HospitalInspections.org

Based on record review and interview, the facility, which primarily provided services to an elderly population, failed to assess and estimate memory functioning in a sufficiently descriptive manner to establish baseline parameters for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate.

Findings include:

A. Record Review

Psychiatric evaluations (dates in parenthesis) of patients A1 (1/8/20), A2 (2/1/20), A3 (2/8/20), A4 (2/5/20), A5 (1/3/20), and A8 (2/4/20), all with a diagnosis of Dementia, contained pre-printed Mental Status Evaluation forms with checkboxes, and the same parameters were checked off for all six patients - "Memory-Remote- relating accurate past personal hx [history], past historical events, Recall 2/3." The intelligence evaluation for Patients A1, A2, A4, A5, and A8, was also similar checkoffs "Average- interaction with patient, past hx." Yet for all five (5) patients (A1, A2, A3, A4, and A5), the Insight was stated as "No, awareness of their mental illness and reasons for admission." Patient A6 (2/6/20) had a Diagnosis of "Schizoaffective disorder," and Patient A7 (2/6/20) had a Diagnosis of "Dementia with behavioral disturbance)" These patients had a documented narrative of the mental status evaluation. Still, the narrative did not have an evaluation of memory or intellectual functioning included.

B. Interview

In a meeting on 2/12/20 at 10:00 a.m., the medical director concurred with the above deficiencies and stated, "I fully agree."

Based on document review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets or personal attributes stated in a descriptive fashion for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.

Findings include:

A. Record Review

1. Psychiatric evaluations (dates in parenthesis) of patients A1(1/8/20), A2 (2/1/20), A4 (2/5/20), A5 (1/30/20), and A8 (2/4/20) had "Inpatient psychiatric admission" as the patients' strength.

2. Psychiatric evaluation of patient A3 (2/8/20) had "Fair physical health, Family appears supportive, Appropriate placement" as the patient's strengths.

3. Psychiatric evaluations of patients A6 (2/6/20) and A7 (2/6/20) had no assessment and documentation of these patients' Assets/Strengths.

B. Interview

In a meeting and review of the above deficiencies on 2/12/20 at 10:00 a.m., the medical director concurred with the above deficiencies.