HospitalInspections.org

Based on record review and interview, it was determined that the Master Treatment Plans of 4 of 4 active sample patients (1, 2, 3 and 4) failed to identify the specific team members responsible for the listed interventions. In all 4 treatment plans, interventions were assigned to disciplines (MD/APN/Nursing/Social Work) rather than to specific staff. This type of assignment diffuses team member's sense of responsibility and hampers the facility's ability to hold staff accountable for essential treatment tasks.

Findings include:

A. Record Review

1. In patient 1's Master Treatment Plan of 4/27/2011, for the intervention (incorrectly listed as a patient objective) was listed as "(MD/APN) stabilize through psychotropic medications by 5/3/2011." The name of the responsible psychiatrist or APN was not in the Master Treatment Plan.

2) Patient 2's Master Treatment Plan of 4/29/2011, did not include the name of a psychiatrist/APN responsible for treatment interventions.

3) Patient 3's Master Treatment Plan of 4/27/2011 did not include the name of a psychiatrist or APN responsible for the treatment interventions.

4) Patient 4's Master Treatment Plan of 4/30/2011 did not include the names of the responsible psychiatrist or APN.

B) Staff Interview

In an interview on 5/3/2011 at 10:30a.m., the Director of Social Work stated, "I know we need to have specific names there. I saw that in the standards..."