HospitalInspections.org

Based on observation, interview and record review, the facility failed to:

I. Provide assessments of memory and intellectual functioning for 6 of 8 active sample patients (B1, B2, B4, H1, H2 and H4.) These deficiencies result in incomplete patient assessments, potentially leading to incorrect patient diagnoses. Failure to do these tests on admission also results in lack of baseline data that can be used for future comparisons. (Refer to B116)

II. Provide Master Treatment Plans that included measurable goals and objectives for 8 of 8 sample patients (B1, B2, B3, B4, H1, H2, H3 and H4). This deficient practice results in treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

III. Provide Master Treatment Plans that included individualized treatment modalities for 8 of 8 active sample patients (B1, B2, B3, B4, H1, H2, H3 and H4). Interventions on the treatment plans included generic and routine discipline functions, and they failed to include the frequencies or methods of delivery. This deficiency results in treatment plans that do not reflect a comprehensive, integrated or individualized approach to multidisciplinary treatment. (Refer to B122)

IV. Provide active treatment for 5 of 8 active sample patients (B1, B2, B3, B4 and H2). The scheduled groups on the treatment units often started late and were poorly attended, and there were few therapeutic modalities on weekends. In addition, interventions by the Psychiatrist and other members of the treatment team were poorly coordinated and were not always conducted in a timely manner. These failures potentially lead to inadequate patient outcomes, including prolonged hospitalizations. (Refer to B125)

V. Assure that Attending Psychiatrists documented progress notes at sufficient intervals for 6 of 8 sample patients (B1, B2, B3, B4, H2 and H3). This deficiency can lead to inadequate communication with, and guidance to, members of the treatment team, potentially resulting in ineffective treatment for patients. (Refer to B126)

Based upon a review of records and interview with staff, the facility failed to document a formal assessment of memory and intellectual functioning for 6 of 8 active sample patients (B1, B2, B4, H1, H2 and H3). These deficiencies result in incomplete patient assessments, potentially leading to incorrect patient diagnoses. Failure to do these tests on admission also results in lack of baseline data that can be used for future comparisons.

Findings include:

A. Record Review:

1. Patient B1 was admitted on 1/16/2011. In the "Admission Psychiatric Evaluation" dated 1/16/2011, "Memory/Estimation of Intelligence" was recorded as "Good memory and intelligence."

2. Patient B2 was admitted on 10/15/2010. In the "Admission Psychiatric Evaluation" dated 10/15/2010, "Memory/Estimation of Intelligence" was recorded as "Average."

3. Patient B4 was admitted on 7/21/2010. In the "Admission Psychiatric Assessment" dated 7/21/2010, "Memory/Estimation of Intelligence" was recorded as "Refuses to answer. Below average intelligence."

4. Patient H1 was readmitted on 12/20/2010. In the "Modified Psychiatric Assessment" (used when the patient is readmitted within 30 days), "Current Mental Status" was documented as "fair cognition." Memory functioning was not recorded. In the "Comprehensive Psychiatric Evaluation" dated 11/22/2010 (used on the patient's most recent previous admission and referenced in the evaluation dated 12/20/2010), the section titled "Memory" recorded the following: "Immediate recall: Could not be tested; Ten minute recall: N/A [not applicable]; Presidents: Could not be tested; Serial 7: Not tested; Serial 3: N/A; Intelligence Estimate: average."

5. Patient H2 was admitted on 9/15/2010. In the "Comprehensive Psychiatric Assessment" dated 9/17/2010, "Cognition" was recorded as "Impaired." "Fund of Knowledge" was recorded as "Inadequate," and "Memory" was recorded as "Immediate recall: Unable to obtain; Presidents: Patient uncooperative; Serial 7: Patient uncooperative; Serial 3: Patient Uncooperative."

6. Patient H3 was admitted on 1/4/2011. In the "Comprehensive Psychiatric Evaluation" dated 1/4/2011, "Cognition" was recorded as: "No full assessment done due to prominent psychosis and mood problems. Concentration was impaired and refused to answer all other questions."

B. Staff Interview

In an interview on 1/25/2011 at 1:00PM, the Medical Director acknowledged the above deficiencies and stated "These assessments were supposed to be a full intake and should include memory testing."

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans of 8 of 8 active sample patients (B1, B2, B3, B4, H1, H2, H3 and H4) defined short-term and long-term goals as specific, measurable patient behaviors to be achieved. This practice compromises the 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 B1's presenting problem was "Risk behavior, suicidal ideation, to 'rob a bank' and get shot, depressed symptoms, expressions of hopelessness, limited support system, undomiciled, unemployed status and legal offense incarceration history." The long-term goal on the treatment plan dated 1/21//11 was "Patient will be able to sustain safety in the community and continue with recovery efforts with a viable residence following discharge with intact crisis management and linkage services in place to continue with recovery." The short-term goal (objective) was "Will maintain personal safety wile hospitalized and evidence stabilized mood conform with unit roles and expectation and maintain treatment adherence while hospitalized.[sic]" The goals/objectives were not measurable or stated in behavioral terms.

2. Patient B2's presenting problem was "Thought disorder, mood disorder, legal offenses, resisting arrest prior to admission." The long-term goal on the treatment plan dated 10/20/10 was "Patient will be adjudged to be sufficiently stabilized to warrant discharge by target date with intact linkage, crisis management and continuity of care programming in place by target date." The short-term goal (objective) was "Will maintain personal safety while hospitalized and evidence stabilizing effects from treatment to include improved and more intact reality orientation and compliance with unit rules and regulations by target date." The goals/objectives were not measurable or stated in behavioral terms.

3.Patient B3's presenting problem was "Risk behavior, overdose on medications in a suicide attempt, mood disorder, depressive symptoms feelings of hopelessness and helplessness, protracted unemployed status, impaired coping skills." The long-term goal on her treatment plan dated 12/11/10 was "Patient will be able to sustain safe and possible functioning ability following discharge to include maintaining personal safety and sustaining engagement in treatment to progress with recovery progressing post discharge." The short-term goal (objective) was "Will identify constructive and adaptive means to effectively deal with mood dysregulation and enact harm avoidance skills and strategies when dysregulated while hospitalized and actively engage in viable aftercare planning while hospitalized." The goals/objectives were not measurable or stated in behavioral terms.

4. Patient B4's presenting problem was "Mood disorder, thought disorder, irritability, poor personal boundaries, inability to passably care for self without structured supportive services, non compliance with treatment and assessment, undomiciled status." The long-term goal of the treatment plan dated 12/22/10 was "Patient will be assessed to be satisfactorily stabilized to warrant discharge to a viable residential setting by target date with intact crisis management, linkage and continuity of care provisions in place upon discharge." The short-term goal (objective) was "Will cite and enact generalizeable [sic] coping and symptom management skills when dysregulated by target date and evidence an understanding of harm avoidance and risk reduction practices by target date and take an active role in securing viable residential and aftercare planning supports while hospitalized." The goals/objectives were not in measurable or stated in behavioral terms.

5. Patient H1's presenting problem was "Psychosis." The long-term goal of his treatment plan dated 1/4/11 was "Stabilize symptoms of psychosis and return patient to baseline/optimal level of functioning." The short-term goal (objective) was "Patient will accept psychotropic medication as prescribed by attending psychiatrist and report results to staff including side effects to clinical staff." The goals/objectives were not measurable or stated in behavioral terms.

6. Patient H2's presenting problem was "Disordered mood/Psychosis." The long-term goal of his treatment plan dated 12/27/10 was "Patient will improve or maintain current mental health status and problem free behaviors in order to be placed in a nursing home." The short-term goal (objective) was "Stay compliant with prescribed medications." The goals/objectives were not measurable or stated in behavioral terms.

7. Patient H3's presenting problem was "Disordered mood & psychosis." The long-term goal of her treatment plan dated 1/21/11 was "Demonstrate stabilization of mood symptoms and elimination of psychosis in order to return to premorbid [sic] level of effective functioning." The short-term goal (objective) was "Take prescribed medication as ordered." The goals/objectives were not measurable or stated in behavioral terms.

8. Patient H4's presenting problem was "Risk behavior, suicidal ideation with plan to cut wrists, delusional ideation, medication noncompliance, sleep disturbance, deficient coping and symptom management skills, shelter housing." The long-term goal of her treatment plan dated 1/20/11 was "Patient will maintain safe and stable functioning in the community with intact continuity of care services ensuring medication delivery, crisis management and therapy supportive resources to continue with recovery post discharge." The short-term goal (objective) was "Will maintain personal safety while hospitalized and evidence more lucid thinking, purposeful action, restorative sleep, and medication and treatment adherence by target date." The goals/objectives were not measurable or stated in behavioral terms.

B. Staff Interview

1. In an interview on 1/25/11 at approximately 3:00PM, after reviewing the treatment plans, RN2 stated "We do need to be more specific; these [goals and objectives] are not measurable."

Based on record review and interview, the facility failed to provide 8 of 8 active sample patients (B1, B2, B3, B4, H1, H2, H3 and H4) with Master Treatment Plans that included individualized treatment modalities. The interventions on the plans: a) were routine generic discipline functions and; b) failed to specify the frequency and/or delivery method. This deficiency results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Routine, generic discipline functions

1. Patient B1 was admitted 1/16/11. His treatment plan dated 1/21/11 listed the following routine, generic discipline functions: "Medications as ordered with periodic review of progress with changes in treatment plan as indicated to optimize treatment and observations as warranted to maintain safety."

2. Patient B2 was admitted 10/15/10. His treatment plan dated 10/20/10 listed the following routine, generic discipline functions: "Medications as ordered with periodic review of progress with changes in treatment programming as indicated to optimize treatment response and observations as warranted to maintain safety."

3. Patient B3 was admitted 12/8/10. Her treatment plan dated 12/11/10 listed the following routine, generic discipline functions: "Medications are ordered with periodic review of progress with changes as warranted to optimize treatment response, regular MSE (mental status exam) and chart reviews and observations as warranted to maintain safety."

4. Patient B4 was admitted 7/21/10. His treatment plan dated 12/22/10 listed the following routine generic discipline functions: "Medications as ordered with periodic changes in treatment and observations indicated to maintain safety."

5. Patient H1 was admitted 12/ 20/10. His treatment plan dated 1/4/10 listed the following routine generic discipline functions: "Prescribe anti psychotic medication monitor effectiveness, observe for side effects and make adjustments as needed."

6. Patient H2 was admitted 9/15/10. His treatment plan dated 12/27/10 listed the following routine generic discipline functions: "Psychiatrist will prescribe medications and assess the effect on patient. Nursing will administer medications, encourage and monitor compliance."

7. Patient H3 was admitted 1/4/11. Her treatment plan dated 1/21/11 listed the following routine generic discipline functions: "Psychiatrist will prescribe medications and assess efficacy. Nursing (to) administer prescribed medications, ensure compliance, and monitor for side effects."

8. Patient H4 was admitted 1/13/11. Her treatment plan dated 1/20/11 listed the following routine generic discipline functions: "Medications as indicated to improve thinking and stabilize mood and observations as warranted to ensure safety with changes in planning as indicated to optimize treatment effects."

B. Interventions with no documented frequency and/or delivery method.

1. Patient B1 was admitted 1/16/11. His treatment plan dated 1/21/11 failed to note the frequency and delivery methods (individual or group sessions) for the following activity therapy interventions: "Pt. (patient) will be offered coping skills, relaxational [sic] current events groups as a means to offer pt. strategies to implement when dysregulated and educational info."

2. Patient B2 was admitted 10/15/10. His treatment plan dated 10/20/10 failed to note the frequency and delivery methods (individual or group sessions) for the following activity therapy interventions: "Pt. will be offered coping skills group as a means to allow pt. to practice symptom management skill in a guided setting."

3. Patient B3 was admitted 12/8/10. Her treatment plan dated 12/11/10 failed to note the frequency and delivery methods (individual or group sessions) for the following social work interventions: "Meet with SW to create a supportive discharge plan to include outpatient mental health treatment at Dupage County Health Department."

4. Patient B4 was admitted 7/21/10. His treatment plan dated 12/22/10 failed to note the frequency and delivery methods (individual or group sessions) for the following activity therapy interventions: "Pt. offered coping skills group as a means to allow pt. [patient] to practice symptom management skills in a guided setting."

5. Patient H1 was admitted 12/20/10. His treatment plan dated 1/4/11 failed to note the frequency and delivery methods (individual or group sessions) for the following psychologist interventions: "Recommend individual psychotherapy with psychologist to address symptom management and relapse prevention."

6. Patient H2 was admitted 9/15/10. His treatment plan dated 12/27/10 failed to note the frequency and delivery methods (individual or group sessions) for the following social work and activity therapy interventions: Social Work: "Clinical and family contacts indicated to broaden resources and data base and formulate a discharge plan" Activity Therapy: "Social programming held both on the unit and centrally physical programming held on the unit to provide opportunities to interact with others."

7. Patient H3 was admitted 1/4/11. His treatment plan dated 1/21/11 failed to note the frequency and delivery methods (individual or group sessions) for the following interventions: "Focus group, creative expression group, coping skills group, relaxation group, solutions for wellness group, AM walking and socials in order to provide opportunities for patient to interact appropriately in small group environment." According to the treatment plan, all of these interventions were to be provided by Activity Therapy.

8. Patient H4 was admitted 1/13/11. Her treatment plan dated 1/20/11 failed to note the frequency and delivery methods (individual or group sessions) for the following psychologist interventions: "Conflict resolution group programming addressing improving problem solving skills and practicing harm avoidance and risk reduction when dysregulated."

B. Staff Interviews

1. In an interview on 1/24/11 at approximately 11:15AM, Social Worker 1 said "I think the activity list is all groups, but I'm not sure."

2. In an interview on 1/26/11 at approximately 10:10AM, the Interim Director of Nursing (DON) said "We do that every day. Doctors prescribe medications and nurses give patients the medications. It's part of the job."

Based on observation, document review, record review and interviews with patients and staff, the facility failed to provide active treatment for 5 of 8 sample patients (B1, B2, B3, B4 and H2). The scheduled groups on the treatment units often started late and were poorly attended, and there were few therapeutic modalities on weekends. Additionally, interventions by the Psychiatrist and other members of the treatment team were poorly coordinated and were not always conducted in a timely manner. These failures potentially lead to inadequate patient outcomes, including prolonged hospitalizations.

Findings include:

A. Observations

1. The group titled: "Relaxation Therapy" was scheduled to begin at 11:00AM on 1/24/11 in the Activities Room on the Brunk Unit. The instructor arrived at 11:15AM, and the group session began at 11:20AM with three patients present, including sample patient B2. The group consisted of listening to music and deep breathing exercises. A fourth non-sample patient joined later and left after several minutes. The instructor ended group at 11:30AM when lunch arrived, saying "You all need a hot lunch." Three other sample patients who were assigned to this treatment modality did not participate in the group: patient B1 was listening to music with headphones, dancing in the hallway by himself; patient B3 was observed to be talking on the phone; and patient B4 was wandering the unit, talking to himself and covering his ears.

2. During an observation on 1/24/11 at approximately 2:00 PM on the Hinton unit, sample patient H2, who was admitted on 9/15/10, was not receiving any active treatment. There also were no observed staff attempts to engage patient H2 in an alternative therapeutic modality. During the same observation, MHT1 was sitting in the nursing station looking into the day room where patient H2 and two other patients were sitting. When the surveyor enquired about the MHT's assignment, MHT1's response was "I came from the other unit to help out. I don't know the patients' here; I'm observing them."

3. The group titled: "Current Events" was scheduled to begin at 1:15PM on 1/25/11 in the Day Room on the Brunk Unit. This group was listed as a required group for all patients per the schedule provided by the facility, and it focused on the importance of taking care of oneself. At 1:25PM, two patients inquired at the Nurses' Station about whether this group was going to occur. Staff initially responded: "No, not today," but several minutes later, the surveyor overheard several staff attempts to find the group leader in his office by phone. A substitute leader was found, and the group began at 1:35 PM. Fourteen patients were in attendance, including one of four sample patients (B1) residing on the Brunk Unit. Sample patient B2 was observed asleep in his room at the beginning of the group but joined the group after awakening at 1:55PM; sample patient B3 was in the shower; and sample patient B4 continued to wander the halls muttering to himself; there were no staff attempts to redirect the patient. The "Current Events" group ended at 2:10PM.

4. During an observation on 1/25/11 at approximately 3:30PM on the Hinton Unit, two MHT's came out of the nursing station and sat on chairs placed outside the nursing station. Patient H2 and three other patients were sitting in the day room staring into space. When the MHTs were asked the purpose of sitting next to the nursing station, they both said they were watching the patients.

5. A "Medication Education" group was held at 10:15AM on 1/26/11 in the Activities Room on the Brunk Unit. The group was attended by only one (B2) of four sample patients from the unit. During the group session, two of the other sample patients (B1 and B3) were escorted off of the unit by staff to the barber shop. Both patients had expressed concerns to the surveyor in individual interviews (B1 on 1/24/11; B3 on 1/25/11) about their lack of response to medication. The other sample patient (B4) was observed at the end of the hall in a chair, looking outside and muttering to himself. There were no attempts by staff to engage Patient B4 in any alternative active therapy during the observation.

6. During other 1/26/11 observations on the Brunk Unit, patient B4, who was admitted to the Unit on 7/21/10, did not receive any active treatment. The patient did not attend any structured unit activities, nor were there any attempts by staff to engage him in alternative therapeutic interactions. Patient B4 was seen wandering the hallways by himself, muttering to himself and covering his ears, lying in bed, or gazing out of the hallway window when groups listed as required on the Unit Schedule were occurring on the unit.

B. Document Review

1. A review of group and therapeutic activities attendance sheets provided by the facility revealed the following documentations:

2. Patient B1 had attended a total of 8 assigned groups in the 8 days since he was admitted to the Brunk Unit, averaging one assigned therapeutic modality per day.

3. Patient B2 had attended a total of 22 assigned groups (including the 15 minute Relaxation Therapy session held on 1/24/11 and referenced above) in the interval between 1/3/11 and 1/24/11, averaging approximately one assigned therapeutic modality per day in the three-week interval for which documentation was provided.

4. Patient B3 had attended a total of 17 assigned groups between 1/3/11 and 1/24/11, averaging 0.7 hours of assigned therapeutic modalities per day in the three-week interval for which documentation was provided.

5. Patient B4 had attended a total of two assigned groups between 1/3/11 and 1/24/11, averaging 0.01 hours of assigned therapeutic modalities per day in the three-week interval for which documentation was provided.

6. Patient H2 had attended a total of nine assigned groups between 1/9/11 and 1/25/11, averaging less than one assigned therapeutic modality per day.

C. Record Review

1. Patient B2

a. Patient B2 was admitted to the Brunk Unit on 10/15/10 after demonstrating aggression toward his brother. In the Comprehensive Psychiatric Evaluation dated 10/20/10, Physician 4 noted: "I did speak with the patient's brother about possibly increasing his Risperdal Consta to a higher dose. We also discussed the possibility of adding a mood stabilizer from an anticonvulsant group."

b. On 10/22/10, Physician 4 recorded: "The nurses indicate that he (patient B2) had his last injection of Risperdal Consta 25mg on 10/9/10 [prior to admission]- next injection is due tomorrow." This history indicated that patient B2 had decompensated despite adherence to his outpatient medication regimen. Physician 4 also noted: "I did discuss the possibility of increasing Risperdal Consta due to recent episode of aggression. (Patient B2) says it was an isolated episode and does not want any changes." No medication modifications were made by Physician 4 for Patient B2 at that time.

c. In a progress note dated 12/8/10, Physician 4 documented: "Will have family meeting with brother regarding placement. There is a conflict-both of them don't get along." A social work note dated 12/22/10 stated: "Family meeting took place on 12/17 (nine days after it was requested by Physician 4)...Pt came and argued with his brother...The argument escalated and discharge is cancelled." No medication modifications were made by Physician 4 for Patient B2 at this time, nor was there any evidence of changes in the planned housing arrangements.

d. On 1/5/11, (an interval of 18 days after the family session was held), a social work note reported: "Discharge planning is to return home once family and patient come to an agreement about resolution of conflicts." No evidence of subsequent family sessions was documented in the patient's medical record.

e. On 1/24/11, the social worker documented: "Patient is communicating with his brother on a regular basis to work out conflict. Both patient and brother attempt to minimize conflict before discharge of patient to home." On 1/24/11, Physician 4 wrote orders to discharge Patient B2 on "Risperdal Consta 25mg IM every two weeks," and "Benztropine 2mg po BID prn for EPS." Patient B2 was still on the Brunk unit on 1/26/11 (end of survey). His length of stay at this point was 104 days, during which time no medication changes had occurred and only one family session was documented.

2. Patient B4

a. Patient B4 was admitted to the Brunk unit on 7/21/10 due to agitation and psychosis secondary to Schizoaffective disorder, bipolar type. The last medication change documented in the medical record occurred on 11/15/10, at which time lorazepam 1mg three times daily was added. No rationale for the medication addition was documented by Physician 4 in the patient's medical record.

b. A review of patient B4's Medication Administration Record revealed that the patient consistently accepted all medications offered. However, on 1/24/11, Physician 4 recorded in a progress note: "Continues to be psychotic with disorganized thought process." In spite of the patient's lack of improvement the physician's plan was to: "Continue current treatment."

D. Patient Interviews

1. In an interview on 1/24/11 at 1:30p.m., Patient B1 reported: "It's okay here but there's not a lot to do. The groups are alright but I've been through this before in prison and the groups there were more intense." When asked about his visits with his physician, Patient B1 replied: "What physician? I've only seen one twice...one a couple of days after I got here and today. She wants to send me out already but I don't feel any different." (Patient B1 had been admitted 1/16/10 for suicidal ideation secondary to multiple losses.) When asked about discharge planning, Patient B1 noted: "They're talking about sending me to PADS (a temporary shelter program) but the PADS units change location every night and I have no money to travel between the sites...I won't be safe back on the street."

2. In an interview on 1/25/11 at 11:00a.m., Patient B3, who had been admitted on 12/8/10 following a relapse with alcohol and an overdose of her medication, reported: "I lost my job and my house but I think the main thing was losing my 44 year old brother who died at the same time." When asked if the facility was helping with these issues, Patient B3 noted: "I guess...they have me in groups but nobody is talking about my brother's death. I'll have to deal with this after I get out." Patient B3 had recently begun the facility's "Recovery Cafe" program, (a two day per week structured experience serving snacks to promote work readiness. She stated: "It helps to pass the time. I have an MBA and worked in the industry before but it keeps my mind occupied." When asked about her visits with her psychiatrist, Patient B3 noted: "She sees me in the hallways. I know she's very busy. She's very nice but I'm still very anxious and I'm not sure these meds are working."

E. Staff Interviews

1. In an interview on 1/25/11 at 1:30p.m., which included a discussion about the lack of active medication changes and the protracted length of stay incurred by Patient B2, the Medical Director stated: "We're discouraged from increasing the dose of the Consta due to cost." We ask that this occur in the outpatient setting.

2. In an interview on 1/25/11 at 10:00AM, Physician 4 acknowledged that Patient B4 had not had medications adjusted since 11/15/10. She stated "He (patient B4) is very refractory and his brain needs time to heal." Physician 4 was unable to articulate any other specific plan to engage Patient B4 in alternate treatment modalities which could help reduce the patient's hostility and paranoia while waiting for the medications to take effect. Physician 4 also could not delineate the time frame for which she would give Patient B4's medications to take effect, or what other medication she would employ if the patient's current medications failed to be effective.

3.In an interview on 1/25/11 at approximately 1:30PM, while reviewing the group attendance sheets with the surveyor, the Director of Activity Therapy reported not being aware of the low patient attendance in unit programming;

4.In an interview on 1/26/11 at approximately 9:40AM, the Director of Activity Therapy acknowledged the deficient hours of active treatment provided on weekends on the Brunk and Hinton units, and said "The Saturday and Sunday Socials are 45 minutes of social activities. They are not counted as active treatment modalities..." The Director of Activity Therapy also verified that there were only two 45 minute groups on Saturdays and one 45 minute group on Sundays which met the facility's criteria for active treatment on each of the two distinct-part units.

5. In an interview on 1/26/11 at 9:00AM regarding patients in the dayroom, the ADON (Assistant Director of Nursing) and the Interim DON acknowledged that the MHTs should be "engaging" patients, not just observing them.

Based on a record review and staff interviews, the Attending Psychiatrists failed to document progress notes at sufficient intervals for 6 of 8 sample patients (B1, B2, B3, B4, H2 and H3). This deficiency can lead to inadequate communication with, and guidance to, members of the treatment team, potentially resulting in ineffective treatment for patients.

Findings include:

A. Record review

A review of progress notes recorded by the Attending Psychiatrists revealed the following:

1. Patient B1, admitted on 1/16/11 for suicidal ideation, had an Admission Psychiatric Evaluation on 1/16/11. One progress note was recorded by a psychiatrist on 1/19/11. No subsequent progress notes were recorded by a psychiatrist as of 1/24/11.

2. Patient B2, admitted on 10/15/10 for agitation and aggression toward his brother, had an Admission Psychiatric Evaluation on 10/15/10. Progress notes were recorded by a psychiatrist on: 10/22/10, 10/27/10, 11/10/10, 11/24/10, and 12/8/10. No subsequent notes by a psychiatrist were recorded in the patient's medical record as of 1/24/11.

3. Patient B3, admitted on 12/8/10 after a suicide attempt, had an Admission Psychiatric Evaluation on 12/8/10. Progress notes were recorded by a psychiatrist only twice -- on 12/17/10 and 1/24/11.

4. Patient B4, admitted on 7/21/10 for agitation and paranoia associated with his diagnosis of Schizoaffective disorder, Bipolar type, had an Admission Psychiatric Evaluation documented on 7/21/11. Progress notes were recorded by a psychiatrist on 7/28/10, 8/13/10, 8/16/10, 8/20/10, 8/23/10, 8/25/10, 8/27/10, 9/10/10, 10/13/10, 10/27/10, 11/10/10, 12/8/10, and 1/24/11. The last interval was 46 days between psychiatrist's entries.

5. Patient H2, admitted on 9/15/10 for "Schizoaffective Disorder, Bipolar Type," had a hand-written Admission Psychiatric Evaluation dated on 9/15/10 and a dictated "Comprehensive Psychiatric Assessment" dated 9/17/10. Progress notes were recorded by the psychiatrist on 9/16/10, 10/1/10, 10/13/10, 11/14/10 and 11/17/10. No subsequent notes were recorded by a psychiatrist as of 1/24/11.

Patient H3, admitted on 1/4/11 for "Bipolar Disorder, chronic, with psychotic features," had an Admission Psychiatric Evaluation on 1/4/11. Progress notes were recorded by the psychiatrist on 1/5/11, 1/7/11, and on 1/19/11. The last interval was 12 days between psychiatrist's entries.

B. Document Review

Review of minutes of the Medical Staff Organization Meetings revealed the following entries recorded in the minutes:

1. [1/21/10], agenda item 16 titled "Peer Review Information": "The Assistant Medical Director noted that the following areas are in need of significant improvement: inadequate progress notes (83.3%) - compliance has to be above 90%."

2. [2/18/10], agenda item 6 titled "Frequency of Progress Notes": "The Director of Quality Improvement clarified as per the "B" tag that psychiatrists must write progress notes minimally, weekly for eight weeks, then monthly thereafter for new patients."

C. Staff Interview

In an interview on 1/25/11 at 1:30PM., the Medical Director acknowledged the problems with the frequency of psychiatry progress notes recorded in the medical record, and stated "They should be at least weekly for the first two months. I have drafted a proposal to reflect this expectation."

Based on observation, record review, review of hospital documents and patient and staff interviews, the Medical Director failed to oversee the quality and appropriateness of services provided by the Medical Staff. Specifically, the Medical Director failed to:

I. Assure documentation of the assessment of memory testing and intellectual functioning for 6 of 8 active sample patients (B1, B2, B4, H1, H2 and H4.) This deficiency results in incomplete patient assessments, potentially leading to incorrect patient diagnoses. Failure to do these tests on admission also results in lack of baseline data that can be used for future comparisons. (Refer to B116)

II. Assure that Master Treatment Plans included measurable goals and objectives for 8 of 8 sample patients (B1, B2, B3, B4, H1, H2, H3 and H4.) This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

III. Assure that Master Treatment Plans included individualized treatment modalities for 8 of 8 active sample patients (B1, B2, B3, B4, H1, H2, H3 and H4). Interventions on the treatment plans included generic and routine discipline functions, and they failed to include the frequencies or methods of delivery. This deficiency results in treatment plans that do not reflect a comprehensive, integrated or individualized approach to multidisciplinary treatment. (Refer to B122)

IV. Assure active treatment for 5 of 8 active sample patients (B1, B2, B3, B4 and H2). Scheduled groups on the treatment units often started late and were poorly attended, and there were few therapeutic modalities on weekends. In addition, interventions by the Psychiatrist and other members of the treatment team were poorly coordinated and were not always conducted in a timely manner. These failures potentially lead to inadequate patient outcomes and can prolong hospitalizations. (Refer to B125)

V. Assure that Attending Psychiatrists documented progress notes at sufficient intervals for 6 of 8 sample patients (B1, B2, B3, B4, H2 and H3). This deficiency can lead to inadequate communication with, and guidance to, members of the treatment team, potentially resulting in ineffective treatment for patients. (Refer to B126)