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Based on record review, policy review, and interview, the facility failed to ensure that the psychiatric evaluations of 4 of 8 active sample patients (A1, A3, B1 and B3) included a medical history. Failure to ascertain and record the medical history of each patient prevents the physician from incorporating the sequelae of these conditions into the understanding of the patients' current mental and physical status.

Findings include:

A. Record Review

1. Patient A1: The Psychiatric evaluation dated 02/07/11 contained no Medical history despite the record indicating that the patient had a serious overdose and hospitalization prior to admission.

2. Patient A3: The Psychiatric evaluation dated 02/05/11 contained no Medical history.

3. Patient B1: The Psychiatric evaluation dated 02/05/11 contained no Medical history despite an Axis III diagnosis of Type II Diabetes.

4. Patient B3: The Psychiatric evaluation dated 02/05/11 contained no Medical history.

B. Policy Review

Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009, noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: "The Psychiatric Evaluation should include: Section e: Medical history."

C. Interview

In an interview on 2/8/11 at 3:00p.m. with the Medical Director, he agreed that the lack of a medical history was a problem and represented a deficiency in the medical record.

Based on record review, policy review and interview, the facility failed to provide psychiatric evaluations that reported memory functioning and/or intellectual functioning in measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure compromises the data base from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A1: In a Psychiatric evaluation dated 2/7/11, there was no assessment of memory present.

2. Patient A2: In a Psychiatric evaluation dated 2/4/11, there was no assessment of memory or intellectual functioning.

3. Patient A3: In a Psychiatric evaluation dated 2/5/11, there was no assessment of memory present.

4. Patient A4: In a Psychiatric evaluation dated 1/28/11, there was no assessment of memory or intellectual functioning.

5. Patient B1: In a Psychiatric evaluation dated 2/5/11 there was no assessment of memory present.

6. Patient B2: In a Psychiatric evaluation dated 2/3/11, memory description stated: "recent, remote and immediate recall intact" with no discussion of methodology or testing used to make this determination.

7. Patient B3: In a Psychiatric evaluation dated 2/5/11, there was no assessment of memory present.

8. Patient B4: In a Psychiatric evaluation dated 2/5/11 there was no assessment of memory present.

B. Policy Review

Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009, noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: The Psychiatric Evaluation should include: 2.8.1 b. "Mental Status evaluation, including description and estimate of intellectual functioning, memory functioning, and orientation."

C. Interview

In an interview on 2/8/11 at 3:00p.m. with the Medical Director, the above findings were reviewed. The Medical Director agreed that this was a problem and represented a deficiency in the Psychiatric evaluation.

Based on record review, policy review, and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in a descriptive manner for 7 of 8 active sample patients (A1, A2, A3, A4, B1, B3 and B4). 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 include:

A. Record review

1. Patient A1: In a psychiatric evaluation dated 2/7/11, there was no description of patient assets noted in the record.

2. Patient A2: In a psychiatric evaluation dated 2/4/11, there was no description of patient assets noted in the record.

3. Patient A3: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

4. Patient A4: In a psychiatric evaluation dated 1/28/11, there was no description of patient assets noted in the record.

5. Patient B1: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

6. Patient B3: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

7. Patient B4: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

B. Policy Review

1. Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009, noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: "The Psychiatric Evaluation should include: 2.8.1 m. Patient strengths and liabilities."

2. Policy No.: 1000.06: Medical Records Documentation Requirements (approved 10/99, last review 3/10): noted under #6: "The Attending Physician must document: a) Psychiatric evaluation including: strengths/weaknesses."

C. Interview

In an interview on 2/8/11 at 3:00p.m. with the Medical Director, the findings noted above were reviewed. The Medical Director agreed that this was a problem and represented a deficiency in the Psychiatric evaluation.

Based on closed record review, policy review and interview, the facility failed to provide a discharge summary that described the treatment instituted in the hospital, the patient's response to treatment, and the extent of progress toward the patient's treatment plan goals for 6 of 8 closed records reviewed (D2, D3, D4, D6, D7 and D8). This failure results in not providing information on effective or ineffective treatment strategies to the patient's next care provider.

Findings include:

A. Record Review:

1. Patient D2: Admitted 01/01/2011 and discharged 01/06/2011. The discharge summary section titled "Therapeutic Response" stated the following: "The patient was transferred to acute services and began a program of individual, group and family therapy in concordance with pharmacotherapy. Medications utilized were Risperdal 0.5 mg (milligrams) at bedtime. An additional diagnosis of dissociative disorder was entered into the record and felt to be accurate and operative. The patient took Amoxicillin 500 mg twice a day for positive strep screen." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

2. Patient D3: Admitted 01/03/2011 and discharged 01/07/2011. The discharge summary section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient utilized Seroquel 100 mg. at bedtime for mood stability. No reported side effects or adversity was reported." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.


3. Patient D4: Admitted 01/03/2011 and discharged 01/10/2011. The discharge summary section titled "Therapeutic Response" stated the following: "The patient was subsequently transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. She did require the use of Cogentin secondary to significant dystonia. She otherwise continued on her usual birth control pills. Her cogentin was discontinued on the day of her discharge. It was felt the patient would not be able to continue neuroleptic medication." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.


4. Patient D6: Admitted 01/04/2011 and discharged 01/11/2011. The discharge summary section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. He appeared to get along well with all staff and patients. No special procedures or sequellae occurred. The patient was placed on Trazadone 100 mg by mouth at bedtime for sleep. Abilify 10 mg was given twice per day. Nausea ensued and the patient's Abilify was discontinued. He eventually was discharged on Lexapro to replace the Abilify. Overall, the patient did well and no special procedures or adversity was reported." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

5. Patient D7: Admitted 01/04/2011 and discharged 01/11/2011. The discharge summary section titled "Therapeutic Response" stated the following: "[Patient D7] was transferred to acute services where he began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient, primarily, utilized Seroquel for mood stability and anxiety control. His discharge medication level was Seroquel 300 mg at bedtime. It was felt that the patient had many symptoms of underlying mood dysregulation, but also considerable anxiety that may be related to the ongoing conflict between his parents. His prognosis appeared to be guarded given the ongoing difficulty in the family." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

6. Patient D8: Admitted 01/04/2011 and discharged 01/08/2011. The discharge summary section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient utilized Trazadone 100 mg at bedtime for sleep with good results." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment, and the extent of progress toward the patient's treatment plan goals.

B. Policy Review

1. Policy #1000.06 titled "Medical Records Documentation Requirements," dated 10/99 with most recent review dated 03/10 stated: "The Attending Physician is responsible for the discharge summary...The discharge summary must...Be complete...Give concise review of the reason the patient was admitted...Describe the findings while hospitalized...Describe the therapy instituted and the patient's response and progress..."

2. Medical staff Rules and Regulations dated 01/12/2010 stated under the section titled "Discharge Documentation": "The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient's condition on discharge."

C. Interview

In an interview conducted 02/08/11 at 3:00PM, the Medical Director concurred that the discharge summaries failed to provide a description of all treatment and response to treatment for each patient per facility policy.

Based on closed record review, policy review and interview, the facility failed to ensure that the discharge summaries for 6 out of 8 patients (D2, D3, D4, D6, D7 and D8) described the status of the patient on the day of discharge, including psychiatric, physical and functional condition. This failure results in critical clinical information indicating the patient's level of psychiatric symptomatology and risk not being available to the aftercare providers.

Findings include:

A. Record Review

The discharge summaries for the following six patients did not contain a description of the condition of the patient on the day of discharge:

1. Patient D2 admitted 01/01/2011 and discharged 01/06/2011 with the discharge summary dictated 02/03/2011 and signed 02/06/2011.

2. Patient D3 admitted 01/03/2011 and discharged 01/07/2011 with the discharge summary dictated 01/30/2011 and signed 02/01/2011.

3. Patient D4 admitted 01/03/2011 and discharged 01/10/2011 with the discharge summary dictated 01/30/2011 and signed 02/01/2011.

4. Patient D6 admitted 01/04/2011 and discharged 01/11/2011 with the discharge summary dictated 01/30/2011 and signed 02/01/2011.

5. Patient D7 admitted 01/04/2011 and discharged 01/11/2011 with the discharge summary dictated 02/03/2011 and signed 02/11/2011.

6. Patient D8 admitted 01/04/2011 and discharged 01/08/2011 with the discharge summary dictated 01/27/2011 and signed 02/01/2011.

B. Policy Review

1. Policy #1000.06 titled "Medical Records Documentation Requirements", dated 10/99 with the most recent review on 03/10, states: "The Attending Physician is responsible for the discharge summary...The discharge summary must...Give the patient's discharge information including Final diagnosis...Patient's disposition...Condition at discharge..."

2. Medical staff Rules and Regulations dated 01/12/2010 stated under the section titled "Discharge Documentation": "The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient's condition on discharge."

C. Staff Interview

In an interview conducted on 02/08/11 at 3:00PM, the Medical Director concurred that the discharge summaries failed to describe the patient's condition at discharge as required by facility policy and Medical Staff Rules and Regulations.

Based on record review, policy review and interview, the Medical Director failed to monitor and ensure:

I. The adequacy of the psychiatric evaluation of patients with regard to inclusion of medical history for 4 of 8 active sample patients (A1, A3, B1 and B3). Failure to ascertain and record the medical history of each patient prevents the physician from incorporating the sequelae of these conditions into the understanding of the patients' current mental and physical status.

Findings include:

A. Record Review

1. Patient A1: In a Psychiatric evaluation dated 02/07/11 contained no Medical history despite the record indicating that the patient had a serious overdose and hospitalization prior to admission.

2. Patient A3: In a Psychiatric evaluation dated 02/05/11 contained no Medical history.

3. Patient B1: In a Psychiatric evaluation dated 02/05/11 contained no Medical history despite an Axis III diagnosis of Type II Diabetes.

4. Patient B3: Psychiatric evaluation dated 02/05/11 contained no Medical history.

B. Policy Review

Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009, noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: "The Psychiatric Evaluation should include: Section e: Medical history,"

C. Interview

In an interview on 2/8/11 at 3:00pm with the Medical Director, he agreed that the lack of a medical history was a problem and represented a deficiency in the medical record.

II. The adequacy of the psychiatric evaluation of patients with regard to memory and intellectual functioning tests for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure compromises the data base from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A1: In a Psychiatric evaluation dated 2/7/11, there was no assessment of memory present.

2. Patient A2: In a Psychiatric evaluation dated 2/4/11, there was no assessment of memory or intellectual functioning.

3. Patient A3: In a Psychiatric evaluation dated 2/5/11, there was no assessment of memory present.

4. Patient A4: In a Psychiatric evaluation dated 1/28/11, there was no assessment of memory or intellectual functioning.

5. Patient B1: In a Psychiatric evaluation dated 2/5/11 there was no assessment of memory present.

6. Patient B2: In a Psychiatric evaluation dated 2/3/11, memory description stated: "recent, remote and immediate recall intact" with no discussion of methodology or testing used to make this determination.

7. Patient B3: In a Psychiatric evaluation dated 2/5/11, there was no assessment of memory present.

8. Patient B4: In a Psychiatric evaluation dated 2/5/11, there was no assessment of memory present.

B. Policy Review:

Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009 noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: The Psychiatric Evaluation should include: 2.8.1 b. "Mental Status evaluation, including description and estimate of intellectual functioning, memory functioning, and orientation."

C. Interview:

In an interview on 2/8/11 at 3:00pm with the Medical Director, the above findings were reviewed and he agreed that this was a problem and represented a deficiency in the Psychiatric evaluation.

III. The adequacy of the psychiatric evaluation of patients with regard to assessment and description of assets for 7of 8 active sample patients (A1, A2, A3, A4, B1, B3 and B4). 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 include:

A. Record review

1. Patient A1: In a psychiatric evaluation dated 2/7/11, there was no description of patient assets noted in the record.

2. Patient A2: In a psychiatric evaluation dated 2/4/11, there was no description of patient assets noted in the record.

3. Patient A3: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

4. Patient A4: In a psychiatric evaluation dated 1/28/11, there was no description of patient assets noted in the record.

5. Patient B1: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

6. Patient B3: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

7. Patient B4: In a psychiatric evaluation dated 2/5/11, there was no description of patient assets noted in the record.

B. Policy Review

Medical Staff Rules and Regulations of Bloomington Meadows Hospital, Effective Date: May 2009 noted in Section 2.8: Psychiatric Evaluation and Mental Status Examination; 2.8.1: The Psychiatric Evaluation should include: 2.8.1 m. "Patient strengths and liabilities."

Policy No.: 1000.06: Medical Records Documentation Requirements (approved 10/99, last review 3/10): noted under #6: The Attending Physician must document: a) Psychiatric evaluation including: "strengths/weaknesses."

C. Interview

In an interview with the Medical Director on 2/8/11 at approximately 1500 3:00p.m. with the Medical Director, the findings noted above findings were reviewed and he agreed that this was a problem and represented a deficiency in the Psychiatric evaluation.

IV. The adequacy of discharge summaries for 6 of 8 sample closed records (D2, D3, D4, D6, D7 and D8). This failure results in not providing information on effective or ineffective treatment strategies to the patient's next care provider.
Findings include:

A. Record Review

1. Patient D2: Admitted 01/01/2011 and discharged 01/06/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "The patient was transferred to acute services and began a program of individual, group and family therapy in concordance with pharmacotherapy. Medications utilized were Risperdal 0.5 mg (milligrams) at bedtime. An additional diagnosis of dissociative disorder was entered into the record and felt to be accurate and operative. The patient took Amoxicillin 500 mg twice a day for positive strep screen." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

2. Patient D3: Admitted 01/03/2011 and discharged 01/07/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient utilized Seroquel 100 mg. at bedtime for mood stability. No reported side effects or adversity was reported." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

3. Patient D4: Admitted 01/03/2011 and discharged 01/10/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "The patient was subsequently transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. She did require the use of Cogentin secondary to significant dystonia. She otherwise continued on her usual birth control pills. Her cogentin was discontinued on the day of her discharge. It was felt the patient would not be able to continue neuroleptic medication." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

4. Patient D6: Admitted 01/04/2011 and discharged 01/11/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute services and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. He appeared to get along well with all staff and patients. No special procedures or sequellae occurred. The patient was placed on Trazadone 100 mg by mouth at bedtime for sleep. Abilify 10 mg was given twice per day. Nausea ensued and the patient's Abilify was discontinued. He eventually was discharged on Lexapro to replace the Abilify. Overall, the patient did well and no special procedures or adversity was reported." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

5. Patient D7: Admitted 01/04/2011 and discharged 01/11/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "[Patient D7] was transferred to acute services where he began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient, primarily, utilized Seroquel for mood stability and anxiety control. His discharge medication level was Seroquel 300 mg at bedtime. It was felt that the patient had many symptoms of underlying mood dysregulation, but also considerable anxiety that may be related to the ongoing conflict between his parents. His prognosis appeared to be guarded given the ongoing difficulty in the family." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

6. Patient D8: Admitted 01/04/2011 and discharged 01/08/2011. The discharge summary under the section titled "Therapeutic Response" stated the following: "Subsequent to admission, the patient was transferred to acute and began a program of individual, group, and family psychotherapy in concordance with pharmacotherapy. The patient utilized Trazadone 100 mg at bedtime for sleep with good results." This summary did not describe all the treatment instituted in the hospital, the patient's response to treatment and the extent of progress toward the patient's treatment plan goals.

B. Policy Review

1. Policy #1000.06 titled "Medical Records Documentation Requirements," dated 10/99 with most recent review dated 03/10 stated: "The Attending Physician is responsible for the discharge summary...The discharge summary must...Be complete...Give concise review of the reason the patient was admitted...Describe the findings while hospitalized...Describe the therapy instituted and the patient's response and progress..."

2. Medical staff Rules and Regulations dated 01/12/2010 stated under the Section titled Discharge Documentation: "The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient's condition on discharge."

C. Interview

In an interview conducted 02/08/11 at 3:00PM with the Medical Director, he concurred that these discharge summaries failed to provide a description of hospital course and response to treatment as required by facility policy.