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Based on document review and interview, the facility failed to ensure staff followed their policies/procedures for patient treatment planning in 5 (patient 1, 2, 3, 4 and 9) of 10 MR's reviewed:

Findings:

1. Policy/procedure, policy no: 704.02, Patient Rights to Care and Treatment, reviewed 1/20, indicated: "5. a) Multidisciplinary team members complete respective assessment for each patient within the designated timeframe after admission".

2. Policy/procedure, policy no: 702.58, Treatment Planning, reviewed 1/20, indicated:
a. page 1: "Members of the treatment team will convene within seventy two (72) hours of patient's admission to discuss, further develop and implement the Master Treatment Plan...".
b. page 2: "D. The patient and/or the family and other caregivers participate in the development of the Master Treatment Plan. This involvement in the treatment planning process will be documented on the Master Treatment Plan".

3. Patient 1's MR: Review of Interdisciplinary Master Treatment Plan dated 8/13/21 lacked documentation of patient and/or parent/guardian signature acknowledging that the treatment plan had been presented and reviewed with the patient and/or parent/guardian and lacked documentation that the treatment team convened within 72 hours of the patient's admission to discuss, develop and implement the Master Treatment Plan.

4. Review of patients' 2 (admitted 8/8/21), 3 (admitted 8/11/21), 4 (admitted 8/9/21) and 9's (admitted 8/10/21) MR indicated each lacked documentation of a completed Interdisciplinary Master Treatment Plan.

5. On 9/9/21 at approximately 1330 hours, staff N1 (Director of Clinical Services) was interviewed and confirmed
patient 1, 2, 3, 4 and 9's MR each lacked documentation of a completed Interdisciplinary Master Treatment Plan. Staff N1 confirmed patient 1's Interdisciplinary Master Treatment Plan lacked documentation of acknowledgement that the patient and/or parent/guardian had been included in the development and on-going progress of the treatment plan.

Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for documentation in a medical record (MR) related to assessment and treatment of wounds for 1 (patient 1) of 10 MR's reviewed:

Findings:

1. Policy/procedure, Policy No: 1000.06, Medical Records Documentation Requirements, reviewed/revised 3/17, indicated on page 1: "Bloomington Meadows Hospital requires all individuals who have access to and responsibility for documentation in the Medical Record to know, understand and abide by the documentation requirements for his/her discipline".

2. Patient 1's MR: Review of Nursing Admission History Note dated 8/13/21 and Nursing Progress Notes dated 8/14/21, 8/15/21, 8/16/21 and 8/17/21 lacked documentation related to the assessment and treatment of patient 1's bilateral forearm laceration wounds.

3. On 9/9/21 at approximately 1330 hours, staff N1 (Director of Clinical Services) was interviewed and confirmed nursing staff failed to document patient 1's daily wound assessments.