HospitalInspections.org

Based on medical record and policy reviews and interviews with staff, it was determined:

1. Daily activity participation records for patients were not always completed for 5 of 5 active records. Medical Records (MR) #'s 2, 3, 4, 6 and 7.

2. The specific type of activity conducted was not included on the daily participation notes for 5 of 5 active records. MR #'s 2, 3, 4, 6 and 7.

3. Activities Therapy initial admission assessments were not available for review for 4 of 5 active records. MR #'s 3, 4, 6 and 7.

Findings include:

Policy: Plan for the Provision of Therapeutic Activities

Purpose: Therapeutic Activities are a part of the patient's treatment as an action oriented process geared towards a positive change. Therapeutic Activities provides the opportunity for the patient to become aware of ways to use his leisure time more effectively, develop interests and express him/herself in a pleasurable way.

Policy: Therapeutic Activities are performed in a specific fashion to have a therapeutic purpose and are not done for solely recreational or diversional reasons. The Activity assessment guides the program plan for each patient and information obtained from both the assessment and interaction with the patient in activities is used as part of the Multidisciplinary Treatment Plan.

Procedure: 1.1 Therapeutic Activities are designed to meet the needs of patients and be directed to restoring and maintaining optimal levels of physical and psychosocial functioning. The individualized activity plan for the patient cannot be only divisional in nature. The activities may be directed toward the following:

1.2 Help to orient patients in all spheres and increase awareness and understanding to their current situation.

1.3 Help patients to maintain effective socialization skills and group cooperation to bring about friendly and appropriate attitudes and behavior.

1.4 Encourage positive group dynamics to decrease anxiety within a group setting.

1.5 Help patients to increase or maintain self esteem to improve body image, coordination, emotional stability and appearance and prevents further mental or physical deterioration from inactivity.

1.6 Help patients to develop skills, physical sensory awareness/mental concrete thinking, decision making techniques and helps the patient develop tolerance and regain lost skills.

1.7 Increase patient motivation, concentration and attention span and problem-solving abilities.

1.8 Encourage creativity to apply acquired skills through recreational activities and provide a mechanism directing emotional conflicts through other channels.

1.9 Presents to the patient acceptable reality situations.

2.0 Therapeutic Activities are provided to all patients unless otherwise ordered by the attending physician. Therapeutic Activities groups are an integral part of the patients schedule seven days of the week.

3.0 If the patient is unable to attend a group activity the therapist may do individual and/or in-room therapy.

5.0 The Therapeutic Activities coordinator attends treatment team meeting on a regular basis and informs the treatment team of the patients progress and needs in this area.

Policy titled Multidisciplinary Treatment Planning included, "Purpose: To insure that each patient will have a multi-disciplinary treatment plan (MDTP) based on the assessments conducted by all disciplines and an inventory of the patient's strengths and disabilities.

Procedure: 4.0 Within 72 working hours of admission the Activities Therapy assessment will be complete."

1. MR # 4 was admitted on 7/23/10 with diagnoses including Psychosis and Schizophrenia.

A review of the medical record revealed no admission activity assessment to address the past interests or therapeutic individualized needs.

The daily activity participation notes reviewed from 7/23/10 to 9/14/10 had no documentation of the specific type of activity provided.

A review of the daily activity participation notes from 7/24/10 to 9/14/10 revealed seventeen of the fifty-three inpatient days had no documentation of activity participation.

2. MR # 2 was admitted on 8/09/10 with diagnosis of Dementia with behavioral disturbances and Psychosis.

A review of the daily activity participation notes from 8/10/10 to 9/14/10 revealed five of the seventeen inpatient days had no documentation of activity participation and no documentation of the type of activity provided.

3. MR # 3 was admitted on 9/3/10 with diagnosis of Dementia with behavioral disturbances.

A review of the medical record revealed no admission activity assessment to address the past interests or therapeutic individualized needs.

A review of the daily activity participation notes from 9/04/10 to 9/14/10 revealed five of the ten inpatient days had no documentation of activity participation and no documentation of the type of activity provided.

4. MR # 6 was admitted on 9/4/10 with diagnosis of Major Depression.

A review of the medical record revealed no admission activity assessment to address the past interests or therapeutic individualized needs.

A review of the daily activity participation notes from 9/05/10 to 9/14/10 revealed five of the nine inpatient days had no documentation of activity participation and no documentation of the type of activity provided.

5. MR # 7 was admitted on 8/29/10 with diagnosis of Chronic Disorganized Schizophrenia.

A review of the medical record revealed no admission activity assessment to address the past interests or therapeutic individualized needs.

A review of the daily activity participation notes from 8/30/10 to 9/14/10 revealed five of the sixteen inpatient days had no documentation of activity participation and no documentation of the type of activity provided.

An interview with EI # 1 (Regional Clinical Director) on 9/16/10 at 1:30 PM confirmed the activity assessments and participation records were not completed as stated in their policy.

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Based on record and policy review and interview, it was determined the facility staff failed to ensure treatment plan meetings were being conducted by all disciplines to address the needs of the patients. This had the potential to affect all patients served.
Findings include:

Policy titled Multidisciplinary Treatment Planning Meeting included, "Representatives from Nursing, Social Service (SS) and the Activity Therapist will be in attendance at all scheduled meetings.

The treatment plan meeting notes were requested on 9/16/10 at 10:40 AM from EI # 1 (Regional Clinical Director). Seven treatment meeting notes dated 9/02/10, 9/07/10 and 9/09/10 included signatures and updates by the physician, SS and registered nurse. There were no signatures of the Activity coordinator as required in their policy.

An interview with Employee Identifier # 5 (Activity Director) on 9/15/10 at 12:05 PM confirmed she does not regularly attend the treatment plan meetings.