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Based on record review and staff interview, the
facility failed to provide a psychiatric evaluation
that contained a sufficiently complete record of
mental status for 3 of 8 active sample patients
(A1, A2 and B2). Mental status examination
findings were not descriptive and did not contain
any supportive information related to the
assessment of insight and judgment. This
deficiency jeopardizes treatment by making it
impossible to track serial changes in the mental
status examination while the patient is in
treatment.

Findings include:

A. Record Review

1. The Psychiatric Admission Note (PAN) for
patient A1 (dated 11/11/10) stated, "Judgment
and insight are quite low."

2. The PAN for patient A2 (dated 11/06/10)
stated, "Insight and judgment are poor."

3. The PAN for patient B2 (dated 09/22/10)
stated, "Judgment and insight: very poor."

B. Interviews

1. In an interview on 11/30/10 at 11:00a.m., the
Medical Director agreed with the findings.

Based on record review and staff interview, the
facility failed to assess patient intellectual
functioning and memory testing in a measureable
and descriptive manner for 5 of 8 active sample
patients (A1, A2, A3 A4 and B2). This deficiency
makes it impossible to follow the changes of
these parameters and adjust treatment
accordingly. Furthermore, the lack of description
makes it impossible to duplicate the evaluation
since the methods used to test intellectual
function and memory were not documented.

Findings include:

A. Record Review

1. The Psychiatric Admission Note (PAN) for
patient A1 (dated 11/11/10) had no intellectual
functioning or memory described. It stated,
"Cognitive assessment, she knew the month and
year, but not the date."

2. The PAN for patient A2 (dated 11/06/10) had
no intellectual functioning or memory mentioned.

3. The PAN for patient A3 (dated 11/13/10) had
no intellectual functioning or memory mentioned.

4. The PAN for patient A4 (dated 11/10/10) had
no intellectual functioning or memory mentioned.

5. The PAN for patient B2 (dated 09/22/10) had
no intellectual functioning or memory described. It
stated, "Cognitive assessment: Limited."

B. Interviews

1. In an interview on 11/30/10 at 11:00a.m. the
Medical Director acknowledged the findings.

Based on record review and interview, the
Medical Director failed to adequately ensure the
quality and appropriateness of services provided
by the medical staff. Specifically, the Medical
Director failed to:

I. Ensure that physicians provide psychiatric
evaluations containing a complete record of
mental status related to the description of insight
and judgment for 3 of 8 active sample patients
(A1, A2 and B2). These deficiencies jeopardize
treatment by making it impossible to track serial
improvements in the mental status examination
as the patient progresses throughout inpatient
treatment. (Refer to B113)

II. Ensure that physicians complete mental status
examinations by providing testing for intellectual
functioning and memory in a descriptive and
measureable manner for 5 of 8 active sample
patients (A1, A2, A3, A4 and B2). This deficiency
makes it impossible to follow any changes in
these parameters and adjust inpatient treatment
accordingly. Furthermore, the lack of description
makes it impossible to duplicate the evaluation
since the mechanisms used to test intellectual
functioning and memory were not documented.
(Refer to B116)