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Based on record review and interview, the facility failed to adequately assess the intellectual and memory functioning of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8), and to describe the testing methods used for the assessments. This deficiency compromises the database from which changes in patients' functioning can be measured throughout the course of treatment, and impedes the clinical team's ability to develop treatment goals and interventions that are appropriate for the patients' estimated cognitive functioning.

Findings include:

A. Record Review

1. Patient A1. A psychiatric evaluation, conducted on 3/8/11, included no estimate of memory functioning. Intellectual functioning was marked as "undetermined."

2. Patient A2. A psychiatric evaluation, conducted on 2/11/11, summarized the cognitive findings as, "Her immediate memory, recent and remote memory, and recall are normal for her age. Intellect is judged to be average."

3. Patient A3. A psychiatric evaluation, conducted on 2/7/11, included no estimate of memory functioning. Intellectual functioning was marked as "average."

4. Patient A4. A psychiatric evaluation, conducted on 3/3/11 indicated, under "Cognition/Memory" that the clinician was "unable to assess," with no indication in the subsequent record that a cognitive status was obtained. Intellectual functioning was marked as "undetermined."

5. Patient A5. A psychiatric evaluation, conducted on 3/9/11, summarized the cognitive findings as "recent memory poor, remote memory fair." There were no comments to explain how the estimate of memory functioning was determined, nor were the terms poor and fair quantified. An assessment of intellectual functioning was not included beyond a statement that it was "average."

6. Patient A6. A psychiatric evaluation, conducted on 1/22/11, summarized the cognitive findings as recent and remote memory showing "some impairment." There were no comments to explain how the estimate of memory functioning was determined, nor was the phrase "some impairment" quantified. An assessment of intellectual functioning was not included beyond a statement that it was "average."

7. Patient A7. A psychiatric evaluation, dated 3/3/11, summarized the cognitive findings as follows: "She has intact recent and remote memory and has intact immediate memory." There were no comments to explain how the estimate of memory functioning was determined. An assessment of intellectual functioning stated that "she has above average intelligence. General fund of information and academics are good."

8. Patient A8. A psychiatric evaluation, conducted on 3/8/11, included no estimate of memory functioning. Intellectual functioning was marked as "undetermined."

B. Staff Interview

In an interview on 3/15/11 at 2:30pm, the Medical Director acknowledged that cognitive assessments did not include methods of assessment of memory function or a data-based outline of intellectual function.

Based on record review and interview, it was determined that the facility failed to develop and document comprehensive master treatment plans based on the individual patient needs. Specifically, the facility failed to develop and document master treatment plans that:

1. Included patient goals/objectives based on the individual needs of 4 of 8 active sample patients (A4, A6, A7 and A8). This failure results in a document that fails to identify expected treatment outcomes in a manner that could be understood by treatment staff and patients. (Refer to B121).

II. Included individualized treatment interventions based on the needs of 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8). The interventions were generic and described routine discipline specific functions. This failure results in staff being unable to provide consistent and focused treatment. (Refer to B122).

III. Identified the assigned treatment team members responsible for treatment interventions for 4 of 8 active sample patients (A3, A4, A5, and A6). Identification of those staff members responsible for ensuring compliance with particular aspects of the patient's master treatment plan is essential to the provision of care. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient's discharge and recovery. (Refer to B123)

Based on record review, interview, the facility failed to ensure that the master treatment plans of 4 of 8 active sample patients (A4, A6, A7, and A8) defined short-and long-term goals as specific, measurable patient behaviors to be achieved. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans.

Findings include:

A. Record Review

1. Patient A4's presenting problem was: "Dx (diagnosis) of MDD recurrent, severe with psychosis/Bipolar." The long-term goal of his/her master treatment plan dated 3/3/11 was: "Pt. (patient) will evidence consistent reality-based thinking, coherent speech, congruent affect, & constructive, cooperative interaction w/o (without) a/v (audio/visual) hallucinations or bizarre or aggressive behavior." The short-term patient goal/objective was: "Pt. (patient) will be stabilized on medications." The goal and objective were not measurable in behavioral terms.

2. Patient A6's presenting problem was: "Patient reports severe mood swings, crying spells thoughts of SI (suicidal intent) depression 8 on 9 scale goal or 1-10."
The long-term goal of his/her master treatment plan dated 1/21/11 was: "Patient will learn and implement effective coping skills and positive self affirmation and appreciation for living by discharge." The short term goal/objective was: "Patient's environment will be safe." The goal and objective were not measurable in behavioral terms

3. Patient A7's presenting problem was: "Frequent suicidal ideation and [unintelligible] to kill and cut self." The long-term goal of his/her master treatment plan dated 3/4/11 was: "Pt. (patient) will cope with depressed feelings without thoughts to harm self." The short-term goal/objective was: "Pt.(patient) will remain safe during admit, aeb (as evidence by) no harm to self." The goal and objective were not measurable in behavioral terms

4. Patient A8's presenting problem was: "Anger and aggression and thoughts of suicide evidence of depression." The long-term goal of his/her master treatment plan dated 3/9/11 was: "Patient's mood will stabilize evidenced by decreased acts of aggression and decreased thoughts of suicide per patient report." The short-term goal/objective was: "Patient will express feeling and thoughts of S/I (suicide intent) and aggression to staff." The goal and objective were not measurable in behavioral terms


B. Staff Interview

In an interview on 3/14/11 at 3:00pm with RN4, s/he acknowledged that the long-term goals and short-term goals/objectives were not measurable.

Based on record review and interview, the facility failed to provide 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7, and A8) with master treatment plans that delineated individualized treatment modalities. Instead, interventions on the plans included routine generic discipline functions. This failure results in a master treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A1 was admitted 3/7/11. His/her master treatment plan dated 3/8/11 noted the following routine, generic discipline function: "monitor patient for safety." This is a discipline role not a treatment modality.

2. Patient A2 was admitted 3/11/11. His/her master treatment plan dated 3/12/11 noted the following routine, generic discipline functions: "administer medication as order by MD to decrease impulsivity & stabilize mood," and "medication management for symptoms of depression to include aggression." These are discipline specific roles not a treatment modalities.

3. Patient A4 was admitted 3/3/11. His/her master treatment plan dated 3/3/11 noted the following routine, generic discipline functions: "Administer medications as ordered." This is a discipline specific role not a treatment modality.

4. Patient A5 was admitted 3/8/11. His/her master treatment plan dated 3/11/11 noted the following routine, generic discipline functions: "Administer medications as ordered." This is a discipline specific role not a treatment modality.

5. Patient A6 was admitted 1/2/11. His/her master treatment plan dated 1/21/11 noted the following routine, generic discipline function: "Patient will be medicated per MD orders." This is a discipline specific role not a treatment modality.

6. Patient A7 was admitted 3/3/11.His/her master treatment plan dated 3/4/11 noted the following routine, generic discipline function: "Medication management for symptoms of depression." This is a discipline specific role not a treatment modality.

7. Patient A8 was admitted 3/8/111. His/her master treatment plan dated3/9/11 noted the following routine, generic discipline function: "Medication management for symptoms of depression or possible bipolar." This is a discipline specific role not a treatment modality.

B. Staff Interview

1. In an interview on 3/15/11 at 2:00pm with RN1, s/he acknowledged that these modalities are routine generic functions.

2. In an interview on 3/15/11 at 4:30pm with the CNO (Chief Nursing Officer), she stated: "education, education, I'm educating nurses about these treatment plans."

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the multidiscipline treatment plans in 4 of 8 treatment plans active sample patients (A3, A4, A5 and A6). This failure results in the facility's inability to monitor staff accountability for specific treatment modalities.

Finding Include:

A. Record Review

1. Review of the following multidisciplinary master treatment plans (dates in parentheses) revealed that they did not delineate the names and responsibilities of treatment team members; Patient A3 (2/4/11), Patient A4 (3/3/11), Patient A5 (3/11/11), and Patient A6 (1/21/11).

B. Staff Interview

In an interview on 3/15/11 at 11:30AM with the Chief Nurse Officer (CNO), she stated "In an interview on 3/15/11 at 4:30p.m. with the Chief Nursing Officer (CNO) she stated: "we don't have a primary care system in place, so we use discipline initials and I'd have to look at the staffing schedule for the day to find out who is responsible (for patient care)."

Based on the review of the discharge records of patients D1 through D10 and on interviews with the Medical Director and the Director of Medical Records, four discharge plans were either not available or failed to include an adequate summary of the course of hospitalization. This failure compromises continuity of care as the clinicians assuming responsibility for the patient's care plan after release from the hospital remain uninformed regarding the interventions exercised during hospitalization and the success or failure engendered by such interventions.

Findings include:

Record Review

1. Record D1 did not contain a discharge summary. The patient was discharged on 1/28/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

2. Record D2, signed on 1-11-11, summarized Hospital Course by noting only one word, "Suboxone."

3. Record D3, signed on 1-18-11, summarized Hospital Course with the following statement, "Detoxed [sic] successfully."

4. Record D5 did not contain a discharge summary. The patient was discharged on 1/25/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

A. Staff Interviews

1. In an interview on 3/15/11 at 9:45am with the Director of Medical Records, she acknowledged that physicians discharge summaries were "minimal." She further said that occasionally doctors failed to either write or dictate discharge summaries altogether.

2. In an interview on 3/15/11 at 2:30pm, the Medical Director acknowledged that the discharge summaries did not contain enough relevant information. He ascribed this problem to "bad old habits." He also was aware that occasionally discharge summaries were missing altogether.

Based on the review of the discharge records of patients D1 through D10, on policy review, and on interviews with the Medical Director and the Director of Medical Records, ten discharge plans were either not available or failed to include adequate recommendations for follow-up care. The failure to specify whom the patient will be seeing, at which location and at what time reduces the likelihood that the patient will actually be assuming aftercare appointments. This, in turn, may increase the risk of relapse.

Findings include:

A. Record Review

1. Record D1 did not contain a discharge summary. The patient was discharged on 1/28/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

2. Record D2, signed on 1-11-2011, summarized follow-up with one abbreviation, "RTC," which means Residential Treatment Center.

3. Record D3, signed on 1-18-2011, summarized follow-up with one abbreviation, "RTC," which means Residential Treatment Center.

4. Record D4, signed on 2-10-2011, explained, "I [i.e. the discharging physician] usually follow up with my patients in my office."

5. Record D5 did not contain a discharge summary. The patient was discharged on 1/25/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

6. Record D6, signed on 1-28-2011, summarized follow-up with one word, "Outpatient."

7. Record D7, signed on 1-19-2011, summarized follow-up as, "MD and therapist to continue treatment."

8. Record D8, signed on 2-1-2011, summarized follow-up with two words, "Outpatient/PHP." (PHP means partial hospitalization program)

9. Record D9, signed on 1-27-2011, summarized follow-up with one abbreviation, "PHP." (PHP means partial hospitalization program)

10. Record D10, signed on 1-12-2011, explained, "He will be followed at MHMR" (MHMR means Mental Health/Mental Retardation)

B. Policy Review

According to the hospital's policy guiding discharge planning (issued on 10/01/05), in Section 5, the "discharge/aftercare plan should define the following: ...the level of care which the patient will be discharged to...all professionals who will follow-up with the patient...referrals to self-help groups, support groups, or community resources...follow-up appointments based on the patient's clinical need."

C. Staff Interviews

1. In an interview on 3/15/11 at 9:45am with the Director of Medical Records, she acknowledged that physicians discharge summaries were "minimal." She further said that occasionally doctors failed to either write or dictate discharge summaries altogether.

2. In an interview on 3/15/11 at 2:30pm with the Medical Director, he acknowledged that the discharge summaries did not contain enough relevant information. He ascribed this problem to "bad old habits." He also was aware that occasionally discharge summaries were missing altogether.

Based on the review of the discharge records of patients D1 through D10 and on interviews with the Medical Director and the Director of Medical Records, six discharge plans were either not available or failed to include an adequate description of the patient's condition on discharge. This failure compromises continuity of care as the clinicians assuming responsibility for the patient's care plan after release from the hospital remain uninformed regarding the patient's clinical status as he or she transitions from inpatient care to ambulatory follow-up.

Findings include:

A. Record Review

1. Record D1 did not contain a discharge summary. The patient was discharged on 1/28/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

2. Record D2, signed on 1-11-2011, summarized Hospital Course by one word, "improved."

3. Record D3, signed on 1-18-2011, left the "Condition on Discharge" section blank.

4. Record D5 did not contain a discharge summary. The patient was discharged on 1/25/11 and medical staff by-laws require that a physician's discharge summary be on the record within 30 days of discharge.

5. Record D6, signed on 1-28-2011, summarized Hospital Course by stating, "Condition improved."

6. Record D8, signed on 2-1-2011, summarized Hospital Course by stating, "Condition improved."

B. Staff Interviews

1. In an interview on 3/15/11 at 9:45am with the Director of Medical Records, she acknowledged that physicians discharge summaries were "minimal." She further said that occasionally doctors failed to either write or dictate discharge summaries altogether.

2. In an interview on 3/15/11 at 2:30pm with the Medical Director, he acknowledged that the discharge summaries did not contain enough relevant information. He ascribed this problem to "bad old habits." He also was aware that occasionally discharge summaries were missing altogether.

Based on the review of the records of patients A1-A8, and on an interview with the Medical Director, the director failed to monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff. These failures are evidenced by:

I. Patient records showed a failure to adequately assess the intellectual and memory functioning of 8 of 8 active sample patients (A1-A8), and to describe the testing methods used for the assessments. (Refer to B116)

II. Discharge summaries were either unavailable (D1, D5) [refer to B133] on the chart or failed to provide adequate information on hospital course (D2, D3) [refer to B133], aftercare arrangements (D2, D3, D4, D6, D7, D8, D9, D10) [refer to B134] or condition on discharge (D2, D3, D6, D8)[refer to B135].

III. Master treatment plans that failed to develop and document treatment. Specifically, the facility failed to develop and document master treatment plans that included patient goals/objectives based on the individual needs of 4 of 8 active sample patients (A4, A6, A7, and A8), included individualized treatment interventions based on the needs of 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7, and A8) and identified the assigned treatment team members responsible for treatment interventions for 4 of 8 active sample patients (A3, A4, A5, and A6). (Refer to B118)

Additional Findings include:

A. Interview

In an interview on 3/15/11 at 2:30pm with the Medical Director, he acknowledged that cognitive assessments did not include methods of assessment of memory function or an outline of intellectual function. He pointed out that the mental status form in use provides check mark options for "serial 7s" etc., but appreciated that these tests were not marked by the admitting psychiatrists. He also agreed that the discharge summaries did not contain enough relevant information and sometimes failed to be generated altogether within the required timeframe, noting "It's hard to change old habits." He also acknowledged the deficiencies in treatment plans and expressed the opinion that improvement was needed.

Based on record review and interview it was determined that the Chief Nurse Officer (CNO) failed to monitor the quality and appropriateness of services and treatment provided. Specifically, the CNO failed to:

I. Ensure that the Master Treatment Plans (MTP) included short and long-term goals that were measurable in 4 of 8 active sample patients (A4, A6, A7, and A8):

Findings include:

A. Record Review

1. Patient A4's presenting problem was: "Dx (diagnosis) of MDD recurrent, severe with psychosis/Bipolar." The long-term goal of his/her master treatment plan dated 3/3/11 was: "Pt. (patient) will evidence consistent reality-based thinking, coherent speech, congruent affect, & constructive, cooperative interaction w/o (without) a/v (audio/visual) hallucinations or bizarre or aggressive behavior." The short-term patient goal/objective was: "Pt. (patient) will be stabilized on medications." The goal and objective were not measurable in behavioral terms.

2. Patient A6's presenting problem was: "Patient reports severe mood swings, crying spells thoughts of SI (suicidal intent) depression 8 on 9 scale goal or 1-10."
The long-term goal of her master treatment plan dated 1/21/11 was: "Patient will learn and implement effective coping skills and positive self affirmation and appreciation for living by discharge." The short term goal/objective was: "Patient's environment will be safe." The goal and objective were not measurable in behavioral terms.

3. Patient A7's presenting problem was: "Frequent suicidal ideation and [unintelligible] to kill and cut self." The long-term goal of her master treatment plan dated 3/4/11 was: "Pt. (patient) will cope with depressed feelings without thoughts to harm self." The short-term goal/objective was: "Pt. (patient) will remain safe during admit, aeb (as evidence by) no harm to self." The goal and objective were not measurable in behavioral terms.

4. Patient A8's presenting problem was: "Anger and aggression and thoughts of suicide evidence of depression." The long-term goal of her master treatment plan dated 3/9/11 was: "Patient's mood will stabilize evidenced by decreased acts of aggression and decreased thoughts of suicide per patient report." The short-term goal/objective was: "Patient will express feeling and thoughts of S/I (suicide intent) and aggression to staff." The goal and objective were not measurable in behavioral terms.

II. Ensure that nursing interventions were not listed in the Master Treatment Plan as generic items that were routine nursing functions in 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8):

1. Patient A1 was admitted 3/7/11. His/her master treatment plan dated 3/8/11 noted the following routine, generic discipline function: "monitor patient for safety." This is a discipline specific role not a treatment modality.

2. Patient A2 was admitted 3/11/11. His/her master treatment plan dated 3/12/11 noted the following routine, generic discipline functions: "administer medication as order by MD to decrease impulsivity & stabilize mood," and "medication management for symptoms of depression to include aggression." These are discipline specific roles not treatment modalities.

3. Patient A4 was admitted 3/3/11. His/her master treatment plan dated 3/3/11 noted the following routine, generic discipline functions: "Administer medications as ordered." This is a discipline specific role not a treatment modality.

4. Patient A5 was admitted 3/8/11. His/her master treatment plan dated 3/11/11 noted the following routine, generic discipline functions: "Administer medications as ordered." This is a discipline specific role not a treatment modality.

5. Patient A6 was admitted 1/2/11. His/her master treatment plan dated 1/21/11 noted the following routine, generic discipline function: "Patient will be medicated per MD orders." This is a discipline specific role not a treatment modality.

6. Patient A7 was admitted 3/3/11. His/her master treatment plan dated 3/4/11 noted the following routine, generic discipline function: "Medication management for symptoms of depression." This is a discipline specific role not a treatment modality.

7. Patient A8 was admitted 3/8/11. His/her master treatment plan dated 3/9/11 noted the following routine, generic discipline function: "Medication management for symptoms of depression or possible bipolar." This is a discipline specific role not a treatment modality.


III. Ensure that the staff name and discipline of 4 or 8 active sample patients (A3, A4, A5, and A6) were listed on the Master Treatment Plan (MTP):

1. Review of the following multidisciplinary master treatment plans (dates in parentheses) revealed that they did not delineate the names and responsibilities of treatment team members; Patient A3 (2/4/11), Patient A4 (3/3/11), Patient A5 (3/11/11) and Patient A6 (1/21/11).

B. Staff interview

In an interview on 3/15/11 at 4:30pm with the Chief Nursing Officer (CNO she stated: "we don't have a primary care system in place, so we use discipline initials and I'd have to look at the staffing schedule for the day to find out who is responsible (for patient care)."