HospitalInspections.org

Based on record review and staff interviews, the facility failed to provide Master Treatment Plans for 3 of 4 active sample patients (1,2 and 3) that identified patient related short term and long term goals, stated in observable or measurable, behavioral terms. There was confusion between patient's goals/objectives and the staff interventions to help the patient achieve these goals. This deficiency results in a document that fails to identify expected treatment outcomes in a manner that can be understood by members of the treatment team and the patient.

Findings include:

A. Record Review

1. In patient 1's Master Treatment Plan of 4/27/2011, the short term objectives were listed as "(MD/APN) [Advanced Practice Nurse] stabilize through psychotropic medications by 5/3/2011." This short term objective was written as a staff intervention, not a measurable patient outcome behavior.

2. In patient 2's Master Treatment Plan of 4/29/2011, the objective (short-term) was listed as "(MD/APN/social work/nursing) stabilize the current acute paranoid episode." This is a generic disciplinary function for staff, not a goal/objective for the patient written in observable or measurable, behavioral terms.

3. In patient 3's Master Treatment Plan of 4/27/2011, the listed objective was "(short-term): (MD/APN/Nursing) report on the side effects and effectiveness of medications by 5/3/2011." This objective was written as a staff intervention, not a measurable patient outcome behavior.

B. Staff Interview

In an interview on 5/3/2011 at 10:30a.m., the Director of Nursing (DON) and the Director of Social Services agreed with the surveyor's findings that the objectives were not described as measurable patient outcome behaviors.

Based on record review and staff interviews, the facility failed to ensure that the Master Treatment Plans of 4 of 4 sample patients (1, 2, 3 and 4) included psychiatric/APN treatment modalities (interventions) which were individualized, based on patient needs. Instead, generic monitoring, assessing and documenting functions were listed as treatment modalities. This deficiency results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. In patient 1's Master Treatment Plan developed on 4/27/2011, no interventions were listed for the psychiatrist/APN.

2. In patient 2's Master Treatment Plan of 4/29/2011, there were no interventions listed by psychiatrist/APN or social worker.

3. In patient 3's Master Treatment Plan of 4/27/2011, there were no interventions listed for either a psychiatrist or an APN.

4. In patient 4's Master Treatment Plan of 4/30/2011, interventions were listed as "psychiatric evaluation and ongoing assessment on a daily basis" and "completion of a physical exam within 24 hours of admission (or copy of one completed in past 30 days)." These are generic, disciplinary functions, not individualized interventions based on the patient's needs.

B. Staff Interview

1. In an interview on 5/2/2011 at 1p.m., the Medical Director agreed with the surveyor's finding that there were no interventions listed for the MD/APN. The Medical Director stated "I dictate my plan as part of my assessment" and later said "We would have to take the doctor's dictated plan from their assessment and make it part of the Master Treatment Plan." The Medical Director also stated that some of the problems were the result of the "electronic record system" which did not allow information to be added later on.

2. In an interview on 5/2/2011 at 3p.m., the DON stated "Nursing staff start the nursing part of the treatment plan as soon as the patient arrives because the patients are discharged very quickly"... "all the information is not always available at the time."

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..."