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Based on record review, policy review and staff interview, it was determined that the facility failed to perform and document a psychiatric evaluation for 1 of 8 active sample patient (R2). The absence of this patient information hinders the clinician's ability to make an accurate diagnosis and plan appropriate treatment.


Findings Include:


Record Review:

Patient R2 was admitted on 08/29/2014. There was no psychiatric evaluation documented in the medical record. Instead, there was a physician progress note dated 08/30/2014 which was labelled "see psych eval dated 7/29/14 (referring to this patient's previous admission to the facility). This is a addendum to psych evaluation."


Policy Review:

The medical staff rules and regulations dated 06/26/2014, stated, "The psychiatric evaluation and mental status examination shall, in all cases, be completed within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. Dictation of such must be completed and in the patient's chart within 48 hours. The admission note will include a DSM IV five axis diagnoses and preliminary plan of treatment. The complete psychiatric evaluation, in all cases, will be completed and recorded in the chart within 24 hours after admission of the patient, unless one has been performed within 30 days prior to admission, in which case a durable, legible copy of the report may be used in the patient ' s medical record provided that the physician reviews such copy, indicates any changes on the report copy in the chart, and signs and dates his review. If the psych eval is dictated, a progress note shall be entered at the time of examination documenting any relevant medical conditions and recommendations. When the patient is readmitted within 30 days for the same or related problem, an "interval" psych eval reflecting any changes may be used, provided that the original physical exam is readily available.


Interview:

During an interview on 09/17/2014 at 02:30PM, the CEO stated, "Psychiatric evaluation is being completed now. It is late but it will be done. Medical staff by laws will also be amended."

Based on record review, policy review and staff interview, it was determined that the facility failed to perform and document psychiatric evaluations for 1 of 8 active sample patients (P7) in a timely manner as per the medical staff rules and regulations. This failure hinders the treatment team's ability to effectively formulate treatment plans in a timely manner.


Findings Include:


Record Review:

Patient P7 was admitted on 09/11/2014. The psychiatric evaluation was not completed within 24 hours of the admission as per the hospital medical staff rules and regulations.


Policy Review:

The medical staff rules and regulations dated 06/26/2014, stated, "The psychiatric evaluation and mental status examination shall, in all cases, be completed within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. Dictation of such must be completed and in the patient's chart within 48 hours. The admission note will include a DSM IV five axis diagnoses and preliminary plan of treatment. The complete psychiatric evaluation, in all cases, will be completed and recorded in the chart within 24 hours after admission of the patient, unless one has been performed within 30 days prior to admission, in which case a durable, legible copy of the report may be used in the patient ' s medical record provided that the physician reviews such copy, indicates any changes on the report copy in the chart, and signs and dates his review. If the psych eval is dictated, a progress note shall be entered at the time of examination documenting any relevant medical conditions and recommendations. When the patient is readmitted within 30 days for the same or related problem, an "interval" psych eval reflecting any changes may be used, provided that the original physical exam is readily available.


Interview:

During an interview on 09/17/2014 at 02:30PM, the CEO stated, "I see psych eval (psychiatric evaluation) is not done within 24 hours."

Based on record review and interview, the facility failed to address significant psychiatric disabilities identified during the assessment process for 7 of 8 active sample patients (R1, R2, R3, R4, P5, P6, and P8). This failure resulted in Master Treatment Plans that were not individualized for the patient and there was no specific direction to staff as to how to intervene regarding the disabilities cited.

Findings include:

A. Record Reviews:
1. Patient R1 had the following liabilities listed in the Master Treatment Plan dated 9/6/14: "Limited or poor social support," "Limited social skills," "Traumatic Event" and "Family Conflict." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

2. Patient R2 had the following liabilities listed in the Master Treatment Plan dated 8/31/14: "Treatment/Medication Non-compliance" and "Traumatic Event." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

3. Patient R3 had the following liabilities listed in the Master Treatment Plan dated 9/7/14: "Limited ability to read and write" and "Traumatic Event." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

4. Patient R4 had the following liabilities listed in the Master Treatment Plan dated 9/4/14: "Substance Abuse" and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

5. Patient P5 had the following liabilities listed in the Master Treatment Plan dated 9/11/14: "Limited or poor social support," "Limited social skills," " Family conflict," and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

6. Patient P6 had the following liabilities listed in the Master Treatment Plan dated 9/11/14: "Educational or school conflicts," "Recent loss," "Traumatic event" and "Family conflict." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

7. Patient P8 had the following liabilities listed in the Master Treatment Plan dated 9/12/14: "Past history of unsuccessful treatment," "Traumatic Event," and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

B. Interviews:
1. On 9/16/14 at 1:10PM, the Director of Clinical Services for the facility stated, "I see what you mean about the interventions not being related to the liabilities mentioned."

2. On 9/16/14 at 1:40PM, the Chief Executive Officer of the facility stated, "No, the interventions are not individualized. We are a work in progress."

3. On 9/17/14 at 10:00AM, the Director of Nursing, "I see that the interventions are not specific to each patient."