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Based on interview and record review, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-related short-termed goals stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This failure hinders the treatment team's ability to measure behavioral change in the patient and may contribute to failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review: (Master Treatment Plan dates in parentheses)

1. Patient # 1 in Master Treatment Plan (9/5/13), for problem "Physical aggression towards others," the short term goal was stated as "(patient's name) will learn to handle not getting his way and hearing 'no' in a positive manner." This goal was not measurable and did not address identified behavior.

2. Patient # 2 in Master Treatment Plan (9/5/13), for problem, "Reduce impulsive, dangerous behavior by elevating mood and resolving grief/loss and sexual abuse issues,"
the short term goals were stated as "(patient's name) will not have suicidal thoughts for 7-10 days prior to discharge." "(Patient's name) will learn new ways to overcome depression through use of positive coping skills." Goals were not measurable and did not address identified behavior.

3. Patient # 3 in Master Treatment Plan (10/15/13), for problem "Suicidal thoughts, inability to contract for safety, psychosis AEB hearing voices when depressed or angry." The short term goals were stated as "(patient's name) will discuss past abuse and effect on current functioning." "(Patient's name) will learn new ways to overcome depression through activity." Goals were not measurable and did not address identified behavior.

4. Patient # 4 in Master Treatment Plan (10/15/13), for problem "Increased threats to kill self (by hanging self in closet) triggered by bullying at school." The short term goals were stated as "(patient's name) will create safety plan." "(Patient's name) will learn and implement at least 2 new calming skills." "(Patient's name) will increase communication of thoughts and feelings." Goals were not measurable and did not address identified behavior.

5. Patient # 5 in Master Treatment Plan (10/15/13), for problem "(patient's name) will terminate threats and acts of violence toward self, others and animals." The short term goals were stated as "(patient's name) will learn alternative ways to think about and manage frustration and anger." "(Patient's name) will implement problem solving and conflict resolution skills." Goals were not measurable and did not address identified behavior.

6. Patient # 6 in Master Treatment Plan (10/15/13), for problem "Reduce psychotic symptoms that lead to feelings to kill self and hurt others." The short term goals were stated as "(patient's name) will verbalize no thoughts to harm self or others with absence of psychosis." "(Patient's name) will express instances of psychosis to staff or therapist when they occur." "(Patient's name) will differentiate between psychosis and reality based thoughts/situations." Goals were not measurable and did not address identified behavior.

7. Patient # 7 in Master Treatment Plan (10/3/13), for problem "Increased physical aggression towards other (biting, kicking, hitting, head butting), property destruction (windows, television, furniture) and verbal threats to cause harm to others." The short term goals were stated as "(patient's name) will increase the number of statements that reflect the acceptance of responsibility for misbehavior and aggressive actions." "(Patient's name) will explore and learn alternative ways to think about and manage anger." "(Patient's name) will utilize behavior modification to decrease targeted behaviors through use of positive replacement behaviors." "(Patient's name) will increase positive statements about accomplishments and experience at school." Goals were not measurable and did not address identified behavior.

8. Patient # 8 in Master Treatment Plan (10/16/13), for problem "Increases suicidal ideation with overdose attempt by taking OTC sinus pills." The short term goals were stated as "(patient's name) will learn and implement problem solving to resolve interpersonal problems." "(Patient's name) will learn and implement relapse prevention skills." "(Patient's name) will learn new ways to overcome depression through activity."
Goals were not measurable and did not address identified behavior.

B. Interview

On 10/18/13 at 2:15 PM, during an interview with the Director of Nursing, when shown the treatment plans and goals, she verified that the short term goals as written were not specific to patient expected behaviors and were not measurable and that the MTPs needed to include the names of staff responsible for the treatment interventions.

Based on interview and record review the facility failed to identify in the Master Treatment Plans the specific team members by their full name that would each be held responsible for seeing that each intervention was carried out. The Master Treatment Plans reflected only the discipline names of 7 of 8 active sample patients (1, 2, 3, 4, 5, 6 and 8.) This failure of not properly identifying the staff can result in confusion in deciphering who is primarily responsible for ensuring compliance with particular aspects of the patient's individualized treatment program.

Findings include:

A. Record Review

1. The Facility's Policy and Procedure titled "Treatment Plans, Policy NO. TS-034" revised on 10/06/13, noted the following on page 1 under the section Procedure 3c "The treatment plan describes the services, activities, and programs to be provided to the individual, and specifies staff members assigned to work with the individual and also the time/frequency for each treatment procedure."

2. Review of Master Treatment Plans (MTPs) of 7 of 8 active sample patients (MTP dates in parentheses); # 1 (9/5/13), # 2 (9/5/13), # 3 (10/15/13), # 4 (10/15/13), # 5 (10/15/13), # 6 (10/15/13) and # 8 (10/16/13), reflected only discipline names documented on the Master Treatment Plans as responsible. Examples are as follows: Nursing, Psychiatrist, Recreation Therapist, Classroom Teacher.


B. Interview

1. On 10/18/13 at 2:15 PM, during an interview with the Director of Nursing when shown the treatment plans and goals, she verified that the short term goals as written were not specific to patient expected behaviors and were not measurable and that the MTPs needed to include the names for staff responsible for the treatment interventions.

2. On 10/16/13 at 10:25 AM, during an interview with the Medical Director, he was asked about the treatment plans and he stated, "I need to have my name on the treatment plans."

3. On 10/16/13 at 10:25 AM, during an interview with the Hospital Administrator/Social Work Director, when asked about the APN as identified on the treatment plans, she stated, "The APRN is no longer with us."