HospitalInspections.org

Based on record review and interview, the facility failed to develop comprehensive treatment plans that identified patient-related short-term and long range goals stated in measurable terms for 2 of 8 active sample patients (A2 and A12), by leaving sections of the treatment plan blank. This failure hinders the treatment team's ability to provide direction and focus to the treatment team and compromises the team's ability to ensure consistency of approach.

Findings include:

A. Record Review

1. The treatment plan for patient A2 (admitted 01/20/11) identified Problem #1 as Disturbed Thought Processes with a listed goal that stated "patient will complete assigned goals in group to address disturbed thought process area: [blank] by learning/doing:[blank]." Neither blank was filled in.

2. The treatment plan for patient A12 (admitted 01/20/11)identified Problem #1 as Disturbed Thought Processes with a listed goal that stated "patient will complete assigned goals in group to address disturbed thought process area: [blank]by learning/doing: [blank]." Neither blank was filled in.

B. Staff Interviews

1. In an interview on 01/25/10 at 9:15a.m., the Medical Director confirmed that these sections on the treatment plan were left blank and should have been filled in.

2. In an interview on 01/25/10 at 11:30a.m., the Director of Social Services confirmed the omission of data stating, "It doesn't say anything. It needs to be filled in."

Based on policy review, record review, and staff interview, the facility failed to ensure that patient discharge summaries were completed in a timely fashion defined by hospital policy for 5 of 5 discharged patients (D1, D2, D3, D4, and D5). This compromises the effective transfer of the patient's care to the next care provider.

Findings include:

A. Policy Review

Delinquent Records Policy HIM 031 revised 11/04/10 requires dictation of a discharge summary and insertion of any reports "not longer than 30 days from discharge."

B. Record Review

1. Closed records of patients D1 (discharged 11/30/10), D3 (discharged 12/24/10), and D5 (discharged 12/17/10) did not contain dictated discharge summaries as of the date of the survey 01/24/11.

2. Closed record of patient D2 (discharged 12/11/10) contained a discharge summary dictated 01/18/11, more than 30 days after discharge, thereby making it delinquent by policy.

3. Closed record of patient D4 (discharged 12/11/10) contained a discharge summary dictated 01/18/11, more than 30 days after discharge thereby making it delinquent by policy.

C. Staff Interview

In an interview on 01/25/11 at 9:15a.m., the Medical Director confirmed that the discharge summaries were delinquent.