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Based on policy review, record review and interview, it was determined that for 1 of 1 active non-sample patient (B4) under the care of a non-psychiatrist physician, the facility failed to document a psychiatric evaluation. The absence of this patient information hinders the treatment team's ability to formulate an appropriate problem list, and plan for appropriate treatment.

Findings are:

A. Policy review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, in Section 4.0, "History and Physical" states the following: "For patients on the Chemical Dependency Unit, a psychiatric evaluation will be ordered upon admission as a consult if the patient's admitting physician is not a psychiatrist." (Bolding was not added, typed as written in policy). Section 5.0, "Initial Psychiatric Evaluation," states: "Within 24 hours of admission to the inpatient [sic], the attending physician of [sic] designee will complete Initial Psychiatric Evaluation (IPE)."

B. Record Review

Patient B4, admitted to the chemical dependency program 04/29/10 for detoxification and assigned to a non-psychiatric attending physician per the daily census dated 05/03/10, did not have an IPE [Initial Psychiatric Evaluation] in the record as of the date of the survey 05/03/10 at 10:00 a.m. A handwritten psychiatric physician progress note dated 05/03/10 at 11:00 a.m. noted "Psych eval/consult. #608004." There was no other medical or psychiatric information noted by the psychiatrist in the patient's record. Physician's signature was authenticated by MD2 on 05/05/10 at 10:45 a.m. There was no dictated psychiatric evaluation in the medical record as of 05/04/10 at 4:30 p.m. Admitting orders dated 04/29/10 did contain an order for a psychiatric consultation.

C. Interview

In an interview on 05/04/10 at 10:40 a.m., the Medical Director acknowledged the findings noted above and stated "the nurses didn't follow through with calling the psychiatrist on Friday (April 30, 2010) and the psych eval wasn't done until Monday (May 3, 2010)."




28205

Based on policy review, record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 6 of 6 active sample patients (A3, A4, A7, B1, B2 and B5). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Policy Review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, under Section 5.0 "Initial Psychiatric Evaluation" states: "The IPE (Initial Psychiatric Evaluation) must include, but it not limited to: ...H. Mental Status Exam. 1. Test memory- list patient's response. 2. Test orientation- list patient's response. 3. Test cognitive function- list patient's response. 4. Test intellectual function- list patient's response."

B. Record Review

1. Patient A3: In an IPE dated 04/17/10, there was no estimation of intellectual function noted.

2. Patient A4: In an IPE dated 04/24/10, there was no estimation of intellectual function noted.

3. Patient A7: In an IPE dated 04/26/10, there was no estimation of intellectual function and no memory testing noted.

4. Patient B1: In an IPE dated 04/28/10, there was no estimation of intellectual function and no memory testing noted. There was a notation stating "Cognitive functions, the patient unable to focus."

5. Patient B2: In an IPE dated 04/29/10, there was no estimation of intellectual function and memory testing was described in a nonspecific and non-reproducible manner: "(B2) cognition is impaired. Memory tensing (sic) is intact for remote recall."

6. Patient B5: In an IPE dated 04/29/10, there was no estimation of intellectual function and memory testing was described in a nonspecific and non-reproducible manner: "Memory testing is intact for immediate, recent and remote recall, although the last couple of days are 'a little fuzzy'."

C. Interview

In an interview with both surveyors on 05/04/10 at 10:45 a.m., The Medical Director agreed with the findings noted above.



28205

Based on policy review, record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets that could be used in designing treatment for 6 of 6 active sample patients (A3, A4, A7, B1, B2 and B5). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings are:

A. Policy Review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, under Section 5.0 "Initial Psychiatric Evaluation," states: "The IPE (Initial Psychiatric Evaluation) must include, but it not limited to: ...I. A description of assets and liabilities. 1. Personal Strengths 2. Personal attributes."

B. Record Review

1. Patient A3: In an IPE dated 04/17/10, assets were described as "Primary asset is that the patient has some insight into her problem with the chemical dependency."

2. Patient A4: In an IPE dated 04/24/10, assets were described as "Family support."

3. Patient A7: In an IPE dated 04/26/10, assets were described as "The patient appears to be motivated for her treatment."

4. Patient B1: In an IPE dated 04/28/10, assets were described as "The patient appears to be fairly motivated for treatment."

5. Patient B2: In an IPE dated 04/29/10, assets were described as "Supportive parent and friends who brought her to the hospital on the patient's desire to detox from opiates."

6. Patient B5: In an IPE dated 04/29/10, assets were described as "The patient has a supportive family and spouse and she is motivated to detox."

C. Interview

In an interview with both surveyors on 05/04/10 at 10:45 a.m., The Medical Director agreed with the findings noted above.



28205

Based on record review, observation and interview, the facility failed to document individualized, behavioral short term goals to be addressed by medical and nursing interventions in the treatment plans of 5 of 6 active sample patients (A3, A4, A7, B1 and B5). Goals were preprinted and were the same for 2 of the 3 psych (psychiatric) patients (A4, A7). Another set were the same for the other psych patient (A3) (also admitted for detoxification) and the 2 detox (detoxification) patients B1 and B5. The preprinted short term goals were not individualized for each patient's problems and were often not behavioral, measurable goals for the patient but rather staff interventions. This failure hinders the ability of the treatment team to measure change in the patient as a result of medical and nursing treatment interventions and may prolong hospital stay.

Findings are:

A. Record Review

1. The treatment plan short term goals for patient A3, admitted 04/16/10, were as follows for medical doctor interventions:

"Pt. [patient] will meet with attending MD daily during entire stay."
"Pt. will work with physician to find proper medications to address [blank not filled in] issues."
"Pt. will report side effects of medication."

Short term goals for nursing staff interventions were:

"Pt. will report a decrease in physical symptoms experienced the day before."
"Pt. will verbalize [blank not filled in] positive way(s) to deal with [blank not filled in]."
"Pt. will verbalize reduction of detox [detoxification] symptoms using daily assessment."
"Pt. will report improved appetite on daily assessment."
"Pt. will report improved energy level on daily assessment."
"Pt. will report improved ability to concentrate on daily assessment."

The initial "identified problems" list included "fall risk" and "potential for harm-self;" there were no short term goals listed for these problems on the initial plan.

2. The treatment plan short term goals for patient A4, admitted 04/23/10, were as follows for medical doctor interventions:

"Pt. will meet with attending MD daily during entire stay."
"Pt. will work with physician to find proper medications to address [blank not filled in] issues."
"Pt. will report side effects of medication."

Short term goals for nursing staff interventions were:

"Pt. will report improved # of hr. [number of hours] of sleep on daily assessment."
"Pt. will report improved appetite on daily assessment."
"Pt. will report improved energy level on daily assessment."
"Pt. will report improved ability to concentrate on daily assessment."
"Pt. will report a decrease in physical symptoms experienced the day before."

The initial "identified problems" list included "fall risk;" there was no short term goal listed for this problem on the initial plan.

3. The treatment plan short term goals for patient A7, admitted 04/26/10, were as follows for medical interventions:

"Pt. will meet with attending MD daily during entire stay."
"Pt. will work with physician to find proper medications to address ["depression" written in] issues."
"Pt. will report side effects of medication."

Short term goals for nursing staff interventions were:

"Pt. will report improved # of hr. of sleep on daily assessment."
"Pt. will report improved appetite on daily assessment."
"Pt. will report improved energy level on daily assessment."
"Pt. will report improved ability to concentrate on daily assessment."
"Pt. will report a decrease in physical symptoms experienced the day before."

The initial "identified problems" list included "altered thoughts," and "potential abuse of sedatives;" there were no short term goals listed for these problems on the initial plan.

4. The treatment plan short term goals for patient B1, admitted 04/27/10, were as follows for medical doctor interventions:

"Pt. will meet with attending MD daily during entire stay."
"Pt. will work with physician to find proper medications to address [blank not filled in] issues."
"Pt. will report side effects of medication."

Short term goals for nursing staff interventions were:

"Pt. will report a decrease in physical symptoms experienced the day before."
"Pt. will verbalize [blank not filled in] positive way(s) to deal with [blank not filled in]."
"Pt. will verbalize reduction of detox symptoms using daily assessment."
"Pt. will report improved appetite on daily assessment."
"Pt. will report improved energy level on daily assessment."
"Pt. will report improved ability to concentrate on daily assessment."

5. The treatment plan short term goals for patient B5, admitted 04/28/10, read as follows for medical doctor interventions:

"Pt. will meet with attending MD daily during entire stay."
"Pt. will work with physician to find proper medications to address [blank not filled in] issues."
"Pt. will report side effects of medication."

Short term goals for nursing staff interventions were:

"Pt. will report a decrease in physical symptoms experienced the day before."
"Pt. will verbalize [blank not filled in] positive way(s) to deal with [blank not filled in]."
"Pt. will verbalize reduction of detox symptoms using daily assessment."
"Pt. will report improved appetite on daily assessment."
"Pt. will report improved energy level on daily assessment."
"Pt. will report improved ability to concentrate on daily assessment."

The initial "identified problems" list included "fall risk;" there was no short term goal listed for this problem on the initial plan.

B. Observation

1. During a treatment planning meeting on the combined Psych/Detox unit on 05/04/10 at 9:00 a.m., the staff did not address the stated short term goals in the treatment plan for each patient.

2. In an interview at 3:15 p.m. on 05/04/10, the Director of Activity Therapy, who has the assigned task of monitoring treatment plan documentation, stated that she agreed with the findings.

Based on record review and interview, the facility failed to ensure that treatment plans clearly stated the names of staff responsible for each treatment intervention in 6 of 6 active sample patient's records reviewed (A3, A4, A7, B1, B2 and B5). There were initials under the heading "staff sig. [signature]" after each intervention listed. It was not clear that the person writing the intervention was also the staff member responsible for providing the treatment. This practice can result in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings are:

A. Record Review

The treatment plan interventions for patients A3, A4, A7, B1, B2 and B5 were followed by initials under the heading "staff sig." The staff member responsible for the treatment intervention was not clearly identified.

B. Interview

In an interview at 3:15 p.m. on 05/04/10, the Director of Activity Therapy, who has the assigned task of monitoring treatment plan documentation, acknowledged that there were only initials which did not clearly indicate staff responsibility for each intervention on the treatment plan.

Based on record review, policy review and interview, the facility failed to provide a discharge summary that summarized the treatment received in the hospital and the patient's response to treatment (other than medication administered) in 2 of 5 reviewed discharge summaries dictated after 03/15/10 (D4 and D7). This deficiency compromises the effective transfer of the patient's care to the next care provider by failing to provide information that identified either effective or ineffective treatment strategies for the individual patient.

Findings are:

A. Policy Review:

Riverside Center for Behavioral Health Medical Staff Rules and Regulations, issued 8/2002, under Section X. "Discharge Summaries" states: "B. Documentation to be Included...The discharge summary will contain a statement on the outcome of hospitalization and disposition of the case to include: 1. The patient and family's achievement of treatment goals...4. Documentation of treatment."

B. Record Review

1. Patient D4 (discharge summary dated 03/17/10).

Documentation of the hospital course noted: "The patient was treated with an attitude of active friendliness. Medications were adjusted throughout hospitalization per study protocols for improvement of mood disorder. He complained of eczema, which was promptly treated with topical treatments."

2. Patient D7 (discharge summary dated 3/22/10).

Documentation of the hospital course noted: "The patient who was started on Trazadone and Neurontin on admission, had the trazadone discontinued secondary to the patient's report of visual hallucinations on trazadone. The patient refused to use Neurontin the second day forward and remained without taking any psychiatric medications. The patient stated the only reason he came to the hospital is to regularize his insomnia, and without using trazadone or gabapentin [Neurontin], he is able to sleep better."

C. Interview

The surveyors showed the Medical Director and the Assistant Medical Director the discharge summaries during the exit conference on 05/05/10 at 11:00 a.m. Both physicians agreed with the findings.



28205

Based on Record review and interviews, the Medical Director failed to properly monitor the care provided at the facility. Specifically, the Medical Director failed to assure that:

I. There was a psychiatric evaluation for 1 of 1 active non-sample patient (B4) under the care of a non-psychiatric physician. The absence of this patient information hinders the treatment team's ability to formulate an appropriate problem list, and plan for appropriate treatment. [Refer to B110]

II. Psychiatric evaluations reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 6 of 6 active sample patients (A3, A4, A7, B1, B2 and B5). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. [Refer to B116]

III. Psychiatric evaluations included an assessment of patient assets that could be used in designing treatment for 6 of 6 active sample patients (A3, A4, A7, B1, B2, and B5). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. [Refer to B117]

IV. Treatment Plans documented individualized, behavioral short term goals to be addressed by medical and nursing interventions for 5 of 6 active sample patients (A3, A4, A7, B1 and B5). Goals were preprinted and were the same for 2 of the 3 psych (psychiatric) patients (A4, A7). Another set were the same for the other psych patient (A3) (also admitted for detoxification) and the 2 detox (detoxification) patients B1, B5. The preprinted short term goals were not further individualized for each patient's problems and were often not behavioral, measurable goals for the patient but rather staff interventions. This failure hinders the ability of the treatment team to measure change in the patient as a result of medical and nursing treatment interventions and may prolong hospital stay. [Refer to B121]

V. Treatment plans clearly stated the names of staff responsible for each treatment intervention in 6 of 6 active records reviewed (A3, A4, A7, B1, B2 and B5). There were initials under the heading "staff sig. [signature]" after each intervention listed. It was not clear that the person writing the intervention was also the staff member responsible for providing the treatment. This practice may result in the facility's inability to monitor staff accountability for specific treatment modalities. [Refer to B123]

VI. Discharge summaries summarized all the treatment received in the hospital and the patient's response to treatment, other than medication administered in 2 of 5 reviewed discharge summaries dictated after 03/15/10 (D4 and D7). This deficiency compromised the effective transfer of the patient's care to the next care provider by failing to provide information that identified either effective or ineffective treatment strategies for the individual patient. [Refer to B133]

In an interview with the Medical Director on 05/04/10 at 11:00 a.m., he acknowledged that the deficiencies noted above were accurate, stating "It's hard to get doctors who are older in practice to change their ways."




28205

Based on record review and interview, the facility failed to have a Director of Nursing (DON) with a master's degree in psychiatric or mental health nursing or to provide documentation that the DON was sufficiently qualified by education in the nursing care of the mentally ill. In lieu of clinical psychiatric nursing education, there was no documented evidence of pertinent continuing education or ongoing consultation from a nurse with a master's degree in psychiatric/mental health nursing.

Findings are:

A. Record Review

1. Review of a 2-page resume provided by the DON revealed that she has an associate degree in nursing, a BS (baccalaureate) degree in health administration, and an MBA (master of business administration) degree with a concentration in health administration and marketing (dates unspecified).

2. An e-mail obtained by the hospital on February 02, 2010, titled "Degree Verify...: Verification Confirmed" from [name deleted] Junior College, listed an "Associate of Arts" degree with the "Major Course(s) of Study: General Studies" which was completed by the DON on 06/15/1977. Further comment provided by the institution was: "Student completed nursing requirements. Did not offer degrees until 1992 when approved by the state." There was no documentation of an associate degree in nursing.

3. On May 5, 2010, just prior to the survey exit report, the surveyor was given a letter from the hospital administrator dated May 5, 2010, stating that the hospital has recruited a current part time nurse employee "to be the preceptor for [the DON]". A document from the [name deleted] University states that this part time nurse has "met all the requirements for a Master of Science in Nursing: Family Mental Health-Psychiatric Nursing Specialty." There was no documentation that any consultation has taken place.

B. Interview

In an interview at approximately 1:00 p.m. on 05/04/10, the Director of Nursing acknowledged that she had no documentation of continuing education in clinical aspects of psychiatric nursing, nor did she have any documentation of consultation from a masters prepared psychiatric/mental health nurse. The surveyors asked the DON to produce any proof of completing a nursing program, preferably a diploma, on 05/04/10 at 1:00 p.m. As of the exit conference on 05/05/10 at 11:00 a.m., the DON failed to produce any documentation for completion of a nursing program.