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Based on record review and staff interview, the facility failed to document neurological examinations in such a way as to verify that all areas of a screening neurological were performed for 11 of 12 active sample patients (A1, A14, A33, B4, B14, B22, C11, D8, D10, E7 and E16). In 10 of the records, sections related to reflex exam, coordination and sensation were left blank. In one record (patient C11) the entire form on which the exam was to be recorded was left blank. This failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions.

Findings are:

I. Record Review

1. Patient A1 - medical evaluation dated 10/23/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.

2. Patient A14 - medical evaluation dated 10/17/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.

3. Patient A33 - medical evaluation dated 10/27/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.

4. Patient B4 - medical evaluation dated 9/8/10, the physical examination was comprised of a check box form with the motor reflexes left blank.

5. Patient B14 - medical evaluation dated 10/23/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination left blank.

6. Patient B22 - medical evaluation dated 10/28/10, the physical examination was comprised of a check box form with the motor reflexes section left blank.

7. Patient C11 - medical evaluation dated 10/28/10, the physical examination was comprised of a check box form which was left entirely blank.

8. Patient D8 - medical evaluation dated 10/25/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.

9. Patient D10 - medical evaluation dated 10/28/10, the physical examination was comprised of a check box form with the motor reflexes section left blank.

10. Patient E7 - medical evaluation dated 10/3/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.

11. Patient E16 - medical evaluation dated 10/10/10, the physical examination was comprised of a check box form with the motor reflexes, sensation and coordination sections left blank.


II. Staff Interview

In an interview on 11/2/10 at 1:40p.m., the medical director confirmed the findings.

Based on medical record reviews, policy review, and staff interviews, the facility failed to document specific psychiatric treatment interventions provided by the Licensed Independent Practitioner (LIP), who was the clinical person responsible for the patients' care, for 10 of 12 sampled patients (A1, A14, A33, B4, C2, C11, D8, D10, E7, and E16). This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A1 - Master treatment plan dated 10/25/10 identified no psychiatric treatment interventions for the LIP.

2. Patient A14 - Master treatment plan dated 10/18/10 identified no psychiatric treatment interventions for the LIP.

3. Patient A33 - Master treatment plan dated 10/29/10 identified no psychiatric treatment interventions for the LIP.

4. Patient B4 - Master treatment plan dated 9/9/10 identified no psychiatric treatment interventions for the LIP.

5. Patient C2 - Master treatment plan dated 10/18/10 identified no psychiatric treatment interventions for the LIP.

6. Patient C11- Master treatment plan dated 10/29/10 identified no psychiatric treatment interventions for the LIP.

7. Patient D8- Master treatment plan dated 10/26/10 identified no psychiatric treatment interventions for the LIP.

8. Patient D10- Master treatment plan dated 10/29/10 identified no psychiatric treatment interventions for the LIP.

9. Patient E7- Master treatment plan dated 10/4/10 identified no psychiatric treatment interventions for the LIP.

10. Patient E16- Master treatment plan dated 10/12/10 identified no psychiatric treatment interventions for the LIP.

B. Policy Review

1. Policy titled, "Treatment Planning," revised 10/09, states "The responsible discipline and the frequency of the treatment approach should be noted for each 'staff intervention.' Medication approaches should state "see LIP order sheet to elaborate type, dosage, and frequency."

2. Policy titled, "Medical Staff Documentation," revised 2/10. Under the treatment plan section it states, "the LIP will complete the following: an objective of care, time frame, intervention and frequency of visits for each major problem identified."

C. Staff Interviews

1. In an interview on 11/2/10 at 12:55p.m., RN1 stated, "The doctors [including LIPs] are supposed to write their interventions on the chart just like everyone else."
2. In an interview on 11/2/10 at 1:30p.m., RN2 stated, "The process is the doctors [including the LIPs] initiate the treatment plan by completing the diagnoses. The doctors [including the LIPs] are supposed to put in their interventions."

Based on record reviews and staff interviews, the facility failed to ensure that the name and discipline of all staff persons responsible for specific aspects of care were listed on the master treatment plans for 10 of 12 sample patients (A1, A14, A33, B4, C2, C11, D8, D10, E7, and E16). Specifically, these treatment plans did not identify the LIP as a staff person providing care to the patient. This practice resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Patient A1 - Master treatment plan dated 10/25/10 identified no psychiatric treatment interventions for the LIP.

2. Patient A14 - Master treatment plan dated 10/18/10 identified no psychiatric treatment interventions for the LIP.

3. Patient B4 - Master treatment plan dated 9/9/10 identified no psychiatric treatment interventions for the LIP.

4. Patient A33 - Master treatment plan dated 10/29/10 indentified no psychiatric treatment interventions for the LIP.

5. Patient C2 - Master treatment plan dated 10/18/10 identified no psychiatric treatment interventions for the LIP.

6. Patient C11- Master treatment plan dated 10/29/10 identified no psychiatric treatment interventions for the LIP.

7. Patient D8- Master treatment plan dated 10/26/10 identified no psychiatric treatment interventions for the LIP.

8. Patient D10- Master treatment plan dated 10/29/10 identified no psychiatric treatment interventions for the LIP.

9. Patient E7- Master treatment plan dated 10/4/10 identified no psychiatric treatment interventions for the LIP.

10. Patient E16- Master treatment plan dated 10/12/10 identified no psychiatric treatment interventions for the LIP.

B. Staff Interviews

In an interview on 11/2/10 at 12:55p.m., RN1 stated, "The doctors [including the LIPs] are supposed to write their interventions on the chart just like everyone else."

Based on record reviews, policy review and staff interviews, the facility failed to ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge in 3 of 5 discharge records reviewed (F2, F3, and F5). This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers.

Findings include:

A. Record Review

1. Record F2 (discharge date 10/1/10) had no discharge summary on 11/1/10.

2. Record F3 (discharge date 10/1/10) had no discharge summary on 11/1/10.

3. Record F5 (discharge date 10/1/10) had no discharge summary on 11/1/10.

B. Staff Interviews

1. In an interview on 11/1/10 at 10:00a.m., the medical director stated, "Our hospital policy requires that discharge summaries be completed within 30 days after discharge."

2. In an interview on 11/1/10 at 2:00p.m., the director of medical records confirmed the findings.

C. Policy Review

Policy titled "Medical Staff Documentation", revised 2/10 states "in order to meet State and TJC Standards for timely completion, all medical records' documents shall be completed by thirty (30) days after discharge."

Based on record reviews and staff interviews, the facility failed to ensure that the discharge summaries for 3 of 5 discharged patients (F2, F3, and F5) contained a summary of the patient's condition on discharge. This results in the subsequent provider lacking valuable information that could facilitate interventions, in a timely manner, to prevent relapse.

Findings include:

A. Record Review

1. Record F2 (discharge date 10/1/10) had no discharge summary on 11/1/10.
2. Record F3 (discharge date 10/1/10) had no discharge summary on 11/1/10.
3. Record F5 (discharge date 10/1/10) had no discharge summary on 11/1/10.

B. Staff Interview

1. In an interview on 11/1/10 at 10:00a.m., the medical director stated, "Our hospital policy requires that discharge summaries be completed within 30 days after discharge."

2. In an interview on 11/1/10 at 2:00p. m., the director of medical records confirmed the findings.

Based on record review and interview, it was determined that the Medical Director failed to monitor and ensure that medical evaluations were comprehensive; that treatment plans contained physician/physician extender interventions and identified the responsible staff member for assigned modalities; and that discharge summaries were completed.

Specifically, the Medical Director failed to:

I. Ensure medical staff completed comprehensive medical evaluations which included a screening neurological assessment covering all areas of the exam for 11 of 12 active sample patients (A1, A14, A33, B4, B14, B22, C11, D8, D10, E7 and E16). This deficient practice could lead to failure to identify conditions that impact treatment. Refer to B109.

II. Ensure that treatment plans included specific physician interventions (refer to B122) and the responsible LIP named (refer to B123) for 10 of 12 active sample patients (A1, A14, A33, B4, C2, C11, D8, D10, E7, and E16). This deficient practice could result in ineffective treatment and prolonged hospitalization.

III. Ensure that each discharged patient had a discharge summary completed, and a description of their condition on discharge for 3 of 5 sample discharge records reviewed (F2, F3, and F5). By failing to make hospital information available to the entity responsible for treatment after discharge, this deficient practice could hinder effective outpatient treatment. Refer to B133 and 135.