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Based on review of documents and staff interview, the facility did not fully ensure sufficient patient participation in treatment plans or development of plans that addressed individualized needs. This finding was noted in 3 of 3 applicable concurrent inpatient psychiatric records reviewed.

Findings include:

1. During a tour of the inpatient Tower 4 Geriatric psychiatric unit on 12/18/12 at approximately 1 PM , it was noted that three of three concurrent inpatient psychiatric records lacked documentation of patient participation or contained incomplete treatment plans that did not address all relevant patient needs.

MR #4: An 80 year old male was admitted on 11/29/12 due to paranoia and suicidal ideation from a nursing home. Treatment plans reviewed for follow up noted goals had been resolved for paranoid delusions on 12/18/12, and for depression and suicidal ideation on 12/11/12. However, on 12/11 and 12/12/12, it was noted that the patient is preoccupied with weight and appearance. No treatment plan goal had been revised to address this matter especially since the prior suicidal ideation was manifested through intent to induce starvation and refusal of meals.

MR #5: An 83 year old patient with Alzheimer's dementia was assessed in the emergency room on 12/11/12 and admitted for inpatient treatment on 12/14/12 due to disorganized behavior, agitation, and medication noncompliance. The patient's treatment plan dated 12/15/12 did not include evidence of patient participation or signature, nor explained the reason why patient participation was not evident. Additionally, the care plan did not address the patient's paranoia directed towards her home care worker. Treatment plan follow up on 12/17/12 repeated that "the patient will not be disorganized " but did not address the patient's response to interventions for the same problems noted on 12/14/12 of disorganized thinking and behavior.
The patient was interviewed on the unit on 12/18/12 at approximately 1:30 PM, where she explained she needed help in making a call to her husband at home and insisted the home care aide was "against" her. The care plan did not include intervention to follow up with the Agency for Adult Protective Services (APS) since the patient had an open case prior to admission.

MR #6: The treatment plan for this 57 year old female admitted on 11/23/12 from a nursing home residence due to aggressive behavior lacked evidence of sufficient patient participation. The patient did not sign the treatment plan dated 11/23/12, nor did this plan include documented explanation for why the patient was unable to sign. The patient was hospitalized for treatment of schizoaffective disorder and the treatment plan did not address the patient's paranoid delusions or response to interventions planned for aggressive behavior. The treatment plan follow up dated 12/6/12 noted a plan to continue steps for goals to address anger directed to self and others, but did not assess patient's response to intervention. Furthermore, the patient's gait instability was noted in the initial treatment plan, but the treatment plan follow up did not incorporate or describe the patient's response to physical therapy provided during the hospitalization.

2. The facility was cited during the first revisit survey of 9/28/12 for issues pertaining to lack of sufficient documentation of treatment goals and patient response to treatment plans. The facility responded with a plan to monitor open records for patient participation in treatment plans, adequacy of treatment plans, patient response to treatment, and discharge summaries which reflect implementation of treatment plans by 10/26/12. Results of this analysis is to be reported quarterly to hospital wide performance improvement.

Interview with the AVP of Psychiatry on 12/20/12 found that while some data was collected for August through October 2012, this information was not analyzed.

This is a repeat deficiency.


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Based on review of records and staff interview, it was determined that the facility did not ensure provision of complete or accurate discharge planning evaluations for high risk patients, in order to provide comprehensive assessment of needs which impact on development of safe discharge plans. This finding was evident in 3/7 applicable records reviewed.

Findings include:

Review of MR #4 on 12/18/12 found that this 80 year old male was admitted on 11/29/12 for suicidal ideation and agitation in setting of paranoid schizophrenia. The patient's discharge summary was completed in advance. There was no discharge order written on the record. The patient was awaiting a PASRR level II clearance and was not yet cleared for discharge.

Review of MR #5 on 12/18/12 found inconsistent information contained in assessments about the patient's living arrangements prior to hospitalization. The patient was admitted on 12/14/12 for non compliance with medication and agitation in the setting of Alzheimer's dementia. The emergency room psychiatric consult indicated that the patient was brought to the ER on 12/11/12 from a nursing home with agitation. However, the psychosocial assessment on the discharge planning record on 12/17/12 noted that the patient was brought to the emergency room from home for evaluation following an argument with her home aide.

Review of MR #7: A patient with HIV and bipolar disorder was admitted 12/1/12 for shortness of breath and chest pain and was treated for pulmonary embolism. The record also noted that the patient had returned to his apartment following hurricane Sandy. The record contained incomplete discharge planning assessment secondary to identified housing need.
Social work notes dated 12/6/12 found that he was working with FEMA for alternate housing and information was faxed to FEMA at the patient's request. Follow up documentation on 12/18/12 at 1500hrs found that during contact with a FEMA worker, the social worker was unable to verify receipt of the documentation sent for hospital verification. The social worker was advised that the patient would need to follow up with FEMA himself. At 1600hrs, the worker noted that the patient told the nurse he would leave with his family and would follow up with FEMA regarding housing. There was no evidence of coordination to verify his whereabouts and to ensure that the patient had a safe discharge plan. The record lacked documentation of comprehensive discharge planning needs and assessment for high risk needs. The discharge /transfer form noted that follow up was needed for HIV, pulmonary, and coumadin clinic for INR testing but no calendar appointments were noted.

The hospital was cited during a revisit survey on 9/28/12 for incomplete discharge planning assessments for discharge related needs. The plan of correction submitted by the hospital noted that 25 records would be monitored for compliance with discharge planning assessments by 12/15/12 and results would be reported quarterly to Hospital wide Performance Improvement Committee . During the re-visit on 12/18/12, this activity was not yet implemented.

At interview with the Director of Care Management/Social Services on 12/18/12 it was reported that other hurricane related activities were prioritized after the hurricane which impeded completion of the monitoring. The review was conducted on 12/19/12 and provided to the surveyor on 12/20/12. This review found continued deficiencies for insufficient completion of psychosocial assessments. It was stated that the department will continue to regularly monitor these issues.

This is a repeat deficiency.



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