to nursing staff in carrying out the specific interventions and purposes for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy, titled "Treatment Plan Documentation," dated reviewed/revised 3/23/16, stated: "Treatment plan - The outline of what the hospital has committed itself to do for the patient, based on an assessment of the patient's needs."---"Written treatment plan must include:"---"Specific treatment interventions utilized, including the focus of the treatment."

2. Active sample patient A1, MTP dated 4/4/16, had for a problem "Danger to self as evidenced by patient's report of being with him/herself and wanting to hurt him/herself." The generic nursing interventions were:

Nursing: "Evaluate suicidal thoughts regularly, Frequent rounding for safety checks and Monitor and record any self-injurious behavior. These were nursing tasks, not active treatment interventions that include a focus of treatment, frequency of contact, and mode of delivery (1:1 [one to one] or group) based on this patient's presenting symptoms."

3. Active sample patient A2, MTP dated 3/23/16, had for a problem "Danger to self as evidenced by patient's report of having suicidal ideations for the past 2 days with a plan." The generic nursing interventions were:

Nursing: "Frequent rounding for safety checks, Evaluate suicidal thoughts regularly, and Provide information on healthy coping skills to utilize when having the urge to self-harm." The first two intervention statements were nursing tasks not active treatment interventions. The third intervention lacked a specific focus of treatment, frequency of contact, and mode of delivery (1:1 or group).

4. Active sample patient A4, MTP dated 3/14/16, had for a problem "Danger to self as evidenced by patient report of being suicidal 'everyday' with a plan to overdose along with the history of suicide attempts which are increasing in frequency and potential lethality." The generic nursing interventions were:

Nursing: "Provide education on healthy coping skills and techniques." This intervention lacked specific focus of treatment, such as skills to handle anger, suicidal impulses, etc. It also lacked frequency of contact and mode of delivery (1:1 or group).

5. Active sample patient A5, MTP dated 4/1/16, had as a problem "Danger to self as evidenced by patients [sic] overdose on his/her brother's Clonidine medications." The generic nursing interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate and record suicidal thoughts of self-injurious behaviors regularly and Provide education on healthy coping strategies." The first two intervention statements were nursing tasks. The third intervention statement lacked a frequency of contact and mode of delivery (1:1 or group).

6. Active sample patient A6, MTP dated 4/1/16, had as a problem "Danger to self as evidenced by reports of patient stating s/he would take the whole bottle of Fluoxetine and a history of attempting to jump out of a moving vehicle." The generic nursing interventions were:

Nursing: "Evaluate suicidal thoughts regularly and Frequent rounding for safety checks." These intervention statements were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

7. Active sample patient A7, MTP dated 4/4/16, had as a problem "Danger to self as evidenced by patient's suicidal ideations with a plan to cut [sic] or overdose." The generic discipline interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate suicidal thoughts regularly and Monitor and record any self-injurious behaviors." These were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

8. Active sample patient A8, MTP dated 4/4/16, had as a problem "Danger to self as evidenced by patients [sic] report to the Northern Lights (group home) staff of being suicidal." The generic nursing interventions were:

Nursing: "Frequent rounding for safety checks. Evaluate suicidal thoughts regularly and Provide a low stimulation environment in the High Acuity Unit." These were nursing tasks, not individualized active treatment interventions based on the patient's presenting symptoms and/or needs.

9. The following six (6) of eight (8) active sample patients (dates of MTPs in parenthesis) did not include the "RN Medication Group" listed on the unit schedule (which all patients were expected to attend) on their Master Treatment: (A1 (4/4/16), A2 (3/23/16), A4 (3/14/16), A5 (4/1/16), A6 (4/1/16), A7 (4/4/16), and A8 (4/4/16)).

B. Interviews

1. In an interview on 4/5/16 at 8:00 a.m., the generic discipline interventions without a specific focus of treatment, frequency of contact, and/or mode of delivery were discussed with RN #1. She agreed with the findings.

2. In an interview on 4/5/16 at 10:20 a.m., with the Nursing Director, the generic interventions on the Master Treatment plans was discussed. She did not dispute the findings.

Based on record review and interviews, the Director of Social Services failed to provide psychosocial assessments, called "Biopsychosocial Assessments" by the facility, that included conclusions and recommendations of the anticipated necessary steps for discharge to occur and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the anticipated social work role in treatment planning was not individualized but was identical or similarly worded despite different presenting symptoms and discharge needs for each patient in the sample. As a result, the social work role, conclusions regarding clinical information collected, and specific recommendations regarding treatment of patients' psychosocial problems are not described for the treatment team. (Refer to B108)