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Based on record review, policy review and interview, the facility failed to provide psychiatric evaluations that reported memory functioning in measurable and behavioral terms for three (3) of nine (9) active sample patients (C, D and H). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient C - In a Psychiatric Evaluation dated 12/9/10, the following was noted: "Memory: recent/remote - normal" (box checked); "memory tested by way of MSE (mental status exam)".

2. Patient D - In a Psychiatric Evaluation dated 11/13/10, the following was noted: "Memory: recent/remote - normal", (box checked); "memory tested by way of MSE (mental status exam)".

3. Patient H - In a Psychiatric Evaluation dated 12/3/10, the following was noted: "orientation and memory is not tested."

B. Policy Review

The facility's "Physician Orientation Manual," dated 7/14/09, contained a guideline for a psychiatric examination which was given to each psychiatrist. Instructions and requirements for psychiatric evaluation are specific: "Dictation must include the following: orientation, intellectual capacity, memory and how tested."

C. Interview

In an interview on 12/14/10 at 3:00PM with the Medical Director, active sample patient records C, D and H were discussed. The Medical Director agreed that memory functioning was not adequately documented with objective findings in these records.

Based on record review, policy review (Policy # ADM -III-007/NSG-III-007, "Treatment Planning", dated revision- 1/2000), and staff interview, the facility failed to ensure that staff members responsible for each modality/intervention were included on the treatment plans by name for nine of nine active sample patients (A, B, C, D, E, F, G, H and I). Because of this failure, it cannot be determined which staff is responsible for individual patient modalities.

Findings include:

A, Record Review

1. Patient A: In a Master Treatment Plan (dated 12/12/10) no staff names were assigned to the modalities.

2. Patient B: In a Master Treatment Plan (dated 12/14/10) no staff names were assigned to the modalities.

3. Patient C: In a Master Treatment Plan (dated 12/10/10) no staff names were assigned to the modalities.

4. Patient D: In a Master Treatment Plan (dated 11/22/10) no staff names were assigned to the modalities.

5. Patient E: In a Master Treatment Plan (dated 12/7/10) no staff names were assigned to the modalities.

6. Patient F: In a Master Treatment Plan (dated 12/7/10) no staff names were assigned to the modalities.

7. Patient G: In a Master Treatment Plan (dated 12/5/10) no staff names were assigned to the modalities.

8. Patient H: In a Master Treatment Plan (dated 12/3/10) no staff names were assigned to the modalities.

9. Patient I: In a Master Treatment Plan (dated 12/10/10) no staff names were assigned to the modalities.

B. Policy Review

The facility's Treatment Plan Policy # ADM -III-007/NSG-III-007, titled "Treatment Planning" with a revision date of 1/2000 noted the following on Page 5, Section 9: "O:The name and discipline of the responsible party and the date of the revision is noted in the space provided."

C. Interview

In an interview on 12/13/10 at 3:00PM with the Director of Nursing and the Staff Development Coordinator, treatment plans were discussed in reference to the lack of identified responsible staff for each modality. Both the DON and the Staff Development Coordinator acknowledged that the responsible discipline was listed rather than specific staff names.

Based on record review, policy review and interview, the Medical Director failed to monitor the completion of psychiatric evaluations with regard to memory testing for three of nine active sample patients (C, D and H). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient C - In a Psychiatric Evaluation dated 12/9/10, the following was noted: "Memory: recent/remote - normal" (box checked); "memory tested by way of MSE (mental status exam)".

2. Patient D - In a Psychiatric Evaluation dated 11/13/10, the following was noted: "Memory: recent/remote - normal", (box checked); "memory tested by way of MSE (mental status exam)".

3. Patient H - In a Psychiatric Evaluation dated 12/3/10, the following was noted: "orientation and memory is not tested."

B. Policy Review

The facility's "Physician Orientation Manual" (dated 7/14/09) contained a guideline for a psychiatric examination which was given to each psychiatrist. Instructions and requirements for psychiatric evaluation are specific: "Dictation must include the following: orientation, intellectual capacity, memory and how tested."

C. Interview

In an interview on 12/14/10 at 3:00PM with the Medical Director, active sample patient records C, D and H were discussed. The Medical Director agreed that memory functioning was not adequately documented with objective findings in these records.

Based on policy review, record review and staff interviews, the Director of Nursing failed to ensure that staff names were listed for interventions/modalities in the treatment plans of 9 of 9 active sample patients (A, B, C, D, E, F, G, H and I) in compliance with the treatment plan policy. Because there were no staff names on the treatment plans, it could not be determined which staff member was responsible for individual patient interventions/modalities. The Staff Development Coordinator is responsible for assigning staff on the treatment plans, and this person reports directly to the DON. Failure to identify the names of staff responsible for interventions for patients results in lack of staff accountability, and can impede the treatment team's ability to provide coordinated care for patients.

Findings include:

A. Policy Review

The facility's Treatment Plan Policy # ADM -III-007/NSG-III-007, titled "Treatment Planning," with a revision date of 1/2000, noted the following on Page 5, Section 9: "O: The name and discipline of the responsible party and the date of the revision is noted in the space provided."

B. Record Review

1. Patient A: In a Master Treatment Plan (dated 12/12/10) no staff names were assigned to the intervention modalities.

2. Patient B: In a Master Treatment Plan (dated 12/14/10) no staff names were assigned to the intervention modalities.

3. Patient C: In a Master Treatment Plan (dated 12/10/10) no staff names were assigned to the intervention modalities.

4. Patient D: In a Master Treatment Plan (dated 11/22/10) no staff names were assigned to the intervention modalities.

5. Patient E: In a Master Treatment Plan (dated 12/7/10) no staff names were assigned to the intervention modalities.

6. Patient F: In a Master Treatment Plan (dated 12/7/10) no staff names were assigned to the intervention modalities.

7. Patient G: In a Master Treatment Plan (dated 12/5/10) no staff names were assigned to the intervention modalities.

8. Patient H: In a Master Treatment Plan (dated 12/3/10) no staff names were assigned to the intervention modalities.

9. Patient I: In a Master Treatment Plan (dated 12/10/10) no staff names were assigned to the intervention modalities.

C. Interview

In an interview on 12/13/10 at 3:00PM with the Director of Nursing (DON) and the Staff Development Coordinator, treatment plans were discussed in reference to the lack of identifying responsible staff for each modality within the plan. Both the DON and the Staff Development Coordinator acknowledged that the responsible discipline was listed on the MTPs rather than specific staff names. During the interview, the Director of Nursing also acknowledged that the Staff Development Coordinator is responsible for assigning staff on the treatment plans, and that the Staff Development Coordinator reports directly to the DON.